Déchirures périnéales obstétricales et épisiotomie : aspects techniques. RPC prévention et protection périnéale en obstétrique CNGOF

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.

Incidencia, complicaciones inmediatas y tempranas de desgarros perineales graves durante el parto en una institución de referencia de atención obstétrica en Medellín, Colombia

Introducción: los desgarros perineales severos (DPS) son complicaciones obstétricas que se presentan durante la atención del parto. Pueden desencadenar fístulas rectales e incontinencia fecal y urinaria, morbilidad a mediano y largo plazo que requiere un diagnóstico, manejo y seguimiento adecuado. Objetivo: determinar la incidencia de los DPS y las complicaciones relacionadas inmediatas −primeras 48 horas− y tempranas −primeros tres meses− posteriores a la atención del parto.Metodología: se hizo un estudio de cohorte descriptiva de pacientes con DPS durante la atención del parto en un centro de referencia de atención obstétrica en Medellín, Colombia, entre enero del 2015 y diciembre del 2017. Se revisaron las historias clínicas y se registraron los datos clínicos y las complicaciones inmediatas y tempranas en las que asistieron a cita de control de piso pélvico. Se presentan medidas descriptivas de resumen.Resultados: se atendieron 14.247 partos vaginales. La incidencia de DPS fue del 1,6 % (233/14.247), 1,3 % (184/14.267) de grado III y 0,3 % (49/14.247) de grado IV. El 66,5 % (155/233) tuvo parto vértice instrumentado, 81,9 % (191/233) episiotomía; la mediana del periodo expulsivo fue de 19 minutos (RIQ 12-35), y el 3 % (7/233) presentó distocia de hombros. Las complicaciones inmediatas en las pacientes con DPS fueron: 0,85 % (2/233) dehiscencia de sutura e infección de la herida, 0,85 % (2/233) solo dehiscencia y 0,42 % (1/233) solo infección de la herida. El 18,4 % (43/233) asistieron al control uroginecológico al tercer mes. Entre ellas, el 38,2 % (13/43) tuvo al menos una complicación, principalmente incontinencia fecal y de flatos, 16,3 % (7/43) y 13,9 % (6/43) respectivamente. Conclusiones: la incidencia de DPS y de complicaciones del posparto inmediato en la institución fueron poco frecuentes. Se deben mejorar las estrategias de seguimiento posparto mediante protocolos institucionales, con el fin de identificar y brindar un manejo oportuno de las complicaciones a mediano plazo.  

Term breech presentation vaginal births in Tibet: A retrospective analysis of 451 cases

Background

In high altitude areas, like Tibet, most fetuses in breech presentation at term are delivered vaginally owing to a variety of reasons, but this has not been published.

Objective

This study aimed to provide references and evidence for the delivery of breach presentation term fetuses in high altitude areas, through comparing and analyzing the data of full-term singleton fetuses with breech or cephalic presentation in Naqu People's Hospital, Tibet.

Study design

We retrospectively analyzed the clinical data of 451 breech presentation fetuses mentioned above over a period of 5  years (2016-2020). A total of 526 cephalic presentation fetuses' data within 3  months (1 June to 1 September 2020) of the same period were collected too. Statistics were compared and assembled on fetal mortality, Apgar scores, and severe neonatal complications for both planned cesarean section (CS) and vaginal delivery. In addition, we also analyzed the types of breech presentation, the second stage of labor, and damage to the maternal perineum during vaginal delivery.

Results

Among the 451 cases of breech presentation fetuses, 22 cases (4.9%) elected for CS and 429 cases (95.1%) elected for vaginal delivery. Of the women who chose vaginal trial labor, 17 cases underwent emergency CSs. The perinatal and neonatal mortality rate was 4.2% in the planned vaginal delivery group and the incidence of severe neonatal complications was 11.7% in the transvaginal group, no deaths were detected in the CS group. Among the 526 cephalic control groups with planned vaginal delivery, the perinatal and neonatal mortality was 1.5% (p = 0.012), and the incidence of severe neonatal complications was 1.9%. Among vaginal breech deliveries, most of them were complete breech presentation (61.17%). Among the 364 cases, the proportion of intact perinea was 45.1%, and first degree lacerations accounted for 40.7%.

Conclusion

In the Tibetan Plateau region, vaginal delivery was less safe than cephalic presentation fetuses for full-term breech presentation fetuses delivered in the lithotomy position. However, if dystocia or fetal distress can be identified in time and then encouraged to convert to cesarean, its safety will be greatly improved.

Fourth degree perineal tears: Surgical repair technique in 10 steps

Obstetrical anal sphincter injury (OASIS) may lead to significant comorbidities, including anal incontinence, rectovaginal fistula, and pain. A correct repair is required to avoid improper healing, as a persistent defect in the external anal sphincter after delivery can increase the risk of complications and worsening of symptoms following subsequent vaginal deliveries. Herein is described the surgical repair technique for a fourth degree perineal tear. Regarding resident education, there are challenges associated with the proper training in OASIS repair. The procedure is illustrated by an instructive video article that standardizes the essential steps to make the technique ergonomic and easy to perform with step-by-step explanations.

Dispareunia en mujeres después de parto vaginal. Prevalencia en dos clínicas de Armenia, Colombia, 2012-2017

Se realizó un estudio de corte transversal que tuvo como objetivo determinar la prevalencia de la dispareunia en mujeres con parto vaginal, evaluar posibles factores de riesgo y la asociación con la episiotomía. Ingresaron mujeres atendidas por parto vaginal entre 2012 y 2017 en dos clínicas de alta complejidad en Armenia (Colombia). Se utilizó el cuestionario Índice de Función Sexual Femenina (IFFS-6) para evaluar la función sexual. Los resultados reportan una prevalencia de dispareunia del 59,37%, siendo más prevalente en mujeres sometidas a episiotomía (OR: 68,17; IC95 %: 60,57-79,15). Respecto a la asociación de la episiotomía con la presencia de dispareunia se encontró asociación significativa con la episiotomía medio-lateral (OR: 8,17; IC95%: 2,15-56,32), lesión del esfínter (OR: 7,32; IC95%: 4,86-12,75) y dehiscencia de la sutura (OR: 6,48; IC95%: 4,92-14,28). Se observaron como factores de riesgo: antecedente de endometriosis (OR: 11,6; IC95 %: 9,15-17,52), dolor pélvico crónico (OR: 3,56; IC95%: 2,21–6,32) e ITS (OR: 2,67; IC95%: 1,54–5,14), p=0,003). Se concluye que la prevalencia de dispareunia en mujeres con parto vaginal, atendidas en Armenia, varía en función de la realización de episiotomía, asociándose tanto a las complicaciones de esta como a otros antecedentes.