Risk factors for severe perineal trauma during vaginal childbirth: A Western Australian retrospective cohort study

Risk factors associated with severe perineal tear at Public Hospitals in Bahir Dar town, Northwest Ethiopia

Background

Birth-related perineal trauma is a public health issue that can lead to significant maternal morbidity in low-income countries like Ethiopia. Research on the proportion and underlying factors of birth-related severe perineal tears is rare, both in the study area and throughout Ethiopia. As a result, this study was intended to determine the proportion of birth-related severe perineal tears and associated factors at hospitals in Bahir Dar town, Ethiopia.

Methods

A cross-sectional study was undertaken at government hospitals in Bahir Dar, Ethiopia. Five hundred fifteen study subjects were selected using a systematic sampling technique. The data was collected through chart reviews and interviews. Data was entered and analyzed using SPSS Version 23. A binary logistic regression was employed to identify factors, and an adjusted odds ratio and a 95% CI were used to estimate the strength of relationships. Statistical significance was declared at p-value < 0.05.

Result

The prevalence of severe perineal tears was 7.4%. Previous history of a perineal tear (AOR = 3.06, 95% CI = 1.24-7.59), being nullipara (AOR = 4.03, 95% CI = 1.42-11.44), occipito-posterior position (AOR = 5.49, 95% CI = 2.27-13.28), duration of second stage of labor > 2 h (AOR = 5.42, 95% CI = 2.26-12.99), birth attendant's work experience <1 year (AOR = 5.98, 95% CI = 2.16-16.57) were found to be associated with birth-related severe perineal tear.

Conclusion

The proportion of birth-related severe perineal tears was high at governmental hospitals in Bahir Dar town. Previous history of perineal tear, work experience of birth attendants, duration of the second stage of labor, being nullipara, and occipito-posterior position were the major determinants of severe perineal tear. This study suggests that strategies and regulations should be developed to shorten the second stage of labor.

Asian-White disparities in obstetric anal sphincter injury: a systematic review and meta-analysis

OBJECTIVE

Obstetrical anal sphincter injury describes a severe injury to the perineum and perianal muscles after birth. Obstetrical anal sphincter injury occurs in approximately 4.4% of vaginal births in the United States; however, racial and ethnic inequities in the incidence of obstetrical anal sphincter injury have been shown in several high-income countries. Specifically, an increased risk of obstetrical anal sphincter injury in individuals who identify as Asian vs those who identify as White has been documented among residents of the United States, Australia, Canada, Western Europe, and the Scandinavian countries. The high rates of obstetrical anal sphincter injury among the Asian diaspora in these countries are higher than obstetrical anal sphincter injury rates reported among Asian populations residing in Asia. A systematic review and meta-analysis of studies in high-income, non-Asian countries was conducted to further evaluate this relationship.

DATA SOURCES

MEDLINE, Ovid, Embase, EmCare, and the Cochrane databases were searched from inception to March 2023 for original research studies.

STUDY ELIGIBILITY CRITERIA

Observational studies using keywords and controlled vocabulary terms related to race, ethnicity and obstetrical anal sphincter injury. All observational studies, including cross-sectional, case-control, and cohort were included. 2 reviewers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Meta-analysis of Observational Studies in Epidemiology recommendations.

METHODS

Meta-analysis was performed using RevMan (version 5.4; Cochrane Collaboration, London, United Kingdom) for dichotomous data using the random effects model and the odds ratios as effect measures with 95% confidence intervals. Subgroup analysis was performed among Asian subgroups. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal tools. Meta-regression was used to determine sources of between-study heterogeneity.

Results

A total of 27 studies conducted in 7 countries met the inclusion criteria encompassing 2,337,803 individuals. The pooled incidence of obstetrical anal sphincter injury was higher among Asian individuals than White individuals (pooled odds ratio, 1.64; 95% confidence interval, 1.48-1.80). Subgroup analyses showed that obstetrical anal sphincter injury rates were highest among South Asians and among population-based vs hospital-based studies. Meta-regression showed that moderate heterogeneity remained even after accounting for differences in studies by types of Asian subgroups included, study year, mode of delivery included, and study setting.

Conclusion

Obstetrical anal sphincter injury is more frequent among Asian versus white birthing individuals in multiple high-income, non-Asian countries. Qualitative and quantitative research to elucidate underlying causal mechanisms responsible for this relationship are warranted.

Differences in rates of severe perineal trauma between midwife-led and obstetrician-led care in the Netherlands: A nationwide cohort study

Objective

To investigate trends and rates of severe perineal trauma (SPT), also known as obstetric anal sphincter injury (OASI), between midwife-led and obstetrician-led care in the Netherlands, and factors associated with SPT.

Methods

This nationwide cohort study included registry data from 2000 to 2019 (n = 2,169,950) of spontaneous vaginal births of term, live, cephalic, single infants, without a (previous) caesarean section or assisted vaginal birth.First, trends of SPT and episiotomy were shown. Second, differences in SPT rates between midwife- and obstetrician-led care were assessed. Third, associations of care factors with SPT were examined. Multivariable logistic regression analyses were used to determine which factors were important in the associations. All outcomes were stratified for parity.

Results

Over time, the SPT incidence increased mainly in midwife-led care and episiotomy rates decreased. Compared to midwife-led care, SPT rates were lower in obstetrician-led care among primiparous women (aOR 0.78; 99 % CI 0.74-0.81) and comparable among multiparous women (aOR 1.04; 99 % CI 0.99-1.10). Among women without epidural analgesia, these differences were smaller for primiparous women (aOR 0.88; 99 % CI 0.84-0.92), but the SPT rate was higher in obstetrician-led care among multiparous women (aOR 1.09; 99 % CI 1.03-1.15). Among women without shoulder dystocia, induction, augmentation, and pain medication, SPT rates were comparable among primiparous women, but higher among multiparous women in obstetrician-led care. In midwife-led care, SPT occurred more often among hospital versus home births. In obstetrician-led care, lower SPT incidences were found among births with epidural analgesia and for multiparous women with induction or augmentation.

Conclusions

Iinduction, augmentation, and epidural analgesia in obstetrician-led care may be an explanatory factor for the higher incidence of SPT among primiparous women in midwife-led care. More research is needed to explain differences in SPT rates and to understand how SPT can be prevented, while maintaining a high intact perineum rate.

Effects of flexible sacrum position at birth on maternal and neonatal outcomes: A retrospective cohort study

OBJECTIVE

To examine the differences in both maternal and neonatal outcomes between flexible and non-flexible sacrum positions at birth.

METHODS

A descriptive, cross-sectional, retrospective study was carried out on a sample of low-risk pregnant women. Univariate and multivariate logistic regressions and multivariate linear regressions were conducted to estimate the association between our discrete or continuous variables of interest. Maternal outcomes were perineal tear, maternal blood loss, second stage length; neonatal outcomes were Apgar scores and neonatal asphyxia. Results were adjusted for maternal age, neonatal birth weight, and epidural analgesia.

RESULTS

We considered for final analysis 2198 women. In primiparous women, women giving birth in the all-fours position were significantly more likely to have an intact perineum (P = 0.011) and a shorter length of the second stage of labor (P = 0.022). Maternal age (P = 0.005) and neonatal weight (P = 0.013) significantly increased perineal tearing; maternal age (P = 0.004) and neonatal birth weight (P < 0.001) were significantly associated with a higher amount of blood loss. Maternal age (P = 0.002) and neonatal weight (P < 0.001) significantly increased the length of the second stage of labor. For multiparous women, the side-lying position was significantly correlated with an intact perineum (P = 0.031); maternal age and intact perineum were statistically inversely associated. Epidural analgesia significantly increased the length of the second stage of labor in both nulliparous (P < 0.001) and pluriparous women (P < 0.001). No significant differences were found in neonatal outcomes.

CONCLUSION

Women with a low-risk labor should be free to choose their birth position as flexible sacrum positions are shown to increase maternal well-being and do not affect neonatal health.

Asian-white disparities in obstetric anal sphincter injury: Protocol for a systematic review and meta-analysis

BACKGROUND

Obstetric anal sphincter injury (OASI) describes severe injury to the perineum and perineum and perianal muscles following birth and occurs in 4.4% to 6.0% of vaginal births in Canada. Studies from high-income countries have identified an increased risk of OASI in individuals who identify as Asian race versus those who identify as white. This protocol outlines a systematic review and meta-analysis which aims to determine the incidence of OASI in individuals living in high-income countries who identify as Asian versus those of white race/ethnicity. We hypothesize that the pooled incidence of OASI will be higher in Asian versus white birthing individuals.

METHODS

We will search MEDLINE, OVID, Embase, Emcare and Cochrane databases from inception to 2022 for observational studies using keywords and controlled vocabulary terms related to race, ethnicity and OASI. Two reviewers will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and Meta-analysis of Observational Studies (MOOSE) recommendations. Meta-analysis will be performed using RevMan for dichotomous data using the random effects model and the odds ratio (OR) as effect measure with a 95% confidence interval (CI). Subgroup analysis will be performed based on Asian subgroups (e.g., South Asian, Filipino, Chinese, Japanese individuals). Study quality assessment will be performed using The Joanna Briggs Institute Critical Appraisal tools.

DISCUSSION

The systematic review and meta-analysis that this protocol outlines will synthesize the extant literature to better estimate the rates of OASI in Asian and white populations in non-Asian, high-income settings and the relative risk of OASI between these two groups. This systematic summary of the evidence will inform the discrepancy in health outcomes experienced by Asian and white birthing individuals. If these findings suggest a disproportionate burden among Asians, they will be used to advocate for future studies to explore the causal mechanisms underlying this relationship, such as differential care provision, barriers to accessing care, and social and institutional racism. Ultimately, the findings of this review can be used to frame obstetric care guidelines and inform healthcare practices to ensure care that is equitable and accessible to diverse populations.

Maternal suicide attempts and deaths in the first year after cesarean delivery

BACKGROUND

Cesarean delivery (CD) has been associated with postpartum psychiatric disorders, but less is known about the risk of suicidal behaviors. We estimated the incidence and risk of suicide attempts and deaths during the first postpartum year in mothers who delivered via CD v. vaginally.

METHOD

All deliveries in Sweden between 1973 and 2012 were identified. The mothers were followed since delivery for 12 months or until the date of one of the outcomes (i.e. suicide attempt or death by suicide), death by other causes or emigration. Associations were estimated using Cox proportional hazards regression models.

RESULTS

Of 4 016 789 identified deliveries, 514 113 (12.8%) were CDs and 3 502 676 (87.2%) were vaginal deliveries. During the 12-month follow-up, 504 (0.098%) suicide attempts were observed in the CD group and 2240 (0.064%) in the vaginal delivery group (risk difference: 0.034%), while 11 (0.0037%) deaths by suicide were registered in the CD group and 109 (0.0029%) in the vaginal delivery group (risk difference: 0.008%). Compared to vaginal delivery, CD was associated with an increased risk of suicide attempts [hazard ratio (HR) 1.46; 95% CI 1.32-1.60], but not of deaths by suicide (HR 1.44; 95% CI 0.88-2.36).

CONCLUSIONS

Maternal suicidal behaviors during the first postpartum year were uncommon in Sweden. Compared to vaginal delivery, CD was associated with a small increased risk of suicide attempts, but not death by suicide. Improved understanding of the association between CD and maternal suicidal behaviors may promote more appropriate measures to improve maternal mental well-being and further reduce suicidal risks.

Management of Third and Fourth-Degree Perineal Tears After Vaginal Birth. Guideline of the DGGG, OEGGG and SGGG (S2k-Level, AWMF Registry No. 015/079, December 2020)

Purpose This guideline provides recommendations for the diagnosis, treatment and follow-up care of 3rd and 4th degree perineal tears which occur during vaginal birth. The aim is to improve the management of 3rd and 4th degree perineal tears and reduce the immediate and long-term damage. The guideline is intended for midwives, obstetricians and physicians involved in caring for high-grade perineal tears.

Methods A selective search of the literature was carried out. Consensus about the recommendations and statements was achieved as part of a structured process during a consensus conference with neutral moderation.

Recommendations After every vaginal birth, a careful inspection and/or palpation by the obstetrician and/or the midwife must be carried out to exclude a 3rd or 4th degree perineal tear. Vaginal and anorectal palpation is essential to assess the extent of birth trauma. The surgical team must also include a specialist physician with the appropriate expertise (preferably an obstetrician or a gynecologist or a specialist for coloproctology) who must be on call. In exceptional cases, treatment may also be delayed for up to 12 hours postpartum to ensure that a specialist is available to treat the individual layers affected by trauma. As neither the end-to-end technique nor the overlapping technique have been found to offer better results for the management of tears of the external anal sphincter, the surgeon must use the method with which he/she is most familiar. Creation of a bowel stoma during primary management of a perineal tear is not indicated. Daily cleaning of the area under running water is recommended, particularly after bowel movements. Cleaning may be carried out either by rinsing or alternate cold and warm water douches. Therapy should also include the postoperative use of laxatives over a period of at least 2 weeks. The patient must be informed about the impact of the injury on subsequent births as well as the possibility of anal incontinence.

The clinical characteristics of perineal tears: A study carried out on 14 pregnant women in a tertiary center: Case series

Background

The sheer quality of the female genital tract is not always respected at the time of childbirth because no protocol for the management of perineal tears exists in our services these days. The management remains dependent on a gynecologist and obstetrician. The study aimed to describe the characteristics of perineal tears.

Methods

Our cross-sectional, retrospective, and descriptive study focused on patients admitted for childbirth and hospitalized in the obstetrics department of the Saint Luc Tertiary Clinic for a period from March 2021 to March 2022. During this period, we recorded 111 deliveries with 14 perineal tears.

Results

A total of 111 deliveries were recorded with a 12.6% frequency of perineal tears. 64.3% of women aged between 26 and 35 and 71.4% of primiparous women were affected by perineal tears. For delivery, 64.3% of births were eutocic deliveries, with 42.9% of children born with a birth weight greater than 4 kg, and the cephalic presentation delivered 86% of children. For degrees of perineal tears, 64.3% of patients had first-degree perineal tears. For postpartum treatment of perineal tears, analgesics help calm the pain, and antibiotic therapy has been considered. For fourth and third-degree tears, episiotomy was performed as a surgical procedure.

Conclusion

Perineal tears are the trauma often encountered in obstetrics; the first few suffer from it essentially. The high birth weight of children is often the cause. They require immediate management to prevent or avoid infections.

•

Women have a very complex anatomy, hence the high risk of trauma or tears of the perineum that are often unavoidable during childbirth. Young primiparous women are the most vulnerable to perineal tears with a very high prevalence.

•

The high weight and cephalic presentation of children at delivery are the factors causing perineal tears in women. Vaginal delivery and the number of foetuses has an impact on the integrity of the perineum.

•

During childbirth, perineal tears should be brought to the attention of obstetric providers to avoid complications for the woman.

Spontaneous Perineal Trauma during Non-Operative Childbirth—Retrospective Analysis of Perineal Laceration Risk Factors

Childbirth-related perineal trauma (CRPT) is defined as damage to the skin, muscles of the perineum, as well as to the anal sphincter complex and anal epithelium. The aim of the study was to analyze the risk factors for spontaneous injuries to the soft tissues of the birth canal during non-operative delivery. This was a single-center retrospective case-control study. The study included the analysis of two groups, the study group featured 7238 patients with spontaneous perineal laceration (any degree of perineal laceration) and the control group featured patients without perineal laceration with 7879 cases. The analysis of single-factor logistic regression showed that the factors related to perineal laceration during childbirth are the age of the patients giving birth (p = 0.000), the BMI before delivery (p = 0.000), the number of pregnancies (p = 0.000) and deliveries (p = 0.000), diagnosed gestational diabetes (p = 0.046), home birth (p = 0.000), vaginal birth after cesarean (VBAC) (p = 0.001), the use of oxytocin in the second stage of childbirth (p = 0.041), the duration of the second stage of childbirth (p = 0.000), body weight (p = 0.000), and the circumference of the newborn head (p = 0.000). Independent factors that increase the risk of perineal laceration during childbirth are an older age of the woman giving birth, a history of cesarean section, a higher birth weight of the newborn, and factors that reduce the risk of spontaneous perineal trauma are a higher number of deliveries and home birth.

[Childbirth outcomes and perineal damage in women with natural childbirth in Korea: a retrospective chart review]

Purpose

This study aimed to determine the actual state of childbirth in Korean women with natural childbirth and the degree of damage to the perineum during childbirth.

Methods

This retrospective study analyzed the medical records of mothers who had natural childbirth at a hospital in Seoul, Korea in 2018. Data from 358 women with cephalic births at greater than 37 gestational weeks were analyzed. To determine natural childbirth characteristics and the degree of damage to the perineum, descriptive statistics were done. The difference in the degree of perineal injury according to obstetric characteristics was analyzed using independent t-test and one-way analysis of variance.

Results

The mean age was 33.18±3.68 years, and 49.2% were primiparas, while 39% gave birth with a doula. The degree of perineal damage differed by age (F=9.15, p<.001), parity (t=19.13, p<.001), number of births in multiparity (F=3.68, p=.027), previous vaginal delivery in multiparity (F=3.00, p=.032) and birthing posture (F=7.44, p<.001). Having received therapeutic procedures (t=-4.62, p<.001), specifically fluid administration (t=-2.72, p=.007), oxygen supply (t=--2.76, p=.006) and epidural anesthesia (t=-2.77, p=.006) were statistically significant for perineal damage. There were no differences, however, by gestational period, doula use, water room use in labor, baby head circumference, or birth weight.

Conclusion

Study findings suggest that support for older women, primiparas, and those who require therapeutic procedures may help to decrease the possibility of perineal damage during childbirth. As perineal damage was also associated with birthing posture, this should be considered when providing intrapartum nursing care.

Obstetric anal sphincter injury by maternal origin and length of residence: a nationwide cohort study

OBJECTIVE

To estimate the association between maternal origin and obstetric anal sphincter injury (OASI), and assess if associations differed by length of residence.

DESIGN

Population-based cohort study.

SETTING

The Medical Birth Registry of Norway.

POPULATION

Primiparous women with vaginal livebirth of a singleton cephalic fetus between 2008 and 2017 (n = 188 658).

METHODS

Multivariable logistic regression models estimated adjusted odds ratios (aORs) for OASI with 95% CI by maternal region of origin and birthplace. We stratified models on length of residence and paternal birthplace.

MAIN OUTCOME MEASURES

OASI.

RESULTS

Overall, 6373 cases of OASI were identified (3.4% of total cohort). Women from South Asia were most likely to experience OASI (6.2%; aOR 2.24, 95% CI 1.87-2.69), followed by those from Southeast Asia, East Asia & the Pacific (5.7%; 1.59, 1.37-1.83) and Sub-Saharan Africa (5.2%; 1.85, 1.55-2.20), compared with women originating from Norway. Among women born in the same region, those with short length of residence in Norway (0-4 years), showed the highest odds of OASI. Migrant women across most regions of origin had the lowest risk of OASI if they had a Norwegian partner.

CONCLUSIONS

Primiparous women from Asian regions and Sub-Saharan Africa had up to two-fold risk of OASI, compared with women originating from Norway. Migrants with short residence and those with a foreign-born partner had higher risk of OASI, implying that some of the risk differential is due to sociocultural factors. Some migrants, especially new arrivals, may benefit from special attention during labour to reduce morbidity and achieve equitable outcomes.

TWEETABLE ABSTRACT

Anal sphincter injury during birth is more common among Asian and Sub-Saharan migrants and particularly among recent arrivals.

Secondary Dyspareunia After Childbirth: A Pilot Study for Comparison Between Group of Women With Episiotomy and Women Without Perineal Trauma

PROBLEM

Dyspareunia research following childbirth usually includes women who received an episiotomy during childbirth. Few studies have examined dyspareunia after childbirth in women who had no episiotomy or perineal trauma.

PURPOSE

The purpose of this study was to compare the incidence of dyspareunia in women with perineal trauma related to childbirth to women without perineal trauma related to childbirth. The second aim was to assess risk factors for dyspareunia after childbirth.

METHODS

A quantitative cross-sectional study was designed and data were collected from a questionnaire that were sent via the internet (online). The study was performed in Slovenia. The study design included purposive and snowball sampling. Participants were assured anonymity.

Analysis of data was conducted using SPSS 20.0. Factor analysis determined the validity and Cronbach's coefficient alpha determined the reliability of the questionnaire. The adequacy of a correlation matrix for factorization was assessed with the Kaiser–Meyer–Olkin (KMO) test and the Bartlett's test. To determine statistically significant differences, the chi-square (χ2) test was used. Kullback–Leibler divergence was used to measure how one probability distribution was different from the other probability distribution when the χ2 test was not satisfactory.

FINDINGS

There were 387 respondents to the online questionnaire and 22% of the women who received an episiotomy prior to childbirth reported dyspareunia after childbirth; 13.69% reporteddyspareunia when they had no perineal trauma associated with childbirth. Dyspareunia persisted up to 18 months in 11% of participants who had an episiotomy and in 8% of women who experienced no perineal trauma.

DISCUSSION

After an atraumatic childbirth, women can also experience dyspareunia. Pregnant women may benefit when their provider knows the risk factors for dyspareunia and limits episiotomy to those situations when there is a clear indication. Additional research may elucidate risk factors for dyspareunia following an atraumatic delivery.

Language barrier as a risk factor for obstetric anal sphincter injury - A case-control study

INTRODUCTION

The incidence of grade 3-4 perineal tears, also known as obstetric anal sphincter injury (OASI), is reported to be between 0.5 and 2.5%. Beyond the medico-economic burden, the consequences of OASI on a woman's emotional, psychological, sexual, and physical wellbeing are considerable. Among the various risk factors of OASI, few data are available about the impact of a language barrier on its incidence.

MATERIAL AND METHODS

We conducted a case-control study to evaluate the effect of language barriers on the risk of OASI comparing 171 women with OASI and 163 matched controls. The matched criteria included ethnicity, age, previous vaginal delivery, delivery mode, prophylactic episiotomy and birthweight. Patients' characteristics were compared and crude ORs and 95% CIs estimated using unadjusted logistic models. Multivariate analysis was performed with recognized potential confounders.

RESULTS

All of the cases had grade 3 tears. Language barrier was a determinant factor of OASI with an OR of 3.32 [1.36-8.90], p = 0.01. Other risk factors were occipito-posterior delivery, African origin and prolonged labor duration (OR 6.33, 95% CI: 2.04-27.78, p = 0.004, OR 1.85, 95% CI: 1.08-3.19, p = 0.03 and OR 1.03, 95% CI: 1.01-1.05, p = 0.004, respectively).

CONCLUSION

Our data suggest that language barrier is an independent risk factor of OASI. Physicians and midwives should attempt to identify patients with a language barrier during prenatal visits. Education about simple terms used during delivery could decrease the incidence of this complication.

Posterior compartment symptoms in primiparous women 1 year after non-assisted vaginal deliveries: a Swedish cohort study

Introduction and hypothesis

This is a prospective cohort follow-up study based on the hypothesis that primiparous women with non-assisted vaginal deliveries and a second-degree perineal tear have more posterior compartment symptoms 1 year after delivery than those with no or first-degree tears.

Methods

A follow-up questionnaire, including validated questions on pelvic floor dysfunction, was completed 1 year postpartum by 410 healthy primiparas, delivered without instrumental assistance at two maternity wards in Stockholm between 2013 and 2015. Main outcome measures were posterior compartment symptoms in women with second-degree perineal tears compared with women with no or only minor tears.

Results

Of 410 women, 20.9% had no or only minor tears, 75.4% had a second-degree tear, and 3.7% had a more severe tear. Of women presenting with second-degree tears, 18.9% had bowel-emptying difficulties compared with 20.0% of women with minor tears. Furthermore, almost 3% of them with second-degree tears complained of faecal incontinence (FI) of formed stool, 7.2% of FI of loose stool compared with 1.2% and 3.5% respectively in women with no or only minor tears.

Conclusions

Symptomatic pelvic floor dysfunction is common among primiparous women within 1 year following uncomplicated vaginal delivery, and there are no significant differences between second-degree perineal tears and minor tears. These symptoms should be addressed in all women after delivery to improve pelvic floor dysfunction and quality of life.

Risks and Associations of Third- and Fourth-Degree Lacerations: An Urban Single Center Experience

OBJECTIVE

Obstetric anal sphincter injuries (OASIs) are severe tears involving the external and internal anal sphincters. We aimed to document the incidence of OASIs within a racially and ethnically diverse institution to elucidate which maternal, fetal, and parturition factors may be associated with OASIs in minority subgroups.

METHODS

This was a retrospective unmatched case-control study of reproductive aged women who delivered between January 1, 2014, and December 31, 2017, at our institution. Data for maternal, fetal, and parturition factors were gathered through chart review. We also investigated the expertise level of the surgeon performing repairs and complications that developed in the postpartum period. Logistic regression analysis was used to compare women with third- and fourth-degree lacerations against the control group of women with first-degree, second-degree, or no lacerations.

RESULTS

Of the 23,362 deliveries between January 1, 2014, and December 31, 2017, the incidence of OASIs was 1%. Of our patients, 38% self-identified as Hispanic, 32% as Black, 13% as White, and 3.5% as Asian. Risk for OASIs was significantly increased in nulliparity, Pitocin use, operative deliveries, episiotomy, and prolonged second stage of labor. Black race and obesity were protective for OASIs. There was no significant difference in complication rates based on type of repair nor the provider level of training.

CONCLUSIONS

The incidence of OASIs at our institution is similar to current published literature. Our study population is unique in its overrepresentation of minority groups, offering insight into potentially distinctive risk and protective factors associated with OASIs.

Social Recovery: A Neglected Dimension of Caring for Women with Perineal Trauma in Iran

BACKGROUND

Social recovery during the postnatal period in women with perineal trauma is a little-known concept. Therefore, this study was designed to explore the experiences of social recovery in women with childbirth-related perineal trauma.

MATERIALS AND METHODS

A qualitative approach using content analysis was adopted to study a purposive sample of 22 postnatal women with perineal trauma during birth at Omol-banin Hospital, Mashhad, Iran from April 20th to December 25th, 2017. The participants were selected between 10 days to one year after childbirth. Data were collected through semi-structured interviews. Conventional content analysis approach was performed, concurrently, with data collection. To organize data, the MAXQDA 10 was used.

RESULTS

Social recovery after perineal trauma was conceptualized as 'shifting from personal ill-health to interactional empowerment'. Two generic categories emerged from data analysis including 1) impaired individual and social function, which was recognized by social isolation and lack of ability to manage daily life and 2) empowering social interactions, which was characterized by rebuilding social partnerships and returning to an interactive lifestyle.

CONCLUSIONS

Social isolation as the result of neglecting social recovery of women with severe perineal trauma endangers the mental health of mothers. Understanding the concept of social recovery for women with perineal trauma, especially in severe cases, will help health professionals to provide quality postpartum care for women with perineal trauma in a longer period after childbirth.

Risk factors for severe perineal trauma during childbirth: An updated meta-analysis

Several studies have investigated the importance of maternal, fetal factors and intrapartum characteristics in predicting severe perineal lacerations. The purpose of the present systematic review is to accumulate current evidence and provide estimated effect sizes for the various risk factors described. We reviewed Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar for published studies in the field for observational studies as well as randomized controlled trials. Two researchers independently assessed the included studies and documented outcomes. Data extraction was performed using a modified data form that was based in Cochrane`s data collection form for intervention reviews for RCTs and non-RCTs. Forty-three articles were selected for inclusion in the present systematic review. The analyzed population reached 716,031 parturient of whom 22,280 (3,1%) sustained third- and fourth-degree perineal lacerations. Several risk factors were identified. Instrumental delivery [RR 3.38 (2.21, 5.18)], midline episiotomy [RR 2.88 (1.79, 4.65)] and a persistent occiput posterior position [RR 2.73 (2.08, 3.58)] were associated with the higher risk of developing severe perineal lacerations. Mediolateral episiotomy did not increase, but was also not protective against perineal lacerations [RR 1.55 (0.95, 2.53)]. Several factors contribute to the development of severe perineal lacerations. The present meta-analysis presents accumulated data that may help physicians estimate risks and provide appropriate patient counseling.

Predictors of obstetric anal sphincter injury during waterbirth: a secondary analysis of a prospective observational study

INTRODUCTION AND HYPOTHESIS

Obstetric anal sphincter injury (OASI) during childbirth is associated with urino-genital pain and dysfunction. Waterbirth is a popular birth choice for women, but controversy remains around the risk of OASI during waterbirth. This study reports on the incidence of OASI, and factors associated with OASI, for a cohort of women who gave birth in water.

METHODS

This secondary analysis used prospectively collected data from 2,908 women who gave birth in water in a hospital setting. The incidence of OASI was calculated. Univariable and multivariable logistic regression analysis evaluated factors associated with OASI.

RESULTS

The incidence of OASI was 1.9% (95% confidence interval (CI) 1.4, 2.4) for all women. In nulliparae it was higher (3.2%, 95% CI 2.3, 4.3) than in multiparae (0.9%, 95% CI 0.5, 1.4). In the multivariable analysis, two variables were associated with OASI; multiparity was negatively associated with OASI (adjusted odds ratio [aOR] 0.24, 95% CI 0.12, 0.50, p < 0.001), and birth weight was positively associated with OASI (aOR 1.001, 95% CI 1.000, 1.002, p = 0.02). A "hands-on" technique was used during only 13% of births. A birth position supporting a flexible sacrum did not influence OASI risk.

CONCLUSIONS

A low incidence of OASI was found for this cohort of women. The low proportion of midwives using a hands-on technique suggests that it may not be required in waterbirth.

The impact of maternal body mass index on the rate of obstetric anal sphincter injury in nulliparous women: A Victorian retrospective cohort study

BACKGROUND

Maternal obesity is an important comorbidity in contemporary obstetrics practice and is associated with significantly increased perinatal complications. Obstetric anal sphincter injury (OASIS) sustained during labour can lead to faecal incontinence, chronic pain and effects on quality of life. Currently, it is unclear if maternal body mass index (BMI) influences the risk of sustaining OASIS.

AIM

To investigate the impact of increased BMI on the rate of OASIS among nulliparous women.

MATERIALS AND METHODS

A retrospective cohort study was conducted, which included nulliparous women with singleton, vaginal deliveries ≥37 weeks gestation at a Victorian regional centre between 2007 and 2017 (n = 3335). Logistic regression was performed to calculate unadjusted and adjusted odds ratios (aOR). Women were grouped by World Health Organization BMI categories, and the rates of OASIS were evaluated.

RESULTS

Women with a BMI ≥ 25 were significantly less likely to develop OASIS compared to women with a BMI < 25 (aOR 0.60, 95% CI 0.41-0.89). Women with a BMI ≥ 35 had significantly decreased odds of OASIS compared to normal weight women (aOR 0.27, 0.10-0.78). While not statistically significant, the odds of OASIS decreased with each increase in BMI class. Other statistically significant risk factors were maternal age, birth weight, forceps delivery, non-smokers (aOR 4.03, 1.46-11.1) and diabetes mellitus (aOR 9.48, 2.1-41.4).

CONCLUSION

Women with a BMI ≥ 25 were less likely to sustain OASIS compared to women with a BMI < 25. Furthermore, the odds of OASIS decreased for each increase in BMI category. These findings warrant further investigation into the mechanism of this protective effect.

A review and comparison of common maternal positions during the second-stage of labor

The second-stage of labor is the most stressful part of childbirth process and the proper maternal position during this period is paramount for women's safe vaginal birth. Midwives play a pivotal role in managing maternal positions during the second-stage of labor. However, there is limited evidence to support an ideal maternal position during the second-stage of labor. Further, the difference between different maternal positions might not be apparent. This paper aims to review and compare the benefits and risks of common maternal positions during the second-stage of labor, thereby to provide midwives evidence-based practical guidelines.

Interdelivery Interval and Diabetes Mellitus in a Subsequent Pregnancy

OBJECTIVE

We determined whether time between deliveries is associated with developing diabetes at the time of a subsequent delivery.

STUDY DESIGN

This is a case-control study of women who had two consecutive singleton births at the same institution with no pregestational diabetes in the baseline pregnancy. Cases were defined as women who were diagnosed with any type of diabetes at the time of the subsequent delivery. Controls were defined as women who had no diagnosis of diabetes at the time of the subsequent delivery. Interdelivery interval (IDI) was categorized as < 18, 18 to 60, or > 60 months.

RESULTS

Of 12,263 women, 4.1% (N = 501) were diagnosed with diabetes at the subsequent delivery. Women with diabetes were more likely to have an IDI of >60 months than women without diabetes (9.0 vs. 4.2%, p < 0.001). After controlling for confounding factors, an IDI > 60 months remained associated with development of pregestational or gestational diabetes by the conclusion of the subsequent pregnancy (adjusted odds ratio = 2.13 compared with an IDI of 18-60 months, 95% confidence interval 1.44-3.15).

CONCLUSION

A longer IDI is an independent risk factor for the development of diabetes at the time of a subsequent delivery.

The effect of the first vaginal birth on pelvic floor anatomy and dysfunction

Introduction and hypothesis

First vaginal delivery severely interferes with pelvic floor anatomy and function. This study determines maternal and pregnancy-related risk factors for pelvic floor dysfunction (PFD), including urinary incontinence (UI), urgency, anal incontinence (AI), pelvic organ prolapse (POP) and levator ani muscle (LAM) avulsion.

Methods

This is a single-centre prospective observational cohort study on healthy women in their first singleton pregnancy. All underwent clinical and 3D transperineal ultrasound examination at 6 weeks and 12 months postpartum. Objective outcomes were POP-Q and presence or absence of LAM trauma. Functional outcomes were measured by the ICIQ-SF and PISQ 12. Multivariate regression was performed to determine birth and maternal habitus-related risk factors for UI, urgency, AI, dyspareunia, LAM avulsion and ballooning.

Results

Nine hundred eighty-seven women were included. Risk factors for UI were maternal age per year of age (OR: 1.09; 95% CI: 1.04–1.13; p = 0.0001) and BMI before pregnancy (OR: 1.08; 95% CI: 1.04–1.13; p = 0.001); for POP stage II+ maternal age (OR: 1.08; 95% CI: 1.08–1.14; p = 0.005). Avulsion was more likely after forceps (OR: 3.22; 95% CI:1.54–8.22; p = 0.015) but less likely after epidural analgesia (OR: 0.58; 95% CI: 0.37–0.90; p = 0.015) and grade I perineal rupture (OR: 0.50; 95% CI: 0.29–0.85; p = 0.012). Ballooning was more likely at increased maternal age (OR: 1.08; 95% CI: 1.02–1.13; p = 0.005), epidural (OR: 1.64; 95% CI: 1.06–2.55; p = 0.027) and grade I perineal rupture (OR: 1.79; 95% CI: 1.10–2.90; p = 0.018).

Conclusion

Though maternal characteristics at birth such as age or BMI increase the risk of PFD, labour and birth factors play a similarly important role. The most critical risk factor for MLA avulsion was forceps delivery, while an epidural had a protective effect.

Electronic supplementary material

The online version of this article (10.1007/s00192-019-04044-2) contains supplementary material, which is available to authorized users.

Diabetes distress is associated with adverse pregnancy outcomes in women with gestational diabetes: a prospective cohort study

BACKGROUND

Around 12% of pregnant women develop gestational diabetes mellitus (GDM), which is associated with increased health risks for both mother and child and pre- and postpartum depression. Little is known about the relationship of GDM with diabetes-specific emotional distress (diabetes distress). The aims of this study are to assess the prevalence of diabetes distress in GDM and its association with adverse pregnancy outcomes.

METHODS

A prospective cohort study was carried out in an Amsterdam based teaching hospital with an ethnic diverse population. Women diagnosed with GDM completed a set of questionnaires at three time points. Questionnaires consisted of Problem Areas in Diabetes Scale 5 (PAID-5) for diabetes distress (T0-T1), Patient Health Questionnaire 9 (PHQ-9) for depressive symptoms (T0-T2), and questions to assess adverse pregnancy outcomes (T2). Adverse pregnancy outcomes (collected via self-report and if feasible from the medical records) were defined as hypertension, pre-eclampsia, caesarean section, severe perineal tearing, postpartum hemorrhage, postpartum depression, shoulder dystocia, neonatal hospitalization, macrosomia, jaundice, hypoglycemia and other (among which low heart rate, fever, hypoxia). Adverse pregnancy outcomes were dichotomized into none and 1 or more. Additional information was collected from the medical charts. Missing data were imputed via predictive mean matching and a multivariable logistic regression analysis was performed with diabetes distress, depressive symptoms, socioeconomic status, parity and ethnicity as predictors and age, HbA1c, and BMI as covariates.

RESULTS

A total of 100 women were included, mean age 32.5 (4.1), mean BMI 26.7 (4.8), 71% were of non-Dutch ethnic background. Elevated diabetes distress (PAID score ≥ 8) was reported by 36% of the women. Multivariable logistic regression analyses revealed that both high diabetes distress (OR 4.70, p = .02) and parity (OR 0.21, p = .02) but not antepartum depressive symptoms were related to adverse pregnancy outcomes.

CONCLUSIONS

Diabetes distress is likely in women with GDM and our findings suggest an association between both diabetes distress, parity and adverse pregnancy outcomes in women with GDM. This warrants replication and further research into the underlying mechanisms explaining the impact of diabetes distress in GDM and potential interventions to reduce distress.

Intact Perineum: What are the Predictive Factors in Spontaneous Vaginal Birth?

Introduction

Perineal trauma at birth is distressing for women and can cause serious short and long term morbidity.

Aim

Investigate the prevalence and predictive factors of intact perineum after normal vaginal birth among Portuguese women who had spontaneous vaginal births.

Methods

A descriptive, cross-sectional, retrospective study was carried out among pregnant women who had spontaneous vaginal births, between January 1, 2017, and December 31, 2017, in a single birth centre in Portugal. Following ethical approval, the prevalence of intact perineum was calculated and multivariate analysis with logistic regression was carried out, to identify the predictive factors of having an intact perineum after spontaneous vaginal birth.

Results

A total of 1748 pregnant women had spontaneous vaginal births. Four hundred and forty-one women (25.2%) had intact perineum whereas in 1307 (74.8%) of women, the perineum was not intact. First-degree tears occurred in 23.2% (405/1748) of women, second-degree tears occurred in 4% (70/1748) of women while three women (0.2%) experienced a third-degree tear. The rate of episiotomies was 43.8% (766/1748). Episiotomy and first-degree tears occurred in 2.6% (45/1748), episiotomy and second-degree tears occurred in 0.7% (12/1748), while episiotomy and third-degree tears occurred in 0.3% (6/1748) of women. Having a previous caesarean section reduced the odds of intact perineum by 60%, while nulliparity reduced the odds by 70%. For every 250 grams increase in birth weight, the odds of sustaining an intact perineum were decreased by 13%. Alternative birth positions (excluding lithotomy) doubled the odds of maintaining an intact perineum.

Conclusion

The prevalence of intact perineum is 25,2%. Predictive factors for intact perineum include birth weight, parity, previous caesarean section and birthing position. Recognizing these factors could support and facilitate the management of spontaneous vaginal birth to promote an intact perineum. Further research is needed to gain better understanding of this phenomenon.

Obstetric perineal tears: risk factors, wound infection and dehiscence: a prospective cohort study

PURPOSE

To assess risk factors for perineal tears, wound infection and dehiscence among primiparous women.

METHODS

A prospective cohort study at four Danish hospitals (Odense, Esbjerg, Aarhus and Kolding) among 603 primiparous women sampled in three groups: 203 with none/labia/1st degree, 200 with 2nd degree, and 200 with 3rd/4th degree tears included between July 2015 and January 2018. Baseline data were obtained and a clinical examination of perineal wound healing was performed 11-21 days postpartum. Main outcome measurements were as follows: degree of perineal tear, 1st to 4th, analyzed with a case-control approach, infection (purulent drainage or wound abscess), and wound dehiscence (a gap between wound edges > 0.5 cm).

RESULTS

Instrumental delivery and birthweight > 4000 g increased the risk of 3rd/4th degree tears (adjusted Odds Ratio [aOR] 13.7, 95% confidence interval [CI] 5.48-34.1 and aOR 3.27, 95% CI 1.52-7.04, respectively). BMI > 35 kg/m² increased the risk of wound infection and dehiscence (aOR 7.66, 95% CI 2.13-27.5 and aOR 3.46, 95% CI 1.10-10.9, respectively). Episiotomy tripled the risk of infection (aOR 2.97, 95% CI 1.05-8.41). Treatment with antibiotics during delivery and postpartum seemed to decrease the risk of dehiscence (aOR 0.32, 95% CI 0.15-0.70).

CONCLUSIONS

Instrumental delivery and high birth weight increased the risk of perineal tears. Severe obesity and episiotomy increased the risk of perineal wound complications. More focus on these women may be warranted postpartum. The use of prophylactic antibiotics among women in high risk of wound complications should be further investigated in interventional studies.

PERINEAL CARE AND OUTCOMES IN A BIRTH CENTER

ABSTRACT Objective: to analyse the perineal outcomes in childbirth and post-partum perineal care in a freestanding birth centre. Method: a cross-sectional study, with data collection performed in the women’s birth records forms from Casa Angela, a freestanding birth centre, São Paulo, Brazil, in 2016-2017 (n=415). The following data was analysed: occurrence and perineal tear degree; maternal, neonatal and birth care-related variables; perineal suture prevalence; complications in wound healing and natural methods on perineal care. Data were subjected to descriptive, inferential and multiple analyses. Results: in 11.8% of women, the perineum was kept intact, 61.9% had spontaneous first-degree tear and 26.3% had second-degree tear. The variables related to the occurrence and higher spontaneous degree tears were maternal age and second period of childbirth >2 hours. The protective factors against the occurrence and higher degree tears were number of previous vaginal childbirths and maternal position different from vertical during childbirth. Perineal suture was performed in 16.0% and 70.6% of women with spontaneous first- and second-degree tears, respectively. The main perineal complications after birth were edema (53.6%) and pain (29.4%); and the perineal suture increased the chance for these complications (OR=2.5; 95%CI 1.5-4.3). Perineum icepack compress was used in 53.8% of women during post-partum period. Conclusion: maternal and health-care related factors were associated to the prevalence and degree of spontaneous perineal tear. First-degree spontaneous perineal tears were prevalent and sutured in a low number of women. There were more complications in the wound healing process when the perineal suture was performed, regardless the tear degree. The number of natural methods in post-partum perineal care was higher than the use of medicines.

Diabetes Mellitus and lower genital tract tears after vaginal birth: A cohort study

INTRODUCTION

Diabetes Mellitus in pregnancy is increasing. No existing studies have examined Diabetes Mellitus as the primary exposure for lower genital tract tears after vaginal birth. The objective was to study the association between Diabetes Mellitus (all types combined), Type 1 Diabetes Mellitus, Type 2 Diabetes Mellitus and Gestational Diabetes Mellitus and lower genital tract tears after vaginal birth.

MATERIAL AND METHODS

A register-based cohort study of women with singleton pregnancy and without a previous cesarean section at near-term (≥ 35 + 0 weeks) and term (≥ 37 + 0 weeks) gestational age, n = 31,297 at Aarhus University Hospital, Denmark from 1 January 2004 to 31 December 2012. The associations between Diabetes Mellitus and lower genital tract tears were analysed using a fixed multiple logistic regression analyses.

RESULTS

Approximately 32,000 women were eligible for the study; 796 women had diabetes (2.5%) and 1318 experienced anal sphincter injury (4.3%). The overall risk of lower genital tract tears was similar among women with a diagnosis of diabetes (Type1 Diabetes Mellitus, Type 2 Diabetes Mellitus, and Gestational Diabetes Mellitus) compared to women without diabetes, except for nulliparous women with Type1 Diabetes Mellitus who experienced a higher risk of episiotomies, crude and adjusted odds ratios (OR 2.13, 95% CI 1.14-3.97) and (OR 2.48, 95% CI 1.21-5.10), respectively.

CONCLUSIONS

Women with Diabetes Mellitus without a previous cesarean section who gave birth vaginally to a single child at term or near term did not experienced an increased risk of lower genital tract tears. However, nulliparous women with Type 1 Diabetes Mellitus experienced a higher risk of episiotomy. These results may be used to individualised counselling of women with Diabetes Mellitus regarding mode of birth and may reduce worries about genital tract tears in women with Diabetes Mellitus considering vaginal birth.

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

OBJECTIVES

The aim of this review was to agree on a definition of the obstetric anal sphincter injuries (OASIS), to determine the prevalence and risk factors.

METHODS

A comprehensive review of the literature on the obstetric anal sphincter injuries (OASIS), establishment of levels of evidence (NP), and grades of recommendation according to the methodology of the recommendations for clinical practice.

RESULTS

To classify obstetric anal sphincter injuries (OASIS), we have used the WHO-RCOG classification, which lists 4 degrees of severity. To designate obstetric anal sphincter injuries, we have used the acronym OASIS, rather than the standard French terms of "complete perineum" and "complicated complete perineum". OASIS with only isolated involvement of the EAS (3a and 3b) appears to have a better functional prognosis than OASIS affecting the IAS or the anorectal mucosa (3c and 4) (LE3). The prevalence of women with ano-rectal symptoms increases with the severity of the OASIS (LE3). In the long term, 35-60% of women who had an OASIS have anal or fecal incontinence (LE3). The prevalence of an OASI in the general population is between 0.25 to 6%. The prevalence of OASIS in primiparous women is between 1.4 and 16% and thus, should be considered more important than among the multiparous women (0.4 to 2.7%). In women with a history of previous OASIS, the risk of occurrence is higher and varies between 5.1 and 10.7% following childbirth. The priority in this context remains the training of childbirth professionals (midwives and obstetricians) to detect these injuries in the delivery room, immediately after the birth. The training and awareness of these practitioners of OASIS diagnosis improves its detection in the delivery room (LE2). Professional experience is associated with better detection of OASIS (LE3) (4). Continuing professional education of obstetrics professionals in the diagnosis and repair of OASIS must be encouraged (Grade C). In the case of second-degree perineal tear, the use of ultrasound in the delivery room improves the diagnosis of OASIS (LE2). Ultrasound decreases the prevalence of symptoms of severe anal incontinence at 1 year (LE2). The diagnosis of OASIS is improved by the use of endo-anal ultrasonography in post-partum (72h-6weeks) (LE2). The principal factors associated with OASIS are nulliparity and instrumental (vaginal operative) delivery; the others are advanced maternal age, history of OASIS, macrosomia, midline episiotomy, posterior cephalic positions, and long labour (LE2). The presence of a perianal lesion (perianal fissure, or anorectal or rectovaginal fistula) is associated with an increased risk of 4th degree lacerations (LE3). Crohn's disease without perianal involvement is not associated with an excess risk of OASIS (LE3). For women with type III genital mutilation, deinfibulation before delivery is associated with a reduction in the risk of OASIS (LE3); in this situation, deinfibulation is recommended before delivery (grade C).

CONCLUSION

It is necessary to use a consensus definition of the OASIS to be able to better detect and treat them.

A comparative study of obstetric anal sphincter injuries in vaginal deliveries of twins and singleton pregnancies

AIMS

Increasing numbers of twin pregnancies necessitate investigation of the risk factors associated with obstetric anal sphincter injuries (OASIS). The aims of this study were to establish the incidence of OASIS, and compare women delivering twins to those delivering singletons in risk of OASIS plus maternal, neonatal, and obstetric outcomes.

METHODS

A retrospective cohort study was undertaken and included women delivering in a tertiary London maternity unit between 1999 and 2015; 51 957 eligible women with singleton and 261 with twin pregnancies were identified. Women delivering twins were compared to those delivering singletons in the occurrence of maternal, neonatal, and obstetric outcomes using unadjusted relative risks. A secondary analysis was performed, and conditional logistic regression used to derive an adjusted relative risk of OASIS. Women delivering singletons were matched to those delivering twins for age, parity, ethnicity, gestation, and mode of delivery in a ratio of 2:1.

RESULTS

Compared to the singleton group, mothers delivering twins had significantly more instrumental deliveries (RR [95%CI] 1.92 [1.67-2.27]; P < 0.0001), smaller fetuses (2754.1 vs 3383.8 g; P < 0.001), and were older (32.9 vs 31.0 years; P < 0.0001). The twin group was not significantly different to the singleton group in risk of OASIS (RR 0.61 [0.27-1.33], P = 0.205). The conditional logistic regression demonstrated similar results for the risk of OASIS (adjusted RR = 0.58 [0.22-1.47]; P = 0.253).

CONCLUSIONS

Women delivering twins vaginally were not at a significantly higher risk of sustaining OASIS compared to those delivering singletons.

Applying a Midwifery-Specific Decision-Making Tool to Midwives’ Clinical Reasoning and Midwifery Practice When Managing a Woman’s Perineum in Labor: An Exploratory Study

Introduction: Many of the risk factors for perineal trauma are modifiable, and midwives are in an ideal position to mitigate such risks. To date, no investigation using a midwifery-specific decision-making tool has sought to determine how midwives make decisions within a midwifery philosophy/context or identify the factors that may contribute to that decision making about perineal management. We sought to apply such a tool to midwives’ narratives and explore their clinical reasoning and midwifery practice when managing a woman’s perineum in labor.

Methods: A qualitative interview-based study with practicing midwives in one regional Australian maternity unit was conducted. The decision-making matrix specified by a psychometrically robust and validated measure of clinical decision making and midwifery practice-guided analysis.

Results: Effective clinical decision making in response to perineal trauma is contingent on a heuristic and individualized “working hypothesis” that combines distinct elements of an optimal clinical decision-making process. Midwives’ narratives highlighted their ability to engage in some form of clinical reasoning. Some elements of midwifery practice was lacking within several midwives’ narratives, thus resulting in them abdicating their professional role.

Conclusion: The manner and processes by which midwives engage effectively with perineal management are complex. However, a significant influence on this process appears to be recollections from original training in perineal management, which appears to be largely rote and taught by example. We recommend balance between practical experience and synthesis with current evidence within a midwifery philosophy to optimize perineal care and risk modification.

Factors associated with obstetric anal sphincter injuries in midwife-led birth: A cross sectional study

INTRODUCTION

Obstetric anal sphincter injurie (OASI) in vaginal births are a serious complication, and are associated with maternal morbidity. Focus on modifiable factors in midwives clinical skills and competences contributing to prevent the occurrence of OASI are essential. The objective of this study was to investigate the association between OASI and factors related to midwife-led birth such as manual support of perineum, active delivery of baby's shoulders, maternal birth position, and pushing and breathing techniques in second stage of labour.

METHODS

A prospective cross sectional study including primiparous (n = 129) and multiparous (n = 628) women in midwife-led non-instrumental deliveries with OASI (n = 96) or intact perineum (n = 661). Data were collected in a university hospital in Norway with two different birth settings: an alongside midwife-led unit with approximately 1500 births per year and an obstetrical unit with approximately 3500 births per year. In midwife-led births, there were a total of 2.6% OASI and 18.9% intact perineum.

RESULTS

The sample consisted of 757 women, 12.7% suffered OASI and 87.3% of participating women had an intact perineum. This selected sample compares the most serious outcome (OASI), and the optimal outcome (intact perineum).In primiparous women, 61 women suffered OASI and 68 women had intact perineum, while for multipara women, 35 women suffered OASI and 593 women had intact perineum. There was an increased risk of OASI if women actively pushed when the head was crowning compared to breathing the head out (adjusted OR: 3.10; 95% CI: 1.75 to 5.47). The maternal birth position associated with the lowest risk of OASI was kneeling position (adjusted OR: 0.15; 95% CI: 0.03 to 0.70), supine maternal birth position (adjusted OR: 2.52; 95% CI: 1.04 to 4.90) and oxytocin augmentation more than 30 min in second stage (OR: 1.93; 95% CI: 1.68 to 15.63) were associated with an increased risk of OASI, when adjusting for maternal, foetal, and obstetric factors.

CONCLUSION

Our study suggests that actively pushing when the baby's head is crowning, a supine maternal birth position and oxytocin augmentation more than 30 min in second stage, were associated with increased risk of OASI when compared to intact perineum. A kneeling maternal birth position was associated with a decreased risk of OASI.

Episiotomy and perineal tear risk factors in a group of 4493 women

Episiotomy belongs to the most frequent procedures carried out during delivery. Performing episiotomy should be reduced as there is scientific evidence indicating that it can cause pain, sexual problems, and serious, long-term health consequences. The aim of the researchers is to identify factors associated with episiotomy and the perineal tear. Analyses were performed using a model of a logistic regression. The study involved 4493 women. The episiotomy risk was related to: a birth weight exceeding 3500 grams, an instrumental delivery by means of forceps or vacuum extraction. The decrease of episiotomy rate increased the rate of perineal tear of first and second degree. The study has shown that episiotomy protects women from third- and fourth-degree perineal tear.

Humanized Care: insertion of obstetric nurses in a teaching hospital

Objective:

to evaluate the care provided at an Antepartum, Intrapartum, Postpartum (AIP) unit at a teaching hospital following the inclusion of obstetric nurses.

Method:

transversal study, performed at a AIP unit at a teaching hospital in the capital of the Brazilian state of Mato Grosso. The sample comprised data regarding the 701 childbirths that took place between 2014 and 2016. The data were organized using Excel and analyzed using version 7 of Epi Info software.

Results:

the results suggest that including obstetric nurses contributed towards qualifying the care provided during labor and childbirth, followed by a reduction in the number of interventions, such as episiotomy caesareans sections, and resulting in encouragement to employ practices that do not interfere in the physiology of the parturition process, which in turn generate good perinatal results.

Conclusion:

inserting these nurses collaborated towards humanizing obstetric and neonatal care.

Urgent EMS managed out-of-hospital delivery dispatches in Helsinki

BACKGROUND

The aim of this study was to examine Helsinki Emergency Medical Services (EMS) and hospital records to determine the incidence and possible complications of out-of-hospital deliveries managed by EMS in Helsinki.

METHODS

We retrospectively analysed all urgent ambulance dispatches relating to childbirth in Helsinki from January 1, 2010 to December 31, 2014 with further analysis of hospital records for the out-of-hospital deliveries. Patients were divided in to two groups: those who delivered before reaching hospital and those who did not deliver before reaching hospital and differences between groups were analysed. Deliveries with gestational age of at least 22 + 0 weeks were considered as births in statistical analysis as this is the current national practice.

RESULTS

There were 799 urgent dispatches during the study period. In 102 (12.8 %) of these delivery took place before reaching the hospital. The incidence of EMS managed out-of-hospital delivery was found to be 3.0/1000 births. The annual number of out-of-hospital deliveries attended by EMS increased from 15 in 2010 to 28 in 2014. No stillbirths were reported. Neither maternal or perinatal deaths nor major maternal complications were noted in the study population.

DISCUSSION

Out-of-hospital deliveries represent a small minority of EMS calls and remain a challenge to maintaining professional capabilities. Small sample size might have limited the ability of the study to pick up rare complications.

CONCLUSIONS

The amount of out-of-hospital deliveries in Helsinki increased during the five-year study period. There were no maternal or perinatal mortality or major complications resulting in long-term sequelae associated with the EMS-managed out-of-hospital births.

Episiotomy and its relationship to various clinical variables that influence its performance

OBJECTIVE

to understand the episiotomy rate and its relationship with various clinical variables.

METHOD

a descriptive, cross-sectional, analytic study of 12,093 births in a tertiary hospital.

VARIABLES

Parity, gestational age, start of labor, use of epidural analgesia, oxytocin usage, position during fetal explusion, weight of neonate, and completion of birth. The analysis was performed with SPSS 19.0.

RESULTS

the global percentage of episiotomies was 50%. The clinical variables that presented a significant association were primiparity (RR=2.98), gestational age >41 weeks (RR=1.2), augmented or induced labor (RR=1.33), epidural analgesia use (RR=1,95), oxytocin use (RR=1.58), lithotomy position during fetal expulsion (RR=6.4), and instrumentation (RR=1.84). Furthermore, maternal age ≥35 years (RR=0.85) and neonatal weight <2500 g (RR=0.8) were associated with a lower incidence of episiotomy.

CONCLUSIONS

episiotomy is dependent on obstetric interventions performed during labor. If we wish to reduce the episiotomy rate, it will be necessary to bear in mind these risk factors when establishing policies for reducing this procedure.

Episiotomy and its relationship to various clinical variables that influence its performance

Objective:

to understand the episiotomy rate and its relationship with various clinical variables.

Method:

a descriptive, cross-sectional, analytic study of 12,093 births in a tertiary hospital. Variables: Parity, gestational age, start of labor, use of epidural analgesia, oxytocin usage, position during fetal explusion, weight of neonate, and completion of birth. The analysis was performed with SPSS 19.0.

Results:

the global percentage of episiotomies was 50%. The clinical variables that presented a significant association were primiparity (RR=2.98), gestational age >41 weeks (RR=1.2), augmented or induced labor (RR=1.33), epidural analgesia use (RR=1,95), oxytocin use (RR=1.58), lithotomy position during fetal expulsion (RR=6.4), and instrumentation (RR=1.84). Furthermore, maternal age ≥35 years (RR=0.85) and neonatal weight <2500 g (RR=0.8) were associated with a lower incidence of episiotomy.

Conclusions:

episiotomy is dependent on obstetric interventions performed during labor. If we wish to reduce the episiotomy rate, it will be necessary to bear in mind these risk factors when establishing policies for reducing this procedure.

Antenatal body mass index (BMI) and weight gain in pregnancy - its association with pregnancy and birthing complications

BACKGROUND

Overweight and obesity is a serious health risk in both developed and developing nations. It is a common finding among women in their reproductive age. Half of patients entering their pregnancy in the US have a BMI >25.0 and therefore qualify as overweight or obese. Moreover, there is a tendency towards increased weight gain during pregnancy. Studies have shown that gestational overweight is associated with complications in pregnancy and birthing as well as short-term and long-term impacts on neonatal outcome in childhood and adulthood.

METHODS

Five hundred and ninety-one women visiting our tertiary perinatal center in 2014 were analyzed for antenatal BMI, gestational weight gain, as well as pregnancy outcome and complication together with neonatal weight and outcome. Pregnancy weight gain was assessed based on the IOM guidelines (Institute of Medicine) issued in 2009.

RESULTS

Twenty-nine percent of our population was overweight with a BMI of more than 25.0. The general weight gain was in every BMI group similar (median ranging from 12.0 to 14.0 kg). Approximately one third gained more than the appropriate amount (37%, P<0.001). Women with more gestational weight were at risk of labor induction (55.0% vs. 45.7% labor induction in total, P=0.007). Strikingly, those patients were found to have significantly higher rates of secondary cesarean section (22.4% vs. 15.4%) and decreased chances of spontaneous vaginal birth (57.5% vs. 61.4%) (P=0.008). Furthermore women with a pregnancy weight gain in excess of the guidelines gave birth to neonates with a higher birth weight (>75.centile, 28.3% vs. 21.3%, P<0.001).

CONCLUSIONS

Altogether, one third of the analyzed population is already overweight or obese when entering pregnancy. A higher gestational weight gain than the recommended amount was found in 37% of cases. We found an association with pregnancy and birthing complications as well as higher infant weight. This highlights the importance of preconceptive and prenatal advice, and if necessary, intervention on BMI and weight gain.

Impact of Bacterial Vaginosis on Perineal Tears during Delivery: A Prospective Cohort Study

Objective

Long term effects of perineal tears pose a major worldwide health issue for women during delivery. Since bacterial vaginosis is related to major obstacles in obstetrics the aim of this study was to determine the relationship between bacterial vaginosis and the occurrence of perineal tears during vaginal delivery.

Methods

Between June 2013 and December 2013 pregnant women delivering after 37 weeks were recruited at one University hospital / tertiary care referral center in the course of this single-center, prospective cohort study. Bacterial vaginosis was assessed according to Nugent score method. Logistic-regression model was used to estimate odds ratios, adjusted for other risk factors to test the relationship between bacterial vaginosis and the occurrence of 1st to 4th degree perineal tears in women undergoing vaginal delivery.

Results

A total of 728 woman were included, 662 analyzed with a complete Nugent Score of the vaginal swab. The prevalence of 1st to 4th degree perineal tears was 35.8% (95% Confidence Interval (95%CI) = [32.2; 39.6]). The presence of BV was not significantly associated to the incidence of perineal tears neither in the univariate analysis (crude Odds Ratio = 1.43; 95%CI = [0.79; 2.60]; p = 0.235) nor in the multivariate analysis (adjusted Odds Ratio = 1.65; 95%CI = [0.81; 3.36]; p = 0.167). Instrumental delivery was the most important risk factor for perineal lacerations.

Conclusions

There is no evidence that vaginosis is a risk factor for vaginal tears.

Trial Registration

ClinicalTrials.gov N° NCT01822782