Effects of an intervention program for reducing severe perineal trauma during the second stage of labor

The association between waterbirth and perineal injury or other adverse outcomes among low-risk women with physiological birth: Results from the Nordic Home Birth Cohort Study

PROBLEM/BACKGROUND

Immersion in water has known benefits, such as reducing pain and shortening the duration of labour. The relationship between waterbirth and perineal injury remains unclear.

AIM

To compare the incidence of perineal injury in waterbirth and birth on land among low-risk women. Secondary outcomes were postpartum haemorrhage and 5-minute Apgar scores <7.

METHODS

Prospective cohort study of 2875 low-risk women who planned a home birth in Denmark, Iceland, Norway, and Sweden in 2008-2013 and had a spontaneous vaginal birth without intervention. Descriptive statistics and logistic regression were performed.

FINDINGS

A total of 942 women had a waterbirth, and 1933 gave birth on land. The groups differed in their various background variables. Multiparous women had moderately lower rates of intact perineum (59.3% vs. 63.9%) and primiparous women had lower rates of episiotomies (1.1% vs. 4.8%) in waterbirth than in birth on land. No statistically significant differences were detected in adjusted regression analysis on intact perineum in waterbirth (primiparous women's aOR = 1.03, CI 0.68-1.58; multiparous women's aOR = 0.84, CI 0.67-1.05). The rates of sphincter injuries (0.9% vs. 0.6%) were low in both groups. No significant differences were detected in secondary outcomes.

DISCUSSION

The decreased incidence of intact perineum among multiparous women was modest and inconclusive, and the prevalence of sphincter injury was low.

CONCLUSION

Low-risk women contemplating waterbirth should be advised to weigh the risks and benefits detected in this study against previously established benefits of waterbirth and should make an informed choice based on their values.

Influence of the maternity unit and region of delivery on episiotomy practice in France: a nationwide population-based study

INTRODUCTION

Our objective was to identify factors associated with episiotomy practice in France, in particular, characteristics of the maternity units and regions of delivery.

MATERIAL AND METHODS

We performed a national cross-sectional population-based study in all French maternity units in 2016 including 9284 women with vaginal delivery. Our outcome was the performance of an episiotomy. After stratification for parity, associations of episiotomy practice with individual and organizational characteristics and the region of delivery were estimated with multilevel logistic regression models. The variability in maternity unit episiotomy rates explained by the characteristics studied was estimated by the proportional change in variance.

RESULTS

A total of 19.9% of the women had an episiotomy. The principal factors associated with episiotomy practice were maternal and obstetric and delivery in a maternity unit with <2000 annual deliveries. After adjusting for individual, obstetric and organizational characteristics, the practice of episiotomy was strongly associated with women's region of delivery. Additionally, women's individual characteristics did not explain the significant variability in episiotomy rates between maternity units (P < 0.001) but maternity unit characteristics partly did (proportion of variance explained: 7.2% for primiparas and 13.6% for multiparas) and regional differences still more (18% and 30.7%, respectively).

CONCLUSIONS

Episiotomy practices in France in 2016 varied strongly between maternity units, largely due to regional differences. Targeted actions by the regional perinatal care networks may reduce the national episiotomy rate and standardize practices.

"From hell to healed" - A qualitative study on women's experience of recovery, relationships and sexuality after severe obstetric perineal injury

OBJECTIVE

Few studies have investigated women's experiences of daily life after childbirth complicated by obstetric anal sphincter injury (OASI). The aim of the present study was to explore experiences related to recovery, sexual function, relationships and coping strategies among women affected by OASI.

METHODS

In-depth interviews were conducted using a purposive sample of 11 women affected by OASI. Women were interviewed 1-2 years after their first childbirth. Inductive qualitative content analysis was applied.

RESULTS

The theme "From hell to healed" illustrates women's experiences of recovery, relationships and sexual function after OASI. Three categories addressing women's perceptions emerged: "Challenged to the core", "At the mercy of the care provider" and "For better or for worse". Support from partners and family and comprehensive care were important elements for the experiences of coping and healing from OASI. Elements that negatively influenced women's experiences were the pain and physical symptoms of pelvic floor dysfunction, normalization of symptoms by heath care providers, and unrealistic expectations about how this period in life should be experienced.

CONCLUSION

OASI greatly affects women's experiences of their first years with their newborn child, relationships, social context and sexuality. For some women, OASI negatively affects everyday life for a long period after childbirth. However, others heal and cope quite quickly. Health care professionals need to identify and pay attention to women with persisting problems after OASI so that they can be directed to the right level of care.

Cross-sectional study of early postpartum pelvic floor dysfunction and related bother in primiparous women 6-10 weeks postpartum

INTRODUCTION AND HYPOTHESIS

To study the prevalence of pelvic floor dysfunction and related bother in primiparous women 6-10 weeks postpartum, comparing vaginal and cesarean delivery.

METHODS

Cross-sectional study of 721 mothers with singleton births in Reykjavik, Iceland, 2015 to 2017, using an electronic questionnaire. Information on urinary and anal incontinence, pelvic organ prolapse and sexual dysfunction with related bother (trouble, nuisance, worry, annoyance) was collected. Main outcome measures were prevalence of pelvic floor dysfunction and related bother.

RESULTS

The overall prevalence of urinary and anal incontinence was 48% and 60%, respectively. Bother regarding urinary symptoms was experienced by 27% and for anal symptoms by 56%. Pelvic organ prolapse was noted by 29%, with less than half finding this bothersome. Fifty-five percent were sexually active, of whom 66% reported coital pain. Of all the women, 48% considered sexual issues bothersome. Urinary incontinence and pelvic organ prolapse were more prevalent in women who delivered vaginally compared to cesarean section, but no differences were observed for anal incontinence and coital pain. Compared to women with BMI < 25, obesity was a predictor for urinary incontinence after vaginal delivery (OR 1.94; 95% CI 1.20-3.14). Birthweight > 50th percentile was predictive for urgency incontinence after vaginal delivery (OR 1.53; 95% CI 1.05-2.21). Episiotomy predicted more anal incontinence (OR 2.19; 95% CI 1.30-3.67). No associations between maternal and delivery characteristics were found for pelvic floor dysfunction after cesarean section.

CONCLUSIONS

Bothersome pelvic floor dysfunction symptoms are prevalent among first-time mothers in the immediate postpartum period.

Key indicators influencing management of prolonged second stage labour by midwives in freestanding birth centres: Results from an ethnographic interview study

PROBLEMS

Complications for newborns and postpartum clients in the hospital are more frequent after a prolonged second stage of labour. Midwives in community settings have little research to guide management in their settings.

AIM

We explored how US birth centre midwives identify onset of second stage of labour and determine when to transfer clients to the hospital for prolonged second stage.

METHODS

Ethnographic interviews of midwives with at least 2 years' experience in birth centres and participant observation of birth centre care.

FINDINGS

We interviewed 21 midwives (18 CNMs, 3 CPMs/equivalent) from 18 birth centres in 11 US states, 45% with hospital practice privileges. Midwives relied on and engaged in embodied practice in evaluating each labour and making decisions concerning management of labour. Midwives considered time a useful but limited measure as a guiding factor in management. Though ideas of time and progress do play an important role in the decision-making process of midwives, their usefulness is limited due to the continual, multifactorial, and multisensory nature of the assessment. Relationship with the transfer hospital structured midwives' decision-making about transfers.

DISCUSSION & CONCLUSION

These findings can inform future robust multivariate evaluation of factors, including but not limited to time, in guidelines for management of second stage of labour. Optimal management may require formal consideration of more than just time and parity. Our findings also suggest the need for evaluation of how structural issues involving hospital privileges for midwives and relationships between birth centre and hospital staff affect the well-being of childbearing families.

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.