[Definition, epidemiology and risk factors of obstetric anal sphincter injuries: CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]

In vitro biomechanical properties of porcine perineal tissues to better understand human perineal tears during delivery

INTRODUCTION

Data concerning the mechanical properties of the perineum during delivery are very limited. In vivo experiments raise ethical issues. The aim of the study was to describe some of the biomechanical properties of each perineal tissue layer collected from sows in order to better understand perineal tears during childbirth.

MATERIAL AND METHODS

Samples of each perineal tissue layer were obtained from the skin, the vagina, the external anal sphincter (EAS), the internal anal sphincter (IAS), and the anal mucosa of fresh dead sows. They were tested in quasi-static uniaxial tension using the testing machine Mach-1®. Tests were performed at a displacement velocity of 0.1 mm·s-1. Stress-strain curves of each perineal tissue layer before the first damage for each sow were obtained and modeled using a hyperelastic Yeoh model described by three coefficients: C1, C2, and C3. Pearson correlation coefficients were calculated to measure the correlation between the C1 hyperelastic coefficient and the duration between the first microfailure and the complete rupture for each perineal tissue layer. Pearson correlation was computed between C1 and the number of microfailures before complete rupture for each tissue.

RESULTS

Ten samples of each perineal tissue layer were analyzed. Mean values of C1 and corresponding standard deviations were 46 ± 15, 165 ± 60, 27 ± 10, 19 ± 13, 145 ± 28 kPa for the perineal skin, the vagina, the EAS, the IAS, and the anal mucosa, respectively. According to this same sample order, the first microfailure in the population of 10 sows appeared at an average of 54%, 27%, 70%, 131%, and 22% of strain. A correlation was found between C1 hyperelastic coefficient and the duration between the first microfailure and the complete rupture (r = 0.7, p = 0.02) or the number of microfailures before complete rupture only for the vagina (r = 0.7, p = 0.02).

CONCLUSIONS

In this population of fresh dead sow's perineum, the vagina and the anal mucosa were the stiffest tissues. The IAS and EAS were more extensible and less stiff. A significantly positive correlation was found between C1 and the duration between the first microfailure and the complete rupture of the vagina, and the duration between the first microfailure and the complete rupture of the vagina.

Vascular Ehlers-Danlos syndrome and pregnancy: A systematic review

BACKGROUND

Vascular Ehlers-Danlos syndrome (vEDS) is a hereditary connective tissue disorder associated with an elevated risk of vascular, uterine and digestive complications. Managing pregnancy in this context can be a challenge.

OBJECTIVES

To systematically review the literature data on the complications in pregnancy associated with vEDS.

SEARCH STRATEGY

We searched the Pubmed Medline and Embase databases for articles using the following terms "vascular Ehlers-Danlos syndrome" or "vEDS" AND "pregnancy".

SELECTION CRITERIA

Women with vEDS.

DATA COLLECTION AND ANALYSIS

We searched the PubMed® MEDLINE® database for publications evaluating obstetric outcomes in women with vEDS.

MAIN RESULTS

A total of 121 publications were screened, with six (accounting for 412 pregnancies) included in our review. Of the women included in this sample, 30% were infertile. The miscarriage rate was 13.8% (57/412) and 8.8% of the live births were premature. Obstetric anal sphincter injuries occurred in 11.3% (23/203) of the deliveries. The maternal mortality rate per pregnancy was 5.7%.

CONCLUSIONS

Women with vEDS present an elevated risk of uterine rupture, vascular events, digestive events and death during pregnancy. Women appear to be most at risk during the peripartum period; to avoid expulsive efforts, a caesarean section should be scheduled at 37 weeks of gestation.

Influence of in utero fetal death on perineal tears in vaginal deliveries

The aim of this work was to evaluate and compare the incidence of perineal tears and Obstetrical anal sphincter injuries (OASIS) after vaginal delivery following a in utero fetal death (IUFD) compared with those with a live-birth. We conducted a single-center, retrospective cohort study using a database of all women who underwent a spontaneous vaginal delivery in the level III maternity ward. Exclusion criteria were breech presentation, cesarean section birth, instrumental delivery, multiple pregnancy, delivery before 24 + 6 weeks of gestation (WG) and termination of pregnancy for medical reasons. Women from the database were divided into two groups: an "in utero fetal death" (IUFD) group and a control group. Women were included in the IUFD group if they had a spontaneous vaginal delivery following a fetal demise after 24 + 6 WG in cephalic presentation between January 2006 and June 2020. Women in the "control" group were selected from the same database and were included if they underwent a spontaneous vaginal delivery of a live fetus in cephalic presentation, after 24 + 6 WG, during the same period. Each woman in the "IUFD" group was matched to two women (ratio 1:2) in the control group for parity, maternal age, body mass index, gestation and birth weight. The primary outcome was the presence of a sutured or unsutured perineal tear. During the study period, 31,208 patients delivered at a level III maternity hospital. Among them, 215 and 430 women were included in the IUFD group and the control group respectively. The two groups were comparable for all demographic and clinical characteristics except for an epidural analgesia (92% versus 70% in the control group, p < 0.01) and labor induction (86% versus 17% in the control group, p < 0.01). The incidence of any perineal tears was 13% (28/15) in the IUFD group versus 16% (70/430) in the control group. Relative risk of any perineal tears was non significative (RR = 0.8 IC95% [0.5-1.2]). The incidence of first-degree perineal tears was 10% in the IUFD group and 11% in the control group. The incidence of second-degree perineal tears was 18% in the IUFD group and 28% in the control group. Relative risk of first-degree perineal tears (RR = 0.88 95% CI [0.5-1.4]) and second-degree tears (RR = 0.51 95% CI [0.2-1.4]) were non significative. No obstetrical anal sphincter injury was found in either group. Vaginal delivery following a fetal demise did not appear to be either a risk factor or a protective factor for perineal tears. But there as a trend toward a lower incidence of second degree perineal tears in this context.

Incidence of obstetric anal sphincter injuries following breech compared to cephalic vaginal births

INTRODUCTION

Obstetric anal sphincter injuries (OASIs) at the time of childbirth can lead to serious consequences including anal incontinence, dyspareunia, pain and rectovaginal fistula. These types of lesions and their incidence have been well studied after cephalic presentation deliveries, but no publications have specifically addressed this issue in the context of vaginal breech delivery. The goal of our study was to evaluate the incidence of OASIs following breech deliveries and compare it with cephalic presentation births.

METHODS

This was a retrospective cohort study involving 670 women. Of these, 224 and 446 had a vaginal birth of a fetus in the breech (breech group) and cephalic (cephalic group) presentations respectively. Both groups were matched for birthweight (± 200 g), date of delivery (± 2 years) and vaginal parity. Main outcome of interest was to evaluate the incidence of OASIs following breech vaginal birth compared to cephalic vaginal births. Secondary endpoints were the incidence of intact perineum or first-degree tear, second-degree perineal tear and rates of episiotomies in each group.

RESULTS

There was no statistically significant difference in OASIs incidence between the breech and cephalic groups (0.9% vs. 1.1%; RR 0.802 (0.157; 4.101); p = 0.31). There were more episiotomies in the breech group (12.5% vs. 5.4%, p = 0.0012) and the rate of intact or first-degree perineum was similar in both groups (74.1% vs. 75.3%, p = 0.7291). A sub-analysis excluding patients with episiotomy and history of OASIs did not show any statistically significant difference either.

CONCLUSION

We did not demonstrate a significant difference in the incidence of obstetric anal sphincter injuries between women who had a breech vaginal birth compared to cephalic.

Is there still an indication for episiotomy? Results from a French national database analysis

OBJECTIVE

To assess the link between mediolateral episiotomy and the occurrence of obstetrical anal sphincter injury (OASIS).

METHODS

Data were collected from the national database (PMSI; Programme de Médicalisation des Systèmes d'Information). Women between 18 and 50 years old, undergoing a vaginal delivery in France in 2018 were included. The main outcome was factors associated with a higher adjusted OASIS rate after a vaginal delivery.

RESULTS

Of 623 003 women with a vaginal delivery, 239 949 were primiparous (38.5%), 62 310 experienced mediolateral episiotomy (10.0%) and 7077 had a third- or fourth-degree perineal tear (1.14%). Risk factors for OASIS were primiparity (adjusted odds ratio [OR] 2.97), shoulder dystocia (aOR 2.57), instrumental delivery (aOR 2.81), gestational diabetes (aOR 1.20), and post-term delivery (aOR 1.53). Mediolateral episiotomy increased the occurrence of OASIS for women without an instrumental delivery, either for parous (OR 1.32, 95% confidence interval [CI] 1.07-1.62) or primiparous (OR 1.26, 95% CI 1.13-1.39) women. In contrast, episiotomy among primiparous women with episiotomy and a vacuum or forceps delivery significantly decreased the risk for OASIS (OR 0.62, 95% CI 0.56-0.67).

CONCLUSIONS

The practice of routine episiotomy should be discouraged. Selective mediolateral episiotomy should be considered with extreme caution and mainly for primiparous women during instrumental vaginal delivery. Further randomized trial may confirm such results.

Comparing male and female pelvic floor muscle function by the number and type of pelvic floor symptoms

AIMS

Pelvic floor symptoms (PFS), including lower urinary tract symptoms, defecation problems, sexual dysfunction, and pelvic pain, are common in males and females. Comparing pelvic floor musculature (PFM) function between sexes may reveal important differences relevant to clinical care. This study aimed to compare male and female PFM function and to assess the function of both sexes with the number and type of PFS.

METHODS

We purposively enrolled males and females aged ≥ 21 years with 0-4 PFS based on questionnaire responses in an observational cohort study. Participants then underwent PFM assessment, and muscle function in the external anal sphincter (EAS) and puborectal muscle (PRM) were compared between sexes. The relationships between muscle function and the number and type of PFS were explored.

RESULTS

Of the invited 400 males and 608 females, 199 and 187 underwent PFM assessment, respectively. Compared with females, males more often showed increased EAS and PRM tone during assessments. Compared with males, females more often showed weaker maximum voluntary contraction (MVC) of the EAS and dysfunctional endurance of both muscles; additionally, those with zero or one PFS, sexual dysfunction, and pelvic pain more often showed a weak MVC of the PRM.

CONCLUSIONS

Despite a few similarities between males and, females we found differences in muscle tone, MVC, and endurance between male and female PFM function. These findings provide useful insights into the differences in PFM function between males and females.

Understanding Healthcare-Seeking Pathways and Dilemmas Among Women with Obstetric Fistulas in Ethiopia: A Qualitative Inquiry

Background

Obstetric fistula is a public health problem with a damaging effect on the health of women around the world. The path to medical care is an integral part of women's experience of illness that may have an impact on their health. Studies have addressed the experiences of patients after fistula repair, but fistula victims' care-seeking pathways and dilemmas are still poorly understood in low-income countries, particularly Ethiopia.

Objective

This study aimed to explore the care-seeking pathways and dilemmas among women with fistulas in Ethiopia.

Methods

An exploratory phenomenological study was carried out from April 1 to August 1, 2019, through in-depth interviews and supplementary informant interviews. Data were obtained from 21 purposively selected women with fistulas who survived with morbidity for one and more years and 12 supplementary interviewees at fistula treatment centers in Oromia Region and Addis Ababa. Data were analyzed assisted by ATLAS. ti 8.4 software.

Results

Respondents gave their testimony that most of the women with fistulas first sought care from traditional care places and finally from fistula treatment centers. The reasons for care-seeking path dilemmas were a wrong perception about fistula, its causes, and treatment; families' pressure and lack of decision-making power on where to seek treatment, and a lack of knowledge on where modern treatments are available for fistula. They received psychological, companionship, and transport support from a family and a community; referral and counseling support from health care providers during their care-seeking pathways.

Conclusion

A myriad of reasons inhibits the right care-seeking pathways among women with fistulas. Communities and women with fistula awareness creation on the right places for fistula treatment and psychological support programs are required. Additionally, developing and implementing tactics for community-level screening programs for targeted victims and early admission to treatment centers can minimize the tragic sequela of the fistula.

Impact of fetal manipulation on maternal and neonatal severe morbidity during shoulder dystocia management

PURPOSE

There are few data on maternal and neonatal morbidities associated with shoulder dystocia (SD), depending on the use of fetal manipulation (FM). A prior 5-year study was conducted in our center in 2012 for this purpose. Our objective was to compare severe maternal and neonatal morbidities according to FM execution in a larger cohort.

METHODS

We conducted a retrospective study between 2007 and 2020. SD was considered when additional maneuvers were required to complete a delivery. Severe maternal morbidity was defined as the occurrence of obstetric anal sphincter injury (OASI). Severe neonatal morbidity was defined as Apgar < 7 at 5 min and/or cord arterial pH < 7.1 and/or or a permanent brachial plexus palsy. We studied these data in the FM group compared to the non- FM group.

RESULTS

FM was associated with increased OASI rates (21.1% vs. 3.8%, OR = 6.72 [2.7-15.8]). We found no significant difference in severe neonatal morbidity. Maternal age > 35 and FM appear to be associated with the occurrence of OASI, with ORa = 13.3 [1.5-121.8] and ORa = 5.3 [2.2-12.8], respectively. FM was the only factor associated with the occurrence of severe neonatal morbidity (ORa = 2.3 [1.1-4.8]. The rate of episiotomy was significantly decreased (20% versus 5% p < 0.05) and there was an increase in the rate of SD managed with FM in our center.

CONCLUSION

FM is the only factor associated with an increased risk of OASI. In case of failure of non-FM maneuvers, the rapid implementation of FM maneuvers resulted in no difference regarding severe neonatal morbidity.

Incidence and risk factors for secondary failure after acute obstetric sphincter injury repair - an audit of 239 women

AIM

The rate of secondary failure after obstetric sphincter injury repair is unknown, with the literature reporting rates ranging from 0.1% to 53%. We aimed to perform an audit to identify the rate and risk factors for failure of sphincter repair in a cohort of postpartum women using endoanal ultrasound (EAUS) and manometry, assessing the risk factors and impact of these events.

METHOD

Prospective data were collected within a 2 year period from patients who attended the perineal clinic at Eastern Health. Variables of primary repair and presence of postpartum complications were recorded and subsequently analysed.

RESULTS

Of 239 patients with obstetric anal sphincter injury (OASI) included, 100 (41.8%) had EUAS evidence of sphincter defects. Only 20% with secondary repair failure were symptomatic with faecal or flatal incontinence at a mean follow-up of 23.4 months postpartum. Patients with secondary repair failure had lower anal resting (p = 0.006) and maximum squeeze pressures compared with patients with intact repairs (p < 0.001). In terms of variables that were investigated, namely location, operator hierarchy, type of repair and material used, none had a statistically significant correlation with secondary repair failure of OASI. Postpartum complications had an overall incidence of 12.7%, and those with any complication were found to have an increased rate of secondary failure of repair (p = 0.157).

CONCLUSION

Using EAUS to confirm secondary failure of repair, incidence was 41.4% in this cohort. There were no identifiable modifiable variables that reduced the risk of secondary failure of repair. Further prospective research with increased sample size and longer follow-up periods is required to assess the validity of the findings.

Body mass index and complications after obstetric anal sphincter injury, 8 weeks postpartum

INTRODUCTION AND HYPOTHESIS

The impact of body mass index (BMI) on pelvic floor recovery after an obstetric anal sphincter injury (OASI) is unclear. The aim of this study was to evaluate the hypothesis that urinary incontinence (UI) and anal incontinence (AI) are more common in overweight and obese women than in normal-weight women 8 weeks postpartum in women with OASI.

METHODS

A population-based cohort study including 6,595 primiparous women, with an OASI, delivered between 2014 and 2019. Exposure and questionnaire data were retrieved from the Swedish Perineal Laceration Registry. Uni- and multivariate analyses were used to compare normal-weight (BMI ≤24.9, reference), overweight (25.0-29.9), and obese (≥ 30) women with regard to UI and AI at 8 weeks post-partum.

RESULTS

Multivariate analyses showed an increased risk for urinary incontinence (OR 1.54, 95% CI 1.27-1.87) among overweight women as well as among obese women (OR 1.72, 95% CI 1.32-2.24). In contrast to our hypothesis, both overweight women (OR 0.68, 95% CI 0.56-0.83) and obese women (OR 0.65, 95% CI 0.49-0.87) were at a decreased risk for any gas and/or faecal incontinence after adjustment to possible confounding factors. The absolute rate of AI was 40.1% among normal-weight women, 34.2% among overweight women, and 29.1% in the obese group.

CONCLUSIONS

Urinary incontinence is more common, whereas AI is less common among overweight and obese women than in primiparous women with a BMI <24.9, 8 weeks after an OASI. The new finding, that overweight women report less AI than normal-weight women, merits further study.

Obstetrical anal sphincter injury and unnecessary episiotomy are both associated with anal incontinence 8 years after childbirth: A nationwide database analysis

OBJECTIVE

to assess the relationship between anal incontinence (AI) 8 years after childbirth and the occurrence of Obstetrical Anal Sphincter Injury (OASI) and/or performance of an episiotomy during childbirth.

METHODS

This is a nationwide database analysis performed on two national medico-administrative databases, including all the women aged ≥18 years who delivered infants in France in 2012. The main outcome measure was AI in the 8-years after delivery.

RESULTS

Of the 163,443 perineal tears reported, 0.47% were grade-3 and 0.08% were grade-4; 8,938 women experienced AI (1.33%) and 261 women experienced severe AI (0.04%). Episiotomies performed in the absence of risk factors for OASI were significantly associated with an increased risk of AI (Odds Ratio (OR)=1.59; 95% Confidence Interval (CI):1.49-1.69;p<0.001). Grade 3 and 4 OASI also significantly increased the risk of AI and severe AI. Mediolateral episiotomy was preventative of OASI when performed in subjects at risk (OR=0.26; 95% CI:0.23-0.30; p<0.001) but contributed to OASI in the absence of risk (OR=2.18; 95% CI:1.98-2.40; p<0.001).

CONCLUSIONS

OASI is a risk factor for AI. Episiotomies could reduce the occurrence of OASI, but they could also have a increase the risk of long-term AI in the absence of risk factors for OASI.

Influence of a Virtual Exercise Program throughout Pregnancy during the COVID-19 Pandemic on Perineal Tears and Episiotomy Rates: A Randomized Clinical Trial

The complications associated with COVID-19 confinement (impossibility of grouping, reduced mobility, distance between people, etc.) influence the lifestyle of pregnant women with important associated complications regarding pregnancy outcomes. Therefore, perineal traumas are the most common obstetric complications during childbirth. The aim of the present study was to examine the influence of a supervised virtual exercise program throughout pregnancy on perineal injury and episiotomy rates during childbirth. A randomized clinical trial design (NCT04563065) was used. Data were collected from 98 pregnant women without obstetric contraindications who attended their prenatal medical consultations. Women were randomly assigned to the intervention (IG, N = 48) or the control group (CG, N = 50). A virtual and supervised exercise program was conducted from 8-10 to 38-39 weeks of pregnancy. Significant differences were found between the study groups in the percentage of episiotomies, showing a lower episiotomy rate in the IG (N = 9/12%) compared to the CG (N = 18/38%) (χ² (3) = 4.665; p = 0.031) and tears (IG, N = 25/52% vs. CG, N = 36/73%) (χ² (3) = 4.559; p = 0.033). A virtual program of supervised exercise throughout pregnancy during the current COVID-19 pandemic may help reduce rates of episiotomy and perineal tears during delivery in healthy pregnant women.

Prevalence of Perineal Tear Peripartum after Two Antepartum Perineal Massage Techniques: A Non-Randomised Controlled Trial

Perineal massage increases elasticity of myofascial perineal tissue and decreases the burning and perineal pain during labour, thus optimising child birth, although an application protocol has not been standardised yet. The objective of this study is to determine the efficiency of massage in perineal tear prevention and identification of possible differences in massage application. Total of 90 pregnant participants were divided into three groups: perineal massage and EPI-NO^® device group, applied by an expert physiotherapist, self-massage group, where women were instructed to apply perineal massage in domestic household, and a control group, which received ordinary obstetric attention. Results: The results showed significant differences among the control group and the two perineal massage groups in perineal postpartum pain. Correlations in perineal postpartum pain, labour duration and the baby's weight were not statistically significant. Lithotomy posture was significantly less prevalent in the massage group than in the other two; this variable is known to have a direct effect on episiotomy incidence and could act as a causal covariate of the different incidence of episiotomy in the groups. Perineal massage reduces postpartum perineal pain, prevalence and severity of perineal tear during delivery.

Stapled transperineal repair for low- and mid-level rectovaginal fistulas: A 5-year experience and comparison with sutured repair

BACKGROUND

Currently, rectovaginal fistula (RVF) continues to be a surgical challenge worldwide, with a relatively low healing rate. Unclosed intermittent suture and poor suture materials may be the main reasons for this.

AIM

To evaluate the efficacy and safety of stapled transperineal repair in treating RVF.

METHODS

This was a retrospective cohort study conducted in the Coloproctology Department of The Sixth Affiliated Hospital of Sun Yat-sen University (Guangzhou, China). Adult patients presenting with RVF who were surgically managed by perineal repair between May 2015 and May 2020 were included. Among the 82 total patients, 37 underwent repair with direct suturing and 45 underwent repair with stapling. Patient demographic data, Wexner faecal incontinence score, and operative data were analyzed. Recurrence rate and associated risk factors were assessed.

RESULTS

The direct suture and stapled repair groups showed similar clinical characteristics for aetiology, surgical history, fistula features, and perioperative Wexner score. The stapled repair group did not show superior results over the suture repair group in regard to operative time, blood loss, and hospital stay. However, the stapled repair group showed better postoperative Wexner score (1.04 ± 1.89 vs 2.73 ± 3.75, P = 0.021), less intercourse pain (1/45 vs 17/37, P = 0.045), and lower recurrence rate (6/45 vs 17/37, P = 0.001). There was no protective effect from previous repair history, smaller diameter of fistula (< 0.5 cm), better control of defecation (Wexner < 10), or stapled repair. Direct suture repair and preoperative high Wexner score (> 10) were risk factors for fistula recurrence. Furthermore, stapled repair gave better efficacy in treating complex RVFs (i.e., multiple transperineal repair history, mid-level fistula position, and poor control of defecation).

CONCLUSION

Stapled transperineal repair is advantageous for management of RVF, providing a high primary healing rate and low recurrence rate.

Effects of Fourth-Degree Perineal Lacerations on Women's Physical and Mental Health

OBJECTIVE

To describe the physical and emotional effects of fourth-degree perineal lacerations that occur during childbirth.

DESIGN

Descriptive phenomenology.

SETTING

Internet survey.

PARTICIPANTS

Eighteen women from the United States, the United Kingdom, Australia, and Canada who sustained fourth-degree perineal lacerations during childbirth.

METHODS

Women were recruited from the Facebook support group Mothers With 4th Degree Tears. Participants were asked to describe the physical and emotional effects of these severe birth injuries on their daily lives. I analyzed these data using Colaizzi's method for phenomenological analysis.

RESULTS

The devastating effects of these birth-related injuries permeated all aspects of the lives of participants. Participants did not receive adequate information about their perineal lacerations, and clinicians often dismissed their concerns. Some participants struggled with postpartum depression and posttraumatic stress disorder. I identified seven themes that described the effects of fourth-degree perineal lacerations: Why Wasn't I Informed I Had This Injury?; The Unthinkable: Fecal Incontinence and So Much More; It Has Cost Me So Much; Seeking Relief: Enduring Surgery After Surgery; Why Didn't Anyone Ask Me About My Mental Health?; To Have More Children, That Is The Question; And Are there Any Positives In All Of This?

CONCLUSION

Women need information to prepare for recovery from their severe perineal injuries related to what to expect, how to care for themselves, and what resources are available. Clinicians have a responsibility to provide a caring environment in which women feel safe to disclose any problems they are experiencing as a result of their perineal injuries. Little, if any, attention is focused on women's mental health by clinicians or researchers as women struggle with the aftermath of fourth-degree perineal lacerations.

Establishing a peripartum perineal trauma clinic: a narrative review

INTRODUCTION AND HYPOTHESIS

Obstetric anal sphincter injury (OASI) is not rare, and its consequences are multiple and potentially severe, especially for young women. Some dedicated perineal clinics have been established to improve the management of OASI. Despite their obvious importance, these specific clinics are underrepresented and underdeveloped. The objectives of this review are to explore various options for developing a peripartum perineal clinic and to compare the different practices regarding the mode of delivery for subsequent pregnancies after an OASI.

METHODS

This narrative review covers information from patients' questionnaires specific to anal incontinence, anal physiology assessment, pelvic floor and anal sphincter imaging, and the arguments for choosing the mode of delivery after an OASI.

RESULTS

This review highlights the extensive range of practices regarding the delivery mode after an OASI throughout national professional organizations and experienced perineal clinics.

CONCLUSION

This review summarizes the different choices in developing a perineal clinic to facilitate their development in promoting health care and education specific for peripartum women concerning the perineal consequences of delivery for obstetrician-gynaecologists, family doctors, and residents.

Physiotherapy for Prevention and Treatment of Fecal Incontinence in Women-Systematic Review of Methods

Fecal incontinence (FI) affects approximately 0.25-6% of the population, both men and women. The most common causes of FI are damage to/weakness of the anal sphincter muscle and/or pelvic floor muscles, as well as neurological changes in the central or peripheral nervous system. The purpose of this study is to report the results of a systematic review of the possibilities and effectiveness of physiotherapy techniques for the prevention and treatment of FI in women. For this purpose, the PubMed, Embase, and Web of Science databases were searched for 2000-2020. A total of 22 publications qualified for detailed analysis. The studies showed that biofeedback (BF), anal sphincter muscle exercises, pelvic floor muscle training (PFMT), and electrostimulation (ES) are effective in relieving FI symptoms, as reflected in the International Continence Society recommendations (BF: level A; PFMT and ES: level B). Research has confirmed that physiotherapy, by improving muscle strength, endurance, and anal sensation, is beneficial in the prevention of FI, both as an independent method of conservative treatment or in pre/post-surgery treatment. Moreover, it can significantly improve the quality of life of patients. In conclusion, physiotherapy (in particular, BF, PFMT, or ES, as effective methods) should be one of the key elements in the comprehensive therapy of patients with FI.

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

INTRODUCTION AND HYPOTHESIS

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

PURPOSE

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

METHODS

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

FINDINGS

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

RESULTS AND CONCLUSIONS

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

The impact of active delivery of the anterior arm during vacuum-assisted vaginal delivery on perineal tears: a clinical practice evaluation

Objective: Our purpose was to evaluate the impact of active delivery of the anterior arm with Couder's Maneuver (CM) during vacuum-assisted vaginal delivery (VAVD) on perineal tears. This maneuver can be beneficial because it has the advantage of reducing fetal biacromial diameter.Methods: This monocentric retrospective study compared two non-concurrent cohorts of nulliparous women before and after implementation of a systematic CM during VAVD: Cohort 1 from 1 January to 31 December 2006 without CM and Cohort 2 from 1 January to 31 December 2016 with systematic CM. This study reviewed all births during these two periods. All live-born singleton pregnancies where VAVD occurred after 37 weeks of gestation were included. The principal endpoint was the type of perineal tear.Results: In total, there were 179 VAVD in the Cohort 1 and 267 VAVD in the Cohort 2. In the Cohort 2, 233 VAVD (87.3%) were performed with systematic CM. No episiotomy was performed in both cohorts. There was a significant decrease in the rate of second-degree perineal tears between the two cohorts (42.4 versus 15%, p < .001) and a significant increase in the rate of intact perineum (34.1 versus 54.7%, p < .001). There was no influence of CM on the rate of obstetrical anal sphincter injury (3.9 versus 2.6%, p = .44).Conclusions: Practicing this maneuver could improve the perineal prognosis during VAVD in nulliparous women.