Severe perineal trauma is rising, but let us not overreact

Women's experiences of being assisted by two midwives during the active second stage of labour: Secondary outcomes from the Oneplus trial

BACKGROUND

'Collegial Midwifery Assistance' (CMA) is a clinical practice aiming to reduce severe perineal trauma (SPT) during childbirth. This practice involves two midwives being present during the active second stage of labour rather than one, which is the case in standard care. The effectiveness of CMA was evaluated in the Oneplus trial and a 30% reduction in SPT was shown.

AIM

The aim was to investigate the experience of women who received the CMA intervention in the trial and to explore factors influencing their experiences.

METHODS

A cohort study using data from the Oneplus trial and a one-month postpartum follow-up questionnaire. Descriptive statistics, univariable and multivariable logistic regression analyses were performed.

RESULTS

A total of 1050 women who received the CMA intervention responded to the questionnaire. Of these, 35.8% reported that they strongly agreed with feeling safe during the second stage of labour and 42.6% were inclined to have an additional midwife present at a subsequent birth. The intervention was favourably received by women who experienced fear of birth, who were non-native Swedish speakers, and had lower educational attainment. Furthermore, women were more positive towards CMA the longer the intervention lasted.

CONCLUSIONS

The results of this study suggest that the CMA intervention is accepted well by women and can be safely implemented into standard care. The duration of the CMA intervention was an important factor that influenced women's experiences and should be used to guide future practice.

Primary midwives' experiences of collegial midwifery assistance during the active second stage of labor: Data from the Oneplus trial

BACKGROUND

Collegial midwifery assistance during the active second stage of labor that involves a second midwife being present has been shown to reduce severe perineal trauma (SPT) by 30%. The aim of this study was to investigate primary midwives' experiences of collegial midwifery assistance with the purpose of preventing SPT during the active second stage of labor.

METHODS

This study uses an observational design with data from a multicenter randomized controlled trial (Oneplus). Data consist of clinical registration forms completed by the midwives after birth. Descriptive statistics as well as univariable and multivariable logistic regression were used to analyze the data.

RESULTS

The majority of the primary midwives felt confident (61%) and were positive (56%) toward the practice. Midwives with less than 2 years' work experience were more likely to completely agree they felt confident (aOR 9.18, 95% CI: 6.28-13.41) and experience the intervention as positive (aOR 4.04, 95% CI: 2.83-5.78) than those with over 20 years' work experience. Factors such as duration of time spent in the birthing room by the second midwife, opportunity for planning and if the second midwife provided support were further associated with the primary midwife's experience of the practice as being positive.

CONCLUSIONS

Our findings indicate that having a second midwife present during the active second stage of labor was an accepted practice, with the majority of primary midwives feeling confident and positive toward the intervention. This was especially pronounced among midwives with less than 2 years' work experience.

Swedish midwives' experiences of collegial midwifery assistance during the second stage of labour: A qualitative study

BACKGROUND

There has been an increased focus on clinical practice that may reduce severe perineal trauma due to awareness of the associated morbidity. Knowledge regarding the best practice to reduce these injuries is limited. Collegial midwifery assistance during the second stage of labour that involves an additional midwife being present has recently been implemented into many Swedish birth units with the aim of reducing severe perineal trauma. However, no studies have been conducted to evaluate midwives' experiences and views of this practice.

AIM

The aim of this study was to explore midwives' experiences of collegial midwifery assistance during the second stage of labour.

METHODS

A qualitative study was undertaken with five focus groups conducted with 37 midwives who were part of a multisite randomised controlled trial. The data was analysed with reflexive thematic analysis.

FINDINGS

Four key themes were generated: (i) "challenging the professional role"; (ii) "a balancing act between different roles"; (iii) "not just why and how - but who"; (iv) "a potential arena for learning".

CONCLUSION

This practice enabled valuable collegial support and learning. The midwives' experiences were multifaceted and influenced by several factors, including norms and culture in the birth units as well as personal relationships and the midwives' views on their role and childbirth. Staffing should be adapted in clinical practice to optimise the conditions for collegial support and learning while avoiding unintended consequences.

The impact of a perineal care bundle on women's birth experiences in Queensland, Australia: A qualitative thematic analysis

A care bundle was introduced into 28 Australian hospitals in 2018 with the aim of reducing severe perineal tears. There has been limited research regarding the impact of this bundle on women's birth experiences.

QUESTION

How does the introduction of a perineal care bundle impact on women's birth experiences in Queensland maternity hospitals?

METHODS

We recruited 18 women who had birthed in five Queensland hospitals where the bundle had been implemented. Semi-structured, individual interviews were analysed using reflexive thematic analysis.

FINDINGS

Three descriptive themes were generated: 1) Lack of information and consent to bundle elements, 2) Other non-consented and disrespectful treatment and 3) Recommendations for hospitals and clinicians. Two analytic themes were generated: 1) Default-position: Prioritising policies over women's autonomy and 2) Counter-position: Women asserting their rights to autonomy and respect.

DISCUSSION

None of the women interviewed could recall having received information about the perineal care bundle from clinicians during pregnancy. While many women accepted that its elements were in their or their baby's best interests, this was not the case for all women. Some women reported coercive and non-consented application of bundle elements, which they found distressing.

CONCLUSION

Given the broader institutional context in which the perineal bundle was implemented, the impact on information provision, informed consent and the detrimental emotional consequences for some women arising from the bundle's implementation were largely foreseeable. The potential for bundled care initiatives to impinge on women's human rights to autonomy and respectful care should be given greater preventative attention prior to implementation.

Midline and Mediolateral Episiotomy: Risk Assessment Based on Clinical Anatomy

Episiotomy is the surgical incision of the vaginal orifice and perineum to ease the passage of an infant's head while crowning during vaginal delivery. Although episiotomy remains one of the most frequently performed surgeries around the world, short- and long-term complications from the procedure are not uncommon. We performed midline and mediolateral episiotomies with the aim of correlating commonly diagnosed postepisiotomy complications with risk of injury to perineal neuromuscular and erectile structures. We performed 61 incisions on 47 female cadavers and dissected around the incision site. Dissections revealed that midline incisions did not bisect any major neuromuscular structures, although they did increase the risk of direct and indirect injury to the subcutaneous portion of the external anal sphincter. Mediolateral incisions posed greater risk of iatrogenic injury to ipsilateral nerve, muscle, erectile, and gland tissues. Clinician discretion is advised when weighing the potential risks to maternal perineal anatomy during vaginal delivery when episiotomy is indicated. If episiotomy is warranted, an understanding of perineal anatomy may benefit diagnosis of postsurgical complications.

One Plus One Equals Two-will that do? A trial protocol for a Swedish multicentre randomised controlled trial to evaluate a clinical practice to reduce severe perineal trauma {1}

Background

Severe perineal trauma sustained during childbirth is a serious complication since it can lead to both short- and long-term consequences for women. Some of the methods used to prevent perineal injuries have been evaluated in clinical trials, but there are still gaps in the evidence. A new clinical practice has been introduced, adopted by more than half of the maternity wards in Sweden with the aim of reducing severe perineal trauma. This procedure involves two midwives assisting the woman during the second stage of labour.

Methods/design

In this multicentre randomised controlled trial, 2946 women will be randomised to be assisted by one or two midwives during the second stage of labour. Women age 18–47, who plan for their first vaginal birth, with a singleton pregnancy in cephalic presentation, will be asked to participate when admitted to the maternity ward. Five maternity wards comprising 19,500 births/year in different parts of Sweden will participate in this study. The sample size is powered to demonstrate a 50% reduction (from 4.1–2.0%) in primary outcome, which is the prevalence of severe perineal trauma (3rd and 4th degree). Secondary outcomes will include maternal and neonatal outcomes, women’s experiences, midwives’ experiences of the intervention, incontinence, and pelvic floor symptoms. The primary analysis is intention to treat. Questionnaires will be sent to the women at 1 month and 1 year after the birth to assess women’s experiences, pain, incontinence, pelvic floor symptoms, sexual function, and mental health.

Discussion

It is important for care during labour and birth to be evidence based. There is a strong desire among midwives to reduce the risk of severe perineal trauma. This may lead to new strategies and practices being implemented into practice without scientific evidence. The intervention might have negative side effects or unintended consequences. On the other hand, there is a possibility of the intervention improving care for women.

Trial registration {2a}

ClinicalTrials.gov NCT03770962. Registered on 10 December 2018

Characteristics and changes in characteristics of women and babies admitted to residential parenting services in New South Wales, Australia in the first year following birth: a population-based data linkage study 2000-2012

OBJECTIVE

To examine the characteristics of women and babies admitted to the residential parenting services (RPS) of Tresillian and Karitane in the first year following birth.

DESIGN

A linked population data cohort study was undertaken for the years 2000-2012.

SETTING

New South Wales (NSW), Australia.

PARTICIPANTS

All women giving birth and babies born in NSW were compared with those admitted to RPS.

RESULTS

During the time period there were a total of 1 097 762 births (2000-2012) in NSW and 32 991 admissions to RPS. Women in cohort 1: (those admitted to RPS) were older at the time of birth, more likely to be admitted as a private patient at the time of birth, be born in Australia and be having their first baby compared with women in cohort 2 (those not admitted to an RPS). Women admitted to RPS experienced more birth intervention (induction, instrumental birth, caesarean section), had more multiple births and were more likely to have a male infant. Their babies were also more likely to be resuscitated and have experienced birth trauma to the scalp. Between 2000 and 2012 the average age of women in the RPS increased by nearly 2 years; their infants were older on admission and women were less likely to smoke. Over the time period there was a drop in the numbers of women admitted to RPS having a normal vaginal birth and an increase in women having an instrumental birth.

CONCLUSION

Women who access RPS in the first year after birth are more socially advantaged and have higher birth intervention than those who do not, due in part to higher numbers birthing in the private sector where intervention rates are high. The rise in women admitted to RPS (2000-2012) who have had instrumental births is intriguing as overall rates did not increase.

Women's Experiences of Emotional Recovery from Childbirth-Related Perineal Trauma: A Qualitative Content Analysis

BACKGROUND

The postpartum health care program in Iran is limited to the first six weeks of delivery and only focuses on women's physical problems. It seems that the issue of emotional recovery is underestimated in postnatal women with prenatal injuries. This study was designed to explore women's experiences of emotional recovery from childbirth-related perineal trauma.

METHODS

This qualitative content analysis was performed on 22 postnatal women with perineal trauma during labor at Omol-banin Hospital from the 20th of April to 25th of December in Mashhad, Iran in 2016. The participants were purposively selected between 10 days to one year after childbirth. Data were collected through semi-structured interviews and saturated after 26 interviews. The analysis of data was concurrently carried out using conventional content analysis adopted by Elo and Kyngas (2008). The MAXQDA software (Ver.10) was used for data organization.

RESULTS

Emotional recovery after birth trauma is defined as going on a journey from negative emotions to subjective well-being. Two super-ordinate generic categories emerged from the analysis: 1) feeling trapped in multifaceted issues, and 2) regaining possession of life. The participants encountered numerous concerns initially and with the help of family and community support, they regained the ability to dominate life and develop a pleasant mood. Improving physical functions had an essential role in regaining emotional well-being and enjoying daily life.

CONCLUSION

The results of this study promoted our understanding of the emotional recovery in women with childbirth-related perineal trauma. This helps the caregivers to understand woman's emotional concerns and needs in order to offer appropriate counseling services.

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

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.

Socio-historical evolution of the episiotomy practice: A literature review

Episiotomy is an enlargement of the vaginal orifice made by a surgical incision of the perineum. This review aimed to provide a socio-historical retrospective on the practice or episiotomy. Using the criteria from the PRISMA guidelines, the authors conducted a literature review, browsing twenty databases and several papers available in the gray literature. Sixty-four articles, seven reports, and fifteen books were selected. Through this study, four eras with different approaches to episiotomy practice could be identified: 1792-1920, 1920-1980, 1980-1996, and 1996-2018. This review shows that institutionalization and medicalization of birth lead to a systematic practice of episiotomy in many westernized countries until 1996. Lay questioning and evidence-based medicine may have reversed this trend into a restrictive practice. After making an inventory of the factors associated with the evolution of change in the rate of episiotomies, the review finally revealed that evolution of the practice of episiotomy has also been influenced by ideological, political, and social factors.

Perineal trauma during vaginal birth in Slovenia

Introduction: The aim of this retrospective study was to examine the rates of perineal tears during childbirth in Slovenian  maternity hospitals in the period from 2013 to 2015.Methods: A causal non-experimental method of quantitative empirical approach was conducted. Data were pooled from the Slovenian National Perinatal Information System and analysed for the period of 2013 to 2015. Data analysis was performed with the use of frequency distribution of attributive variables and the basic descriptive statistics of numerical variables.Results: The incidence of perineal trauma during childbirth in all the 14 maternity hospitals varies from the "perineum without injury" to the "fourth degree perineal tear". Overall, 26.1 % of women sustained a first degree perineal tear, whereas 4.8 % of women had a second degree perineal tear. Severe perineal trauma included 0.8 % of third degree tears and 0.1 % of fourth degree tears.Discussion and conclusion: Perineal trauma varies between Slovenian maternity hospitals. Women who have sustained tears that cut into their bowels may face serious health problems and should be given relevant advice regarding the state of their pelvic floor after childbirth. It is of great importance to appropriately recognise the severity of the perineal trauma. Moreover, health professionals should be familiar with the perineal trauma classification and the factors that may cause the perineum to tear during childbirth.

A multi-centre quality improvement project to reduce the incidence of obstetric anal sphincter injury (OASI): study protocol

BACKGROUND

Third and fourth degree perineal tears, or obstetric anal sphincter injuries (OASI), sustained during childbirth can result in anal incontinence and psychosocial problems which require ongoing treatment. Within the English National Health System (NHS) reported rates of OASI have gradually increased. In response, a care bundle was developed incorporating four elements: 1) antenatal information to women, 2) manual perineal protection during all vaginal births, 3) episiotomy to be performed with a 60° mediolateral angle at crowning (when clinically indicated) and 4) perineal examination (including per rectum) after childbirth. Implementation of the OASI Care Bundle is aided by a skills development module and an awareness campaign. The project is a collaboration between two national professional bodies, an NHS hospital trust and an academic institution.

METHODS

Implementation of the OASI Care Bundle will be evaluated using a stepped-wedge design. From January 2017 sixteen maternity units across England, Wales and Scotland will participate in the study over a 15-month period, with sequential roll-out of the intervention in four blocks (regions) of four units. The primary clinical outcome is OASI rate. Regression analysis will adjust for differences in organisational characteristics and obstetric risk factors in women who gave birth before and after implementation of the care bundle. Focus group discussions and in-depth interviews with clinicians will evaluate the feasibility of integrating the care bundle into routine practice. Interviews with women will explore the acceptability of the intervention.

DISCUSSION

This protocol outlines the evaluation of our quality improvement project which aims to prevent OASI using a bundle of evidence-based interventions that are each widely used in practice. The OASI project aims to 1) standardise practice to prevent OASI in a way that is acceptable to clinicians and women and 2) identify the barriers and enablers associated with upscaling interventions within maternity units. If found to be effective, feasible and acceptable, the OASI Care Bundle will be shared with a range of audiences using the communication channels available to the professional bodies.

TRIAL REGISTRATION

The OASI Project was retrospectively registered on the ISCTRN12143325 database date assigned 03/10/2017.

Midwifery management of second-degree perineal tears in New Zealand: A cross-sectional survey of practice

BACKGROUND

Second-degree tears are the most common form of perineal trauma occurring after vaginal birth managed by New Zealand midwives, although little is known about midwives' perineal practice.

AIM

The aim of this study was to identify how midwives managed the last second-degree perineal tear they treated and the level to which their practice reflects National Institute for Health and Care Excellence guidelines.

METHODS

An (anonymous) online survey was conducted over a six-week period in 2013. New Zealand midwives who self-identified as currently practising perineal management and could recall management of the last second-degree tear they treated were included in the analysis.

FINDINGS

Of those invited, 645 (57.1% self-employed, 42.9% employed) were eligible and completed surveys. Self-employed midwives reported greater confidence (88.0% vs 74.4%, p<0.001) and more recent experience (85.1% vs 57.4%, p<0.001) with perineal repair than employed midwives. Midwives who left the last second-degree tear unsutured (7.3%) were more likely to report low confidence (48.9% vs 15.4%, p<0.001) and less recent experience with repair (53.2% vs 24.7%, p<0.001), and were less likely to report a digital-rectal examination (10.6% vs 49.0%, p<0.001), compared to midwives who sutured. Care consistent with evidence-based guidelines (performing a digital-rectal examination, 59.4% vs 49.3% p=0.005; optimal suturing techniques, 62.2% vs 48.7%, p=0.001) was associated with recent perineal education.

CONCLUSIONS

Midwives' management of the last second-degree perineal tear is variable and influenced by factors including: employment status, experience, confidence, and perineal education. There is potential for improvement in midwives' management through increased uptake of evidence-based guidelines and through ongoing education.

Incidence of episiotomy in Slovenia: The story behind the numbers

Episiotomy is a surgical cut of the perineum performed in the second stage of labor in order to widen the vaginal opening and thus facilitate the birth of an infant. Despite current recommendations against the routine use of episiotomy, it is one of the most commonly performed surgical interventions during childbirth. This retrospective study explores the number of episiotomies performed in Slovenian maternity hospitals and the differences in episiotomy rates in relation to parity. Data were obtained from the Slovenian National Perinatal Information System and pooled for 2013. A causal and non-experimental method of empirical research was used. The results of the study show that episiotomy rates vary widely across Slovenian maternity hospitals, ranging from 2.5% to 51.7%. Moreover, the majority of Slovenian maternity hospitals exceed the recommended rate, with an overall incidence of episiotomy as high as 31.3%. Further research is recommended to obtain relevant information from women as well as from midwives and to draw new, evidence-based conclusions related to the maternal benefits and adverse effects of episiotomy.

Reducing the incidence of Obstetric Sphincter Injuries using a hands-on technique: an interventional quality improvement project

A main concern for women giving birth is the risk of obstetric anal sphincter injuries. In our department the incidence of sphincter injuries was around 8 % among vaginally delivering first time mothers. We aimed to halve the incidence to 4 % or less. A prospective interventional program was instituted. We implemented a hands-on technique with four elements in a bundle of care together with a certification process for all staff on the delivery ward. The incidence of episiotomies served as a balancing indicator. The adherence to three of the four elements of the care bundle rose significantly while the all-or-nothing indicator leveled around 80 %. The median number of deliveries between cases with a sphincter injury increased from 9.5 in the baseline period to 20 during the intervention period. This corresponded with a reduction in the incidence from 7.0 % to 3.4 %. The rate of episiotomy remained low at 8.4 % in this group. By implementing the hands-on technique, we halved the risk of obstetric anal sphincter injuries. Our data suggest that further improvement may be anticipated. The study has demonstrated how implementation of a hands-on technique can be carried out within a quality improvement framework with rapid and sustainable results.

Non-surgical intrapartum practices for the prevention of severe perineal trauma: a systematic review protocol

REVIEW QUESTION/OBJECTIVE

The objective of this review is to determine the effectiveness of non-surgical intrapartum practices in reducing the incidence of severe perineal trauma (third and fourth degree tears) during childbirth.

Does the Finnish intervention prevent obstetric anal sphincter injuries? A systematic review of the literature

OBJECTIVES

A rise in obstetric anal sphincter injuries (OASIS) has been observed and a preventive approach, originating in Finland, has been introduced in several European hospitals. The aim of this paper was to systematically evaluate the evidence behind the 'Finnish intervention'.

DESIGN

A systematic review of the literature conducted according to the Preferred Reporting for Systematic Reviews and Meta-analyses (PRISMA) guidelines.

OUTCOME MEASURES

The primary outcome was OASIS. Secondary outcomes were (perinatal): Apgar scores, pH and standard base excess in the umbilical cord, and (maternal): episiotomy, intact perineum, first and second-degree perineal lacerations, duration of second stage, birth position and women's perceptions/birth experiences.

METHODS

Multiple databases (Cochrane, Embase, Pubmed and SveMed) were systematically searched for studies published up to December 2014. Both randomised controlled trials and observational studies were eligible for inclusion. Studies were excluded if a full-text article was not available. Studies were evaluated by use of international reporting guidelines (eg, STROBE).

RESULTS

Overall, 1042 articles were screened and 65 retrieved for full-text evaluation. Seven studies, all observational and with a level of evidence at 2c or lower, were included and consistently reported a significant reduction in OASIS. All evaluated episiotomy and found a significant increase. Three studies evaluated perinatal outcomes and reported conflicting results. No study reported on other perineal outcomes, duration of the second stage, birth positions or women's perceptions.

CONCLUSIONS

A reduction in OASIS has been contributed to the Finnish intervention in seven observational studies, all with a low level of evidence. Knowledge about the potential perinatal and maternal side effects and women's perceptions of the intervention is extremely limited and the biological mechanisms underlying the Finnish intervention are not well documented. Studies with a high level of evidence are needed to assess the effects of the intervention before implementation in clinical settings can be recommended.