The prevention of perineal trauma during vaginal birth

Lateral episiotomy or no episiotomy in vacuum assisted delivery in nulliparous women (EVA): multicentre, open label, randomised controlled trial

OBJECTIVE

To assess the effect of lateral episiotomy, compared with no episiotomy, on obstetric anal sphincter injury in nulliparous women requiring vacuum extraction.

DESIGN

A multicentre, open label, randomised controlled trial.

SETTING

Eight hospitals in Sweden, 2017-23.

PARTICIPANTS

717 nulliparous women with a single live fetus of 34 gestational weeks or more, requiring vacuum extraction were randomly assigned (1:1) to lateral episiotomy or no episiotomy using sealed opaque envelopes. Randomisation was stratified by study site.

INTERVENTION

A standardised lateral episiotomy was performed during the vacuum extraction, at crowning of the fetal head, starting 1-3 cm from the posterior fourchette, at a 60° (45-80°) angle from the midline, and 4 cm (3-5 cm) long. The comparison was no episiotomy unless considered indispensable.

MAIN OUTCOME MEASURES

The primary outcome of the episiotomy in vacuum assisted delivery (EVA) trial was obstetric anal sphincter injury, clinically diagnosed by combined visual inspection and digital rectal and vaginal examination. The primary analysis used a modified intention-to-treat population that included all consenting women with attempted or successful vacuum extraction. As a result of an interim analysis at significance level P<0.01, the primary endpoint was tested at 4% significance level with accompanying 96% confidence interval (CI).

RESULTS

From 1 July 2017 to 15 February 2023, 717 women were randomly assigned: 354 (49%) to lateral episiotomy and 363 (51%) to no episiotomy. Before vacuum extraction attempt, one woman withdrew consent and 14 had a spontaneous birth, leaving 702 for the primary analysis. In the intervention group, 21 (6%) of 344 women sustained obstetric anal sphincter injury, compared with 47 (13%) of 358 women in the comparison group (P=0.002). The risk difference was -7.0% (96% CI -11.7% to -2.5%). The risk ratio adjusted for site was 0.47 (96% CI 0.23 to 0.97) and unadjusted risk ratio was 0.46 (0.28 to 0.78). No significant differences were noted between groups in postpartum pain, blood loss, neonatal outcomes, or total adverse events, but the intervention group had more wound infections and dehiscence.

CONCLUSIONS

Lateral episiotomy can be recommended for nulliparous women requiring vacuum extraction to significantly reduce the risk of obstetric anal sphincter injury.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02643108.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

CRD42023415996 (PROSPERO).

Midwives' approach to the prevention and repair of obstetric perineal trauma in Spain

AIM

Different clinical practice guidelines include recommendations on how to prevent and repair obstetric perineal trauma, as well as the use of episiotomy. To evaluate the variability in midwives' professional practices for preventing and repairing perineal trauma, as well as the professional factors that may be associated with the restrictive use of episiotomy.

DESIGN

Observational cross-sectional study.

METHODS

Three hundred five midwives completed an anonymous questionnaire developed by the authors and distributed across various midwifery scientific societies. The main outcomes measured were the frequencies of adopting specific practices related to perineal injury prevention and repair, episiotomy technique and restrictive episiotomy use (<10%). Odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals were estimated.

RESULTS

Intrapartum perineal massage was not normally used by 253 (83%) of midwives, and 186 (61%) applied compresses soaked in warm water to the perineum. Regarding episiotomy, there was a great deal of variability, noting that 129 (42.3%) adopted a restrictive use of this procedure, 125 (41%) performed it between 10% and 20%, while 51 midwives (16.7%) performed it in more than 20% of cases. In addition, 165 (54.1%) midwives followed an incision angle of 60º. Concerning tears, 155 (50.8%) usually sutured first-degree tears and 273 (89.5%) always sutured second-degree tears. Midwives attending home births (aOR = 6.5; 95% CI: 2.69-15.69), working at a teaching hospital (aOR = 3.69; 95% CI: 1.39-9.84), and the ones who recently completed their professional training (aOR = 3.58; 95% CI: 1.46-8.79) were significantly more likely to adopt a restrictive use of episiotomy.

CONCLUSIONS

There is a significant variability in Spanish midwives' practices for preventing and repairing perineal tears. Moreover, the restrictive use of episiotomy is associated with midwives attending home births, working in teaching hospitals and having recent professional training.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Evaluation of perineal wound healing and pain outcomes after low-angle mediolateral episiotomy in women undergoing vaginal childbirth: A systematic review and meta-analysis

The efficacy of episiotomy, particularly the angle of incision in mediolateral episiotomies, remains a significant area of inquiry in obstetrics. This meta-analysis aimed to evaluate the impact of low-angle mediolateral episiotomy on perineal wound healing and pain outcomes in women undergoing vaginal childbirth. Adhering to PRISMA guidelines, a systematic review was conducted using the PICO framework. Studies were selected based on predefined inclusion and exclusion criteria, focusing on randomised controlled trials (RCTs) involving low-angle mediolateral episiotomies. Comprehensive literature searches were performed across major electronic databases including PubMed, Embase, Web of Science and Cochrane Library. Data extraction and quality assessments were meticulously carried out by independent reviewers, employing the Cochrane Collaboration's risk of bias tool. A total of 1246 articles were initially identified, with 8 articles meeting the strict inclusion criteria for the final analysis. The meta-analysis revealed significant heterogeneity among studies regarding postoperative pain (p < 0.0001, I2 = 77.5%), and employed a random-effects model. Results showed that low-angle episiotomies significantly reduced postoperative pain (OR = 0.27, 95% CI: 0.17-0.42, p < 0.001), and increased first-degree healing rates (OR = 2.95, 95% CI: 2.20-3.96, p < 0.001) compared to traditional angles. Sensitivity analyses confirmed the stability of these findings, and no significant publication bias was detected. The analysis suggests that low-angle episiotomies can potentially reduce postoperative perineal pain and enhance wound healing. However, the limited number and varying quality of the included studies warrant cautious interpretation of these results. Further well-designed studies are needed to corroborate these findings and guide clinical practice.

Parturition at term: induction, second and third stages of labor, and optimal management of life-threatening complications-hemorrhage, infection, and uterine rupture

Childbirth is a defining moment in anyone's life, and it occurs 140 million times per year. Largely a physiologic process, parturition does come with risks; one mother dies every two minutes. These deaths occur mostly among healthy women, and many are considered preventable. For each death, 20 to 30 mothers experience complications that compromise their short- and long-term health. The risk of birth extends to the newborn, and, in 2020, 2.4 million neonates died, 25% in the first day of life. Hence, intrapartum care is an important priority for society. The American Journal of Obstetrics & Gynecology has devoted two special Supplements in 2023 and 2024 to the clinical aspects of labor at term. This article describes the content of the Supplements and highlights new developments in the induction of labor (a comparison of methods, definition of failed induction, new pharmacologic agents), management of the second stage, the value of intrapartum sonography, new concepts on soft tissue dystocia, optimal care during the third stage, and common complications that account for maternal death, such as infection, hemorrhage, and uterine rupture. All articles are available to subscribers and non-subscribers and have supporting video content to enhance dissemination and improve intrapartum care. Our hope is that no mother suffers because of lack of information.

Pelvic floor injury during vaginal birth is life-altering and preventable: what can we do about it?

Pelvic floor disorders after childbirth have distressing lifelong consequences for women, requiring more than 300,000 women to have surgery annually. This represents approximately 10% of the 3 million women who give birth vaginally each year. Vaginal birth is the largest modifiable risk factor for prolapse, the pelvic floor disorder most strongly associated with birth, and is an important contributor to stress incontinence. These disorders require 10 times as many operations as anal sphincter injuries. Imaging shows that injuries of the levator ani muscle, perineal body, and membrane occur in up to 19% of primiparous women. During birth, the levator muscle and birth canal tissues must stretch to more than 3 times their original length; it is this overstretching that is responsible for the muscle tear visible on imaging rather than compression or neuropathy. The injury is present in 55% of women with prolapse later in life, with an odds ratio of 7.3, compared with women with normal support. In addition, levator damage can affect other aspects of hiatal closure, such as the perineal body and membrane. These injuries are associated with an enlarged urogenital hiatus, now known as antedate prolapse, and with prolapse surgery failure. Risk factors for levator injury are multifactorial and include forceps delivery, occiput posterior birth, older maternal age, long second stage of labor, and birthweight of >4000 g. Delivery with a vacuum device is associated with reduced levator damage. Other steps that might logically reduce injuries include manual rotation from occiput posterior to occiput anterior, slow gradual delivery, perineal massage or compresses, and early induction of labor, but these require study to document protection. In addition, teaching women to avoid pushing against a contracted levator muscle would likely decrease injury risk by decreasing tension on the vulnerable muscle origin. Providing care for women who have experienced difficult deliveries can be enhanced with early recognition, physical therapy, and attention to recovery. It is only right that women be made aware of these risks during pregnancy. Educating women on the long-term pelvic floor sequelae of childbirth should be performed antenatally so that they can be empowered to make informed decisions about management decisions during labor.