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Sun R, Huang J, Zhu X, Hou R, Zang Y, Li Y, Pan J, Lu H. Effects of Perineal Warm Compresses during the Second Stage of Labor on Reducing Perineal Trauma and Relieving Postpartum Perineal Pain in Primiparous Women: A Systematic Review and Meta-Analyses. Healthcare (Basel) 2024; 12:702. [PMID: 38610125 PMCID: PMC11011582 DOI: 10.3390/healthcare12070702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 03/08/2024] [Accepted: 03/20/2024] [Indexed: 04/14/2024] Open
Abstract
Non-pharmaceutical midwifery techniques, including perineal warm compresses, to improve maternal outcomes remain controversial. The aims of this study are to assess the effects of perineal warm compresses on reducing perineal trauma and postpartum perineal pain relief. This systematic review included randomized controlled trials (RCTs). We searched seven bibliographic databases, three RCT register websites, and two dissertation databases for publications from inception to 15 March 2023. Chinese and English publications were included. Two independent reviewers conducted the risk of bias assessment, data extraction, and the evaluation of the certainty of the evidence utilizing the Cochrane risk of bias 2.0 assessment criteria, the Review Manager 5.4, and the online GRADEpro tool, respectively. Seven RCTs involving 1362 primiparous women were included. The combined results demonstrated a statistically significant reduction in the second-, third- and/or fourth- degree perineal lacerations, the incidence of episiotomy, and the relief of the short-term perineal pain postpartum (within two days). There was a potential favorable effect on improving the integrity of the perineum. However, the results did not show a statistically significant supportive effect on reducing first-degree perineal lacerations and the rate of perineal lacerations requiring sutures. In summary, perineal warm compresses effectively reduced the second-, third-/or fourth-degree perineal trauma and decreased the short-term perineal pain after birth.
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Affiliation(s)
- Ruiyang Sun
- School of Nursing, Beijing University of Chinese Medicine, Beijing 102488, China;
| | - Jing Huang
- Division of Care for Long Term Conditions, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King’s College London, London SE1 8WA, UK;
| | - Xiu Zhu
- School of Nursing, Peking University, Beijing 100191, China; (X.Z.); (R.H.); (J.P.)
| | - Rui Hou
- School of Nursing, Peking University, Beijing 100191, China; (X.Z.); (R.H.); (J.P.)
| | - Yu Zang
- School of Nursing, Hebei Medical University, Shijiazhuang 050017, China;
| | - Yuxuan Li
- Vanke School of Public Health, Tsinghua University, Beijing 100084, China;
| | - Jingyu Pan
- School of Nursing, Peking University, Beijing 100191, China; (X.Z.); (R.H.); (J.P.)
| | - Hong Lu
- School of Nursing, Peking University, Beijing 100191, China; (X.Z.); (R.H.); (J.P.)
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Maghalian M, Alikamali M, Nabighadim M, Mirghafourvand M. The effects of warm perineal compress on perineal trauma and postpartum pain: a systematic review with meta-analysis and trial sequential analysis. Arch Gynecol Obstet 2024; 309:843-869. [PMID: 37632600 DOI: 10.1007/s00404-023-07195-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 08/15/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND In order to reduce the complications of perineal damage and the pain caused by it for the mother, this study was conducted to determine the effect of warm perineal compress on perineal trauma (1st-, 2nd-, 3rd-, and 4th-degree perineal tears), postpartum pain, intact perineum (primary outcomes), episiotomy, length of the second stage, and APGAR score at 1 and 5 min after childbirth (secondary outcome). METHODS PubMed, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, Web of Science, SID, Magiran, and ClinicalTrials.gov were searched to identify the relevant articles from inception to November 1, 2022, with language restriction (only English and Persian). A manual search was also performed. Risk of bias 2 (RoB2) and ROBIN-I were employed to evaluate the quality of the included papers. Meta-analysis was conducted using RevMan 5.3. Heterogeneity was assessed using I2. In cases with high heterogeneity, subgroup analysis was utilized based on the parity and ethnicity, and time of pain measurement after delivery also a random-effects model was used instead of a fixed-effects model. Trial sequential analysis (TSA) was performed for the primary outcomes. The certainty of evidence was assessed using the GRADE approach. RESULTS A total number of 228 articles were found in databases. Of these articles, eighty-six were screened by title, 27 by abstract, and 21 by full text. Finally, 14 articles were included, of which ten were RCT and four were non-RCT. Meta-analysis results revealed that warm perineal compress significantly reduced perineal pain (RR 0.23, 95% CI 0.08-0.66; P = 0.0006), average pain (SMD - 0.73, 95% CI 1.23 to - 0.23; P = 0.004), second-degree perineal tear (RR 0.65, 95% CI 0.54-0.79; P˂0.00001), third-degree perineal tear (RR 0.32, 95% CI 0.15-0.67; P = 0.003), fourth-degree perineal tear (RR 0.11, 95% CI 0.01-0.87; P = 0.04), episiotomy (RR 0.63, 95% CI 0.46-0.86; P = 0.004), and intact perineum significantly increased (RR 3.06, 95% CI 1.79-5.22; P < 0.0001) compared to the control group. However, there was no statistically significant difference in terms of first-degree tear (RR 1.04, 95% CI 0.86-1.25; P = 0.72), length of the second stage of labor (MD - 0.60, 95% CI - 2.43 to 1.22; P = 0.52), the first minute (MD - 0.03, 95% CI - 0.07 to 0.02; P = 0.24) and the fifth minute Apgar score (MD - 0.02, 95% CI - 0.07 to 0.03; P = 0.46) between the two groups. CONCLUSION Warm perineal compress administered during the second stage of labor reduce postpartum pain, second and third-degree perineal tears, and episiotomy rate while it increases the incidence of intact perineum compared to the control group.
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Affiliation(s)
| | | | - Mahsan Nabighadim
- Medical School, Ardabil University of Medical Sciences, Ardabil, Iran
| | - Mojgan Mirghafourvand
- Social Determinants of Health Research Center, Tabriz University of Medical Sciences, Tabriz, Iran.
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Okeahialam NA, Sultan AH, Thakar R. The prevention of perineal trauma during vaginal birth. Am J Obstet Gynecol 2024; 230:S991-S1004. [PMID: 37635056 DOI: 10.1016/j.ajog.2022.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/08/2022] [Accepted: 06/12/2022] [Indexed: 08/29/2023]
Abstract
Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%. The incidence of obstetrical anal sphincter injury is approximately 3%, with a significantly higher rate in primiparous than in multiparous women (6% vs 2%). Obstetrical anal sphincter injury is a significant risk factor for the development of anal incontinence, with approximately 10% of women developing symptoms within a year following vaginal birth. Obstetrical anal sphincter injuries have significant medicolegal implications and contribute greatly to healthcare costs. For example, in 2013 and 2014, the economic burden of obstetrical anal sphincter injuries in the United Kingdom ranged between £3.7 million (with assisted vaginal birth) and £9.8 million (with spontaneous vaginal birth). In the United States, complications associated with trauma to the perineum incurred costs of approximately $83 million between 2007 and 2011. It is therefore crucial to focus on improvements in clinical care to reduce this risk and minimize the development of perineal trauma, particularly obstetrical anal sphincter injuries. Identification of risk factors allows modification of obstetrical practice with the aim of reducing the rate of perineal trauma and its attendant associated morbidity. Risk factors associated with second-degree perineal trauma include increased fetal birthweight, operative vaginal birth, prolonged second stage of labor, maternal birth position, and advanced maternal age. With obstetrical anal sphincter injury, risk factors include induction of labor, augmentation of labor, epidural, increased fetal birthweight, fetal malposition (occiput posterior), midline episiotomy, operative vaginal birth, Asian ethnicity, and primiparity. Obstetrical practice can be modified both antenatally and intrapartum. The evidence suggests that in the antenatal period, perineal massage can be commenced in the third trimester of pregnancy to increase muscle elasticity and allow stretching of the perineum during birth, thereby reducing the risk of tearing or need for episiotomy. With regard to the intrapartum period, there is a growing body of evidence from the United Kingdom, Norway, and Denmark suggesting that the implementation of quality improvement initiatives including the training of clinicians in manual perineal protection and mediolateral episiotomy can reduce the incidence of obstetrical anal sphincter injury. With episiotomy, the International Federation of Gynecology and Obstetrics recommends restrictive rather than routine use of episiotomy. This is particularly the case with unassisted vaginal births. However, there is a role for episiotomy, specifically mediolateral or lateral, with assisted vaginal births. This is specifically the case with nulliparous vacuum and forceps births, given that the use of mediolateral or lateral episiotomy has been shown to significantly reduce the incidence of obstetrical anal sphincter injury in these groups by 43% and 68%, respectively. However, the complications associated with episiotomy including perineal pain, dyspareunia, and sexual dysfunction should be acknowledged. Despite considerable research, interventions for reducing the risk of perineal trauma remain a subject of controversy. In this review article, we present the available data on the prevention of perineal trauma by describing the risk factors associated with perineal trauma and interventions that can be implemented to prevent perineal trauma, in particular obstetrical anal sphincter injury.
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Affiliation(s)
| | - Abdul H Sultan
- Croydon University Hospital, London, United Kingdom; St George's University of London
| | - Ranee Thakar
- Croydon University Hospital, London, United Kingdom; St George's University of London.
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Tern H, Edqvist M, Ekelin M, Dahlen HG, Rubertsson C. Primary midwives' experiences of collegial midwifery assistance during the active second stage of labor: Data from the Oneplus trial. Birth 2023; 50:868-876. [PMID: 37401365 DOI: 10.1111/birt.12739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 05/08/2023] [Accepted: 06/09/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Collegial midwifery assistance during the active second stage of labor that involves a second midwife being present has been shown to reduce severe perineal trauma (SPT) by 30%. The aim of this study was to investigate primary midwives' experiences of collegial midwifery assistance with the purpose of preventing SPT during the active second stage of labor. METHODS This study uses an observational design with data from a multicenter randomized controlled trial (Oneplus). Data consist of clinical registration forms completed by the midwives after birth. Descriptive statistics as well as univariable and multivariable logistic regression were used to analyze the data. RESULTS The majority of the primary midwives felt confident (61%) and were positive (56%) toward the practice. Midwives with less than 2 years' work experience were more likely to completely agree they felt confident (aOR 9.18, 95% CI: 6.28-13.41) and experience the intervention as positive (aOR 4.04, 95% CI: 2.83-5.78) than those with over 20 years' work experience. Factors such as duration of time spent in the birthing room by the second midwife, opportunity for planning and if the second midwife provided support were further associated with the primary midwife's experience of the practice as being positive. CONCLUSIONS Our findings indicate that having a second midwife present during the active second stage of labor was an accepted practice, with the majority of primary midwives feeling confident and positive toward the intervention. This was especially pronounced among midwives with less than 2 years' work experience.
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Affiliation(s)
- Helena Tern
- Department of Obstetrics and Gynecology, Skane University Hospital, Malmö, Sweden
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Malin Edqvist
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Maria Ekelin
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Hannah G Dahlen
- School of Nursing and Midwifery, Western Sydney University, Sydney, Australia
| | - Christine Rubertsson
- Department of Obstetrics and Gynecology, Skane University Hospital, Malmö, Sweden
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
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Homer C, Neylon K, Kennedy K, Baird K, Gilkison A, Keogh S, Middleton S, Gray R, Whitehead L, Finn J, Rickard C, Sharplin G, Neville S, Eckert M. Midwife led randomised controlled trials in Australia and New Zealand: A scoping review. Women Birth 2023; 36:401-408. [PMID: 36894484 DOI: 10.1016/j.wombi.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 03/02/2023] [Accepted: 03/04/2023] [Indexed: 03/09/2023]
Abstract
BACKGROUND Midwives are the largest workforce involved in caring for pregnant women and their babies, and are well placed to translate research into practice and ensure midwifery priorities are appropriately targeted in researched. Currently, the number and focus of randomised controlled trials led by midwives in Australia and New Zealand is unknown. The Australasian Nursing and Midwifery Clinical Trials Network was established in 2020 to build nursing and midwifery research capacity. To aid this, scoping reviews of the quality and quantity of nurse and midwife led trials were undertaken. AIM To identify midwife led trials conducted between 2000 and 2021 in Australia and New Zealand. METHODS This review was informed by the JBI scoping review framework. Medline, Emcare, and Scopus were searched from 2000-August 2021. ANZCTR, NHMRC, MRFF, and HRC (NZ) registries were searched from inception to July 2021. FINDINGS Of 26,467 randomised controlled trials registered on the Australian and New Zealand Clinical Trials Registry, 50 midwife led trials, and 35 peer-reviewed publications were identified. Publications were of moderate to high quality with scores limited due to an inability to blind participants or clinicians. Blinding of assessors was included in 19 published trials. DISCUSSION Additional support for midwives to design and conduct trials and publish findings is required. Further support is needed to translate registration of trial protocols into peer reviewed publications. CONCLUSION These findings will inform the Australasian Nursing and Midwifery Clinical Trials Network plans to promote quality midwife led trials.
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Affiliation(s)
| | - Kim Neylon
- Rosemary Bryant AO Research Centre, UniSA Clinical & Health Sciences, University of South Australia, South Australia, Australia
| | - Kate Kennedy
- Rosemary Bryant AO Research Centre, UniSA Clinical & Health Sciences, University of South Australia, South Australia, Australia
| | - Kathleen Baird
- University Technology Sydney, School of Nursing and Midwifery, New South Wales, Australia
| | - Andrea Gilkison
- Auckland University of Technology, School of Clinical Sciences, Auckland, New Zealand
| | - Samantha Keogh
- Queensland University of Technology, Faculty of Health, School of Nursing, Queensland, Australia
| | - Sandy Middleton
- Australian Catholic University, Nursing Research Institute, New South Wales, Australia
| | | | | | - Judith Finn
- Curtin University, Faculty of Health Sciences, Curtin School of Nursing, Western Australia, Australia
| | - Claire Rickard
- University of Queensland, School of Nursing, Midwifery and Social Work, Queensland, Australia
| | - Greg Sharplin
- Rosemary Bryant AO Research Centre, UniSA Clinical & Health Sciences, University of South Australia, South Australia, Australia
| | - Stephen Neville
- Auckland University of Technology, School of Clinical Sciences, Auckland, New Zealand
| | - Marion Eckert
- Rosemary Bryant AO Research Centre, UniSA Clinical & Health Sciences, University of South Australia, South Australia, Australia.
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Rodrigues S, Silva P, Rocha F, Monterroso L, Silva JN, de Sousa NQ, Escuriet R. Perineal massage and warm compresses - Randomised controlled trial for reduce perineal trauma during labor. Midwifery 2023; 124:103763. [PMID: 37385009 DOI: 10.1016/j.midw.2023.103763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 06/12/2023] [Accepted: 06/14/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVE The aim of this study is to evaluate the effect of perineal massage and warm compresses technique on the perineum integrity during second stage of labor. DESIGN AND SETTING A single-center, prospective, randomized controlled trial was conducted between March 1st, 2019, and December 31st, 2020, at Hospital of Braga. PARTICIPANTS Women with 18 years or older, between 37 weeks and 41 weeks pregnant, in whom a vaginal birth of a fetus in the cephalic presentation was planned were recruited. Eight hundred forty-eight women were randomly assigned (Perineal massage and warm compresses group, n = 424 and control group, n = 424), and 800 women, both perineal massage and warm compresses group (n = 400) and control group (n = 400) were included in the strict per protocol analysis. INTERVENTION In the perineal massage and warm compresses group, women received perineal massage and warm compresses and in the control group, women received hands-on technique. RESULTS The incidence of intact perineum was significantly higher in the perineal massage and warm compresses group [perineal massage and warm compresses group: 47% vs control group: 26.3%; OR 2.53, 95% CI 1.86-3.45, p<0.001], whereas second-degree tears and episiotomy rate were significantly lower in this group [perineal massage and warm compresses group: 7.2% vs control group: 12.3%; OR 1.96, 95% CI 1.17-3.29, p = 0.010 and perineal massage and warm compresses group: 9.5% vs control group: 28.5%; OR 3.478, 95% CI 2.236-5.409, p<0.001, respectively]. Also, obstetric anal sphincter injury with and without episiotomy and second-degree tears with episiotomy were significantly lower in the perineal massage and warm compresses group [perineal massage and warm compresses group: 0.5% vs control group: 2.3%; OR 5.404, 95% CI 1.077-27.126, p = 0.040 and perineal massage and warm compresses group: 0.3% vs control group: 1.8%; OR 9.253, 95% CI 1.083-79.015, p = 0.042, respectively]. CONCLUSIONS The perineal massage and warm compresses technique increased the incidence of intact perineum and reduced the incidence of second-degree tear, episiotomy and obstetric anal sphincter injury. IMPLICATIONS FOR PRACTICE Perineal massage and warm compresses technique is feasible, inexpensive and reproductible. Therefore, this technique should be taught and trained to midwives students and midwives team. Thus, women should have this information and have the option to decide whether they want to receive the perineal massage and warm compresses technique in the second stage of labor.
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Affiliation(s)
- Silvia Rodrigues
- Biomedical Sciences Institute Abel Salazar, Portugal and Hospital of Braga, Sete Fontes - São Victor, 4710-243 Braga, Portugal.
| | - Paulo Silva
- Hospital of Braga, Sete Fontes - São Victor, 4710-243 Braga, Portugal.
| | - Fátima Rocha
- Hospital of Braga, Sete Fontes - São Victor, 4710-243 Braga, Portugal.
| | - Ligia Monterroso
- Higher Health Institute, Rua Castelo de Almourol, nº 13, 4720-155 Amares, Portugal.
| | - João Neves Silva
- ISAVE - Instituto Superior de Saúde, CICS - Centro Interdisciplinar em Ciências da Saúde, Portugal.
| | | | - Ramon Escuriet
- Health and Integrated Care division, Catalan Health Service, Spain.
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Morganelli G, Fieni S, Dall'Asta A, di Pasquo E, Capozzi VA, Valenti A, Pezzani A, Kiener AJO, Ghi T. Effect of the "shoulder-up" bundle on the incidence of spontaneous perineal injury after vaginal delivery: comparison of 2 historic cohorts after propensity score matching. Am J Obstet Gynecol MFM 2023; 5:101038. [PMID: 37245605 DOI: 10.1016/j.ajogmf.2023.101038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 04/29/2023] [Accepted: 05/22/2023] [Indexed: 05/30/2023]
Abstract
BACKGROUND Perineal injury following vaginal delivery represents a major cause of long-term maternal morbidity, and its prevention is among the priorities of modern obstetrical practice. OBJECTIVE This study aimed to investigate whether the systematic implementation of a bundle of maneuvers to prevent perineal injury (ie, the "shoulder-up" bundle) may reduce the rate of spontaneous perineal tears in women delivering at a single tertiary maternity unit. STUDY DESIGN This was a single-center retrospective intervention study including all vaginal deliveries between April 1, 2020 and March 31, 2022. On March 1, 2021, a bundle focused on perineal injury prevention in vaginal deliveries was implemented and introduced as a standard of care. The "shoulder-up" bundle includes the addition of a hands-on technique for the delivery of the posterior shoulder, which is slowly lifted up under the direct visualization of the perineal body, immediately after the disengagement of the anterior shoulder. The labor ward staff underwent dedicated training to acquire expertise on the "shoulder-up" bundle. Little changes in terms of medical and midwifery staffing were recorded during the study period. The incidence of spontaneous second-degree or higher perineal tears was compared between the patients who gave birth before the clinical implementation of the bundle (standard-care group) and those who were delivered following the implementation of the bundle (shoulder-up group). A 1:1 propensity score matching of the 2 groups was done for the variables that proved to be independently associated with the perineal outcome. RESULTS From April 1, 2020 to March 31, 2022, 3671 patients had a vaginal birth at our tertiary care unit (1786 in the standard-care group and 1885 in the "shoulder-up" group) and were enrolled in the study population. Of these, 1191 (32.4%) had a spontaneous second-degree or higher perineal tear. At univariate analysis, nulliparity (59.6% vs 39.1%; P<.001), higher gestational age at delivery (39.8±1.28 vs 39.4±1.97 weeks; P<.001), epidural analgesia (40.6% vs 31.2%; P<.001), vacuum-assisted delivery (9.6% vs 4.0%; P<.001), and birthweight >4 kg (11.0% vs 6.3%; P<.001) were independently associated with the perineal outcome. Following propensity score matching for the above cited factors, the 1703 patients of each group were compared. A significant increase in the rate of intact perineum (71.0% vs 64.1%; P=.014) and a reduction in the incidence of second- (27.2% vs 32.9%; P=.006) and third to fourth-degree perineal tears (1.3% vs 3.0%; P<.001) was demonstrated in the "shoulder-up" group. Among the subgroup of patients undergoing vacuum-assisted delivery, a borderline significant reduction in the rate of obstetrical anal sphincter injury (10.4% vs 2.9%; P=.052) was also observed. CONCLUSION Our study showed that the clinical implementation of the "shoulder-up" bundle at vaginal delivery is associated with a significant reduction in the incidence of spontaneous second-degree or higher perineal tears.
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Affiliation(s)
- Giovanni Morganelli
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy.
| | - Stefania Fieni
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
| | - Andrea Dall'Asta
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
| | - Elvira di Pasquo
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
| | - Vito Andrea Capozzi
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
| | - Alissa Valenti
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
| | - Alessandra Pezzani
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
| | | | - Tullio Ghi
- Department of Obstetrics and Gynecology, University Hospital of Parma, Parma, Italy
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Lucena da Silva M, Andressa Bastos Primo de Sousa Santos T, Wane Carvalho Leite L, Emanoel Chaves da Silva C, Oliveira do Nascimento A, Teixeira Alves A, Driusso P, da Costa Cunha K. The effectiveness of interventions in the prevention of perineal trauma in parturients: A systematic review with meta-analysis. Eur J Obstet Gynecol Reprod Biol 2023; 283:100-111. [PMID: 36827751 DOI: 10.1016/j.ejogrb.2023.02.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 02/07/2023] [Accepted: 02/11/2023] [Indexed: 02/19/2023]
Abstract
AIM To investigate the effectiveness of interventions to prevent the occurrence of perineal trauma in parturients. METHODS A bibliographic search was carried out in Cochrane Library, MEDLINE via PUBMED, LILACS via Virtual Health Library (VHL), Embase, Scopus, CINAHL, Scielo, Web of Science, and PEDro databases. Randomized clinical trials evaluating the effects of any intervention to prevent perineal trauma during pregnancy and/or childbirth were included. There were no temporal or language restrictions. The risk of bias assessment was performed using the Revised Cochrane Risk-of-bias Tool for Randomized Trials. RESULTS Fifty studies, with a total of 17,221 participants, were included in this meta-analysis. No intervention during childbirth was effective for the prevention of perineal trauma (RR = 1.07, 95% CI [0.98.1.18], p < 0.01, I2 = 83%) when compared to no intervention. However, a lower risk of perineal laceration was verified with techniques performed during pregnancy, when compared to no intervention (RR = 0.81, 95% CI [0.71, 0.93], p = 0.05, I2 = 47%). Among them, highlight the effects of perineal massage in preventing lacerations (RR = 0.69, 95% CI [0.54, 0.87], p < 0.01) when compared to no intervention. CONCLUSIONS The techniques performed during pregnancy, especially perineal massage, are associated with a lower risk of perineal laceration.
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Affiliation(s)
- Marianne Lucena da Silva
- Universidade Federal de Jataí, UFJ - Campus Riachuelo, Rua Riachuelo n° 1530 - Setor - Samuel Grahan, Jataí - GO, 75804-020, Jataí, Goiás, Brazil
| | | | - Lindely Wane Carvalho Leite
- Universidade do Estado do Pará, Avenida Hiléia, s/n° - Agrópolis do Incra - Bairro Amapá CEP: 68502-100, Marabá, Pará, Brazil
| | - Carlos Emanoel Chaves da Silva
- Universidade do Estado do Pará, Avenida Hiléia, s/n° - Agrópolis do Incra - Bairro Amapá CEP: 68502-100, Marabá, Pará, Brazil
| | - Alef Oliveira do Nascimento
- Universidade do Estado do Pará, Avenida Hiléia, s/n° - Agrópolis do Incra - Bairro Amapá CEP: 68502-100, Marabá, Pará, Brazil
| | - Aline Teixeira Alves
- Universidade de Brasília, Universidade de Brasília, Faculdade de Ceilândia, Campus Universitário - Centro Metropolitano, Ceilândia Sul, Brasília-DF. CEP: 72220-275, Brazil.
| | - Patrícia Driusso
- Universidade Federal de São Carlos, Rodovia Washington Luís, km 235 - SP-310. São Carlos, CEP 13565-905, São Paulo, Brazil
| | - Katiane da Costa Cunha
- Universidade do Estado do Pará, Avenida Hiléia, s/n° - Agrópolis do Incra - Bairro Amapá CEP: 68502-100, Marabá, Pará, Brazil
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Swedish midwives' experiences of collegial midwifery assistance during the second stage of labour: A qualitative study. Women Birth 2023; 36:72-79. [PMID: 35307300 DOI: 10.1016/j.wombi.2022.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 02/12/2022] [Accepted: 03/09/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND There has been an increased focus on clinical practice that may reduce severe perineal trauma due to awareness of the associated morbidity. Knowledge regarding the best practice to reduce these injuries is limited. Collegial midwifery assistance during the second stage of labour that involves an additional midwife being present has recently been implemented into many Swedish birth units with the aim of reducing severe perineal trauma. However, no studies have been conducted to evaluate midwives' experiences and views of this practice. AIM The aim of this study was to explore midwives' experiences of collegial midwifery assistance during the second stage of labour. METHODS A qualitative study was undertaken with five focus groups conducted with 37 midwives who were part of a multisite randomised controlled trial. The data was analysed with reflexive thematic analysis. FINDINGS Four key themes were generated: (i) "challenging the professional role"; (ii) "a balancing act between different roles"; (iii) "not just why and how - but who"; (iv) "a potential arena for learning". CONCLUSION This practice enabled valuable collegial support and learning. The midwives' experiences were multifaceted and influenced by several factors, including norms and culture in the birth units as well as personal relationships and the midwives' views on their role and childbirth. Staffing should be adapted in clinical practice to optimise the conditions for collegial support and learning while avoiding unintended consequences.
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Hübner M, Rothe C, Plappert C, Baeßler K. Aspects of Pelvic Floor Protection in Spontaneous Delivery - a Review. Geburtshilfe Frauenheilkd 2022; 82:400-409. [PMID: 35392067 PMCID: PMC8983111 DOI: 10.1055/a-1515-2622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 05/17/2021] [Indexed: 11/17/2022] Open
Abstract
The necessity of increasingly addressing aspects of pelvic floor protection, i.e., prevention of the most frequent female pelvic floor disorders, such as urinary incontinence, faecal incontinence and pelvic organ prolapse, is the result of the steadily improving understanding of the association of pregnancy and delivery with the prevalence of these disorders. About a quarter of all women experience one or more such symptoms during their life. Apart from age and weight, pregnancies and births play an important part. While initial discussion of pelvic floor protection often focused very rapidly on the mode of delivery and elective caesarean section as a possible protective intervention, it has become apparent in the last few decades how varied and wide-ranging the options are that can be used to protect against pelvic floor disorders. The mode of delivery as such is "only" one element among numerous other considerations and has diminished markedly in importance. Interprofessionality and interdisciplinarity undoubtedly represent an important development as resulting recommendations must always be incorporated in an overall context that considers mother and child at the same time. Considering the pelvic floor only certainly does not make sense. This review article will analyze in greater detail important pre-, intra- and postpartum aspects that in their entirety can provide insight into the various aspects of pelvic floor protection. The authors regard the following article as an additional basis for discussion on achieving a sustained reduction in the incidence and prevalence of female pelvic floor disorders.
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Affiliation(s)
- Markus Hübner
- Klinik für Frauenheilkunde, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Germany
- Medizinische Fakultät der Universität Tübingen, Tübingen, Germany
| | | | - Claudia Plappert
- Institut für Gesundheitswissenschaften, Abt. Hebammenwissenschaft, Universität Tübingen, Tübingen, Germany
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Hong JGS, Abdullah N, Rajaratnam RK, Ahmad Shukri S, Tan SP, Hamdan M, Lim BK. Combined perineal massage and warm compress compared to massage alone during active second stage of labour in nulliparas: A randomised trial. Eur J Obstet Gynecol Reprod Biol 2022; 270:144-150. [DOI: 10.1016/j.ejogrb.2022.01.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 01/08/2022] [Indexed: 11/04/2022]
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12
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Meyer R, Levin G. Risk factors for obstetric anal sphincter injury among nulliparous of advanced maternal age. J Matern Fetal Neonatal Med 2022; 35:9391-9397. [PMID: 35125063 DOI: 10.1080/14767058.2022.2035714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Data regarding the risk factors for obstetrical anal sphincter injury (OASI) among nulliparous advanced maternal age (AMA) women are scarce. We aimed to evaluate the risk factors and the rate of OASI in this population. METHODS A retrospective case-control study of nulliparous women aged ≥35 who delivered vaginally between March 2011 and August 2021. The study cohort included nulliparous AMA women, aged 35 years or older, delivering vaginally a singleton, vertex neonate. We excluded cases with missing data. Maternal and intrapartum characteristics were compared between OASI and no-OASI groups. We matched groups to the earliest gestational age in which OASI has occurred. RESULTS A total of 3,635 women met inclusion criteria. Mean age of the participants was 38 years (range 35-56, interquartile range 36-39). The oldest age in which an OASI was diagnosed was 45. A total of 55 (1.5%) cases of OASI were diagnosed. Gestational age at delivery was higher in the OASI group compared to the no-OASI group (mean 396/7±12/7 vs. 391/7±23/7 weeks respectively, p=.039). The rate of induction of labor, oxytocin and epidural analgesia, prolonged second stage, mode of delivery, and rate of blood transfusion did not vary between groups. Estimated fetal weight was higher in the OASI group (3,324 ± 308 vs. 3,114 ± 566 g, p<.001). Sonographic abdominal circumference was higher in the OASI group (338 ± 13 vs. 328 ± 28 mm, p<.001). Mean birthweight was higher in the OASI group (3,286 ± 400 vs. 3,059 ± 541 g, p=.002) and the birthweight centile was higher as well (60 ± 26 vs. 52 ± 25, p=.024).In a multivariable regression analysis including birthweight, gestational age, operative vaginal delivery, epidural anesthesia, and hypertensive disorders-birthweight and hypertensive disorder were positively associated with an OASI odds ratio [OR 95% CI 1.6 (1.1-2.32) for every 500 g increase; 2.42 (1.006-5.82), respectively]. Epidural anesthesia was negatively associated with OASI [OR 95% CI 0.49) 0.27-0.87)]. CONCLUSIONS Epidural anesthesia is the only modifiable risk factor and is protective against OASI among nulliparous AMA women. Birthweight and hypertensive disorders are also independent predictors of OASI in this population.
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Affiliation(s)
- Raanan Meyer
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel.,Faculty of Medicine, The Sheba Talpiot Medical Leadership Program, Tel-Aviv University, Tel-Aviv, Israel
| | - Gabriel Levin
- The Department of Gynecologic Oncology, Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem, Israel
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13
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Martínez EML, Sáez ZA, Sánchez EH, Ávila MC, Conesa EM, Ferrer MBC. Perineal protection methods: knowledge and use. Rev Esc Enferm USP 2021; 55:e20200193. [PMID: 34477194 DOI: 10.1590/1980-220x-reeusp-2020-0193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 03/23/2021] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To analyse the knowledge and use of perineal protection methods during the expulsive stage by health professionals involved in childbirth and whether they correspond to the World Health Organization's recommendations. METHOD This was a cross-sectional descriptive study aimed at health workers involved in births in Spain. RESULTS Fifty-seven professionals participated in the study: midwives (47%), gynaecologists (25%), nurse residents (14%) and resident physicians (14%) in obstetrics and gynaecology. The degree of knowledge and use of perineal protection methods differed according to the position held and was very limited among gynaecologists and resident physicians. The only method recognized by all positions was "hands on" (p = 0.05). "Hands off " (p = 0.002), "delayed pushing" (p = 0.0001) and "maternal posture" (p = 0.03) were only known to midwives and nurse residents. "Flexion technique" (p = 0.035) and "delayed pushing" (p = 0.011) were used effectively by midwives and nurse residents. "Episiotomy" was erroneously identified as a method to protect the perineum by gynaecologists and resident physicians (p = 0.003). CONCLUSION The degree of knowledge and use of perineal protection methods by health care professionals does not correspond to the recommendations of the World Health Organization.
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Goh YP, Tan PC, Hong JGS, Sulaiman S, Omar SZ. Combined massage and warm compress to the perineum during active second stage of labor in nulliparas: A randomized trial. Int J Gynaecol Obstet 2021; 155:532-538. [PMID: 33484158 DOI: 10.1002/ijgo.13613] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 12/28/2020] [Accepted: 01/21/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To evaluate the combined effect of massage and warm compress to the perineum (MassComp) compared with standard "hands-off" in the second stage of labor. METHODS A randomized trial was conducted in a University hospital in Malaysia. Nulliparous women at term who were about to start pushing were randomized to massage during pushing and warm compress to the perineum in between pushes or to standard "hands-off" care. Primary outcome was suturing for perineal injury (episiotomy or tear). RESULTS A total of 156 participants were analyzed based on intention to treat. Perineal repair rates were 53/79 (67%) for MassComp versus 70/77 (91%) for control (relative risk [RR] 0.72, 95% confidence interval [CI] 0.61-0.98, number needed to treat for an additional beneficial outcome [NNTb ] 5, 95% CI 2.83-8.62, P < 0.001). Of the secondary outcomes, participants' satisfaction with care (visual numerical rating scale 0-10; 8.3 ± 1.2 vs 7.8 ± 1.2, P = 0.014), major perineal injury (second degree or higher) rates 34/79 (43%) versus 51/77 (66%) (RR 0.72, 95% CI 0.58-0.97, NNTb 5, 95% CI 2.61-12.56, P = 0.004), episiotomy rates 28/79 (37%) versus 40/77 (53%) (RR 0.72, 95% CI 0.52-0.98, NNTb 8, 95% CI 3.63-36.46, P = 0.043), intervention to delivery intervals 29.5 ± 13.6 versus 27.9 ± 13.8 minutes (P = 0.472) and spontaneous vaginal delivery rates 63/79 (79.7%) versus 56/77 (72.7%) (RR 1.11, 95% CI 0.92-1.34, P = 0.306) for MassComp versus control, respectively. CONCLUSION Massage and warm compress during pushing decreased the perineal suturing, major perineal injury, and episiotomy rates and improved maternal satisfaction. CLINICAL TRIAL REGISTRATION https://doi.org/10.1186/ISRCTN42773879.
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Affiliation(s)
- Yi Pei Goh
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Peng Chiong Tan
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Jesrine Gek Shan Hong
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Sofiah Sulaiman
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia
| | - Siti Zawiah Omar
- Department of Obstetrics and Gynecology, Faculty of Medicine, University of Malaya, Lembah Pantai, Kuala Lumpur, Malaysia
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Pizzagalli F. [Normal childbirth: physiologic labor support and medical procedures. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynaecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF) - Maternal postures during the second stage of labour, delivery techniques and perineal protection]. GYNECOLOGIE, OBSTETRIQUE, FERTILITE & SENOLOGIE 2020; 48:931-943. [PMID: 33011376 DOI: 10.1016/j.gofs.2020.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To assess maternal postures during the second stage of labour on course of labour, mode of delivery and maternal and neonatal morbidity. To describe the different techniques of spontaneous vaginal delivery and their influence on maternal and neonatal morbidity. To describe the different perineal protection techniques. METHOD Systematic review of the literature through consultation of Medline, Cochrane databases and international recommendations. RESULTS There is no particular posture that has demonstrated its superiority (Level of Evidence (LE) 2). In case of no contraindication and permanent maternal and fetal monitoring, it is recommended to encourage women to adopt the postures they consider most comfortable during the second stage of labour (Consensus agreement). There is insufficient evidence in the literature to recommend a technique for fetal head and shoulders delivery. There is not enough data in the literature to recommend the use of Ritgen maneuver (grade B), perineal massage (gradeC) or hot compresses (Consensus agreement). The abdominal expression must be abandoned (grade B). CONCLUSION The second stage of labour is a crucial time in labour that can lead to significant maternal and neonatal morbidity. It is necessary to take the greatest possible care in the supervision and management of women, especially for the perineal protection. The influence of non-medicinal techniques on the course of the second stage of labour should be studied.
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Affiliation(s)
- F Pizzagalli
- Service de gynécologie-obstétrique, hôpital Antoine-Béclère, AP-HP, 92140 Clamart, France.
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16
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Cueva‐Reguera M, Rodríguez‐Sanz D, Calvo‐Lobo C, Fernández‐Martínez S, Martínez‐Pascual B, Robledo‐Do‐Nascimento Y, Blanco‐Morales M, Romero‐Morales C. Effectiveness of manual lymphatic drainage vs. perineal massage in secundigravida women with gestational oedema: A randomised clinical trial. Int Wound J 2020; 17:1453-1461. [DOI: 10.1111/iwj.13427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 05/19/2020] [Accepted: 05/21/2020] [Indexed: 11/29/2022] Open
Affiliation(s)
- Mónica Cueva‐Reguera
- Faculty of Sport Sciences Universidad Europea de Madrid Madrid 28670 Spain
- Facultad de Enfermería, Físioterapia y Podologia Universidad Complutense de Madrid Madrid 28040 Spain
| | - David Rodríguez‐Sanz
- Facultad de Enfermería, Físioterapia y Podologia Universidad Complutense de Madrid Madrid 28040 Spain
| | - César Calvo‐Lobo
- Facultad de Enfermería, Físioterapia y Podologia Universidad Complutense de Madrid Madrid 28040 Spain
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Papoutsis D, Antonakou A, Gornall A, Tzavara C. The Incidence of and Predictors for Severe Perineal Trauma and Intact Perineum in Women Having a Waterbirth in England: A Hospital-Based Study. J Womens Health (Larchmt) 2020; 30:681-688. [PMID: 32907460 DOI: 10.1089/jwh.2019.8244] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: To determine the incidence of and predictors for obstetric anal sphincter injuries (OASIS) and intact perineum in women giving birth in the water and compare with the general obstetric population. Materials and Methods: Data were retrospectively collected for women who had singleton cephalic presentation vaginal births in the water and the general obstetric population between August 2007 and December 2017. Results: We identified 1,007 women who had a waterbirth and 36,924 women from the general obstetric population. There was no significant difference in the incidence of OASIS between waterbirths and the general obstetric population (2.3% vs. 2.0%). Having a waterbirth was associated with a lower probability for an intact perineum (odds ratio [OR] = 0.83; confidence interval [95% CI]: 0.73-0.94) when compared with the general obstetric population (44.7% vs. 51.3%). Nulliparous women with a waterbirth when compared with multiparous women had an eightfold higher likelihood for the occurrence of OASIS (OR = 8.28; 95% CI: 2.64-25.86). The risk for a higher degree of OASIS was associated with increased maternal age in the total sample (OR = 1.08; 95% CI: 1.06-1.11) and with a lower body mass index (BMI) at booking in multiparous women (OR = 0.96; 95% CI: 0.92-0.99). The risk for any type of perineal trauma was associated with increased maternal age in the total sample (OR = 1.10; 95% CI: 1.07-1.13) and with a lower BMI at booking in multiparous women (OR = 0.95; 95% CI: 0.91-0.99). Conclusions: We found that giving birth in the water reduced the chance of having an intact perineum. We have also shown that nulliparity, increased maternal age in all women, and a lower BMI at booking in multiparous were associated with OASIS and lower rates of intact perineum in waterbirths.
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Affiliation(s)
- Dimitrios Papoutsis
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom.,School of Health Sciences, University of Western Macedonia, Kozani, Greece
| | - Angeliki Antonakou
- Department of Midwifery, Midwifery School, International Hellenic University, Thessaloniki, Greece
| | - Adam Gornall
- Department of Obstetrics and Gynaecology, Shrewsbury and Telford Hospitals NHS Trust, Telford, United Kingdom
| | - Chara Tzavara
- Department of Hygiene, Epidemiology and Medical Statistics, Medical School, University of Athens, Athens, Greece
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18
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Türkmen H, Çetinkaya S, Apay E, Karamüftüoğlu D, Kılıç H. The Effect of Perineal Warm Application on Perineal Pain, Perineal Integrity, and Postpartum Comfort in the Second Stage of Labor: Randomized Clinical Trial. Complement Med Res 2020; 28:23-30. [PMID: 32460297 DOI: 10.1159/000507605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 03/30/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Protection of perineum and reduction of perineal pain is important in the second stage of labor. AIM The aim of this study was to determine the effect of perineal warm application on perineal pain, perineal integrity, and postnatal comfort in the second stage of labor. METHODS A single blind randomized and controlled experimental study was conducted with a total of 100 primiparous pregnant women in the warm application (n = 50) and control groups (n = 50). The warm application group was given a damp and warm application to the perineal region during the second stage of labor and only the standard midwifery care was given to the control group. Pregnant Introductory Form was used in the collection of data. Perineal pain level was measured prior to and after the intervention, after delivery, and 2 h from delivery by means of Visual Analogue Scale. In the postpartum period, the perineal condition was evaluated by the midwife with Questionnaire to Determine the Perineal Condition. Two hours from the delivery, Postpartum Comfort Questionnaire was used to determine the comfort level of the women. RESULTS It was found that there was a decrease in the pain levels of the warm application group compared to pre-intervention pain levels (p < 0.0001). When the warm application and control groups were compared, we found statistically significant differences between the pain levels immediately after the intervention (perineal pain: 8.54 ± 1.38 vs. 9.56 ± 0.57, p < 0.0001), after delivery (perineal pain: 2.20 ± 1.72 vs. 3.64 ± 2.07, p < 0.0001), and 2 h after delivery (perineal pain: 0.30 ± 0.78 vs. 0.68 ± 0.98, p = 0.028). In the study, the intactness of perineum was found to be significantly higher in the warm application group compared to the control group (p = 0.003). The suture need for perinea was significantly higher in the control group than in the warm application group (p = 0.016). In the study, the physical comfort level of the warm application group was found to be significantly higher than the control group (56.06 ± 4.61 vs. 54.30 ± 4.73, p = 0.012). CONCLUSIONS In the second stage of labor, it was found that the application of warmth decreases perineal pain, maintains the perineal integrity, and improves postpartum comfort.
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Affiliation(s)
- Hülya Türkmen
- Department of Midwifery, School of Health, Balıkesir University, Balıkesir, Turkey,
| | | | - Emine Apay
- Atatürk City Hospital, Delivery Room, Balıkesir, Turkey
| | | | - Hafize Kılıç
- Atatürk City Hospital, Delivery Room, Balıkesir, Turkey
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19
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Wilson AN, Homer CSE. Third- and fourth-degree tears: A review of the current evidence for prevention and management. Aust N Z J Obstet Gynaecol 2020; 60:175-182. [PMID: 32065386 DOI: 10.1111/ajo.13127] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Accepted: 01/12/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Third- and fourth-degree tears are associated with significant pain, discomfort and impact on quality of life and intimate relationships. Australian women experience comparatively higher rates of third- and fourth-degree tears relative to countries of similar economic development. AIMS We aimed to conduct a comprehensive review of the literature, published over the past five years, to identify the best ways to prevent and manage third- and fourth-degree perineal tears in Australian maternity centres. MATERIALS AND METHODS We searched the literature using the Cochrane Database of Systematic Reviews, EMBASE, MEDLINE, Maternity and Infant Care Database and Google Scholar for articles published since 2013 using key search terms. A review of reviews was undertaken given the extensive amount of literature on this topic. RESULTS Twenty-six systematic reviews were identified. The most common risk factors reported in the literature for third- and fourth-degree tears included primiparity, mother's ethnicity, large for gestational age infants and certain interventions used in labour and birth, such as instrumental deliveries. Preventive practices with varying degrees of effectiveness and often dependant on parity included: antenatal perineal massage, different maternal birthing positions, water births, warm compresses, protection of the perineum and episiotomy for instrumental births. CONCLUSIONS Third- and fourth-degree perineal tears are associated with immediate and long-term implications for women and health systems. Evidence-based approaches can reduce the number of women who sustain a severe perineal tear and alleviate the associated disease burden for those who do.
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Affiliation(s)
- Alyce N Wilson
- Maternal and Child Health Program, Burnet Institute, Melbourne, Victoria, Australia.,Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Caroline S E Homer
- Maternal and Child Health Program, Burnet Institute, Melbourne, Victoria, Australia.,Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Faculty of Health, University of Technology Sydney, Sydney, New South Wales, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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20
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The effect of hypericum perforatum oil on the healing process in the care of episiotomy wounds: A randomized controlled trial. Eur J Integr Med 2020. [DOI: 10.1016/j.eujim.2019.100995] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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21
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Magoga G, Saccone G, Al-Kouatly HB, Dahlen G H, Thornton C, Akbarzadeh M, Ozcan T, Berghella V. Warm perineal compresses during the second stage of labor for reducing perineal trauma: A meta-analysis. Eur J Obstet Gynecol Reprod Biol 2019; 240:93-98. [PMID: 31238205 DOI: 10.1016/j.ejogrb.2019.06.011] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 05/30/2019] [Accepted: 06/11/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Perineal trauma may have a negative impact on women's lives as it has been associated with perineal pain, urinary incontinence and sexual dysfunction. The aim of this systematic review and meta-analysis of randomized controlled trials was to evaluate the effectiveness of warm compresses during the second stage of labor in reducing perineal trauma. METHODS Electronic databases were searched from inception of each database to May 2019. Inclusion criteria were randomized trials comparing warm compresses (i.e. intervention group) with no warm compresses (i.e. control group) during the second stage of labor. Types of participants included pregnant women planning to have a spontaneous vaginal birth at term with a singleton in a cephalic presentation. The primary outcome was the incidence of intact perineum. Meta-analysis was performed using the Cochrane Collaboration methodology with results being reported as relative risk (RR) with 95% confidence interval (CI). RESULTS Seven trials, including 2103 participants, were included in this meta-analysis. Women assigned to the intervention group received warm compresses made from clean washcloths or perineal pads immersed in warm tap water. These were held against the woman's perineum during and in between pushes in second stage. Warm compresses usually started when the baby's head began to distend the perineum or when there was active fetal descent in the second stage of labor. We found a higher rate of intact perineum in the intervention group compared to the control group (22.4% vs 15.4%; RR 1.46, 95% CI 1.22 to 1.74); a lower rate of third degree tears (1.9% vs 5.0%; RR 0.38, 95% CI 0.22 to 0.64), fourth degree tears (0.0% vs 0.9%; RR 0.11, 95% CI 0.01 to 0.86) third and fourth degree tears combined (1.9% vs 5.8%; RR 0.34, 95% CI 0.20 to 0.56) and episiotomy (10.4% vs 17.1%; RR 0.61, 95% CI 0.51 to 0.74). CONCLUSION Warm compresses applied during the second stage of labor increase the incidence of intact perineum and lower the risk of episiotomy and severe perineal trauma.
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Affiliation(s)
- Giulia Magoga
- Department of Medical, Surgical and Health Sciences, University of Trieste, Trieste, Italy
| | - Gabriele Saccone
- Department of Neuroscience, Reproductive Sciences and Dentistry, School of Medicine, University of Naples Federico II, Naples, Italy.
| | - Huda B Al-Kouatly
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Hannah Dahlen G
- School of Nursing and Midwifery, Western Sydney University, Locked Bag 1797, Penrith, NSW 2751, Australia
| | - Charlene Thornton
- College of Nursing and Health Sciences, Flinders University, Adelaide, Australia
| | - Marzieh Akbarzadeh
- Maternal-Fetal Medicine Research Center, Shiraz University of Medical Sciences, Iran
| | - Tulin Ozcan
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, USA
| | - Vincenzo Berghella
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
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22
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Genital tract tears in women giving birth on a birth seat: A cohort study with prospectively collected data. Women Birth 2019; 33:15-21. [PMID: 30642782 DOI: 10.1016/j.wombi.2018.12.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2018] [Revised: 11/29/2018] [Accepted: 12/09/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Birth positions may influence the risk of tears in the genital tract during birth. Birth positions are widely studied yet knowledge on genital tract tears following birth on a birth seat is inconclusive. AIM The objective of this study was to describe the proportion of genital tract tears in women who gave birth on a birth seat compared to women who did not. METHOD An observational cohort study based on birth information collected prospectively. In total 10 629 live, singleton, non-instrumental births in cephalic presentation were studied. RESULTS Fewer women who gave birth on a birth seat experienced an overall intact genital tract compared to women who gave birth in any other position. Women who gave birth on a birth seat were less likely to have an episiotomy performed. Women who gave birth vaginally on a birth seat after a previous caesarean section may have an increased risk for sustaining a sphincter tear. DISCUSSION It is important to be aware of the decreased chance of an overall intact genital tract area when giving birth on a birth seat. Furthermore, there is a possibly increased risk of sphincter tear in women having a vaginal birth after caesarean. It is required and of importance to provide pregnant women with evidence-based information on factors associated with genital tract tears including birth positions.
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Garcia-Lausin L, Perez-Botella M, Duran X, Rodríguez-Pradera S, Gutierrez-Martí MJ, Escuriet R. Relation between Epidural Analgesia and severe perineal laceration in childbearing women in Catalonia. Midwifery 2018; 70:76-83. [PMID: 30594059 DOI: 10.1016/j.midw.2018.12.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 11/07/2018] [Accepted: 12/11/2018] [Indexed: 11/19/2022]
Abstract
OBJECTIVE Our objectives were to study the association between epidural analgesia and risk of severe perineal laceration (SPL), and identify additional risk factors for SPL. This multicentre study consisted of an analysis of data from the MidconBirth Phase I Database, on the use of EA and perineal results during childbirth. (World Health Organization, International Clinical Trials Registry Platform, 2016: http://apps.who.int/trialsearch/Trial2.aspx?TrialID=ISRCTN17833269). METHODS We conducted a prospective study of pregnant women at term between July 2016 and July 2017 in 30 public maternity hospitals in Catalonia, Spain. Inclusion criteria were an uncomplicated singleton pregnancy, in cephalic presentation and vaginal birth. Data was analysed separately for instrumental births and spontaneous vaginal births, as the former is more frequently associated with episiotomy and more perineal lacerations. Risk factors as well as protective factors in each cohort of women (instrumental and spontaneous vaginal birth), were identified. Multivariate logistic regression model was performed to study the association between epidural analgesia and SPL to identify potential confounders. Odds ratios (OR), using 95% confidence intervals (CI) were constructed. FINDINGS During the study period, 5497 eligible women gave birth, 77.46% of them received epidural analgesia. SPL occurred in 1.63% of births. The univariate analysis showed births with epidural analgesia had significantly higher rates of inductions, augmentation of labour, lithotomy position for birth and episiotomy. However, this association disappeared when the variable "type of vaginal birth" was introduced. In multivariate logistic regression, nulliparity was the major predictor for SPL (OR: 0.17; CI 95%: 0.08-0.34, p: 0.000). KEY CONCLUSIONS Epidural analgesia was not associated with SPL once confounding factors were included. Other interesting factors associated with SPL were identified. IMPLICATIONS FOR PRACTICE This paper identifies important practice areas which contribute to SPL and which have the potential to be rectified. It offers evidence on the role that EA plays on pelvic floor injuries and it adds to existing evidence about the disadvantages of using the lithotomy position for birth, especially in relation to SPL. It highlights the need for practice change in Catalonia from what can be considered a medical model of care to one more aligned with the midwifery philosophy of care through the development of clinical guidelines. It also signals the need to provide women with evidence base upon which to make informed choices on the use of EA, specifically in relation to SPL.
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Affiliation(s)
- L Garcia-Lausin
- Department of Experimental and Health Science, Universitat Pompeu Fabra (UPF), Barcelona, Spain; Mar Health Park, Spain.
| | - M Perez-Botella
- Research in Childbirth and Health unit (ReaRH), University of Central Lancashire, United Kingdom
| | - X Duran
- Methodology and Biostatistics Support Unit, Institut Hospital del Mar d´Investigacions Mèdiques (IMIM), Spain
| | | | | | - R Escuriet
- Innovation and Health Division, Catalan Health Service, Spain; Mar School of Nursing, Universitat Pompeu Fabra (UPF), Spain
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Le Ray C, Pizzagalli F. [Which interventions during labour to decrease the risk of perineal tears? CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]. ACTA ACUST UNITED AC 2018; 46:928-936. [PMID: 30377092 DOI: 10.1016/j.gofs.2018.10.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The objective of this review was to evaluate whether interventions performed during labour could influence the risk of perineal tears. METHODS A separate keyword search for each medical intervention during labor was performed by selecting only studies evaluating perineal consequences, particularly the risk of obstetrical anal sphincter injury (LOSA). Interventions during pregnancy and during fetal expulsion have been specifically addressed in other chapters of the recommendations. RESULTS Maternal mobilisation and postures during the first stage of labour have not been shown to reduce the risk of OASIS (LE3). No particular posture has demonstrated its superiority over any other during the second stage of labour for preventing obstetric perineal lesions including OASIS and postnatal incontinence (urinary or faecal) (LE2). There is no reason to recommend one maternal posture rather than another during the first and the second stages of labour for the purpose of reducing the risk of OASIS (Grade C). Women should be allowed to choose the position most comfortable for them during the first and second stages of labour (Professional consensus). Posterior cephalic positions present the greatest risks of perineal injury (LE2). Manual rotation of cephalic posterior positions to the anterior during the second stage of labour may make it possible to reduce the risk of operative vaginal delivery, although no reduction in the risk of perineal injuries or OASIS has been clearly demonstrated (LE3). For fetuses in posterior cephalic positions, no data justifies a preference for manual rotation at full dilation to diminish the risk of perineal injury (Professional consensus). Urinary catheterisation is recommended for women with epidural analgesia during labour when spontaneous micturition is not possible (Professional consensus). Although current data does not justify a preference for continuous or intermittent urinary catheterisation (LE2), intermittent catheterisation nonetheless appears preferable in this situation (Professional consensus). During the second stage phase, delayed pushing does not modify the risk of OASIS (LE1). It does, however, increase the chances of spontaneous delivery (LE1). It is thus recommended that, when maternal and fetal status allow it, the start of pushing should be delayed (Grade A). There is no evidence to support preferring one pushing technique rather than another to diminish the risk of OASIS (grade B). Performing an operative vaginal delivery for the sole purpose of reducing the duration of the second stage of labour may increase the risk of OASIS (LE3). Perineal massage or the application of warm compresses during the second stage of labour appear to reduce the risk of OASIS (LE2). However, we have not made a determination about their use in clinical practice.
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Affiliation(s)
- C Le Ray
- Maternité Port-Royal, hôpital Cochin, Assistance publique-Hôpitaux de Paris, 123, boulevard de Port-Royal, 75014 Paris, France; Inserm U1153, épidémiologie obstétricale, périnatale et pédiatrique (équipe EPOPé), centre de recherche en épidémiologie et statistiques Sorbonne Paris Cité (CRESS), DHU risques et grossesse, université Paris Descartes, 75014 Paris, France.
| | - F Pizzagalli
- Service de gynécologie-obstétrique et médecine de la reproduction, CHU Antoine-Béclère, Assistance publique-Hôpitaux de Paris, 157, rue de la Porte-de-Trivaux, 92140 Clamart, France
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Abbas AM, Mohamed AA, Mattar OM, El Shamy T, James C, Namous LO, Yosef AH, Khamis Y, Samy A. Lidocaine-prilocaine cream versus local infiltration anesthesia in pain relief during repair of perineal trauma after vaginal delivery: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2018; 33:1064-1071. [PMID: 30107755 DOI: 10.1080/14767058.2018.1512576] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
Background: Perineal trauma is a common problem that may affect women during vaginal delivery; this trauma can be either spontaneous (tear) or intentional (episiotomy). When repair of perineal trauma is required, adequate analgesics must be obtained. Topical products as lidocaine-prilocaine (EMLA) cream is one of the suggested methods, but still there is lack of evidence with regard to its efficacy and safety.Objective: The aim of this review is to assess the evidence of utilizing EMLA cream in comparison to local perineal infiltration anesthesia for pain control during perineal repair after vaginal delivery.Data sources: Medline, Embase, Dynamed Plus, ScienceDirect, TRIP database, ClinicalTrials.gov and the Cochrane Library were searched electronically from January 2006 to May 2018 for studies investigating the effect of lidocaine-prilocaine cream in relieving pain during repair of perineal trauma.Methods of study selection: All randomized controlled trials assessing effect of lidocaine-prilocaine cream versus local infiltration anesthesia in relieving pain during repair of perineal trauma were considered for this meta-analysis. Fifteen studies were identified of which four studies deemed eligible for this review. Quality and risk of bias assessment was performed for all studies.Data extraction: Two researchers independently extracted the data from the individual articles and entered into RevMan software. The weighted mean difference (WMD) and 95% confidence interval (CI) was calculated. Statistical heterogeneity between studies was assessed by the Higgins chi-square and (I2) statistics. When heterogeneity was significant, a random-effects model was used for meta-analysis. Otherwise, the fixed effect meta-analysis was used when there was no significant heterogeneity.Results: Pooled analysis of result in "pain score" was insignificant between the two groups (WMD -1.11; 95% CI (-2.55 to 0.33); p = .13). Furthermore, the use of additional analgesia showed no statistically significant difference between the two groups (WMD 1.34; 95% CI (0.66-2.71), p = .42). Regarding patient satisfaction, an overall analysis of three studies showed significant results favoring EMLA cream group users (WMD 4.65; 95% CI (1.96-11.03), p = .0005). The pooled analysis of the outcome "duration of repair" showed the significantly shorter duration of repair in EMLA cream users (n = 92) than local infiltration anesthesia (n = 95) (1.72 min; 95% CI (-2.76 to -0.67), p = .001).Conclusions: This meta-analysis suggests that topical lidocaine-prilocaine cream gives comparable results in reducing pain during perineal repair after vaginal delivery.
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Affiliation(s)
- Ahmed M Abbas
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Ahmed A Mohamed
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Assiut University, Assiut, Egypt.,Department of Obstetrics and Gynaecology, University of Nottingham, Royal Derby Hospital, Derby, United Kingdom
| | - Omar M Mattar
- Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Tarek El Shamy
- Derby Teaching Hospitals NHS Foundation Trust, Derby, United Kingdom
| | - Cathryn James
- Derby Teaching Hospitals NHS Foundation Trust, Derby, United Kingdom
| | - Lubaba O Namous
- Kasr Al-Ainy Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ali H Yosef
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Yasser Khamis
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Beni-Suef University, Cairo, Egypt
| | - Ahmed Samy
- Department of Obstetrics and Gynaecology, Faculty of Medicine, Cairo University, Cairo, Egypt
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Arias T, Coxon K. An experiential model of education introduced to improve the confidence of student midwives in undertaking second stage management of the perineum (SSMP). Midwifery 2018; 59:144-148. [PMID: 29453123 DOI: 10.1016/j.midw.2018.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 01/16/2018] [Accepted: 01/19/2018] [Indexed: 12/23/2022]
Abstract
BACKGROUND AND OBJECTIVE the limited availability of high quality evidence related to second stage management of the perineum (SSMP) combined with a perceived shift in UK practice towards a 'hands off' the perineum/fetal head approach are likely to have impacted significantly on student midwives' understanding of SSMP. This paper presents a classroom based educational session using low fidelity simulation, which was designed in response to student feedback and aimed to improve confidence in this skill. DESIGN reflective teaching practice, based on evaluation of SSMP teaching. SETTING an undergraduate midwifery programme based at an inner city university in London UK. PARTICIPANTS student midwives. FINDINGS the education session based on Kolb's experiential approach to learning appeared to address gaps in the previous teaching which was identified by students. The Classroom setting offered students a supportive setting in which to experiment with different SSMP approaches with a view to personalising care and without compromising safety. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE although further longitudnal research is needed, the experiential model appears to offer a low resource approach to teaching SSMP and has potential application in other countries.
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Affiliation(s)
- Teresa Arias
- Department of Midwifery, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, 57 Waterloo Road, SE1 8WA, United Kingdom.
| | - Kirstie Coxon
- Department of Midwifery, Faculty of Health, Social Care and Education, Kingston and St Georges University, United Kingdom.
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Frigerio M, Manodoro S, Bernasconi DP, Verri D, Milani R, Vergani P. Incidence and risk factors of third- and fourth-degree perineal tears in a single Italian scenario. Eur J Obstet Gynecol Reprod Biol 2017; 221:139-143. [PMID: 29304391 DOI: 10.1016/j.ejogrb.2017.12.042] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/17/2017] [Accepted: 12/22/2017] [Indexed: 12/26/2022]
Abstract
OBJECTIVE This study aimed to evaluate III and IV degree tears rates and related risk factors in a single Italian centre. The secondary goal was to build a predictive model based on identified risk factors. STUDY DESIGN This was a retrospective cohort study. All vaginal deliveries from 2011 to 2015 in a single Italian University Hospital were analysed. Univariate analysis was applied to evaluate the overall association between each factor and severe tear. Multivariate logistic regression was used to build a predictive model for the absolute risk of severe tear. We computed a resampling validated measure (AUC) of the predictive accuracy of the model and we provided a nomogram for the risk calculation in clinical practice. RESULTS 62 out of 10133 patients (0.61%) had a severe perineal tear. Univariate analysis identified gestational age >40 weeks, nulliparity, moderate/severe obesity, oxytocin use in pushing stage, sinciput presentation, instrumental delivery, shoulder dystocia, pushing stage ≥90 min, lithotomy position, birth weight >4 kg, head circumference at birth >34 cm and length at birth >50 cm as risk factors. Multivariate analysis identify moderate/severe obesity (OR = 2.8), instrumental delivery (OR = 2.6) and birth weight (OR = 1.1/hg) as independent risk factors. Using the predicted risk score from the final model (bootstrap-validated AUC 70%), we designed a nomogram for severe perineal tears absolute risk calculation. CONCLUSION Moderate/severe obesity, instrumental delivery and foetal weight resulted as independent risk factors for severe obstetrical tears.
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Affiliation(s)
| | | | - Davide P Bernasconi
- School of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Italy
| | - Debora Verri
- ASST Monza, Ospedale San Gerardo, Monza, Italy; School of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Italy
| | - Rodolfo Milani
- ASST Monza, Ospedale San Gerardo, Monza, Italy; School of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Italy
| | - Patrizia Vergani
- ASST Monza, Ospedale San Gerardo, Monza, Italy; School of Medicine and Surgery, Università degli Studi di Milano-Bicocca, Italy
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Waldenström U, Ekéus C. Risk of obstetric anal sphincter injury increases with maternal age irrespective of parity: a population-based register study. BMC Pregnancy Childbirth 2017; 17:306. [PMID: 28915858 PMCID: PMC5602858 DOI: 10.1186/s12884-017-1473-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 08/28/2017] [Indexed: 01/20/2023] Open
Abstract
Background Obstetric anal sphincter injury (OASI) is a rare but serious outcome of vaginal birth. Based on concerns about the increasing number of women who commence childbearing later than previous generation, this study aimed at investigating age-related risk of OASI in women of different parity. Methods A population-based register study including 959,559 live singleton vaginal births recorded in the Swedish Medical Birth Register 1999 to 2011. In each parity group risks of OASI at age 25–29 years, 30–34 years, and ≥35 years compared with age < 25 years were investigated by logistic regression analyses, adjusted for year of birth, education, region of birth, smoking, Body Mass Index, infant birthweight and fetal presentation; and in parous women, history of OASI and cesarean section. Additional analyses also adjusted for mediating factors, such as epidural analgesia, episiotomy, and instrumental delivery, and maternal age-related morbidity. Results Rates of OASI were 6.6%, 2.3% and 0.9% in first, second and third births respectively. Age-related risk increased from 25-29 years in first births (Adjusted OR 1.66; 95% CI 1.59–1.72) and second births (Adjusted OR 1.78; 95% CI 1.58–2.01), and from 30-34 years in third births (Adjusted OR 1.60; 95% CI 1.00–2.56). In all parity groups the risk was doubled at age ≥ 35 years, compared with the respective reference group of women under 25 years. Adding mediating factors and maternal age-related morbidity only marginally reduced these risk estimates. Conclusion Maternal age is an independent risk factor for OASI in first, second and third births. Although age-related risks by parity are relatively similar, more nulliparous than parous women will be exposed to OASI due to the higher baseline rate. Electronic supplementary material The online version of this article (10.1186/s12884-017-1473-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ulla Waldenström
- Department of Women's and Children's Health, Division of Reproductive Health, Karolinska Institutet, Retzius väg 13 a-b, 171 77, Stockholm, Sweden. .,, Bastugatan 42, 118 25, Stockholm, Sweden.
| | - Cecilia Ekéus
- Department of Women's and Children's Health, Division of Reproductive Health, Karolinska Institutet, Retzius väg 13 a-b, 171 77, Stockholm, Sweden
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Aasheim V, Nilsen ABV, Reinar LM, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 2017; 6:CD006672. [PMID: 28608597 PMCID: PMC6481402 DOI: 10.1002/14651858.cd006672.pub3] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Most vaginal births are associated with trauma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including perineal massage, warm or cold compresses, and perineal management techniques have been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011. OBJECTIVES To assess the effect of perineal techniques during the second stage of labour on the incidence and morbidity associated with perineal trauma. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (26 September 2016) and reference lists of retrieved studies. SELECTION CRITERIA Published and unpublished randomised and quasi-randomised controlled trials evaluating perineal techniques during the second stage of labour. Cross-over trials were not eligible for inclusion. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. We checked data for accuracy. MAIN RESULTS Twenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Overall, trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques.Most studies did not report data on our secondary outcomes. We downgraded evidence for risk of bias, inconsistency, and imprecision for all comparisons. Hands off (or poised) compared to hands onHands on or hands off the perineum made no clear difference in incidence of intact perineum (average risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.12, two studies, Tau² 0.00, I² 37%, 6547 women; moderate-quality evidence), first-degree perineal tears (average RR 1.32, 95% CI 0.99 to 1.77, two studies, 700 women; low-quality evidence), second-degree tears (average RR 0.77, 95% CI 0.47 to 1.28, two studies, 700 women; low-quality evidence), or third- or fourth-degree tears (average RR 0.68, 95% CI 0.21 to 2.26, five studies, Tau² 0.92, I² 72%, 7317 women; very low-quality evidence). Substantial heterogeneity for third- or fourth-degree tears means these data should be interpreted with caution. Episiotomy was more frequent in the hands-on group (average RR 0.58, 95% CI 0.43 to 0.79, Tau² 0.07, I² 74%, four studies, 7247 women; low-quality evidence), but there was considerable heterogeneity between the four included studies.There were no data for perineal trauma requiring suturing. Warm compresses versus control (hands off or no warm compress)A warm compress did not have any clear effect on the incidence of intact perineum (average RR 1.02, 95% CI 0.85 to 1.21; 1799 women; four studies; moderate-quality evidence), perineal trauma requiring suturing (average RR 1.14, 95% CI 0.79 to 1.66; 76 women; one study; very low-quality evidence), second-degree tears (average RR 0.95, 95% CI 0.58 to 1.56; 274 women; two studies; very low-quality evidence), or episiotomy (average RR 0.86, 95% CI 0.60 to 1.23; 1799 women; four studies; low-quality evidence). It is uncertain whether warm compress increases or reduces the incidence of first-degree tears (average RR 1.19, 95% CI 0.38 to 3.79; 274 women; two studies; I² 88%; very low-quality evidence).Fewer third- or fourth-degree perineal tears were reported in the warm-compress group (average RR 0.46, 95% CI 0.27 to 0.79; 1799 women; four studies; moderate-quality evidence). Massage versus control (hands off or routine care)The incidence of intact perineum was increased in the perineal-massage group (average RR 1.74, 95% CI 1.11 to 2.73, six studies, 2618 women; I² 83% low-quality evidence) but there was substantial heterogeneity between studies). This group experienced fewer third- or fourth-degree tears (average RR 0.49, 95% CI 0.25 to 0.94, five studies, 2477 women; moderate-quality evidence).There were no clear differences between groups for perineal trauma requiring suturing (average RR 1.10, 95% CI 0.75 to 1.61, one study, 76 women; very low-quality evidence), first-degree tears (average RR 1.55, 95% CI 0.79 to 3.05, five studies, Tau² 0.47, I² 85%, 537 women; very low-quality evidence), or second-degree tears (average RR 1.08, 95% CI 0.55 to 2.12, five studies, Tau² 0.32, I² 62%, 537 women; very low-quality evidence). Perineal massage may reduce episiotomy although there was considerable uncertainty around the effect estimate (average RR 0.55, 95% CI 0.29 to 1.03, seven studies, Tau² 0.43, I² 92%, 2684 women; very low-quality evidence). Heterogeneity was high for first-degree tear, second-degree tear and for episiotomy - these data should be interpreted with caution. Ritgen's manoeuvre versus standard careOne study (66 women) found that women receiving Ritgen's manoeuvre were less likely to have a first-degree tear (RR 0.32, 95% CI 0.14 to 0.69; very low-quality evidence), more likely to have a second-degree tear (RR 3.25, 95% CI 1.73 to 6.09; very low-quality evidence), and neither more nor less likely to have an intact perineum (RR 0.17, 95% CI 0.02 to 1.31; very low-quality evidence). One larger study reported that Ritgen's manoeuvre did not have an effect on incidence of third- or fourth-degree tears (RR 1.24, 95% CI 0.78 to 1.96,1423 women; low-quality evidence). Episiotomy was not clearly different between groups (RR 0.81, 95% CI 0.63 to 1.03, two studies, 1489 women; low-quality evidence). Other comparisonsThe delivery of posterior versus anterior shoulder first, use of a perineal protection device, different oils/wax, and cold compresses did not show any effects on perineal outcomes. Only one study contributed to each of these comparisons, so data were insufficient to draw conclusions. AUTHORS' CONCLUSIONS Moderate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent. Poor-quality evidence suggests hands-off techniques may reduce episiotomy, but this technique had no clear impact on other outcomes. There were insufficient data to show whether other perineal techniques result in improved outcomes.Further research could be performed evaluating perineal techniques, warm compresses and massage, and how different types of oil used during massage affect women and their babies. It is important for any future research to collect information on women's views.
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Affiliation(s)
- Vigdis Aasheim
- Western Norway University of Applied SciencesFaculty of Health and Social SciencesBergenNorway
| | - Anne Britt Vika Nilsen
- Western Norway University of Applied SciencesFaculty of Health and Social SciencesBergenNorway
| | - Liv Merete Reinar
- Norwegian Institute of Public HealthDivision for Health ServicesPO Box 4404NydalenOsloNorway0403
| | - Mirjam Lukasse
- University College of Southeast NorwayFaculty of Health and Social SciencesOsloNorway
- Oslo and Akershus University CollegeFaculty of Health SciencesPB4St.Olavs plassOsloNorwayN‐0130
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The Effect of Warm Compress Bistage Intervention on the Rate of Episiotomy, Perineal Trauma, and Postpartum Pain Intensity in Primiparous Women with Delayed Valsalva Maneuver Referring to the Selected Hospitals of Shiraz University of Medical Sciences in 2012-2013. Adv Skin Wound Care 2017; 29:79-84. [PMID: 26765160 DOI: 10.1097/01.asw.0000476073.96442.91] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Genital trauma during vaginal delivery may result from episiotomy, spontaneous perineal tears (perineum, vagina), or both. In 2012, this study aimed to investigate the effect of warm compress bistage intervention on the rate of episiotomy, perineal trauma, and postpartum pain intensity in the primiparous woman with delayed Valsalva maneuver. METHODS In this randomized clinical trial, which was performed in hospitals in Shiraz, Iran, in 2012-2013, 150 women were randomly divided into 2 groups: 1 intervention and 1 control. The intervention group received warm compress bistage intervention at 7-cm and 10-cm dilatation and zero position during the first and second stages of labor for 15 to 20 minutes, whereas the control group received the hospitals' routine care. After delivery, the prevalence of episiotomy; intact perineum; location, degree, and length of rupture; and postpartum pain intensity were assessed in the 2 groups. Following that, the data were analyzed with SPSS statistical software (version 16) using χ test, t test, and odds ratio. RESULTS The results revealed a significant difference between the intervention and control groups regarding the frequency of intact perinea (27% vs 6.7%) and the frequency of episiotomy (45% vs 90.70%). In addition, the frequency of the location of rupture (P = .019), mean length of episiotomy incision (P = .02), and mean intensity of pain the day after delivery (P < .001) were significantly lower in the intervention group compared with the control group. However, the rate of ruptures was higher in the intervention group. CONCLUSIONS Warm compress bistage intervention was effective in reducing episiotomies and the mean length of episiotomy incision, reducing pain after delivery, and increasing the rate of intact perinea. However, the rate of ruptures slightly increased in the intervention group compared with the control group.
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Abstract
The effects of providing education regarding comfort options available in the hospital setting on level of maternal comfort and pain during labor were explored in a quasi-experimental pretest/posttest comparison group design (N = 80). No significant difference was found in maternal comfort or pain between the intervention group that received comfort education and the control group. Comfort education did result in change for plans to maintain comfort during labor (p = .000), an increased use of comfort measures during labor (p = .000), and an increased probability of continuation with original plans for pain control during labor. Providing education for maintaining comfort during labor can allow women to make informed choices during labor.
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Bazi T, Takahashi S, Ismail S, Bø K, Ruiz-Zapata AM, Duckett J, Kammerer-Doak D. Prevention of pelvic floor disorders: international urogynecological association research and development committee opinion. Int Urogynecol J 2016; 27:1785-1795. [PMID: 26971276 DOI: 10.1007/s00192-016-2993-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 02/18/2016] [Indexed: 12/19/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Pelvic floor disorders (PFD), including urinary incontinence, anal incontinence, and pelvic organ prolapse, are common and have a negative effect on the quality of life of women. Treatment is associated with morbidity and may not be totally satisfactory. Prevention of PFDs, when possible, should be a primary goal. The purpose of this paper is to summarise the current literature and give an evidence-based review of the prevention of PFDs METHODS: A working subcommittee from the International Urogynecological Association (IUGA) Research and Development (R&D) Committee was formed. An initial document addressing the prevention of PFDs was drafted, based on a review of the English-language literature. After evaluation by the entire IUGA R&D Committee, revisions were made. The final document represents the IUGA R&D Committee Opinion on the prevention of PFDs. RESULTS This R&D Committee Opinion reviews the literature on the prevention of PFDs and summarises the findings with evidence-based recommendations. CONCLUSIONS Pelvic floor disorders have a long latency, and may go through periods of remission, thus making causality difficult to confirm. Nevertheless, prevention strategies targeting modifiable risk factors should be incorporated into clinical practice before the absence of symptomatology.
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Affiliation(s)
- Tony Bazi
- Department of Obstetrics and Gynecology, Faculty of Medicine, American University of Beirut Medical Center, PO Box 11-0236, Riad El-Solh, Beirut, 1107 2020, Lebanon.
| | - Satoru Takahashi
- Department of Urology, Nihon University School of Medicine, Tokyo, Japan
| | - Sharif Ismail
- Brighton and Sussex Medical School, Brighton and Sussex University Hospitals NHS Trust, Brighton, England, UK
| | - Kari Bø
- Norwegian School of Sport Sciences, Oslo, Norway
| | - Alejandra M Ruiz-Zapata
- Department of Obstetrics and Gynecology, Department of Urology, Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Jonathan Duckett
- Directorate of Women's Health, Medway NHS Foundation Trust, Gillingham, UK
| | - Dorothy Kammerer-Doak
- Women's Pelvic Specialty Care of New Mexico, University of New Mexico Hospital, Albuquerque, NM, USA
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Risk factors for obstetric anal sphincter injury: To prolong or to vacuum? Midwifery 2015; 34:178-182. [PMID: 26825356 DOI: 10.1016/j.midw.2015.11.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 10/29/2015] [Accepted: 11/12/2015] [Indexed: 11/22/2022]
Abstract
INTRODUCTION An awareness of risk factors for obstetric anal sphincter injuries (OASIS) is essential in order to reduce the occurrence of the primary event. These risk factors are demographic, obstetric and intrapartum related. We aimed to identify the risk factors for OASIS and to examine how modifiable risk factors may be used in order to reduce the incidence of OASIS. METHODS A retrospective, matched case-control study was conducted in the delivery ward of a single university teaching hospital in Israel, using data from January 2004 to July 2012. All singleton vaginal deliveries at term with OASIS were included. The controls included women matched at a ratio of 1:2 based on gestational age and deliveries that occurred immediately before and after the delivery of the women in the study group. RESULTS Overall, 113 OASIS were identified. Stepwise conditional logistic regression revealed that the first vaginal birth (OR = 7.6; 95% confidence interval (CI), 3.5-16.3; p < 0.001) particularly after a previous caesarean section (OR = 13.6; 95% CI, 4.7-39.3; p < 0.001) and the length of the second stage (OR 1.5; 95% CI, 1.1-2.1, p = 0.045) were the only risk factors for OASIS. Among 24 primiparous women who already had a prolonged second stage, 15 delivered by vacuum extraction and nine spontaneously; OASIS occurred in eight (53%) and three (33%) women, respectively. Multivariate analysis showed that this difference was not significant (OR = 2.3; 95% CI, 0.4-12.7; p = 0.35). CONCLUSIONS The first vaginal birth particularly after a caesarean delivery and the length of the second stage increased the risk of OASIS. Vacuum extraction performed to shorten a prolonged second stage is not necessarily protective.
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Battut A, Nizard J. [Impact of pelvic floor muscle training on prevention of perineal pain and dyspareunia in postpartum]. Prog Urol 2015; 26:237-44. [PMID: 26455776 DOI: 10.1016/j.purol.2015.09.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2015] [Revised: 09/06/2015] [Accepted: 09/07/2015] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Assessing the impact of perineal rehabilitation and massage on perineal pain and dyspareunia in the postpartum period, between 15days and 12months after delivery. METHODS We conducted an exhaustive review of the literature concerning pelvic floor rehabilitation in the postpartum between 1987 and May 2015, grading data by levels of evidence (LOE) according to the methodology recommendations for clinical guidelines. RESULTS Pelvic floor rehabilitation in the postpartum is not associated with a decreased prevalence of perineal pain and dyspareunia at 1year (LOE3). The practice of digital perineal massage during the third trimester of pregnancy is not associated with decreased prevalence at 3-month postpartum of perineal pain or dyspareunia (RR=0.64; 95% CI [0.39-1.08] and RR=0.96; 95% CI [0.84-1.08], respectively), except for women who have delivered vaginally (RR=0.45; 95% CI [0,24-0.87]) (LOE2). The practice of digital perineal massage or application of warm packs in the second stage of labor does not reduce perineal pain (RR=0.93; 95% CI [0.66-1.32]) or dyspareunia (RR=0.99; 95% CI [0.74-1.34]) at 3-month postpartum (LOE2). CONCLUSION There is no evidence of long-term benefit of perineal rehabilitation and perineal massage on perineal pain and dyspareunia in the year following childbirth. Further studies are needed to accurately assess the impact of therapeutic strategies proposed in France.
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Affiliation(s)
- A Battut
- Cabinet de sage-femme et rééducation périnéale, 68, rue des Prairies, 75020 Paris, France.
| | - J Nizard
- Service de gynécologie-obstétrique, groupe hospitalier de la Pitié-Salpêtrière, AP-HP, Sorbonne universités, université Paris 06, CNRS UMR 7222, inserm U1150, 75013 Paris, France
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Dahlen HG, Priddis H, Thornton C. Severe perineal trauma is rising, but let us not overreact. Midwifery 2015; 31:1-8. [DOI: 10.1016/j.midw.2014.09.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Chaillet N, Belaid L, Crochetière C, Roy L, Gagné GP, Moutquin JM, Rossignol M, Dugas M, Wassef M, Bonapace J. Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth 2014; 41:122-37. [PMID: 24761801 DOI: 10.1111/birt.12103] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/13/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess the effects of nonpharmacologic approaches to pain relief during labor, according to their endogenous mechanism of action, on obstetric interventions, maternal, and neonatal outcomes. DATA SOURCE Cochrane library, Medline, Embase, CINAHL and the MRCT databases were used to screen studies from January 1990 to December 2012. STUDY SELECTION According to Cochrane criteria, we selected randomized controlled trials that compared nonpharmacologic approaches for pain relief during labor to usual care, using intention-to-treat method. RESULTS Nonpharmacologic approaches, based on Gate Control (water immersion, massage, ambulation, positions) and Diffuse Noxious Inhibitory Control (acupressure, acupuncture, electrical stimulation, water injections), are associated with a reduction in epidural analgesia and a higher maternal satisfaction with childbirth. When compared with nonpharmacologic approaches based on Central Nervous System Control (education, attention deviation, support), usual care is associated with increased odds of epidural OR 1.13 (95% CI 1.05-1.23), cesarean delivery OR 1.60 (95% CI 1.18-2.18), instrumental delivery OR 1.21 (95% CI 1.03-1.44), use of oxytocin OR 1.20 (95% CI 1.01-1.43), labor duration (29.7 min, 95% CI 4.5-54.8), and a lesser satisfaction with childbirth. Tailored nonpharmacologic approaches, based on continuous support, were the most effective for reducing obstetric interventions. CONCLUSION Nonpharmacologic approaches to relieve pain during labor, when used as a part of hospital pain relief strategies, provide significant benefits to women and their infants without causing additional harm.
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Affiliation(s)
- Nils Chaillet
- Department of Obstetrics and Gynaecology, University of Sherbrooke, Sherbrooke, QC, Canada
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Priddis H, Schmied V, Dahlen H. Women's experiences following severe perineal trauma: a qualitative study. BMC Womens Health 2014; 14:32. [PMID: 24559056 PMCID: PMC3933507 DOI: 10.1186/1472-6874-14-32] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2013] [Accepted: 02/13/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Literature reports that the psychological impact for women following severe perineal trauma is extensive and complex, however there is a paucity of research reporting on women's experience and perspective of how they are cared for during this time. The aim of this study was to explore how women experience and make meaning of living with severe perineal trauma. METHODS A qualitative interpretive approach using a feminist perspective guided data collection and analysis. Data were collected through semi-structured face to face interviews with twelve women in Sydney, Australia, who had experienced severe perineal trauma during vaginal birth. Thematic analysis was used to analyse the data. RESULTS Three main themes were identified: The Abandoned Mother describes how women feel vulnerable, exposed and disempowered throughout the labour and birth, suturing, and postpartum period and how these feelings are a direct result of the actions of their health care providers. The Fractured Fairytale explores the disconnect between the expectations and reality of the birth experience and immediate postpartum period for women, and how this reality impacts upon their ability to mother their newborn child and the sexual relationship they have with their partner. A Completely Different Normal discusses the emotional pathway women travel as they work to rediscover and redefine a new sense of self following severe perineal trauma. CONCLUSION How women are cared for during their labour, birth and postnatal period has a direct impact on how they process, understand and rediscover a new sense of self following severe perineal trauma. Women who experience severe perineal trauma and associated postnatal morbidities undergo a transition as their maternal body boundaries shift, and the trauma to their perineum results in an extended physical opening whereby the internal becomes external, and that creates a continual shift between self and other.
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Affiliation(s)
- Holly Priddis
- School of Nursing and Midwifery, College of Health and Science, University of Western Sydney, Building EB, Parramatta Campus, Locked Bag 1797, Penrith South DC NSW 2751, Australia
| | - Virginia Schmied
- School of Nursing and Midwifery, College of Health and Science, University of Western Sydney, Building EB, Parramatta Campus, Locked Bag 1797, Penrith South DC NSW 2751, Australia
| | - Hannah Dahlen
- School of Nursing and Midwifery, College of Health and Science, University of Western Sydney, Building EB, Parramatta Campus, Locked Bag 1797, Penrith South DC NSW 2751, Australia
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Abstract
BACKGROUND Perineal hyaluronidase (HAase) injection was widely used to reduce the occurrence of perineal trauma, pain and need for episiotomy in the 1950s to 1960s. Reports suggested that the administration of HAase was a simple, low risk, low cost and effective way to decrease perineal trauma without adverse effects. OBJECTIVES The objective of this review was to assess the effectiveness and safety of perineal HAase injection for reducing spontaneous perineal trauma, episiotomy and perineal pain in vaginal deliveries. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2013), the International Clinical Trials Registry Platform (ICTRP) and the Networked Digital Library of Theses and Dissertations (both on 1 April 2013), and reference lists of retrieved studies. We also contacted relevant organisations. SELECTION CRITERIA Published and unpublished randomised and quasi-randomised controlled trials comparing perineal HAase injection with placebo injection or no intervention in vaginal deliveries. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. Data were checked for accuracy. MAIN RESULTS The search strategy identified six potentially eligible studies. Two studies were excluded. We included four randomised controlled trials that randomised a total of 599 women (data were available for 595 women).Two trials (283 women) compared the effects of perineal HAase injection during the second stage of labour with placebo injection and were at low risk of bias. Three trials (one three-armed trial was analysed twice) (373 women) compared the effects of perineal HAase injection during second stage of labour with no intervention and two out of the three trials were at high risk of bias. Data from four trials involving 599 women suggested that perineal HAase injection during second stage of labour had a lower incidence of perineal trauma (average risk ratio (RR) 0.69, 95% confidence interval (CI) 0.50 to 0.95,Tau² = 0.08, I² = 82% compared with women in the control group, but there was no clear evidence of a reduction in the incidence of episiotomy (average RR 0.74, 95% CI 0.43 to 1.29, Tau² = 0.17, I² = 66%), first and second degree perineal lacerations (average RR 0.54, 95% CI 0.38 to 1.33, Tau² = 0.30 , I² = 85%) and third and fourth degree perineal lacerations (RR 0.12, 95% CI 0.01 to 2.13). Data from two trials involving 283 women indicated that there was no clear evidence of a reduction in the incidence of perineal trauma (RR 0.90, 95% CI 0.77 to 1.06, Tau²=1.07, I² = 7%), episiotomy (RR 0.77, 95% CI 0.32 to 1.89, Tau² = 0.27, I² = 54%), first and second degree perineal lacerations (RR 1.08, 95% CI 0.83 to 1.40, Tau² = 1.11, I² = 10%) and third and fourth degree perineal lacerations (RR 0.12, 95% CI 0.01 to 2.13) with perineal HAase injection. Data from three trials involving 373 women suggested that perineal HAase injection during second stage of labour had a lower incidence of perineal trauma (RR 0.61, 95% CI 0.42 to 0.88, Tau² = 0.08, I² = 78%) compared with no intervention, but had no clear effect on in the incidence of episiotomy (RR 0.79, 95% CI 0.44 to 1.42, Tau² = 0.16, I² = 70%) and first and second degree perineal lacerations (RR 0.58, 95% CI 0.31 to 1.10, Tau² = 0.18, I² = 59%). No side effects were reported in the included trials.No included trials reported on perineal pain and other pre-specified secondary outcomes: perineal trauma requiring suturing; blood loss; dyspareunia; urinary incontinence; faecal incontinence; assisted delivery rate; women's satisfaction; Apgar score less than seven at five minutes and need for admission to special care baby unit. AUTHORS' CONCLUSIONS Perineal HAase injection during second stage of labour had a lower incidence of perineal trauma compared with control or no intervention, but there was no clear evidence of benefit compared with placebo injection. The difference in incidence of perineal trauma may probably be due to bias and confounding in the non-placebo controlled comparison, this result should be interpreted cautiously. The potential use of perineal HAase injection as a method to reduce perineal trauma were yet to be determined as there was no appropriate established dose for HAase, no evidence of follow up, and the number of high-quality trials and outcomes reported were too limited to draw conclusions on its effectiveness and safety. Further rigorous randomised controlled trials are required to evaluate the role of perineal HAase injection in vaginal deliveries.
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Affiliation(s)
- Fan Zhou
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynaecologyRenmin Nan RoadChengduSichuanChina610041
| | - Xiao Dong Wang
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynaecologyRenmin Nan RoadChengduSichuanChina610041
| | - Jing Li
- West China Hospital, Sichuan UniversityChinese Cochrane CentreNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Gui Qiong Huang
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynaecologyRenmin Nan RoadChengduSichuanChina610041
| | - Bing Xin Gao
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynaecologyRenmin Nan RoadChengduSichuanChina610041
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Eshkevari L, Trout KK, Damore J. Management of Postpartum Pain. J Midwifery Womens Health 2014; 58:622-31. [DOI: 10.1111/jmwh.12129] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Ampt AJ, Ford JB, Roberts CL, Morris JM. Trends in obstetric anal sphincter injuries and associated risk factors for vaginal singleton term births in New South Wales 2001-2009. Aust N Z J Obstet Gynaecol 2013; 53:9-16. [PMID: 23405994 DOI: 10.1111/ajo.12038] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Accepted: 11/15/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Changes in clinical practice and in the characteristics of childbearing women have the potential to influence the rate of obstetric anal sphincter injuries (OASIS). To date, little investigation has been undertaken to assess the effect of risk factor trends for the Australian population on OASIS rates. AIMS To ascertain the OASIS rates amongst singleton vaginal births ≥37 weeks gestation in NSW, 2001 - 2009; to determine risk factor effect sizes and trends; and to compare predicted with observed OASIS rates. METHODS Using two linked population-based data sets, risk factors for OASIS were determined by logistic regression. Contingency tables and predictive modelling were used to determine trends and predicted rates of OASIS, respectively. RESULTS The OASIS rate increased from 2.2% in 2001 to 2.9% in 2009. Highest risks were for forceps deliveries without episiotomy (primiparas aOR 6.10, multiparas aOR 6.15), followed by multiparas with no previous vaginal birth (aOR 5.61). High birthweight, vacuum delivery and Asian country of birth posed risks for all women. The greatest risk factor trends were increases in Asian country of birth and vacuum delivery, while the greatest trend amongst protective factors was an increase in maternal age ≥35 years for primiparas. Predicted OASIS rates were lower than observed rates. CONCLUSION In an environment of changing demographic and clinical risk factors, the OASIS rate has increased. This increase is only minimally explained by the identified risk factors and may be related to other unmeasured risk factors or a possible increase in clinical ascertainment and/or documentation of OASIS.
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Affiliation(s)
- Amanda J Ampt
- Clinical and Population Perinatal Health Research, Kolling Institute of Medical Research, University of Sydney, St Leonards, New South Wales, Australia.
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Dahlen HG, Dowling H, Tracy M, Schmied V, Tracy S. Maternal and perinatal outcomes amongst low risk women giving birth in water compared to six birth positions on land. A descriptive cross sectional study in a birth centre over 12 years. Midwifery 2013; 29:759-64. [DOI: 10.1016/j.midw.2012.07.002] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 07/04/2012] [Accepted: 07/08/2012] [Indexed: 10/28/2022]
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Dahlen H, Priddis H, Schmied V, Sneddon A, Kettle C, Brown C, Thornton C. Trends and risk factors for severe perineal trauma during childbirth in New South Wales between 2000 and 2008: a population-based data study. BMJ Open 2013; 3:e002824. [PMID: 23793688 PMCID: PMC3657654 DOI: 10.1136/bmjopen-2013-002824] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2013] [Revised: 04/09/2013] [Accepted: 04/25/2013] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVES To determine trends and risk factors for severe perineal trauma between 2000 and 2008. DESIGN This was a population-based data study. SETTING New South Wales, Australia. PARTICIPANTS 510 006 women giving birth to a singleton baby during the period 2000-2008. MAIN OUTCOME MEASURES Rates of severe perineal trauma between 2000 and 2008 and associated demographic, fetal, antenatal, labour and delivery events and factors. RESULTS There was an increase in the overall rate of severe perineal trauma from 2000 to 2008 from 1.4% to 1.9% (36% increase). Compared with women who were intact or had minor perineal trauma (first-degree tear, vaginal graze/tear), women who were primiparous (adjusted OR (AOR) 1.8 CI (1.65 to 1.95), were born in China or Vietnam (AOR 1.1 CI (1.09 to 1.23), gave birth in a private hospital (AOR 1.1 CI (1.03 to 1.20), had an instrumental birth (AOR 1.8 CI (1.65 to 1.95) and male baby (AOR 1.3 CI (1.27 to 1.34) all had a significantly higher risk of severe perineal trauma. Only giving birth to a male baby, adjusted for birth weight (AOR 1.5 CI (1.44 to 1.58), remained significant, when women with severe perineal trauma were compared with all other women not experiencing severe perineal trauma. This association increased over the study period. CONCLUSIONS To our knowledge, this is the first time that having a male baby has been found to exert such a strong independent risk for severe perineal trauma and the increasing significance of this in recent years needs further exploration.
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Affiliation(s)
- Hannah Dahlen
- School of Nursing and Midwifery, University of Western Sydney, Penrith, New South Wales, Australia
| | - Holly Priddis
- School of Nursing and Midwifery, University of Western Sydney, Penrith, New South Wales, Australia
| | - Virginia Schmied
- School of Nursing and Midwifery, University of Western Sydney, Penrith, New South Wales, Australia
| | - Anne Sneddon
- Obstetrics and Gynaecology Gold Coast, Griffith University, Gold Coast, New South Wales, Australia
| | - Christine Kettle
- Women's Health Stafford, Staffordshire University, Beaconside, UK
| | - Chris Brown
- NHMRC Clinical Trials Centre Sydney, University of Sydney, Sydney, New South Wales, Australia
| | - Charlene Thornton
- School of Nursing and Midwifery, University of Western Sydney, Penrith, New South Wales, Australia
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Priddis H, Dahlen HG, Schmied V, Sneddon A, Kettle C, Brown C, Thornton C. Risk of recurrence, subsequent mode of birth and morbidity for women who experienced severe perineal trauma in a first birth in New South Wales between 2000-2008: a population based data linkage study. BMC Pregnancy Childbirth 2013; 13:89. [PMID: 23565655 PMCID: PMC3635942 DOI: 10.1186/1471-2393-13-89] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2012] [Accepted: 04/03/2013] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Severe perineal trauma occurs in 0.5-10% of vaginal births and can result in significant morbidity including pain, dyspareunia and faecal incontinence. The aim of this study is to determine the risk of recurrence, subsequent mode of birth and morbidity for women who experienced severe perineal trauma during their first birth in New South Wales (NSW) between 2000 - 2008. METHOD All singleton births recorded in the NSW Midwives Data Collection between 2000-2008 (n=510,006) linked to Admitted Patient Data were analysed. Determination of morbidity was based upon readmission to hospital within a 12 month time period following birth for a surgical procedure falling within four categories: 1. Vaginal repair, 2. Fistula repair, 3. Faecal and urinary incontinence repair, and 4. Rectal/anal repair. Women who experienced severe perineal trauma during their first birth were compared to women who did not. RESULTS 2,784 (1.6%) primiparous women experienced severe perineal trauma during this period. Primiparous women experiencing severe perineal trauma were less likely to have a subsequent birth (56% vs 53%) compared to those not who did not (OR 0.9; CI 0.81-0.99), however there was no difference in the subsequent rate of elective caesarean section (OR 1.2; 0.95-1.54), vaginal birth (including instrumental birth) (OR 1.0; CI 0.81-1.17) or normal vaginal birth (excluding instrumental birth) (OR 1.0; CI 0.85-1.17). Women were no more likely to have a severe perineal tear in the second birth if they experienced this in the first (OR 0.9; CI 0.67-1.34). Women who had a severe perineal tear in their first birth were significantly more likely to have an 'associated surgical procedure' within the ≤12 months following birth (vaginal repair following primary repair, rectal/anal repair following primary repair, fistula repair and urinary/faecal incontinence repair) (OR 7.6; CI 6.21-9.22). Women who gave birth in a private hospital compared to a public hospital were more likely to have an 'associated surgical procedure' in the 12 months following the birth (OR 1.8; CI 1.54-1.97), regardless of parity, birth type and perineal status. CONCLUSION Primiparous women who experience severe perineal trauma are less likely to have a subsequent baby, more likely to have a related surgical procedure in the 12 months following the birth and no more likely to have an operative birth or another severe perineal tear in a subsequent birth. Women giving birth in a private hospital are more likely to have an associated surgical procedure in the 12 months following birth.
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Affiliation(s)
- Holly Priddis
- School of Nursing and Midwifery, University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW, Australia
| | - Hannah G Dahlen
- School of Nursing and Midwifery, University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW, Australia
| | - Virginia Schmied
- School of Nursing and Midwifery, University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW, Australia
| | - Annie Sneddon
- The Gold Coast Health Services District, Griffith University, 108 Nerang Street, Southport, QLD, 4215, Australia
| | - Christine Kettle
- Faculty of Health, Staffordshire University, Blackheath Lane, Beaconside, Stafford, ST18 0AD, UK
| | - Chris Brown
- NHMRC Clinical Trials Centre, Locked Bag 77, Camperdown, NSW, 1450, Australia
| | - Charlene Thornton
- School of Nursing and Midwifery, University of Western Sydney, Locked Bag 1797, Penrith South DC, NSW, Australia
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Wesnes SL, Lose G. Preventing urinary incontinence during pregnancy and postpartum: a review. Int Urogynecol J 2013; 24:889-99. [DOI: 10.1007/s00192-012-2017-3] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2012] [Accepted: 12/01/2012] [Indexed: 11/30/2022]
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Priddis H, Dahlen H, Schmied V. Women's experiences following severe perineal trauma: a meta-ethnographic synthesis. J Adv Nurs 2012; 69:748-59. [DOI: 10.1111/jan.12005] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2012] [Indexed: 11/29/2022]
Affiliation(s)
- Holly Priddis
- School of Nursing and Midwifery; College of Health and Science; University of Western Sydney; Penrith South DC New South Wales Australia
| | - Hannah Dahlen
- School of Nursing and Midwifery; College of Health and Science; University of Western Sydney; Penrith South DC New South Wales Australia
| | - Virginia Schmied
- School of Nursing and Midwifery; College of Health and Science; University of Western Sydney; Penrith South DC New South Wales Australia
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Wheeler J, Davis D, Fry M, Brodie P, Homer CSE. Is Asian ethnicity an independent risk factor for severe perineal trauma in childbirth? A systematic review of the literature. Women Birth 2012; 25:107-13. [PMID: 21880563 DOI: 10.1016/j.wombi.2011.08.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2011] [Revised: 07/11/2011] [Accepted: 08/03/2011] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To undertake a systematic review of the literature to determine whether Asian ethnicity is an independent risk factor for severe perineal trauma in childbirth. METHOD Ovid Medline, CINAHL, and Cochrane databases published in English were used to identify appropriate research articles from 2000 to 2010, using relevant terms in a variety of combinations. All articles included in this systematic review were assessed using the Critical Appraisal Skills Programme (CASP) 'making sense of evidence' tools. FINDINGS Asian ethnicity does not appear to be a risk factor for severe perineal trauma for women living in Asia. In contrast, studies conducted in some Western countries have identified Asian ethnicity as a risk factor for severe perineal trauma. It is unknown why (in some situations) Asian women are more vulnerable to this birth complication. The lack of an international standard definition for the term Asian further undermines clarification of this issue. Nevertheless, there is an urgent need to explore why Asian women are reported to be significantly at risk for severe perineal trauma in some Western countries. CONCLUSION Current research on this topic is confusing and conflicting. Further research is urgently required to explore why Asian women are at risk for severe perineal trauma in some birth settings.
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Affiliation(s)
- Janet Wheeler
- Liverpool Hospital, Sydney South West Area Health Service, Elizabeth Street, Liverpool, NSW, 2170, Australia.
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Rathfisch G, Kızılkaya Bejı N. Protection of continence in pregnancy, labor and postpartum periods. INTERNATIONAL JOURNAL OF UROLOGICAL NURSING 2012. [DOI: 10.1111/j.1749-771x.2012.01159.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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East CE, Begg L, Henshall NE, Marchant PR, Wallace K. Local cooling for relieving pain from perineal trauma sustained during childbirth. Cochrane Database Syst Rev 2012:CD006304. [PMID: 22592710 DOI: 10.1002/14651858.cd006304.pub3] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Perineal trauma is common during childbirth and may be painful. Contemporary maternity practice includes offering women numerous forms of pain relief, including the local application of cooling treatments. OBJECTIVES To evaluate the effectiveness and side effects of localised cooling treatments compared with no treatment, other forms of cooling treatments and non-cooling treatments. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (10 January 2012), CINAHL (1982 to 10 January 2012), the Australian New Zealand Clinical Trials Register (10 January 2012) and contacted experts in the field. SELECTION CRITERIA Published and unpublished randomised and quasi-randomised trials (RCTs) that compared localised cooling treatment applied to the perineum with no treatment or other treatments applied to relieve pain related to perineal trauma sustained during childbirth. DATA COLLECTION AND ANALYSIS At least two review authors independently assessed trials for inclusion, assessed trial quality and extracted data. A sub-set of data were double checked for accuracy. Analyses were performed on an intention-to-treat basis where data allowed. We sought additional information from the authors of three trials. MAIN RESULTS Ten published RCTs were included (involving 1825 women). Comparisons were local cooling treatments (ice packs, cold gel pads (with or without compression) or cold/iced baths) with no treatment, gel pads with compression, hamamelis water (witch hazel), pulsed electromagnetic energy (PET), hydrocortisone/pramoxine foam (Epifoam), oral paracetamol or warm baths. Ice packs provided improved pain relief 24 to 72 hours after birth compared with no treatment (risk ratio (RR) 0.61; 95% confidence interval (CI) 0.41 to 0.91; one study, n = 208). Women preferred the utility of the gel pads compared with ice packs or no treatment (RR 0.82; 95% CI 0.73, 0.92). Differences detected in a composite of perineal oedema and bruising and overall wound healing were noted in one small study, favouring cold gel pads (n = 37) over ice (n = 35, mean difference (MD) 0.63 on a scale of 0 to 15; 95% CI 0.20 to 1.06) or no treatment (n = 39, MD -2.10; 95% CI -3.80 to -0.40) three to 14 days after giving birth. Women reported more pain (RR 5.60; 95% CI 2.35 to 13.33; one study, 100 women) and used more additional analgesia (RR 4.00; 95% CI 1.44 to 11.13; one study, 100 women) following the application of ice packs compared with PET. AUTHORS' CONCLUSIONS There is only limited evidence to support the effectiveness of local cooling treatments (ice packs, cold gel pads, cold/iced baths) applied to the perineum following childbirth to relieve pain.
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Affiliation(s)
- Christine E East
- Department ofObstetrics and Gynaecology, University ofMelbourne, Pregnancy Research Centre,Department of PerinatalMedicine,RoyalWomen’sHospital, Parkville, Australia.
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Perineal pain following childbirth: Prevalence, effects on postnatal recovery and analgesia usage. Midwifery 2012; 28:93-7. [DOI: 10.1016/j.midw.2010.11.009] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2010] [Revised: 11/15/2010] [Accepted: 11/21/2010] [Indexed: 11/20/2022]
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Aasheim V, Nilsen ABV, Lukasse M, Reinar LM. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 2011:CD006672. [PMID: 22161407 DOI: 10.1002/14651858.cd006672.pub2] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Most vaginal births are associated with some form of trauma to the genital tract. The morbidity associated with perineal trauma is significant, especially when it comes to third- and fourth-degree tears. Different perineal techniques and interventions are being used to prevent perineal trauma. These interventions include perineal massage, warm compresses and perineal management techniques. OBJECTIVES The objective of this review was to assess the effect of perineal techniques during the second stage of labour on the incidence of perineal trauma. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 May 2011), the Cochrane Central Register of ControlledTrials (The Cochrane Library 2011, Issue 2 of 4), MEDLINE (January 1966 to 20 May 2011) and CINAHL (January 1983 to 20 May 2011). SELECTION CRITERIA Published and unpublished randomised and quasi-randomised controlled trials evaluating any described perineal techniques during the second stage. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trails for inclusion, extracted data and evaluated methodological quality. Data were checked for accuracy. MAIN RESULTS We included eight trials involving 11,651 randomised women. There was a significant effect of warm compresses on reduction of third- and fourth-degree tears (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.28 to 0.84 (two studies, 1525 women)). There was also a significant effect towards favouring massage versus hands off to reduce third- and fourth-degree tears (RR 0.52, 95% CI 0.29 to 0.94 (two studies, 2147 women)). Hands off (or poised) versus hand on showed no effect on third- and fourth-degree tears, but we observed a significant effect of hands off on reduced rate of episiotomy (RR 0.69, 95% CI 0.50 to 0.96 (two studies, 6547 women)). AUTHORS' CONCLUSIONS The use of warm compresses on the perineum is associated with a decreased occurrence of perineal trauma. The procedure has shown to be acceptable to women and midwives. This procedure may therefore be offered to women.
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Affiliation(s)
- Vigdis Aasheim
- Department of Postgraduate Studies, Bergen University College, Møllendalsveien 6, PO Box7030, Bergen, Norway, 5020
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