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Halfdansdottir B, Ellinger-Kaya K, Fjøsne K, Lindgren H, Hegaard HK, Blix E. The association between waterbirth and perineal injury or other adverse outcomes among low-risk women with physiological birth: Results from the Nordic Home Birth Cohort Study. Women Birth 2024; 37:101625. [PMID: 38754250 DOI: 10.1016/j.wombi.2024.101625] [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: 02/23/2023] [Revised: 04/05/2024] [Accepted: 05/04/2024] [Indexed: 05/18/2024]
Abstract
PROBLEM/BACKGROUND Immersion in water has known benefits, such as reducing pain and shortening the duration of labour. The relationship between waterbirth and perineal injury remains unclear. AIM To compare the incidence of perineal injury in waterbirth and birth on land among low-risk women. Secondary outcomes were postpartum haemorrhage and 5-minute Apgar scores <7. METHODS Prospective cohort study of 2875 low-risk women who planned a home birth in Denmark, Iceland, Norway, and Sweden in 2008-2013 and had a spontaneous vaginal birth without intervention. Descriptive statistics and logistic regression were performed. FINDINGS A total of 942 women had a waterbirth, and 1933 gave birth on land. The groups differed in their various background variables. Multiparous women had moderately lower rates of intact perineum (59.3% vs. 63.9%) and primiparous women had lower rates of episiotomies (1.1% vs. 4.8%) in waterbirth than in birth on land. No statistically significant differences were detected in adjusted regression analysis on intact perineum in waterbirth (primiparous women's aOR = 1.03, CI 0.68-1.58; multiparous women's aOR = 0.84, CI 0.67-1.05). The rates of sphincter injuries (0.9% vs. 0.6%) were low in both groups. No significant differences were detected in secondary outcomes. DISCUSSION The decreased incidence of intact perineum among multiparous women was modest and inconclusive, and the prevalence of sphincter injury was low. CONCLUSION Low-risk women contemplating waterbirth should be advised to weigh the risks and benefits detected in this study against previously established benefits of waterbirth and should make an informed choice based on their values.
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Affiliation(s)
- Berglind Halfdansdottir
- University of Iceland, Faculty of Nursing and Midwifery, School of Health Sciences, Eirberg, Eiriksgata 34, 101 Reykjavik, Iceland.
| | - Karianne Ellinger-Kaya
- Oslo University Hospital, Division of Obstetrics and Gynaecology, P.O. box 4950, Nydalen, 0424 Oslo, Norway
| | - Kathrine Fjøsne
- Oslo University Hospital, Division of Obstetrics and Gynaecology, P.O. box 4950, Nydalen, 0424 Oslo, Norway
| | - Helena Lindgren
- Karolinska Institutet, Department of Women's and Children's Health, 17177 Stockholm, Sweden; Sophiahemmet University, Department of Health Promotion Science, P O Box 5605, SE-114 86 Stockholm, Sweden
| | - Hanne K Hegaard
- Copenhagen University Hospital - Rigshospitalet, Department of Obstetrics, Section 3021, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Ellen Blix
- Oslo Metropolitan University, Research group Midwifery Science, School of Nursing and Health Promotion, Faculty of Health Sciences, P.O. box 4, St Olavs plass, 0130 Oslo, Norway
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Laderas Díaz E, Rodríguez‐Almagro J, Picón Rodríguez R, Martínez Galiano JM, Martínez Rodríguez S, Hernández‐Martínez A. Midwives' approach to the prevention and repair of obstetric perineal trauma in Spain. Nurs Open 2024; 11:e2160. [PMID: 38660722 PMCID: PMC11043828 DOI: 10.1002/nop2.2160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Revised: 02/17/2024] [Accepted: 03/26/2024] [Indexed: 04/26/2024] Open
Abstract
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.
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Affiliation(s)
- Estíbaliz Laderas Díaz
- Department of Obstetrics & GynecologyLa Mancha Centro General HospitalAlcázar de San Juan, Ciudad RealSpain
| | - Julián Rodríguez‐Almagro
- Department of Nursing, Physiotherapy and Occupational Therapy, Ciudad Real Faculty of NursingUniversity of Castilla‐La ManchaCiudad RealSpain
| | - Rafael Picón Rodríguez
- Department of General and Digestive SurgerySanta Bárbara HospitalPuertollano, Ciudad RealSpain
| | - Juan Miguel Martínez Galiano
- Department of NursingJaen UniversityJaenSpain
- Consortium for Biomedical Research in Epidemiology and Public Health (CIBERESP)MadridSpain
| | - Sandra Martínez Rodríguez
- Department of Nursing, Physiotherapy and Occupational Therapy, Ciudad Real Faculty of NursingUniversity of Castilla‐La ManchaCiudad RealSpain
| | - Antonio Hernández‐Martínez
- Department of Nursing, Physiotherapy and Occupational Therapy, Ciudad Real Faculty of NursingUniversity of Castilla‐La ManchaCiudad RealSpain
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Okeahialam NA, Sultan AH, Thakar R. The prevention of perineal trauma during vaginal birth. Am J Obstet Gynecol 2024; 230:S991-S1004. [PMID: 37635056 DOI: 10.1016/j.ajog.2022.06.021] [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: 04/05/2022] [Revised: 06/08/2022] [Accepted: 06/12/2022] [Indexed: 08/29/2023]
Abstract
Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%. The incidence of obstetrical anal sphincter injury is approximately 3%, with a significantly higher rate in primiparous than in multiparous women (6% vs 2%). Obstetrical anal sphincter injury is a significant risk factor for the development of anal incontinence, with approximately 10% of women developing symptoms within a year following vaginal birth. Obstetrical anal sphincter injuries have significant medicolegal implications and contribute greatly to healthcare costs. For example, in 2013 and 2014, the economic burden of obstetrical anal sphincter injuries in the United Kingdom ranged between £3.7 million (with assisted vaginal birth) and £9.8 million (with spontaneous vaginal birth). In the United States, complications associated with trauma to the perineum incurred costs of approximately $83 million between 2007 and 2011. It is therefore crucial to focus on improvements in clinical care to reduce this risk and minimize the development of perineal trauma, particularly obstetrical anal sphincter injuries. Identification of risk factors allows modification of obstetrical practice with the aim of reducing the rate of perineal trauma and its attendant associated morbidity. Risk factors associated with second-degree perineal trauma include increased fetal birthweight, operative vaginal birth, prolonged second stage of labor, maternal birth position, and advanced maternal age. With obstetrical anal sphincter injury, risk factors include induction of labor, augmentation of labor, epidural, increased fetal birthweight, fetal malposition (occiput posterior), midline episiotomy, operative vaginal birth, Asian ethnicity, and primiparity. Obstetrical practice can be modified both antenatally and intrapartum. The evidence suggests that in the antenatal period, perineal massage can be commenced in the third trimester of pregnancy to increase muscle elasticity and allow stretching of the perineum during birth, thereby reducing the risk of tearing or need for episiotomy. With regard to the intrapartum period, there is a growing body of evidence from the United Kingdom, Norway, and Denmark suggesting that the implementation of quality improvement initiatives including the training of clinicians in manual perineal protection and mediolateral episiotomy can reduce the incidence of obstetrical anal sphincter injury. With episiotomy, the International Federation of Gynecology and Obstetrics recommends restrictive rather than routine use of episiotomy. This is particularly the case with unassisted vaginal births. However, there is a role for episiotomy, specifically mediolateral or lateral, with assisted vaginal births. This is specifically the case with nulliparous vacuum and forceps births, given that the use of mediolateral or lateral episiotomy has been shown to significantly reduce the incidence of obstetrical anal sphincter injury in these groups by 43% and 68%, respectively. However, the complications associated with episiotomy including perineal pain, dyspareunia, and sexual dysfunction should be acknowledged. Despite considerable research, interventions for reducing the risk of perineal trauma remain a subject of controversy. In this review article, we present the available data on the prevention of perineal trauma by describing the risk factors associated with perineal trauma and interventions that can be implemented to prevent perineal trauma, in particular obstetrical anal sphincter injury.
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Affiliation(s)
| | - Abdul H Sultan
- Croydon University Hospital, London, United Kingdom; St George's University of London
| | - Ranee Thakar
- Croydon University Hospital, London, United Kingdom; St George's University of London.
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4
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Lee N, Allen J, Jenkinson B, Hurst C, Gao Y, Kildea S. A pre-post implementation study of a care bundle to reduce perineal trauma in unassisted births conducted by midwives. Women Birth 2024; 37:159-165. [PMID: 37598048 DOI: 10.1016/j.wombi.2023.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Revised: 07/09/2023] [Accepted: 08/14/2023] [Indexed: 08/21/2023]
Abstract
PROBLEM The perineal-bundle is a complex intervention widely implemented in Australian maternity care facilities. BACKGROUND Most bundle components have limited or conflicting evidence and the implementation required many midwives to change their usual practice for preventing perineal trauma. AIM To measure the effect of perineal bundle implementation on perineal injury for women having unassisted births with midwives. METHODS A retrospective pre-post implementation study design to determine rates of second degree, severe perineal trauma, and episiotomy. Women who had an unassisted, singleton, cephalic vaginal birth at term between two time periods: January 2011 - November 2017 and August 2018 - August 2020 with a midwife or midwifery student accoucheur. We conducted logistic regression on the primary outcomes to control for confounding variables. FINDINGS data from 20,155 births (pre-implementation) and 6273 (post-implementation) were analysed. After implementation, no significant difference in likelihood of severe perineal trauma was demonstrated (aOR 0.86, 95% CI 0.71-1.04, p = 0.124). Nulliparous women were more likely to receive an episiotomy (aOR 1.49 95% CI 1.31-1.70 p < 0.001) and multiparous women to suffer a second degree tear (aOR 1.18 95% CI 1.09-1.27 p < 0.001). DISCUSSION This study adds to the growing body of literature which suggests a number of bundle components are ineffective, and some potentially harmful. Why, and how, the bundle was introduced at scale without a research framework to test efficacy and safety is a key concern. CONCLUSION Suitably designed trials should be undertaken on all proposed individual or grouped perineal protection strategies prior to broad adoption.
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Affiliation(s)
- Nigel Lee
- Level 3 Chamberlain Building, School of Nursing Midwifery and Social Work, University of Queensland, St Lucia, Queensland, Australia.
| | - Jyai Allen
- Molly Wardaguga Research Centre, College of Nursing & Midwifery, Charles Darwin University, Level 11, East building, 410 Ann St, Brisbane, Queensland 4000, Australia.
| | - Bec Jenkinson
- Australian Women and Girl's Health Research Centre, School of Public Health, University of Queensland, Herston, Queensland, Australia.
| | - Cameron Hurst
- Australian Nurse-Family Partnership Program and Molly Wardaguga Research Centre, Level 11, East building, 410 Ann St, Brisbane, Queensland 4000, Australia.
| | - Yu Gao
- Level 3 Chamberlain Building, School of Nursing Midwifery and Social Work, University of Queensland, St Lucia, Queensland, Australia.
| | - Sue Kildea
- Molly Wardaguga Research Centre, College of Nursing & Midwifery, Charles Darwin University, 17 Grevillea Drive, Sadadeen, Alice Springs 0870, Australia.
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5
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Edqvist M, Dahlen HG, Häggsgård C, Tern H, Ängeby K, Teleman P, Ajne G, Rubertsson C. The effect of two midwives during the second stage of labour to reduce severe perineal trauma (Oneplus): a multicentre, randomised controlled trial in Sweden. Lancet 2022; 399:1242-1253. [PMID: 35303474 DOI: 10.1016/s0140-6736(22)00188-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 01/11/2022] [Accepted: 01/19/2022] [Indexed: 12/17/2022]
Abstract
BACKGROUND Severe perineal trauma (SPT) affecting the anal sphincter muscle complex is a serious complication following childbirth, associated with short-term and long-term maternal morbidity. Effective preventive strategies are still scarce. The aim of the Oneplus trial was to test the hypothesis that the presence of a second midwife during the second stage of labour, with the purpose of preventing SPT, would result in fewer injuries affecting the anal sphincter than if attended by one midwife. METHODS In this multicentre, randomised, controlled parallel group, unmasked trial done at five obstetric units in Sweden, women were randomly assigned to be assisted by either one or two midwives in late second stage. Nulliparous women and women planning the first vaginal birth after caesarean section who were age 18-47 years were randomly assigned to an intervention when reaching the second stage of labour. Further inclusion criteria were gestational week 37+0, carrying a singleton live fetus in vertex presentation, and proficiency in either Swedish, English, Arabic, or Farsi. Exclusion criteria were a multiple pregnancy, intrauterine fetal demise, a planned caesarean section, or women who were less than 37 weeks pregnant. Randomisation to the intervention group of two midwives or standard care group of one midwife (1:1) was done using a computer-based program and treatment groups were allocated by use of sealed opaque envelopes. All women and midwives were aware of the group assignment, but the statistician from Clinical Studies Forum South, who did the analyses, was masked to group assignment. Midwives were instructed to implement existing prevention models and the second midwife was to assist on instruction of the primary midwife, when asked. Midwives were also instructed to complete case report forms detailing assistance techniques and perineal trauma prevention techniques. The primary outcome was the proportion of women who had SPT, for which odds ratios (ORs) and 95% CIs were calculated, and logistic regression was done to adjust for study site. All analyses were done according to intention to treat. The trial is registered with ClinicalTrials.gov, NCT0377096. FINDINGS Between Dec 10, 2018, and March 21, 2020, 8866 women were assessed for eligibility, and 4264 met the inclusion criteria and agreed to participate. 3776 (88·5%) of 4264 women were randomly assigned to an intervention after reaching the second stage of labour. 1892 women were assigned to collegial assistance (two midwives) during the second stage of labour and 1884 women were assigned to standard care (one midwife). 13 women in each group did not meet the inclusion criteria and were excluded. After further exclusions, 1546 women spontaneously gave birth in the intervention group and 1513 in the standard care group. 1546 women in the intervention group and 1513 in the standard care group were included in the intention-to-treat analysis of the primary outcome. There was a significant reduction in SPT in the intervention group (3·9% [61 of 1546] vs 5·7% [86 of 1513]; adjusted OR 0·69 (0·49-0·97). INTERPRETATION The presence of two midwives during the active second stage can reduce SPT in women giving birth for the first time. FUNDING The Swedish Research Council for Health, Working Life and Welfare; Jan Hains Research Foundation; and Skane County Council's Research and Development Foundation.
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Affiliation(s)
- Malin Edqvist
- Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden.
| | - Hannah G Dahlen
- School of Nursing and Midwifery, Western Sydney University, Sydney, NSW, Australia
| | - Cecilia Häggsgård
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Helena Tern
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Karin Ängeby
- Centre for Clinical Research and Education, Region Värmland, Karlstad, Sweden; School of Education, Health and Social Studies, Dalarna University, Falun, Sweden
| | - Pia Teleman
- Department of Clinical Sciences, Faculty of Medicine, Lund University, Lund, Sweden; Department of Obstetrics and Gynecology, Skåne University Hospital, Malmö, Sweden
| | - Gunilla Ajne
- Division of Obstetrics and Gynaecology, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Women's Health and Health Professions, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | - Christine Rubertsson
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
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Bunn JG, Sheeder J, Schulkin J, Diko S, Estin M, Connell KA, Hurt KJ. Obstetric anal sphincter injuries and other delivery trauma: a US national survey of obstetrician-gynecologists. Int Urogynecol J 2022; 33:1463-1472. [PMID: 35113178 DOI: 10.1007/s00192-021-05062-9] [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: 09/19/2021] [Accepted: 12/01/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Obstetric lacerations complicate the majority of deliveries. The application of standardized guidelines for assessing delivery trauma has not been assessed thoroughly in the United States. We recently identified gaps in US midwives' clinical assessment of delivery trauma. We conducted a cross-sectional national survey of practicing obstetricians in the USA to characterize their classification of obstetric lacerations. We hypothesized that attending obstetricians' identification and diagnosis of delivery trauma would be similar to our findings for midwives with frequent inaccuracy. METHODS We recruited clinically active obstetricians through the Pregnancy-Related Care Research Network. We asked participants to classify (from written definitions) and diagnose (from standard illustrations) common forms of vaginal delivery trauma using the widely employed perineal laceration degree system. We performed bivariate analysis of high- and low-scoring respondents and logistic regression to model characteristics associated with higher diagnostic accuracy. RESULTS Of the 162 respondents who started the survey, 76% (123) were included for analysis (22% of solicited emails). Overall, we found wide variation in response accuracy with as few as 62% of respondents correctly classifying certain types of lacerations. Only 49 out of 123 (40%) use the Sultan third-degree subclassification system and 67 out of 123 (52%) continue to use the midline/median approach for episiotomies. Providers reporting fewer deliveries per month and fewer publicly insured patients earned higher scores. CONCLUSIONS Obstetricians in a nationally representative US perinatal provider network inconsistently identify perineal and nonperineal lacerations. We found important clinical knowledge gaps, suggesting that vaginal delivery diagnoses in obstetric quality studies and pelvic floor research might be inaccurate.
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Affiliation(s)
- Jason G Bunn
- Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jeanelle Sheeder
- Division of Family Planning, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jay Schulkin
- Pregnancy-Related Care Research Network, Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Sindi Diko
- Department of Surgery, St. Joseph's University Medical Center, Paterson, NJ, USA
| | - Miriam Estin
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, NC, USA
| | - Kathleen A Connell
- Division of Urogynecology, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.,Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - K Joseph Hurt
- Division of Reproductive Sciences, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, Aurora, CO, USA. .,Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Colorado Anschutz Medical Campus, 12700 E 19th Avenue, Mailstop 8613, Research Complex-2, P15-3003, Aurora, CO, 80045, USA.
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7
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Allen J, Small K, Lee N. How a perineal care bundle impacts midwifery practice in Australian maternity hospitals: A critical, reflexive thematic analysis. Women Birth 2021; 35:e1-e9. [PMID: 33485817 DOI: 10.1016/j.wombi.2021.01.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 01/13/2021] [Accepted: 01/13/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND A care bundle to reduce severe perineal trauma (the bundle) was introduced in 28 Australian maternity hospitals in 2018. The bundle includes five components of which only one - warm perineal compresses - has highest level evidence. There is scant published research about the impact of implementation of perineal bundles. QUESTION How does a perineal care bundle impact midwifery practice in Australian maternity hospitals? METHODS Purposively sampled midwives who worked in hospitals where the bundle had been implemented. Interested midwives were recruited to participate in one-to-one, semi-structured interviews. The researchers conducted critical, reflexive thematic analysis informed by Foucauldian concepts of power. FINDINGS We interviewed 12 midwives from five hospitals in one state of Australia. Participants varied by age, clinical role, experience, and education. Three themes were generated: 1) bundle design and implementation 2) changing midwifery practice: obedience, subversion, and compliance; and 3) obstetric dominance and midwifery submission. DISCUSSION The bundle exemplifies tensions between obstetric and midwifery constructs of safety in normal birth. Participants' responses appear consistent with oppressed group behaviour previously reported in nurses and midwives. Women expect midwives to facilitate maternal autonomy yet decision-making in maternity care is commonly geared towards obtaining consent. In our study midwives encouraged women to consent or decline depending on their personal preferences. CONCLUSION The introduction of the perineal bundle acts as an exemplar of obstetric dominance in Australian maternity care. We recommend midwives advocate autonomy - women's and their own - by using clinical judgement, evidence, and woman-centred care.
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Affiliation(s)
- Jyai Allen
- Transforming Maternity Care Collaborative & School of Nursing and Midwifery, Griffith University, Australia(1).
| | - Kirsten Small
- Transforming Maternity Care Collaborative & School of Nursing and Midwifery, Griffith University, Australia(1). https://twitter.com/@birthsmalltalk
| | - Nigel Lee
- School of Nursing, Midwifery and Social Work, University of Queensland, Australia. https://twitter.com/@Nigel_Lee01
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Ginath S, Alcalay M, Ben Ami M, Bssam Abbas Y, Cohen G, Condrea A, Feit H, Gershi H, Gold R, Goldschmidt E, Gordon D, Groutz A, Lavy Y, Levy G, Lowenstein L, Marcus N, Padoa A, Samuelof A, Tevet A, Weintraub AY. The impact of a nationwide hands-on workshop on the diagnostic rates and management of obstetrical anal sphincter Injuries in Israel. Colorectal Dis 2020; 22:1677-1685. [PMID: 32583513 DOI: 10.1111/codi.15220] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 05/14/2020] [Indexed: 02/08/2023]
Abstract
AIM The aim was to evaluate the influence of a half day, hands-on, workshop on the detection and repair of obstetric anal sphincter injuries (OASIs). METHOD Starting in February 2011, hands-on workshops for the diagnosis and repair of OASIs were delivered by trained urogynaecologists in departments of tertiary medical centres in Israel. The structure of the hands-on workshop resembles the workshop organized at the International Urogynecological Association annual conferences. Participants included medical staff, midwives and surgical residents from each medical centre. We collected data regarding the rate of OASIs, 1 year before and 1 year following the workshop, in 11 medical centres. The study population was composed of parturients with the following inclusion criteria: singleton pregnancy, vertex presentation and vaginal delivery. Pre-viable preterm gestations (< 24 weeks), birth weight < 500 g, stillborn, and those with major congenital anomalies, multifoetal pregnancies, breech presentations and caesarean deliveries were excluded from the analysis. RESULTS In the reviewed centres, 70 663 (49.3%) women delivered prior to the workshop (pre-workshop group) and 72 616 (50.7%) women delivered following the workshop (post-workshop group). Third- or fourth-degree perineal tears occurred in 248 women (0.35%) before the workshop, and in 328 (0.45%) following the workshop, a significant increase of 28.7% (P = 0.002). The increase in diagnosis was significant also in women with third-degree tears alone, 226 women (0.32%) before the workshop and 298 (0.41%) following the workshop, an increase of 28.3% (P = 0.005). CONCLUSION The detection rate of OASIs has significantly increased following the hands-on workshop. The implementation of such programmes is crucial for increasing awareness and detection rates of OASI following vaginal deliveries.
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Affiliation(s)
- S Ginath
- Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Alcalay
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Ramat Gan, Israel
| | - M Ben Ami
- Department of Obstetrics and Gynecology, Baruch Padeh Medical Center, Poriya, Israel.,Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - Y Bssam Abbas
- Department of Obstetrics and Gynecology, Baruch Padeh Medical Center, Poriya, Israel.,Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Ramat Gan, Israel
| | - G Cohen
- Department of Obstetrics and Gynecology, Bnei Zion Medical Center, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - A Condrea
- Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - H Feit
- Department of Obstetrics and Gynecology, Edith Wolfson Medical Center, Holon, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - H Gershi
- Department of Obstetrics and Gynecology, Mayanei HaYeshua Medical Center, Bnei Brak, Israel
| | - R Gold
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Obstetrics and Gynecology, Tel Aviv Sourasky Medical Center, Lis Maternity Hospital, Tel Aviv, Israel
| | - E Goldschmidt
- Department of Obstetrics and Gynecology, Bnei Zion Medical Center, Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - D Gordon
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Obstetrics and Gynecology, Tel Aviv Sourasky Medical Center, Lis Maternity Hospital, Tel Aviv, Israel
| | - A Groutz
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Obstetrics and Gynecology, Tel Aviv Sourasky Medical Center, Lis Maternity Hospital, Tel Aviv, Israel
| | - Y Lavy
- Department of Obstetrics and Gynecology, Hadassah Mount Scopus, Jerusalem, Israel.,Hebrew University, Jerusalem, Israel
| | - G Levy
- Department of Obstetrics and Gynecology, Mayanei HaYeshua Medical Center, Bnei Brak, Israel
| | - L Lowenstein
- Department of Obstetrics and Gynecology, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - N Marcus
- Azrieli Faculty of Medicine in the Galilee, Bar-Ilan University, Ramat Gan, Israel.,Department of Obstetrics and Gynecology, Rivka Ziv Medical Center, Safed, Israel
| | - A Padoa
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.,Department of Obstetrics and Gynecology, Yitzhak Shamir Medical Center, Tsrifin, Israel
| | - A Samuelof
- Hebrew University, Jerusalem, Israel.,Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - A Tevet
- Hebrew University, Jerusalem, Israel.,Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - A Y Weintraub
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel
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9
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Bidwell P, Thakar R, Gurol-Urganci I, Harris JM, Silverton L, Hellyer A, Freeman R, Morris E, Novis V, Sevdalis N. Exploring clinicians' perspectives on the 'Obstetric Anal Sphincter Injury Care Bundle' national quality improvement programme: a qualitative study. BMJ Open 2020; 10:e035674. [PMID: 32907894 PMCID: PMC7482496 DOI: 10.1136/bmjopen-2019-035674] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 05/07/2020] [Accepted: 06/30/2020] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Obstetric anal sphincter injuries (OASI) can have severe debilitating consequences to women and health systems. The OASI Care Bundle quality improvement programme was introduced in 16 maternity units across England, Scotland and Wales (January 2017 to March 2018) to address increasing OASI rates. OBJECTIVES To explore clinicians' (midwives' and obstetricians') perspectives of the OASI Care Bundle with respect to (1) acceptability, (2) feasibility, and (3) sustainability. DESIGN A qualitative exploratory study using focus groups methodology. SETTING A total of 16 focus groups were conducted in 16 maternity units in England, Scotland and Wales where the OASI Care Bundle was implemented. Focus groups took place approximately 3 months following initial implementation of the care bundle in each unit. PARTICIPANTS A total of 101 clinicians participated, with an average of six per focus group. Participants volunteered to take part and compromised of 37 obstetricians and 64 midwives (including eight students). The majority were female and the mean age was 36.5 years. RESULTS Four main themes emerged: 'Implementation strategies', 'Opportunities to use the OASI Care Bundle', 'Does current practice need to change?' and 'Perceptions of what women want'. Midwives were more likely than obstetricians to report themes alluding to 'what women want' and variations in intrapartum perineal protection techniques. Both professional groups reported similar views of other themes, in particular regarding the supporting clinical evidence. Gaps were identified in clinicians' knowledge and experience of intrapartum perineal management. CONCLUSIONS Adoption of the OASI Care Bundle was associated with a number of cognitive and interpersonal factors, such as personal values, interprofessional working and how the intervention was launched; which both facilitated and impeded adoption. The 'what women want' theme has implications for maternal autonomy and needs further exploration. Our findings can be used by similar initiatives to reduce perineal trauma both nationally and internationally. TRIAL REGISTRATION NUMBER ISCTRN 12143325; https://doi.org/10.1186/ISRCTN12143325.
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Affiliation(s)
- Posy Bidwell
- Royal College of Obstetricians and Gynaecologists, London, UK
| | | | - Ipek Gurol-Urganci
- Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - James M Harris
- Centre for Nursing, Midwifery and Allied Health Professional Research, University College London Hospitals NHS Foundation Trust, London, UK
| | | | | | | | - Edward Morris
- Royal College of Obstetricians and Gynaecologists, London, UK
| | - Vivienne Novis
- Royal College of Obstetricians and Gynaecologists, London, UK
| | - Nick Sevdalis
- Centre for Implementation Science, King's College London, London, UK
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10
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Baumfeld Y, Yohay D, Rotem R, Yohay Z, Weintraub AY. Temporal decline in the improved detection rates following OASIS workshops. Int Urogynecol J 2020; 32:1889-1895. [PMID: 32561957 DOI: 10.1007/s00192-020-04395-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 06/09/2020] [Indexed: 12/24/2022]
Abstract
INTRODUCTION AND HYPOTHESIS To evaluate the long-term sustainability of the effect of a hands-on workshop on the diagnosis of deliveries complicated by obstetrical anal sphincter injuries (OASIS). METHODS A population-based retrospective cohort study looking over a 4-year period, 1 year before and 3 years after an OASIS workshop. All deliveries that took place at the Soroka University Medical Center during the study period were included. Data were collected from the obstetrical electronic database. Interrupted time series analysis assessing the change in the OASIS detection rate over time from the workshop was conducted, assuming that the OASIS rate remained constant during the study period. RESULTS During the study period, 147 parturients suffered from OASIS. The baseline characteristics of the patients before and after the workshop did not differ. In the year following the workshop a significant increase in the detection rate was noted compared with the year prior to the workshop. In an interrupted time series analysis, the improved detection rate declined with time. In the last year following the workshop the detection rate declined, almost reaching the pre-workshop rate. CONCLUSIONS Attending an OASIS workshop increases the detection rate in the year following the workshop but declines gradually. To maximize its benefits, the workshop must be repeated periodically.
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Affiliation(s)
- Yael Baumfeld
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, POB 151, Beer Sheva, Israel. .,Clinical Research Center, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, Negev, Israel.
| | - David Yohay
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, POB 151, Beer Sheva, Israel
| | - Reut Rotem
- Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Affiliated with the Hebrew University Medical School of Jerusalem, Jerusalem, Israel
| | - Zehava Yohay
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, POB 151, Beer Sheva, Israel
| | - Adi Y Weintraub
- Department of Obstetrics and Gynecology, Soroka University Medical Center, Faculty of Health Sciences, Ben-Gurion University of the Negev, POB 151, Beer Sheva, Israel
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11
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Koh LM, van Roon Y, Pradhan A, Pathak S. Impact of the EPISCISSORS-60 mediolateral episiotomy scissors on obstetric anal sphincter injuries: a 2-year data review in the United Kingdom. Int Urogynecol J 2020; 31:1729-1734. [DOI: 10.1007/s00192-019-04201-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 11/25/2019] [Indexed: 12/23/2022]
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12
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The effects of a severe perineal trauma prevention program in an Australian tertiary hospital: An observational study. Women Birth 2019; 33:e371-e376. [PMID: 31537498 DOI: 10.1016/j.wombi.2019.07.301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Revised: 07/30/2019] [Accepted: 07/30/2019] [Indexed: 11/23/2022]
Abstract
BACKGROUND Severe perineal trauma during childbirth is associated with significant morbidity and rates internationally, are on the rise. AIMS To determine the impact of a prevention program on severe perineal trauma in a nulliparous population at a tertiary hospital in Australia. METHODS Routinely collected maternity data were used comparing outcomes in two time periods; two years before and two years after the introduction of the program. Categorical data were compared using the Chi Squared statistic and continuous data Student's t-test. Logistic regression examined the association between independent and dependent variables using unadjusted and adjusted odds ratios, with 95% confidence intervals and p -values with significance set at 0.05. The main outcome of interest is severe perineal trauma. RESULTS The proportion of women in this nulliparous population experiencing severe perineal trauma during vaginal birth decreased from 8.8% in the first time period to 5.6% in the second. Reductions were achieved in all modes of vaginal birth but were most pronounced in vacuum births. Rates of episiotomy increased between time periods and further analysis found that this was protective of severe perineal trauma in all modes of birth for women of Asian country of birth and only in forceps birth for non-Asian women. Factors found to contribute to severe perineal trauma in this population were Asian country of birth, neonatal weight ≥4000gm, forceps birth and maternal age. CONCLUSIONS The prevention program is associated with reduced rates of severe perineal trauma. The challenge for the service is to maintain this positive change.
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13
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A Clinical Risk Model to Predict Obstetric Anal Sphincter Injuries in Laboring Patients. Female Pelvic Med Reconstr Surg 2019; 26:520-525. [DOI: 10.1097/spv.0000000000000777] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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14
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Maimburg RD, De Vries R. Coaching a slow birth with the woman in an empowered position may be less harmful than routine hands-on practice to protect against severe tears in birth - A discussion paper. SEXUAL & REPRODUCTIVE HEALTHCARE 2019; 20:38-41. [PMID: 31084816 DOI: 10.1016/j.srhc.2019.02.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 02/04/2019] [Accepted: 02/21/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Different hands-on interventions to protect women from severe perineal tears after birth have been widely implemented. Evidence to support the routine use of hands-on interventions to reduce severe tears is mainly based on aggregated data from observational studies. AIM To critically discuss the current evidence for the implementation of hands-on intervention as a routine practice to protect women from severe tears after birth. DISCUSSION Observational studies have been used to justify the routine use of hands-on intervention to protect women from severe perineal tears despite randomized controlled trials and systematic reviews showing lack of benefit. There is strong evidence supporting the slow speed at the time of birth to prevent severe perineal tears. While hands-on intervention does reduce the speed of birth, it may have a negative effect on the birth process, on neonatal outcomes and women's agency. CONCLUSION Evidence-based practice requires sufficient evaluation of interventions before being implemented in clinical practice as well as valuing the level of evidence when making clinical decisions. Evaluation of hands-on interventions to protect women from severe perineal tears must include not just one outcome of interest, but also an assessment of how the intervention interferes with the normal mechanism of birth, and how it affects neonatal outcomes and the autonomy of women.
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Affiliation(s)
- Rikke Damkjær Maimburg
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Gynaecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark.
| | - Raymond De Vries
- Research Centre for Midwifery Science, Zuyd University, Maastricht, the Netherlands; Caphri School for Publich Health and Primary Care, Maastricht University, Maastricht, the Netherlands
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15
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Genital tract tears in women giving birth on a birth seat: A cohort study with prospectively collected data. Women Birth 2019; 33:15-21. [PMID: 30642782 DOI: 10.1016/j.wombi.2018.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 11/29/2018] [Accepted: 12/09/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Birth positions may influence the risk of tears in the genital tract during birth. Birth positions are widely studied yet knowledge on genital tract tears following birth on a birth seat is inconclusive. AIM The objective of this study was to describe the proportion of genital tract tears in women who gave birth on a birth seat compared to women who did not. METHOD An observational cohort study based on birth information collected prospectively. In total 10 629 live, singleton, non-instrumental births in cephalic presentation were studied. RESULTS Fewer women who gave birth on a birth seat experienced an overall intact genital tract compared to women who gave birth in any other position. Women who gave birth on a birth seat were less likely to have an episiotomy performed. Women who gave birth vaginally on a birth seat after a previous caesarean section may have an increased risk for sustaining a sphincter tear. DISCUSSION It is important to be aware of the decreased chance of an overall intact genital tract area when giving birth on a birth seat. Furthermore, there is a possibly increased risk of sphincter tear in women having a vaginal birth after caesarean. It is required and of importance to provide pregnant women with evidence-based information on factors associated with genital tract tears including birth positions.
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16
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Rasmussen OB, Yding A, Lauszus F, Andersen CS, Anhøj J, Boris J. Importance of Individual Elements for Perineal Protection in Childbirth: An Interventional, Prospective Trial. AJP Rep 2018; 8:e289-e294. [PMID: 30377553 PMCID: PMC6205860 DOI: 10.1055/s-0038-1675352] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Accepted: 09/14/2018] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Ole Bredahl Rasmussen
- Department of Obstetrics and Gynaecology, Herning Regional Hospital, Herning, Denmark
| | - Annika Yding
- Department of Obstetrics and Gynaecology, Herning Regional Hospital, Herning, Denmark
| | - Finn Lauszus
- Department of Obstetrics and Gynaecology, Herning Regional Hospital, Herning, Denmark
| | | | - Jacob Anhøj
- Centre of Diagnostic Investigation, University of Copenhagen, Copenhagen, Denmark
| | - Jane Boris
- Department of Obstetrics and Gynaecology, Herning Regional Hospital, Herning, Denmark
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17
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Affiliation(s)
- Mary Steen
- Professor of Midwifery, School of Nursing and Midwifery, University of South Australia
| | - Monica Diaz
- Research and clinical midwife, School of Nursing and Midwifery, University of South Australia and Women and Children's Hospital, Adelaide
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18
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Åhlund S, Rådestad I, Zwedberg S, Edqvist M, Lindgren H. Haemorrhoids - A neglected problem faced by women after birth. SEXUAL & REPRODUCTIVE HEALTHCARE 2018; 18:30-36. [PMID: 30420084 DOI: 10.1016/j.srhc.2018.08.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 08/09/2018] [Accepted: 08/14/2018] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To investigate the prevalence and severity of haemorrhoids after birth among first-time mothers in relation to management during the second stage of labour and to describe the women's experiences with haemorrhoids. METHOD A mixed method explanatory sequential design was used. Nulliparous women were allocated to an intervention group for whom the second-stage of labour practice followed the MIMA model (Midwives management during second stage of labour) or to a control group for whom standard-care practice was followed. Data were collected three weeks and 1.5 years after birth. RESULT A total of 496 (82.1%) women responded to the questionnaire three weeks after birth, 120 (70%) responded to the questionnaire 1.5 years after the birth. The women in the intervention group had fewer symptoms from haemorrhoids three weeks after birth compared to the women in the control group (adj. OR 0.6 95% CI 0.4-0.9). Half of the women in the intervention and control group (50.8%) who reported problems with haemorrhoids three weeks after birth still experienced problems after 1.5 years. The majority of all women did not seek medical care due to their symptoms. The women who described that they experienced haemorrhoids as a problem after birth felt neglected by the healthcare system. CONCLUSION A substantial percentage of women had symptoms from haemorrhoids after birth. Many of these women felt that their problems were neglected. Women who experienced a slow birth of the baby's head and spontaneous pushing suffered less from haemorrhoids 3 weeks after birth.
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Affiliation(s)
- Susanne Åhlund
- Department of Women's and Children's Health, Karolinska Institute, Sweden.
| | - Ingela Rådestad
- Department for Health Promoting Science, Sophiahemmet University, Stockholm, Sweden
| | - Sofia Zwedberg
- Department of Women's and Children's Health, Karolinska Institute, Sweden; Department for Health Promoting Science, Sophiahemmet University, Stockholm, Sweden; Department of Obstetrics, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Malin Edqvist
- Department of Women's and Children's Health, Karolinska Institute, Sweden; Department of Obstetrics, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Helena Lindgren
- Department of Women's and Children's Health, Karolinska Institute, Sweden
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Basu M, Smith D. Long-term outcomes of the Stop Traumatic OASI Morbidity Project (STOMP). Int J Gynaecol Obstet 2018; 142:295-299. [PMID: 29885253 DOI: 10.1002/ijgo.12565] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Revised: 04/07/2018] [Accepted: 06/08/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To evaluate long-term sustainability of the Stop Traumatic OASI Morbidity Project (STOMP) in reducing the incidence of obstetric anal sphincter injury (OASI). METHODS A prospective observational study of women undergoing vaginal delivery at a UK district general hospital between September 1, 2014, and February 28, 2017. The principles of STOMP involve encouraging upright positioning, verbal coaching to avoid expulsive pushing and to slow down delivery, and tactile support to the vertex to judge speed and slow down delivery. After a training period, STOMP was implemented for all vaginal deliveries. Clinical and demographic data on women affected by OASI were collected across a 30-month period. The primary outcome measure was the incidence of OASI. RESULTS There were 8782 vaginal deliveries during the 30-month period after implementation of STOMP. There was a significant decrease in the mean incidence of OASI relative to the 9 months before implementation (P<0.001). There was a significant decrease in the incidence of OASI for both spontaneous vaginal and instrumental deliveries (both P<0.05). There was no change in the frequency of episiotomy. CONCLUSIONS Implementation of STOMP led to a significant decrease in OASI, confirming the sustainability of this approach to improve outcomes.
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Affiliation(s)
- Maya Basu
- Department of Obstetrics and Gynaecology, Medway NHS Foundation Trust, Gillingham, UK
| | - Dot Smith
- Department of Obstetrics and Gynaecology, Medway NHS Foundation Trust, Gillingham, UK
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20
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Lee N, Firmin M, Gao Y, Kildea S. Perineal injury associated with hands on/hands poised and directed/undirected pushing: A retrospective cross-sectional study of non-operative vaginal births, 2011–2016. Int J Nurs Stud 2018; 83:11-17. [DOI: 10.1016/j.ijnurstu.2018.04.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 04/03/2018] [Accepted: 04/03/2018] [Indexed: 10/17/2022]
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21
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Begley C, Guilliland K, Dixon L, Reilly M, Keegan C, McCann C, Smith V. A qualitative exploration of techniques used by expert midwives to preserve the perineum intact. Women Birth 2018; 32:87-97. [PMID: 29730096 DOI: 10.1016/j.wombi.2018.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 03/29/2018] [Accepted: 04/18/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND The perineum stretches during birth to allow passage of the baby, but 85% of women sustain some degree of perineal trauma during childbirth, which is painful post-partum. Episiotomy rates vary significantly, with some countries having rates of >60%. Recent Irish and New Zealand studies showed lower severe perineal trauma and episiotomy rates than other countries. AIM To explore expert Irish and New Zealand midwives' views of the skills that they employ in preserving the perineum intact during spontaneous vaginal birth. METHODS Following ethical approval a qualitative, descriptive study was undertaken. Semi-structured, recorded, interviews were transcribed and analysed using the constant comparative method. Expert midwives employed in New Zealand and one setting in Ireland, were invited to join the study. "Expert" was defined as achieving, in the preceding 3.5 years, an episiotomy rate for nulliparous women of <11.8%, a 'no suture' rate of 40% or greater, and a severe perineal tear rate of <3.2%. Twenty-one midwives consented to join the study. RESULTS Four core themes emerged: 'Calm, controlled birth', 'Position and techniques in early second stage', 'Hands on or off?' and 'Slow, blow and breathe the baby out.' Using the techniques described enabled these midwives to achieve rates, in nulliparous women, of 3.91% for episiotomy, 59.24% for 'no sutures', and 1.08% for serious lacerations. CONCLUSIONS This study provides further understanding of the techniques used by expert midwives at birth. These findings, combined with existing quantitative research, increases the evidence on how to preserve the perineum intact during spontaneous birth.
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Affiliation(s)
- C Begley
- School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin D02 T283, Ireland; Institute of Health and Care Sciences, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - K Guilliland
- New Zealand College of Midwives, Christchurch, New Zealand
| | - L Dixon
- New Zealand College of Midwives, Christchurch, New Zealand
| | - M Reilly
- Midwife-Led Unit, Cavan General Hospital, Cavan, Ireland
| | - C Keegan
- Midwife-Led Unit, Our Lady of Lourdes Hospital, Drogheda, Ireland
| | - C McCann
- Our Lady of Lourdes Hospital, Drogheda, Ireland
| | - V Smith
- School of Nursing and Midwifery, Trinity College Dublin, 24 D'Olier Street, Dublin D02 T283, Ireland
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22
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[Anal incontinence and obstetrical anal sphincter injuries, epidemiology and prevention]. ACTA ACUST UNITED AC 2018; 46:419-426. [PMID: 29500142 DOI: 10.1016/j.gofs.2018.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Indexed: 12/11/2022]
Abstract
Our main objectives were to identify risk factors, methods for early diagnosis, and prevention of obstetric anal sphincter injuries (OASIs), using a literature review. The main risk factors for OASIs are nulliparity, instrumental delivery, posterior presentation, median episiotomy, prolonged second phase of labor and fetal macrosomia. Asian origin, short ano-vulvar distance, ligamentous hyperlaxity, lack of expulsion control, non-visualization of the perineum or maneuvers for shoulder dystocia also appear to be risk factors. There is a risk of under-diagnosis of OASIs in the labor ward. Experience of the accoucheur is a protective factor. Secondary prevention is based on the training of birth professionals in recognition and repair of OASIs. Primary prevention of OASIs is based on training in the maneuvers of the second phase of labor; if possible, instrumental extractions should be avoided. Mediolateral episiotomy may have a preventive role in high-risk OASIs deliveries. A robust predictive model is still lacking to allow a selective use of episiotomy.
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23
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Jansova M, Kalis V, Rusavy Z, Räisänen S, Lobovsky L, Laine K. Fetal head size and effect of manual perineal protection. PLoS One 2017; 12:e0189842. [PMID: 29287104 PMCID: PMC5747446 DOI: 10.1371/journal.pone.0189842] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2016] [Accepted: 12/03/2017] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The aim of this study was to evaluate whether a previously identified modification of Viennese method of perineal protection remains most effective for reduction of perineal tension in cases with substantially smaller or larger fetal heads. METHODS A previously designed finite element model was used to compare perineal tension of different modifications of the Viennese method of perineal protection to "hands-off" technique for three different sizes of the fetal head. Quantity and extent of tension throughout the perineal body during vaginal delivery at the time when the suboccipito-bregmatic circumference passes between the fourchette and the lower margin of the pubis was determined. RESULTS The order of effectiveness of different modifications of manual perineal protection was similar for all three sizes of fetal head. The reduction of perineal tension was most significant in delivery simulations with larger heads. The final position of fingers 2cm anteriorly from the fourchette (y = +2) consistently remains most effective in reducing the tension. The extent of finger movement along the anterior-posterior (y-axis) contributes to the effectiveness of manual perineal protection. CONCLUSION Appropriately performed Viennese manual perineal protection seems to reduce the perineal tension regardless of the fetal head size, and thus the method seems to be applicable to reduce risk of perineal trauma for all parturients.
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Affiliation(s)
- Magdalena Jansova
- New Technologies-Research Centre, University of West Bohemia, Pilsen, Czech Republic
| | - Vladimir Kalis
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Obstetrics and Gynecology, University Hospital, Pilsen, Czech Republic
| | - Zdenek Rusavy
- Biomedical Centre, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic.,Department of Obstetrics and Gynecology, University Hospital, Pilsen, Czech Republic
| | - Sari Räisänen
- University of Helsinki, Helsinki, Finland.,National Library of Finland, Helsinki, Finland
| | - Libor Lobovsky
- NTIS-New Technologies for Information Society, Faculty of Applied Sciences, University of West Bohemia, Pilsen, Czech Republic
| | - Katariina Laine
- Department of Obstetrics, Oslo University Hospital, Oslo, Norway
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