Factors associated with spontaneous perineal lacerations in deliveries without episiotomy in a university maternity hospital in the city of Recife, Brazil: a cohort study

Prevalence and factors associated with the perception of perineal laceration: a cross-sectional study with data from the Nascer no Brasil Survey, 2011 and 2012

OBJECTIVE

To describe the prevalence of perineal laceration, based on the self-reported perception of postpartum women, and to analyze factors associated with its occurrence in Brazil.

METHODS

This was a cross-sectional study conducted with 23,894 postpartum women, excluding twin pregnancies, cesarean sections, and births with episiotomies, between 2011 and 2012. Prevalence ratios (PR) and 95% confidence intervals (95%CI) of association between the event and maternal, fetus/newborn, obstetric and clinical management characteristics were estimated in hierarchical Poisson regression models.

RESULTS

Out of 4,606 postpartum women, 49.5% (95%CI 46.1;42.9) self-reported perineal laceration. Being an adolescent (PR = 1.12; 95%CI 1.02;1.25), primipara (PR = 1.47; 95%CI 1.33;1.63), having had excessive gestational weight gain (PR = 1.17; 95%CI 1.07;1.29) and having undergone the Kristeller maneuver (PR = 1.18; 95%CI 1.08;1.29) increased the proportion of the outcome.

CONCLUSION

The results found call for prenatal care and adjustments to childbirth care so as to be in accordance with current recommendations.

MAIN RESULTS

Prevalence of self-reported perineal laceration was 49.5%. Being in the adolescent age group, primiparity, excessive gestational weight and the Kristeller maneuver were risk factors associated with the event.

IMPLICATIONS FOR SERVICES

Studying self-reported prevalence of perineal laceration supports new care practices, highlights the prevention of risk factors considered modifiable and confirms the need to follow current guidelines.

PERSPECTIVES

New national studies are needed comparing prevalence of self-reported perineal laceration with that recorded in medical records in order to support care practices and public obstetric policies.

The infection, cervical and perineal lacerations in relation to postpartum hemorrhage following vaginal delivery induced by Cook balloon catheter

OBJECTIVE

To identify whether infection, cervical laceration and perineal laceration are associated with postpartum hemorrhage in the setting of vaginal delivery induced by Cook balloon catheter.

MATERIALS AND METHODS

The retrospective study included 362 women who gave birth vaginally at or beyond 37 weeks of gestation with a diagnosis of postpartum hemorrhage between February 2021 to May 2022, of which including 216 women with induction of labor (Cook balloon catheter followed by oxytocin or oxytocin) and 146 women with spontaneous delivery. Risk factors for postpartum hemorrhage were collected and compared.

RESULTS

362 women were divided into three groups, group 1 with spontaneous delivery, group 2 with oxytocin, group 3 with Cook balloon catheter followed by oxytocin. There was no significant difference in incidence of infection within three groups (P > 0.05). The rate of cervical laceration and perineal laceration was significantly higher in group 3 compared with groups 2 and 1 (P < 0.05); Multivariate logistic regression analysis found that compared with group 1, either group 3 or group 2 was associated with increased risks of cervical laceration and perineal laceration (P < 0.05), and compared with group 2, group 3 was not associated with increased risks of cervical laceration and perineal laceration (P > 0.05).

CONCLUSION

Infection, cervical laceration and perineal laceration are identified not to be independent risk factors for postpartum hemorrhage for women undergoing labor with Cook balloon catheter; Cervical laceration and perineal laceration increase the risk of postpartum hemorrhage in women with labor induction.

Measurement of perineal tears as an additional tool for laceration assessment during vaginal birth

INTRODUCTION

Spontaneous lacerations at vaginal birth are everyday events, but their classification and management still challenge midwifery care. This study aims to measure and describe first-degree and second-degree perineal lacerations resulting from vaginal birth, describe their repair, and the education provided for care.

METHODS

A descriptive study was conducted in a public maternity hospital in São Paulo, Brazil, with 87 parturients. Data were collected between October 2017 and June 2018 using a structured instrument containing obstetric variables and a description of lacerations. The obstetricians and nurse midwives assisted with births, determining the degree of laceration and intervention, and the researchers measured and reported them.

RESULTS

The majority of parturients (82.7%) had lacerations only in the anterior region, 8% had them in the posterior region, and 9.2% in both regions. The lacerations were classified as first-degree (78.1%) or second-degree (21.8%). Among the 32 nulliparous parturients, 27.6% had first-degree lacerations, and 9.2% had second-degree. Of the 55 multiparous parturients, 50.6% had first-degree, and 12.6% had second-degree. Among the lacerations assessed as first-degree, 25% had deeper tissue layers compromised in addition to the skin and mucosa. There were 180 lacerations, with an average length of 33.1 mm, depth of 19.8 mm, and width of 23.8 mm. Half of the parturients did not receive guidance on laceration care. There was no association between parity and size, number, location, or degree classification of lacerations.

CONCLUSIONS

This study provides a broad description of the characteristics of perineal lacerations and presents measurement techniques as a complementary resource for evaluating lacerations.

Vocalization during the second stage of labor to prevent perineal trauma: A randomized controlled trial

BACKGROUND AND PURPOSE

Most women suffer some degree of perineal trauma during vaginal delivery. Second stage management strategies, including vocalization, to protect the perineum have been investigated.

OBJECTIVE

To compare the frequency and degree of perineal trauma at vaginal delivery, with and without use of the vocalization maneuver during the second stage of labor.

MATERIALS AND METHODS

This is an open-label, randomized controlled trial. We conducted the study at the Center for Normal Deliveries of IMIP. We included low-risk women without prior cesarean deliveries. Women who met the inclusion criteria and signed the informed consent form were randomized to one of two groups: Group A (experimental) and Group B (control). A physical therapist encouraged women in Group A to maintain an open glottis during pushing and to emit sounds when exhaling (vocalization). Women in Group B underwent routine humanized vaginal deliveries. The outcomes of the study were perineal integrity and degree of perineal laceration. These were measured by the study team immediately after completion of the third stage of labor.

RESULTS

Women in Group A tended to have less severe perineal tear (less second and third degree lacerations) and smaller lacerations than women in group B. The vocalization maneuver reduced the risk of a perineal tear greater than 2 cm by 68% (NNT 2.2). There was no difference in other outcomes.

CONCLUSION

Encouraging women to follow a vocalization protocol coached by a physical therapist during the second stage of labor can be a helpful labor assistance technique, since this study showed that vocalization is associated with less extensive perineal tears.

CLINICAL TRIAL REGISTRATION

This study was registered on ClinicalTrials.gov (www.

CLINICALTRIAL

gov) registration number: NCT03605615.

Perineal Lacerations: A Retrospective Study in a Habitual-Risk Public Maternity

OBJECTIVE

 In around 85% of vaginal births, the parturients undergo perineal lacerations and/or episiotomy. The present study aimed to determine the incidence of lacerations and episiotomies among parturients in 2018 in a habitual-risk public maternity hospital in southern Brazil, and to determine the risk and protective factors for such events.

METHODOLOGY

 A retrospective cross-sectional study. Data were obtained from medical records and analyzed using the Stata software. Univariate and multivariate logistic regressions were performed. Values of p < 0.05 were considered significant.

RESULTS

 In 2018, there were 525 vaginal births, 27.8% of which were attended by obstetricians, 70.7% by obstetric nurses, and 1.5% evolved without assistance. Overall, 55.2% of the parturients had some degree of laceration. The professional who attended the birth was a significant variable: a greater number of first- and second-degree lacerations, as well as more severe cases, occurred in births attended by nurses (odds ratio [OR]: 2,95; 95% confidence interval [95%CI]: 1,74 to 5,03). Positions at birth that did not enable perineal protection techniques (expulsive period with the "hands-off" method), when analyzed in isolation, determined the risk; however, in the final regression model, this relationship was not confirmed. Although reported in the literature, there were no associations between the occurrence of laceration and age, skin color, or birth weight. In 24% of the births, episiotomy was performed, and doctors performed 63.5% of them.

CONCLUSION

 Births attended by nurses resulted in an increased risk of perineal lacerations, of varying degrees. In turn, those assisted by physicians had a higher occurrence of episiotomy.

Can pelvic floor muscle training prevent perineal laceration? A systematic review and meta-analysis

BACKGROUND

Pelvic floor muscle training (PFMT) is reportedly able to reduce risk factors for perineal trauma. However, the effects of these exercises on perineal injuries are unclear.

OBJECTIVE

To investigate the effectiveness of PFMT in the prevention of perineal laceration.

SEARCH STRATEGY

Searches were conducted in PubMed/Medline, LILACS, Scopus, Cochrane Library, Web of Science, and CINAHL. For search strategies, we combined the terms PFMT, tear, laceration, perineum, and delivery.

SELECTION CRITERIA

We included randomized controlled trials that evaluated the effectiveness of PFMT for the prevention of perineal laceration during vaginal delivery. There were no period or language limitations.

DATA COLLECTION AND ANALYSIS

We conducted data extraction and synthesis. We performed a quality appraisal, a qualitative synthesis, and for meta-analysis we used the Software R.

MAIN RESULTS

Nine studies were included. In most studies, PFMT was performed daily, with a wide range of the number of contractions and sustainability. Prevalence of perineal laceration had a wide range and information on laceration degree was limited. Meta-analysis showed that PFMT was not effective to prevent perineal laceration.

CONCLUSION

Pelvic floor muscle training does not prevent perineal laceration. Further studies are needed to investigate different protocols and interventions.

Selective episiotomy versus no episiotomy for severe perineal trauma: a systematic review with meta-analysis

INTRODUCTION AND HYPOTHESIS

We hypothesized whether a non-episiotomy protocol or administration of selective episiotomy as an intrapartum intervention would modify the incidence of obstetric anal sphincter injuries (OASIS).

METHODS

We registered this systematic review with the PROSPERO database (CRD42018111018). Prospective randomized controlled trials (RCTs) were included from databases until February 2019. The primary outcome was OASIS, and the secondary outcomes were any perineal trauma, duration of the second stage of labor, instrumental delivery, and post-partum hemorrhage. The risk of bias (Cochrane Handbook) and the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria were used to assess the RCTs.

RESULTS

A total of 1,833 results (PubMed 650, SCOPUS 1,144, Cochrane Library 33, LILACS 6) were obtained. However, only 2 studies fulfilled the criteria for quantitative analysis and meta-analysis (n = 574). The non-episiotomy arm included two episiotomies (1.7% of deliveries), whereas the selective episiotomy included 33 episiotomies (21.4%). Performance of selective episiotomy demonstrated no difference compared with that of the non-episiotomy group with regard to OASIS (OR = 0.46 [0.15-1.39]; n = 543; I² = 0%,p = 0.17), any perineal trauma (OR = 0.90 [0.61-1.33]; I² = 0%, n = 546, p = 0.59), instrumental delivery (OR = 1.40 [0.80-2.45]; I² = 0%, n = 545, p = 0.24), duration of the second stage of labor (MD = -3.71 [-21.56, 14.14]; I² = 72%,n = 546, p = 0.68), perineal pain (MD = 0.59 [0.01-1.17]; I² = 0%,p = 0.05), and post-partum hemorrhage (OR = 1.75 [0.87-3.54]; I² = 0%,n = 546,p = 0.12). The evaluated studies displayed a low risk of bias in at least four of the seven categories analyzed. GRADE demonstrated a low certainty for severe perineal tears, postpartum hemorrhage, duration of the second stage of labor, and a moderate certainty for any perineal tear.

CONCLUSIONS

There was no significant difference between non-episiotomy and selective episiotomy regarding OASIS. No RCT was able to confirm a benefit of the non-performance of episiotomies in the non-episiotomy arm.

Perineal massage during labor: a systematic review and meta-analysis of randomized controlled trials

Background: Different techniques have been analyzed to reduce the risk of perineal trauma during labor.Objective: To evaluate whether perineal massage techniques during vaginal delivery decreases the risk of perineal trauma.Search strategy: Electronic databases (Medline, Prospero, Scopus, ClinicalTrials.gov, Embase, ScienceDirect, the Cochrane Library, SciELO) were searched from their inception until February 2018. No restrictions for language or geographic location were applied.Selection criteria: We included all randomized controlled trials (RCTs) comparing the use of perineal massage during labor (i.e. intervention group) with a control group (i.e. no perineal massage) in women with singleton gestation and cephalic presentation at ≥36 weeks. Perineal massage was defined as massage of the posterior perineum by the clinician's fingers (with or without lubricant). Trials on perineal massage during antenatal care, before the onset of labor, or only in the early part of the first stage, were not included.Data collection and analysis: All analyses were done using an intention-to-treat approach. The primary outcome was severe perineal trauma, defined as third and fourth degree perineal lacerations. Meta-analysis was performed using the random-effects model of DerSimonian and Laird to produce summary treatment effects in terms of either a relative risk (RR) with 95% confidence interval (CI).Main results: Nine trials including 3374 women were analyzed. All studies included women with singleton pregnancy in cephalic presentation at ≥36 weeks undergoing spontaneous vaginal delivery. Perineal massage was usually done by a midwife in the second stage, during or between and during pushing time, with the index and middle fingers, using a water-soluble lubricant. Women randomized to receive perineal massage during labor had a significantly lower incidence of severe perineal trauma, compared to those who did not (RR 0.49, 95% CI 0.25-0.94). All the secondary outcomes were not significant, except for the incidence of intact perineum, which was significantly higher in the perineal massage group (RR 1.40, 95% 1.01-1.93), and for the incidence of episiotomy, which was significantly lower in the perineal massage group (RR 0.56, 95% CI 0.38-0.82).Conclusions: Perineal massage during labor is associated with significant lower risk of severe perineal trauma, such as third and fourth degree lacerations. Perineal massage was usually done by a midwife in the second stage, during or between and during pushing time, with the index and middle fingers, using a water-soluble lubricant.