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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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Vu DH, Ta BTT, Aasen IL, Le DQT, Mathisen R, Becker GE, Phan HT, Bui CM, Nguyen TTK, Hoang STT, Cashin J. Promoting Respectful Maternity Care by Reducing Unnecessary Episiotomies: Experiences from Centers of Excellence for Breastfeeding in Vietnam. Healthcare (Basel) 2023; 11:2520. [PMID: 37761718 PMCID: PMC10530948 DOI: 10.3390/healthcare11182520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 08/31/2023] [Accepted: 09/06/2023] [Indexed: 09/29/2023] Open
Abstract
(1) Background: Routine episiotomy is not recommended by international guidelines; however, it occurs at a high rate in Vietnam. (2) Methods: A process to reduce unnecessary episiotomies was developed and implemented as part of the Centers of Excellence for Breastfeeding initiative, which aims to deliver high-quality breastfeeding and early essential newborn care services within a supportive policy environment. The aim of this project report is to outline the steps undertaken to reduce episiotomies, the experience in pilot hospitals, and the process towards changing policy. (3) Results: During the 14 months following the change in episiotomy policy, pilot hospital records showed no infant death or injury. Monthly monitoring data from four pilot hospitals showed that the prevalence of episiotomy was substantially lower than the average in national hospitals in Vietnam. Facilitators to reducing the episiotomy rate include the incentive of Centers of Excellence for Breastfeeding designation and supportive hospital leadership. Challenges include the ambiguity of Vietnam's national guideline on episiotomy and lack of routine monitoring on the episiotomy rate and indications. (4) Discussion: Our experience suggests that through training and routine monitoring hospitals can apply a policy of selective episiotomy and reduce the practice, particularly among multiparous women, and improve breastfeeding rates.(5) Conclusions: Sharing our experience of implementing this process and offering four areas for action will hopefully contribute to expanded use of mother-friendly, evidence-based care as policy and routine practice in Vietnam and similar settings.
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Affiliation(s)
- Duong Hoang Vu
- Alive & Thrive East Asia Pacific, FHI Solutions, Hanoi 11022, Vietnam (R.M.)
| | - Binh T. T. Ta
- Alive & Thrive East Asia Pacific, FHI Solutions, Hanoi 11022, Vietnam (R.M.)
| | - Ina Landau Aasen
- Norwegian Institute of Public Health (NIPH), N-0473 Oslo, Norway
| | - Dai Q. T. Le
- Alive & Thrive East Asia Pacific, FHI Solutions, Hanoi 11022, Vietnam (R.M.)
| | - Roger Mathisen
- Alive & Thrive East Asia Pacific, FHI Solutions, Hanoi 11022, Vietnam (R.M.)
| | | | - Hang Thi Phan
- Hung Vuong Hospital, Ho Chi Minh City 72700, Vietnam
| | - Cuong Minh Bui
- Quang Ninh Obstetrics and Pediatrics Hospital, Ha Long City 01100, Vietnam
| | | | | | - Jennifer Cashin
- Alive & Thrive East Asia Pacific, FHI Solutions, Washington, DC 20037, USA
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Levaillant M, Loury C, Venara A, Hamel-Broza JF, Legendre G. Is there still an indication for episiotomy? Results from a French national database analysis. Int J Gynaecol Obstet 2023; 160:880-885. [PMID: 35942710 DOI: 10.1002/ijgo.14385] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 07/07/2022] [Accepted: 07/28/2022] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Mathieu Levaillant
- Univ. Lille, CHU Lille, ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Lille, France.,Methodology and Biostatistics Department, Angers University Hospital, University of Angers, Angers, France
| | - Charlotte Loury
- Faculté de Santé, Département de Médecine, Angers, France.,Service de gynécologie-Obstétrique, CHU d'Angers, Angers, France
| | - Aurélien Venara
- Faculté de Santé, Département de Médecine, Angers, France.,Service de chirurgie digestive, CHU d'Angers, Angers, France.,UMR_S1085, University of Angers, CHU Angers, University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail), Angers, France
| | - Jean-François Hamel-Broza
- Methodology and Biostatistics Department, Angers University Hospital, University of Angers, Angers, France.,Faculté de Santé, Département de Médecine, Angers, France.,Service de chirurgie digestive, CHU d'Angers, Angers, France.,UMR_S1085, University of Angers, CHU Angers, University of Rennes, Inserm, EHESP, Irset (Institut de Recherche en Santé, Environnement et Travail), Angers, France
| | - Guillaume Legendre
- Faculté de Santé, Département de Médecine, Angers, France.,Service de gynécologie-Obstétrique, CHU d'Angers, Angers, France
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Perrin A, Korb D, Morgan R, Sibony O. Effectiveness of episiotomy to prevent OASIS in nulliparous women at term. Int J Gynaecol Obstet 2023. [PMID: 36728572 DOI: 10.1002/ijgo.14706] [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: 08/30/2022] [Revised: 01/26/2023] [Accepted: 02/01/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the association between episiotomy and severe obstetric anal sphincter injury (OASIS) in nulliparous women at term according to the use of an instrument for delivery with control confounding by indication. METHODS This was an observational retrospective cohort study including 12 346 women from 2004 to 2020. All nulliparous women with a cephalic singleton pregnancy were included. The primary outcome was the occurrence of OASIS. Association between episiotomy and OASIS was assessed by multivariate logistic regression with adjustment for confounding factors and stratification on the use of an instrument at delivery. Propensity score matching was used to account for indication bias. RESULTS Among 12 346 women included, 7803 (63.2%) had an episiotomy and 4543 (36.8%) did not have an episiotomy; the rate of OASIS was similar in both groups (0.7%). After stratification on use of instrument, an association between episiotomy and OASIS was shown in the case of instrumental delivery (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.26-0.80) but not if the delivery was spontaneous (OR 0.76, 95% CI 0.29-1.98). The result was similar after matching on propensity score (in the case of operative vaginal delivery: OR 0.20, 95% CI 0.10-0.75). CONCLUSION Episiotomy seems to be a protective factor for OASIS in nulliparous woman at term only in the case of operative vaginal delivery.
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Affiliation(s)
- Antoine Perrin
- Department of Obstetrics and Gynecology, Robert Debré Hospital, APHP, Paris, France
| | - Diane Korb
- Department of Obstetrics and Gynecology, Robert Debré Hospital, APHP, Paris, France.,Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, University Paris Cité, Paris, France
| | - Rosemary Morgan
- Department of Obstetrics and Gynecology, Robert Debré Hospital, APHP, Paris, France
| | - Olivier Sibony
- Department of Obstetrics and Gynecology, Robert Debré Hospital, APHP, Paris, France
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Morgan R, Korb D, Sibony O. Classification and evaluation of episiotomy practices from 2004 to 2020 and association with OASIS. Int J Gynaecol Obstet 2022; 159:237-245. [PMID: 34995361 DOI: 10.1002/ijgo.14091] [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: 10/05/2021] [Revised: 12/16/2021] [Accepted: 01/06/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To apply a new classification based on 7 clinically relevant subgroups to accurately describe episiotomy practices and evaluate the association between episiotomy and obstetrical anal sphincter injuries (OASIS) rates according to the classification's subgroups. METHODS Observational retrospective cohort study based on a population comprising 39487 women from 01/01/2004 to 31/12/2020 in a level III university maternity unit. The primary outcome was the overall episiotomy rate in the institution, its trend over the time as well as in each subgroup of obstetric population classification. Secondary outcome was the rate of OASIS third and fourth degree, its association with episiotomy practice. RESULTS The episiotomy rate decreased significantly from 43,2% to 20% in the total population. The overall OASIS rate was 0,34%, it remained significantly the same during the study period, although the association between OASIS and episiotomy was significant only in group 2 (Nulliparous with instrumental delivery) with a decrease of OASIS rate if using episiotomy (OR 0.5; 95% CI[0,3-0,8]). CONCLUSION The episiotomy rate can be decreased without exposing women to an increased risk of OASIS. It encourages restrictive practice of episiotomy, but episiotomy should be considered in case of nulliparous women with instrumental delivery.
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Affiliation(s)
- Rosemary Morgan
- Department of Obstetrics and Gynecology, Robert Debré Hospital, APHP, Paris, France
| | - Diane Korb
- Department of Obstetrics and Gynecology, Robert Debré Hospital, APHP, Paris, France.,University of Paris, Centre for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, Paris, France
| | - Olivier Sibony
- Department of Obstetrics and Gynecology, Robert Debré Hospital, APHP, Paris, France
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Blanc-Petitjean P, Saumier S, Meunier G, Sibiude J, Mandelbrot L. Prolongation of active second stage of labor: Associated factors and perinatal outcomes. J Gynecol Obstet Hum Reprod 2021; 50:102205. [PMID: 34391951 DOI: 10.1016/j.jogoh.2021.102205] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 07/09/2021] [Accepted: 08/09/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Current data does not allow to define a reasonable threshold of duration of active second stage (ASS) of labor beyond which a medical intervention should be considered. Primary objective was to analyse perinatal outcomes associated with prolonged ASS beyond 45 min. Secondarily, we analysed associated maternal, gestational, labor and delivery characteristics associated with prolonged ASS. METHODS We performed a monocentric retrospective study among women with vaginal delivery, a term singleton cephalic fetus, without history of cesarean section. We compared women with active second stage of labor longer than 45 min (ASS ≥45 min, group A) and women with instrumental vaginal delivery (IVD) only for failure to progress (FtP) before 45 min of pushing (group B). Primary outcome was postpartum hemorrhage (PPH). Maternal and neonatal outcomes associated with ASS ≥ 45 min were assessed with multivariable logistic regression models. RESULTS Prolonged ASS ≥45 min (group A, N=177) was associated with lower rate of persistent occiput posterior position (1.7 vs 9.5%, p<0.01) and of non-engaged presentation when expulsive efforts started (10.7 vs 27.4%, p<0.01), compared to IVD for FtP <45 min (group B, N=84). In group A, 52% of women had instrumental delivery. Prolonged active second stage was independently associated with lower odds of episiotomy (38.4 vs 61.9%, AOR(95%CI)=0.43[0.24-0.78]) and was not associated with PPH (5.1 vs 5.9%, AOR=1.01[0.28-3.68]), pH<7.20, 5-min Apgar score < 7 (20.2 vs 15.9%, AOR=2.00[0.89-4.48]), lactates > 6 (23.0 vs 24.3, AOR=1.45[0.68-3.07]) or transfer to neonatal intensive care unit (6.2 vs 2.4%, AOR=4.71[0.76-29.08]. DISCUSSION Extending the duration of active second stage of labor beyond 45 min seems reasonable under rigorous surveillance of maternal and fetal wellbeing.
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Affiliation(s)
- Pauline Blanc-Petitjean
- Université de Paris, CRESS, INSERM, INRA, F-75004 Paris, France; AP-HP, Louis Mourier Hospital, Department of Obstetrics and Gynecology, Université de Paris, F-92700, Colombes, France.
| | - Solenne Saumier
- Université de Paris, CRESS, INSERM, INRA, F-75004 Paris, France; Université de Paris, Baudelocque Midwifery school, F-75014, Paris, France
| | | | - Jeanne Sibiude
- AP-HP, Louis Mourier Hospital, Department of Obstetrics and Gynecology, Université de Paris, F-92700, Colombes, France; Université de Paris, IAME, INSERM, F-75018 Paris, France
| | - Laurent Mandelbrot
- AP-HP, Louis Mourier Hospital, Department of Obstetrics and Gynecology, Université de Paris, F-92700, Colombes, France; Université de Paris, IAME, INSERM, F-75018 Paris, France
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Sagi-Dain L, Kreinin-Bleicher I, Shkolnik C, Bahous R, Sagi S. In women with spontaneous vaginal delivery, repair of perineal tears might be easier compared to episiotomy. Int Urogynecol J 2021; 32:1727-1732. [PMID: 33439282 DOI: 10.1007/s00192-020-04642-5] [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: 10/02/2020] [Accepted: 12/04/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION AND HYPOTHESIS To examine a common assumption that suturing of episiotomy, a straight performer-controlled incision, might be easier compared to repair of unpredictable spontaneous perineal tears. METHODS Data for this study were collected prospectively, as part of a randomized controlled trial examining the outcomes of episiotomy avoidance. Suturing characteristics were compared between vaginal deliveries with episiotomy vs. spontaneous perineal tears. Primary outcomes included the duration of the repair, number of suture packs used for the repair, and subjective rating of suturing difficulty (rated from 1 to 5 by practitioner performing the suturing). RESULTS Of 525 vaginal deliveries, episiotomy was performed in 165 (31.4%) of the cases, 59 of which (35.8%) were accompanied by additional vaginal tears. Spontaneous vaginal tears without episiotomy were noted in 272 deliveries (51.8%). Compared to spontaneous perineal tears, episiotomy performance was associated with an adverse effect on all three suturing characteristics in the overall cohort and in subgroup of non-operative deliveries. When comparing episiotomy only to second-degree tear suturing, in the subgroup of non-operative vaginal deliveries a higher rate of suturing duration < 10 min was noted in favor of spontaneous tears. However, in sub-analysis of vacuum-assisted deliveries, a benefit was noted in favor of the episiotomy-only group in terms of fewer suture packs and lower subjective difficulty. CONCLUSIONS In women with non-operative vaginal delivery, suturing of spontaneous perineal tears was easier and shorter compared to episiotomy repair. This might be related to the unpredictable nature of perineal tears, which might be shorter and shallower compared to the standard episiotomy incision.
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Affiliation(s)
- Lena Sagi-Dain
- Department of Obstetrics and Gynecology, Carmel Medical Center, 7 Michal St., Haifa, Israel. .,The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
| | | | - Chen Shkolnik
- Department of Obstetrics and Gynecology, Bnai-Zion Medical Center, Haifa, Israel
| | - Rabia Bahous
- Department of Obstetrics and Gynecology, Bnai-Zion Medical Center, Haifa, Israel
| | - Shlomi Sagi
- The Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.,Department of Obstetrics and Gynecology, Bnai-Zion Medical Center, Haifa, Israel
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