Women's experiences following severe perineal trauma: a meta-ethnographic synthesis

Overlooked by the obstetric gaze - how women with persistent health problems due to severe perineal trauma experience encounters with healthcare services: a qualitative study

BACKGROUND

During the first year postpartum, about 25 per cent of Swedish women with severe perineal trauma (SPT), i.e., a third- or fourth-degree perineal laceration at childbirth, are unsatisfied with their healthcare contacts. Further, there is a lack of research on the more long-term experiences of healthcare encounters among women with persistent SPT-related health problems. This study explores how women with self-reported persistent SPT-related health problems experience their contact with healthcare services 18 months to five years after childbirth when the SPT occurred.

METHODS

In this descriptive qualitative study, a purposive sample of twelve women with self-reported persistent health problems after SPT were individually interviewed from November 2020 - February 2022. The data was analysed using inductive qualitative content analysis.

RESULTS

Our results showed a paradoxical situation for women with persistent health problems due to SPT. They struggled with their traumatised body, but healthcare professionals rejected their health problems as postpartum normalities. This paradox highlighted the women's difficulties in accessing postpartum healthcare, rehabilitation, and sick leave, which left them with neglected healthcare needs, diminished emotional well-being, and loss of financial and social status. Our results indicated that these health problems did not diminish over time. Consequently, the women had to search relentlessly for a 'key person' in healthcare who acknowledged their persistent problems as legitimate to access needed care, rehabilitation, and sick leave, thus feeling empowered.

CONCLUSIONS

Our study revealed that women with persistent SPT-related health problems experienced complex health challenges. Additionally, their needs for medical care, rehabilitation, and sick leave were largely neglected. Thus, the study highlights an inequitable provision of SPT-related healthcare services in Sweden, including regional disparities in access to care. Hence, the authors suggest that Swedish national guidelines for SPT-related care need to be developed and implemented, applying a woman-centered approach, to ensure equitable, effective, and accessible healthcare.

Development of aids to relieve vulvodynia during the postpartum period

Postpartum women live with a low quality of life due to pain caused by episiotomy and perineal laceration. In particular, they endure pain when sitting for long periods of time to breastfeed. The purpose of this study is to develop a sitting aid to alleviate postpartum vulvodynia. This study was conducted in the following four phases from July 2017 to May 2019. They are: material selection and molding, cleaning and disinfection testing, pressure distribution measurement testing, and trial testing by postpartum women. The main material was a 100% polypropylene object with a three-dimensional reticular fiber spring structure and fiber density of 3.8 kg/m2. As a result, a sitting aid that withstands washing and disinfection well in the medical field and is breathable. It had moderate resilience and elasticity and reduced pressure on the seating surface for women weighing approximately 45 kg and 55 kg, but we were skeptical about its use for women weighing more than that. The completed sitting aid is noninvasively effective in improving the quality of life of many postpartum women, but the density and thickness of the main material should be reexamined to meet the needs of women in a wider weight range. In addition, a self-administered questionnaire survey of trial users revealed that some women did not experience relief from vulvodynia even after using the sitting aid. Such women also had physical problems such as discomfort in the lower back, difficulty breastfeeding, and difficulty standing up. For women with multiple physical problems, individual causes should be addressed.

Patient Perspectives Following Obstetric Anal Sphincter Injury

IMPORTANCE

An obstetric anal sphincter injury can significantly affect patients. Support for these patients is both limited and not well understood.

OBJECTIVE

The aim of this study was to describe patient experiences after an obstetric anal sphincter injury.

STUDY DESIGN

This is a prospective cross-sectional qualitative study of patients who experienced an obstetric anal sphincter injury within a tertiary care network between May and June of 2022. Demographic data, clinical data regarding the delivery, and the Edinburgh Postnatal Depression Scale were collected. Prospective semistructured interviews were conducted approximately 5-12 weeks postpartum to address opportunities to improve obstetric anal sphincter injury care. Qualitative analysis was performed using a grounded theory approach.

RESULTS

Fifteen women with a mean age of 31 (±3.93) years participated. The majority identified as White (93.3%) and non-Hispanic (100%). All participants identified as being married to men and completing undergraduate education; 9 (60%) also received postgraduate education. Five participants (33.3%) screened positive (score of 10 or greater) for postnatal depression on the Edinburgh Postnatal Depression Scale. Thematic saturation was reached with 3 major themes identified: (1) pain control, (2) desire for multifactorial support, and (3) obstetric anal sphincter injury knowledge and awareness.

CONCLUSIONS

Experiencing an obstetric anal sphincter injury represents a great unknown to most women. This study identifies opportunities for improved postpartum care through education, pain control, and patient support. Interventions are needed to improve the postpartum experience for women who experience an obstetric anal sphincter injury with childbirth.

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

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.

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

BACKGROUND

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Antenatal perineal massage - risk of perineal injuries, pain, urinary incontinence and dyspereunia - a systematic review

BACKGROUND

Natural childbirth is associated with the risk of damage to the perineum - a tears or a episiotomy. Adequate preparation of the woman for childbirth is essential to minimize the occurrence of perinatal injuries.

AIM

The aim of the review is to assess and analyze the impact of APM (antental perineal massage) on perinatal perineal injuries and the development of pelvic pain and other complications in postpartum women, such as dyspareunia, urinary (UI), gas (GI), and fecal incontinence (FI).

METHODS

PubMed, Web of Science, Scopus and Embase were searched. Three authors independently searched databases and selected articles for inclusion and exclusion criteria. Next one author did Risk of Bias 2 and ROBINS 1 analyze.

FINDINGS

Of 711 articles, 18 publications were left for the review. All 18 studies examined the risk of perineal injuries (tearing and episiotomy), 7 pain in postpartum period, 6 postpartum urinary, gas/fecal incontinence and 2 described dyspareunia. Most authors described APM from 34 weeks of pregnancy until delivery. There were different techniques and times for doing APM procedures.

DISCUSSION

APM has many benefits for women during labor and the postpartum period (e.g. lower rate of perineal injuries and pain). However, it can be observed that individual publications differ from each other in the time of massage, the period and frequency of its performance, the form of obtaining instruction and control of patients. These components may affect the results obtained.

CONCLUSION

APM can protects the perineum from injuries during labor. It also reduces risk of fecal and gas incontinence in postpartum period.

Perineal tear and childbirth-related posttraumatic stress: A prospective cohort study

OBJECTIVE

Quantitative studies examining the occurrence of childbirth-related posttraumatic stress disorder (CB-PTSD) following severe perineal rupture are lacking. The objective of this population-based study was to investigate the prospective associations between the degree of perineal tear during childbirth and CB-PTSD symptoms, when adjusting for known covariates (maternal age, years of school education, premature birth, and parity). We hypothesized that women with different degrees of perineal tear will differ regarding (1) the level of CB-PTSD symptoms at 8 weeks and 2 years postpartum and (2) the rate of change in CB-PTSD symptoms from 8 weeks to 2 years postpartum.

METHOD

Secondary data analysis from the Akershus Birth Cohort, a large population-based prospective cohort study using self-report questionnaires and hospital record data.

RESULTS

The degree of perineal tear was significantly associated with CB-PTSD symptoms at 8 weeks and 2 years postpartum. However, the degree of perineal tear was not significantly associated with the change in CB-PTSD symptoms over time. Similar patterns were found for both total CB-PTSD symptoms as well as for avoidance and intrusion symptoms only.

CONCLUSION

Results seem to support a dose-response model, suggesting that the higher the severity of the perineal tear, the higher the posttraumatic morbidity.

A complex and demanding situation - Midwifery preceptors and midwifery students' experiences of teaching and learning prevention of severe perineal trauma

BACKGROUND

Many high-income countries have seen an increase in severe perineal trauma. Teaching strategies and conditions for learning during the active second stage of labour are scarcely described.

AIM

To describe midwifery preceptors and midwifery students' experiences' of teaching and learning how to manage the second stage of labour, with the specific aim of preventing severe perineal trauma.

METHODS

A qualitative study with focus group discussions and individual in depth-interviews with preceptor midwives (n = 23) and student midwives (n = 10). Data were analysed by qualitative content analysis.

RESULTS

"A complex and demanding situation with mutual need for feedback, reflection and safety" was the overall theme describing the conditions. Three sub-themes were identified. "Adapting to a unique situation" refers to the difficulty of teaching and learning the aspects needed to prevent severe perineal trauma, and to provide care during this stage. "Hindering and limiting circumstances" describes teaching strategies that were perceived negatively, and how midwifery students tried to adapt to the preceptors rather than the birthing women. "A trustful and communicative relationship" describes the importance of the relationship between the student and the preceptor, where communication was a central, but not obvious part.

CONCLUSION

An increased awareness among preceptors is needed to optimize teaching strategies, enabling the students to focus on learning the art of the second stage of labour; supporting the woman, preventing severe perineal trauma and ensuring the safety of the unborn baby. Future research should address how existing prevention models can include training to increase preceptors' confidence in teaching.

Factors associated with fear of childbirth in a subsequent pregnancy: a nationwide case-control analysis in Finland

BACKGROUND

Fear of childbirth can develop due to the concerns or adverse maternal or foetal outcomes experienced in a previous pregnancy. The aim of this study was to examine the main risk factors associated with the development of fear of childbirth during subsequent pregnancies and deliveries.

METHODS

In this case-control study, data from the National Medical Birth Register were used to evaluate the events in previous pregnancies that were potential risk factors for fear of childbirth in subsequent pregnancies. The first and second pregnancies of women registered during our study period (2004-2018) were included. The exposure variable was delivery mode, obstetric challenge or adverse neonatal outcomes during the first pregnancy. The outcome was the development of FOC during the second pregnancy. Adjusted odds ratios with 95% CIs were used for comparison.

RESULTS

A total of 13 064 pregnancies were included in the case group and 195 351 in the control group. Previous emergency caesarean section was the strongest risk factor for the development of FOC in the second pregnancy (adjusted odds ratio 5.27, CIs 4.83-5.75). In addition, unplanned CS (adjusted odds ratio 3.93, CIs 3.77-4.10) and vacuum delivery (adjusted odds ratio 1.69, CIs 1.61-1.77) also increased the odds of fear of childbirth. Of the obstetric complications, third- or fourth-degree tear of the perineum was the strongest risk factor (adjusted odds ratio 2.99, CIs 2.69-3.31), followed by shoulder dystocia (adjusted odds ratio 2.82, CIs 2.16-3.62). Neonatal mortality also increased the odds for the development of FOC (adjusted odds ratio 2.17, CIs 1.77-2.64).

CONCLUSION

The main risk factors for the development of fear of childbirth in the second pregnancy were previous fear of childbirth, unplanned CS, vacuum delivery, perineal tear or shoulder dystocia. The results of this study can be used in a clinical setting to improve the prevention of fear of childbirth.

Influence of previous delivery mode on perineal trauma risk

OBJECTIVE

To evaluate the impact of a previous pregnancy and delivery on perineal trauma rates in the subsequent vaginal birth.

METHODS

Retrospective cohort study. The perineal outcomes of secundiparous women with history of previous (first) delivery in one of three categories: failed operative vaginal delivery (FOVD) and second-stage emergency cesarean section (EmCS); elective cesarean section (ElCS), and vaginal delivery (VD) with intact perineum, were compared with a control primiparous group.

RESULTS

The percentage obstetric anal sphincter injuries (OASIS)at first vaginal delivery was 17.3% (n = 9) after previous FOVD+EmCS, 12.9% (n = 18) after previous ElCS, and 0.6% (n = 9) after previous VD maintaining an intact perineum, compared with 6% (n = 1193) in the control primiparous group of women. Multivariate regression analysis demonstrated that previous FOVD+EmCS and ElCS were associated with a statistically significant increased risk of OASIS of 180% and 110% when compared with control (odds ratio [OR] 2.80; 95% confidence interval [CI] 1.35-5.78 and OR 2.10; 95% CI 1.27-3.48, respectively). Previous VD with intact perineum was associated with a statistically significantly reduced risk of OASIS (OR 0.09; 95% CI 0.04-0.17).

CONCLUSIONS

Previous FOVD+EmCS and ElCS were associated with increased risk of OASIS in subsequent vaginal delivery compared with control, whereas previous VD with intact perineum was associated with decreased risk.

The effect of two midwives during the second stage of labour to reduce severe perineal trauma (Oneplus): a multicentre, randomised controlled trial in Sweden

BACKGROUND

Severe perineal trauma (SPT) affecting the anal sphincter muscle complex is a serious complication following childbirth, associated with short-term and long-term maternal morbidity. Effective preventive strategies are still scarce. The aim of the Oneplus trial was to test the hypothesis that the presence of a second midwife during the second stage of labour, with the purpose of preventing SPT, would result in fewer injuries affecting the anal sphincter than if attended by one midwife.

METHODS

In this multicentre, randomised, controlled parallel group, unmasked trial done at five obstetric units in Sweden, women were randomly assigned to be assisted by either one or two midwives in late second stage. Nulliparous women and women planning the first vaginal birth after caesarean section who were age 18-47 years were randomly assigned to an intervention when reaching the second stage of labour. Further inclusion criteria were gestational week 37+0, carrying a singleton live fetus in vertex presentation, and proficiency in either Swedish, English, Arabic, or Farsi. Exclusion criteria were a multiple pregnancy, intrauterine fetal demise, a planned caesarean section, or women who were less than 37 weeks pregnant. Randomisation to the intervention group of two midwives or standard care group of one midwife (1:1) was done using a computer-based program and treatment groups were allocated by use of sealed opaque envelopes. All women and midwives were aware of the group assignment, but the statistician from Clinical Studies Forum South, who did the analyses, was masked to group assignment. Midwives were instructed to implement existing prevention models and the second midwife was to assist on instruction of the primary midwife, when asked. Midwives were also instructed to complete case report forms detailing assistance techniques and perineal trauma prevention techniques. The primary outcome was the proportion of women who had SPT, for which odds ratios (ORs) and 95% CIs were calculated, and logistic regression was done to adjust for study site. All analyses were done according to intention to treat. The trial is registered with ClinicalTrials.gov, NCT0377096.

FINDINGS

Between Dec 10, 2018, and March 21, 2020, 8866 women were assessed for eligibility, and 4264 met the inclusion criteria and agreed to participate. 3776 (88·5%) of 4264 women were randomly assigned to an intervention after reaching the second stage of labour. 1892 women were assigned to collegial assistance (two midwives) during the second stage of labour and 1884 women were assigned to standard care (one midwife). 13 women in each group did not meet the inclusion criteria and were excluded. After further exclusions, 1546 women spontaneously gave birth in the intervention group and 1513 in the standard care group. 1546 women in the intervention group and 1513 in the standard care group were included in the intention-to-treat analysis of the primary outcome. There was a significant reduction in SPT in the intervention group (3·9% [61 of 1546] vs 5·7% [86 of 1513]; adjusted OR 0·69 (0·49-0·97).

INTERPRETATION

The presence of two midwives during the active second stage can reduce SPT in women giving birth for the first time.

FUNDING

The Swedish Research Council for Health, Working Life and Welfare; Jan Hains Research Foundation; and Skane County Council's Research and Development Foundation.

Women's experiences of surviving severe obstetric complications: a qualitative inquiry in southern Ghana

Women who survive severe obstetric complications (SOC) have health and well-being issues even up to 1 year postpartum and have challenges in their quality-of-life (QoL). However, little is known about their predicaments. This study aimed to describe the impact of severe obstetric complications on women’s QoL and well-being after surviving severe obstetric complications. Using the WHO standards for near-miss, twelve (12) women who survived severe obstetric complications were recruited between January and March 2019. The study adopted a qualitative approach with an exploratory descriptive design to explore the experiences of women who survived SOC in Southern Ghana. The participants were purposively sampled and were interviewed face to face in their homes and healthcare facility after discharge from the Hospital. Recorded interviews were transcribed and analyzed. Two (2) major themes and nine (9) sub-themes emerged. The findings revealed that women who suffered SOC are unable to perform functional activities, have financial constraints, residual hypertension, signs and symptoms of anaemia, pain, and mostly have difficulty in sleeping due to fear of death when they fall asleep. Anxiety, sadness, and emotional trauma was a common phenomenon. The study findings offer insights and directions on measures to improve the care and QoL of women who have survived severe obstetric complications in Ghana.

Improving women's experiences of perineal suturing: A pragmatic qualitative analysis of what is helpful and harmful

BACKGROUND

Perineal trauma requiring suturing is increasing, along with the associated physiological and psychological morbidities for women. Provider training appears to focus more on technical aspects rather than respectful, relational care for women. Studies exploring women's experiences have identified that how women are cared for can significantly impact upon overall experiences.

AIM

To identify areas of improvement to the perineal suturing process and provide robust recommendations for urgent change by investigating what aspects are most traumatic to women and which are most supportive.

METHODS

A pragmatic qualitative analysis of data generated from 15 in-depth interviews with women who were sutured following birth.

FINDINGS

Regardless of tear severity, what was identified as helpful included anything that made the process better by increasing feelings of trust and reassurance, and providing women with a sense of being seen and heard. Harmful experiences were identified as those that worsened the experience, by increasing feelings of fear and vulnerability and leaving women with a sense of being disregarded or disrespected.

CONCLUSION

The study confirmed that how the suturing process is conducted can have a significant detrimental impact upon women's short- and longer-term physical and psychological well-being.

IMPLICATIONS FOR PRACTICE

An improved experience for women is most likely with kind professionals who explain the process as it goes along, check-in regularly and validate how the women feel. Women prefer to be sutured by a known professional, only if this provider is also kind and respectful.

A core outcome set for clinical trials of first- and second-degree perineal tears prevention and treatment: a study protocol for a systematic review and a Delphi survey

BACKGROUND

Perineal tear is a common consequence of vaginal births affecting females globally. Even mild perineal tears could cause short- and long-term complications for females. Though many studies of interventions to prevent or treat perineal tears to minimize the consequences have been conducted, there is a significant heterogeneity in the outcomes measured and reported in existing studies, which makes meaningful comparison difficult and makes the generalizability to clinical practice challenging. Developing a core outcome set (COS) could solve these methodological concerns. In this paper, we report a protocol to develop a COS for clinical trials of mild perineal tears, which shall assist in establishing the evidence base and implementation of effective measures to reduce the incidence and minimize the consequences of mild perineal tears.

METHODS/DESIGN

The development of this COS will be guided by a study advisory group composed of obstetricians, midwives, nursing managers, service users, and methodologists. This study will include four stages: (1) a systematic research of the literature to identify outcomes reported in prior studies, (2) a semi-structured interview with key stakeholders to collect their opinions on important outcomes, (3) a panel of experts will be invited to conduct a three-round Delphi survey to prioritize these outcomes, and (4) a consensus meeting with key stakeholders to determine the list of outcomes included in the final COS.

DISCUSSION

The development of this COS will provide international standards for the outcomes to be collected and reported in all clinical trials and audits of practice, which involve prevention and treatment of first- and second-degree perineal tears for women with vaginal delivery. This will facilitate comparing and contrasting of studies and allow for combining of appropriate studies with the ultimate goal of improved perineal care for women choosing vaginal delivery.

TRIAL REGISTRATION

This study was registered in the database of Core Outcome Measures in Effectiveness Trials (COMET) on June11th, 2021 ( https://comet-initiative.org/Studies/Details/1884 ).

Adverse events in women giving birth in a labor ward: a retrospective record review study

Background

Childbirth could negatively affect the woman’s health through adverse events. To prevent adverse events and increase patient safety it is important to detect and learn from them. The aim of the study was to describe adverse events, including the preventability and severity of harm during planned vaginal births, in women giving birth in the labor ward.

Methods

The study had a descriptive design with a retrospective birth record review to assess the preventability of adverse events using the Swedish version of the Global Trigger Tool. The setting was a labor ward in Sweden with low-risk and risk childbirths. Descriptive statistics, Pearson’s Chi-square test and Student’s t-test were used.

Results

A total of 38 adverse events (12.2%) were identified in 311 reviewed birth records. Of these, 28 (73.7%) were assessed as preventable. Third- or fourth-degree lacerations and distended urinary bladder were most prevalent together with anesthesia-related adverse events. The majority of the adverse events were classified into the harm categories of ‘prolonged hospital care’ (63.2%) and ‘temporary harm’ (31.6%). No permanent harm were identified, but over two-thirds of the adverse events were assessed as preventable.

Conclusions

This first study using Global Trigger Tool in a labor ward in Sweden identified a higher incidence of adverse events than previous studies in obstetric care. No permanent patient harm was found, but over two-thirds of the adverse events were assessed as preventable. The results draw particular attention to 3^rd-or 4^th-degree lacerations, distended urinary bladder and anesthesia-related adverse events. The feedback on identified adverse events should be used for systematic quality improvement and clinical recommendations how to prevent adverse events must be implemented.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07109-5.

A systematic review of clinical effectiveness of psychological interventions to reduce post traumatic stress symptoms following childbirth and a meta-synthesis of facilitators and barriers to uptake of psychological care

AIM

To review the literature on psychological interventions for post-traumatic stress following childbirth (PTSDFC) and determine clinical effectiveness. To synthesise the qualitative literature on the facilitators and barriers to uptake of care for PTSDFC.

BACKGROUND

The context of childbirth trauma differs from that of other events perceived as traumatic. Current guidance on treatment for PTSDFC requires further clarification.

METHOD

Web of Knowledge, CINAHL, MEDLINE, PSYCINFO, the Cochrane Central Register of Controlled Trials (CENTRAL), Open Grey, UKCTG, and the ISRCTN were consulted to include journal articles published in English.. Articles were segregated according to methodology and appraised using the Mixed Methods Appraisal Tool.

RESULTS

A total of 5355 papers were identified with five quantitative and 13 qualitative included in the review. Four types of interventions were identified: eye movement desensitisation and reprocessing, trauma focussed CBT, debriefing and expressive writing. All showed some effectiveness in treating PTSDFC. Themes emerging from the meta-synthesis included women finding it difficult to recognise having a problem, needing validation and only seeking help 'at breaking point'. Women wanted health professionals actively asking in a non-judgemental way at different time points and providing support and listening, ideally with continuity of carer to make sense of their experiences.

LIMITATIONS

Quantitative studies were not disaggregated by intervention timing or follow-up duration. A single independent reviewer with team discussion was utilised.

CONCLUSION

There is little definitive evidence assessing the effectiveness of psychological interventions for PTSDFC. There are psychological barriers for women accessing help for traumatic childbirth which services can mitigate.

Effects of Fourth-Degree Perineal Lacerations on Women's Physical and Mental Health

OBJECTIVE

To describe the physical and emotional effects of fourth-degree perineal lacerations that occur during childbirth.

DESIGN

Descriptive phenomenology.

SETTING

Internet survey.

PARTICIPANTS

Eighteen women from the United States, the United Kingdom, Australia, and Canada who sustained fourth-degree perineal lacerations during childbirth.

METHODS

Women were recruited from the Facebook support group Mothers With 4th Degree Tears. Participants were asked to describe the physical and emotional effects of these severe birth injuries on their daily lives. I analyzed these data using Colaizzi's method for phenomenological analysis.

RESULTS

The devastating effects of these birth-related injuries permeated all aspects of the lives of participants. Participants did not receive adequate information about their perineal lacerations, and clinicians often dismissed their concerns. Some participants struggled with postpartum depression and posttraumatic stress disorder. I identified seven themes that described the effects of fourth-degree perineal lacerations: Why Wasn't I Informed I Had This Injury?; The Unthinkable: Fecal Incontinence and So Much More; It Has Cost Me So Much; Seeking Relief: Enduring Surgery After Surgery; Why Didn't Anyone Ask Me About My Mental Health?; To Have More Children, That Is The Question; And Are there Any Positives In All Of This?

CONCLUSION

Women need information to prepare for recovery from their severe perineal injuries related to what to expect, how to care for themselves, and what resources are available. Clinicians have a responsibility to provide a caring environment in which women feel safe to disclose any problems they are experiencing as a result of their perineal injuries. Little, if any, attention is focused on women's mental health by clinicians or researchers as women struggle with the aftermath of fourth-degree perineal lacerations.

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

Background

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

Methods/design

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

Discussion

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

Trial registration {2a}

ClinicalTrials.gov NCT03770962. Registered on 10 December 2018

Development and Psychometric Properties of the Women's Recovery of Postnatal Perineal Injuries Questionnaire (WRPPIQ)

BACKGROUND

Recovery of postnatal women with perineal injuries, especially when perineal tear is severe, occurs much later than the healthy women. There is no specific questionnaire to assess the postnatal recovery in these women. The aim of this study was development and psychometric evaluation of a new tool to measure women's recovery of postnatal perineal injuries questionnaire (WRPPIQ).

METHODS

In this validation study, which was conducted based on the method developed by DeVellis (2003), 270 women with postnatal perineal injuries who referred to healthcare centers in Mashhad, Iran, were studied between 2018 and 2020. This method consisted of steps: (1) definition of postnatal recovery based on in-depth qualitative interview with 22 women, (2) generation of an item pool, (3) selection of the Likert scale, (4) review of the initial item pool, (5) inclusion of items from relevant instruments, (6) conducting exploratory factor analysis, (7) evaluation of the items, and (8) optimization of the scale length.

RESULTS

The initially generated item pool consisted of 144 items on a 5-point Likert scale, which reduced to 85 items following face and content validity measurement. The value of the SCVI/Ave was measured 0.901. The conduction of exploratory factor analysis resulted in 33 items and three factors including evidence of wellness, emotional changes as well as independence and support. The Cronbach's alpha for the three factors was calculated 0.92, 0.80, and 0.83, respectively.

CONCLUSION

WRPPIQ has validity and reliability to measure the women's recovery of postnatal perineal injuries in Iran. It is, therefore, recommended that health care providers to assess women's recovery of postnatal perineal injuries using this newly developed questionnaire.

Women's experience of obstetric anal sphincter injury following childbirth: An integrated review

BACKGROUND

Perineal injury during childbirth is a very common event which affect women during childbirth. Significant morbidities are associated with third-and-fourth degree perineal tears in particular, also referred to as obstetric anal sphincter injuries (OASIS). With an increasing global birth rate and rising interventions in birth, the incidence of perineal trauma following vaginal birth is increasing on an international scale, impacted also by more accurate classification and definitions of OASIS and increased pre-existing co morbidities amongst affected women. The consequences of OASIS can be physically and psychologically distressing for affected women and have significant impact on quality of life.

METHODOLOGY

The aim of this integrative review was to examine women's experience of OASIS following childbirth using a systematic approach. This is presented in a five-stage process that includes problem identification, literature search, data extraction and evaluation, data analysis and presentation of results. A number of academic electronic databases were systematically searched and results are presented and analysed. Results of the complete search are presented in PRISMA format. Eight papers, which were assessed for quality using an appropriate appraisal tool, are included in the review and thematic analysis used to identify themes.

FINDINGS

The themes identified were; psychological consequences, the role of the health care professionals and implications for future pregnancies. Psychological consequences included anxiety, loneliness, isolation, shame, fear, many of which were associated with physical ramifications of OASIS and how these feelings affect activities of daily living. The importance of access to and support from health care professionals was highlighted. The impact the experience of OASIS had on women's decisions about future pregnancies was also evident.

CONCLUSION

The association between OASIS and maternal quality of life following childbirth can be substantial as evidenced by this literature review. The review identifies the need for improvement in the care and management of these women to alleviate the physical and psychological consequences of OASIS, including decisions in relation to future pregnancies and childbirth. Health care professionals caring for women in pregnancy and childbirth need to be educated and informed on the sequelae of OASIS, to ensure appropriate information and support is provided to these women and their families. Such knowledge may enable health care professionals to alleviate symptoms associated with OASIS and help women make sense and cope with their experiences.

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

BACKGROUND

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Re-suturing of puerperal perineal wound: An assessment of indications, risk factors and outcomes

OBJECTIVE

To assess the frequency of puerperal perineal wound re-suturing, and to evaluate the indications, risk factors and outcomes of this procedure.

STUDY DESIGN

A retrospective series of all parturients that underwent puerperal perineal tear suturing between 2005 and 2019 was undertaken. All parturients who required re-suturing during the delivery hospitalization were identified and compared with those who had puerperal perineal wound repair and did not require re-suturing. General demographics, obstetrical history, current delivery characteristics, re-suturing indications, and outcome were obtained and analyzed.

RESULTS

During the study period, 54,934 parturients required puerperal perineal tear suturing, of which 47 (0.09%) required re-suturing within their postpartum hospitalization. Median time from delivery to perineal re-suturing was 5.38 h [IQR 4.07-7.14]. The most common indication was vulvovaginal hematoma (n = 37, 78.7%). The independent risk factors found to be associated with re-suturing were: cephalic malposition (aOR 9.3, 95% CI 1.26-67.74) and meconium stained amniotic fluid (aOR 2.1, 95% CI 1.10-3.85). Parturients who underwent re-suturing had significantly higher rates of postpartum hemorrhage (78.5% vs. 11.4%) blood transfusions (36.2% vs. 1.3%), puerperal fever, and longer hospitalizations (P < 0.01 for all).

CONCLUSION

In our population, early re-suturing of puerperal perineal tears is rare, however, it is associated with increased short term maternal morbidity.

Third- and fourth-degree tears: A review of the current evidence for prevention and management

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.

What is the total impact of an obstetric anal sphincter injury? An Australian retrospective study

Introduction

Most data on obstetric anal sphincter injury (OASI) reflect short-term (< 12 months) or much longer term (> 10 years) impact. This study aimed to collate the extent of medium-term symptomology (1–6 years) and observe the effect on future birth choices to evaluate the cumulative impact of OASI in affected women.

Methods

A retrospective cohort of women affected by OASI completed a questionnaire covering bowel symptomology, sexual function, life impact and future birth choices. A custom-created adverse composite outcome for OASI incorporating effects on daily life, flatal/fecal incontinence and sexual function (OASIACO) was used as a threshold score to identify women with high levels of symptoms.

Results

Of 265 eligible and contactable women, 210 questionnaires were received (response rate 79%) at a mean of 4 years post-OASI. More than half (54%) experienced an OASIACO. A forceps birth (p = 0.03) or more severe grade of tear (p = 0.03) was predictive of OASIACO. One hundred one women had further children, with 48% reporting their delivery choices were impacted, 32% electing a cesarean delivery and 26% shifting to private care. Eighty women (40%) had not given birth again, and 29 (36%) of these indicated their OASI influenced this decision.

Conclusions

The total impact of an OASI on women affected is substantial. More than half experience ongoing symptoms and close to half report an impact on their future birth choices. It follows there would be a consequential load on the healthcare sector, and improved management and prevention programs should be implemented.

Electronic supplementary material

The online version of this article (10.1007/s00192-019-04108-3) contains supplementary material, which is available to authorized users.

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

BACKGROUND

Obstetric anal sphincter injuries lead frequently to short- and long-term consequences for the mother, including perineal pain, genital prolapse, and sexual problems. The aim of the study was to evaluate whether the implementation of an intervention program in the second stage of labor involving altered perineal support techniques reduced severe perineal trauma.

METHODS

All women reaching the second stage of labor and giving birth vaginally to singleton babies at Landspítali University Hospital (comprising 76% of births in Iceland in 2013) were enrolled in a cohort study. Data were recorded retrospectively for 2008-2010 and prospectively in 2012-2014, for a total of 16 336 births. During 2011, an intervention program was implemented, involving all midwives and obstetricians working in the labor wards. Two professionals assessed and agreed on classification of every perineal tear.

RESULTS

The prevalence of obstetric anal sphincter injuries decreased from 5.9% to 3.7% after the implementation (P < 0.001). Third-degree tears decreased by 40%, and fourth-degree tears decreased by 56% (P < 0.001). The prevalence of first-degree tears increased from 25.8% to 33.1%, whereas second-degree tears decreased from 44.7% to 36.6% between the before and after study periods. Severe perineal trauma was linked to birthweight, and this did not change despite the new intervention.

CONCLUSIONS

Active intervention to reduce perineal trauma was associated with an overall significant decrease in obstetric anal sphincter injuries. Good perineal visualization, manual perineal support, and controlled delivery of the fetal head were essential components for reducing perineal trauma.

The impact of third- or fourth-degree perineal tears on the second pregnancy: A cohort study of 182,445 Scottish women

This study aimed to investigate the reproductive impact of a third- or fourth-degree tear in primigravid women. A retrospective population-based cohort study was conducted using data from Scottish Morbidity Records (SMR02). Primigravid women with a vaginal birth in Scotland from 1997 until 2010 were included. Exposure was third- or fourth-degree tear in the first pregnancy. The second pregnancy rate, interpregnancy interval and third- or fourth-degree tear in a second pregnancy were the primary outcomes. A nested case-control study was used to determine factors associated with repeat third- or fourth-degree tears in a second vaginal birth. Cox regression analysis and logistic regression were used to look for associations. Initial third- or fourth-degree tear occurred in 2.8% women (5174/182445). The percentage of third- or fourth-degree tears in first vaginal births increased from 1% in 1997 to 4.9% in 2010. There was no difference in having a second pregnancy (adjusted Odds Ratio (aOR) 0.98 (99%CI 0.89–1.09)) or the median interpregnancy interval to second pregnancy (adjusted Hazard Ratio (aHR) 1.01 (99%CI 0.95–1.08)) after an initial third- or fourth-degree tear. Women were over four times more likely to have a repeat injury in a subsequent vaginal birth (n = 149/333, aOR 4.68 (99% 3.52–6.23)) and were significantly more likely to have an elective caesarean section in their second pregnancy (n = 887/3333, 26.6%; 12.75 (11.29–14.40)). Increased maternal age and birthweight ≥4500g were risk factors for repeat injury. Third- and fourth-degree tears are increasing in Scotland. Women do not delay or avoid childbirth after initial third- or fourth-degree tear. However, women are more likely to have a repeat third- or fourth-degree tear or an elective caesarean section in the second pregnancy. Strategies to prevent third- or fourth-degree tears are needed.

Developing a reporting guideline to improve meta-ethnography in health research: the eMERGe mixed-methods study

Background

Meta-ethnography is a commonly used methodology for qualitative evidence synthesis. Research has identified that the quality of reporting of published meta-ethnographies is often poor and this has limited the utility of meta-ethnography findings to influence policy and practice.

Objective

To develop guidance to improve the completeness and clarity of meta-ethnography reporting.

Methods/design

The meta-ethnography reporting guidance (eMERGe) study followed the recommended approach for developing health research reporting guidelines and used a systematic mixed-methods approach. It comprised (1) a methodological systematic review of guidance in the conduct and reporting of meta-ethnography; (2) a review and audit of published meta-ethnographies, along with interviews with meta-ethnography end-users, to identify good practice principles; (3) a consensus workshop and two eDelphi (Version 1, Duncan E, Swinger K, University of Stirling, Stirling, UK) studies to agree guidance content; and (4) the development of the guidance table and explanatory notes.

Results

Results from the methodological systematic review and the audit of published meta-ethnographies revealed that more guidance was required around the reporting of all phases of meta-ethnography conduct and, in particular, the synthesis phases 4–6 (relating studies, translating studies into one another and synthesising translations). Following the guidance development process, the eMERGe reporting guidance was produced, comprising 19 items grouped into the seven phases of meta-ethnography.

Limitations

The finalised guidance has not yet been evaluated in practice; therefore, it is not possible at this stage to comment on its utility. However, we look forward to evaluating its uptake and usability in the future.

Conclusions

The eMERGe reporting guidance has been developed following a rigorous process in line with guideline development recommendations. The guidance is intended to improve the clarity and completeness of reporting of meta-ethnographies, and to facilitate use of the findings within the guidance to inform the design and delivery of services and interventions in health, social care and other fields. The eMERGe project developed a range of training materials to support use of the guidance, which is freely available atwww.emergeproject.org(accessed 26 March 2018). Meta-ethnography is an evolving qualitative evidence synthesis methodology and future research should refine the guidance to accommodate future methodological developments. We will also investigate the impact of the eMERGe reporting guidance with a view to updating the guidance.

Study registration

This study is registered as PROSPERO CRD42015024709 for the stage 1 systematic review.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

"Struggling to settle with a damaged body" - A Swedish qualitative study of women's experiences one year after obstetric anal sphincter muscle injury (OASIS) at childbirth

OBJECTIVE

This study aimed to explore women's experiences related to recovery from obstetric anal sphincter muscle injuries (OASIS) one year after childbirth.

METHOD

This is a qualitative study based on written responses from 625 women approximately one year after childbirth in which OASIS occurred. Data was obtained from a questionnaire distributed by the national Perineal Laceration Register (PLR) in Sweden. Inductive qualitative content analysis was applied for analysis.

RESULTS

The theme "Struggling to settle with a damaged body" indicated that the first year after OASIS involved a struggle to settle to and accept living with a changed and sometimes still-wounded body. Many participants described problems related to a non-functional sexual life, physical and psychological problems that left them feeling used and broken, and increased worries for their future health and pregnancies. However, some women had adjusted to their situation, had moved on with their lives, and felt recovered and strong. Encountering a supportive and helpful health care professional was emphasized as vital for recovery after OASIS.

CONCLUSION

This study provides important insights on how women experience their recovery approximately one year after having had OASIS at childbirth, wherein many women still struggled to settle into their damaged bodies. Clear pathways are needed within health care organizations to appropriate health care services that address both physical and psychological health problems of women with prolonged recovery after OASIS.

Psychological consequences of pelvic floor trauma following vaginal birth: a qualitative study from two Australian tertiary maternity units

Vaginal birth may result in damage to the levator ani muscle (LAM) with subsequent pelvic floor dysfunction and there may be accompanying psychological problems. This study examines associations between these somatic injuries and psychological symptoms. A qualitative study using semi-structured interviews to examine the experiences of primiparous women (n = 40) with known LAM trauma was undertaken. Participants were identified from a population of 504 women retrospectively assessed by a perinatal imaging study at two obstetric units in Sydney, Australia. LAM avulsion was diagnosed by 3D/4D translabial ultrasound 3-6 months postpartum. The template consisted of open-ended questions. Main outcome measures were quality of information provided antenatally; intrapartum events; postpartum symptoms; and coping mechanisms. Thematic analysis of maternal experiences was employed to evaluate prevalence of themes. Ten statement categories were identified: (1) limited antenatal education (29/40); (2) no information provided on potential morbidities (36/40); (3) conflicting advice (35/40); (4) traumatized partners (21/40); (5) long-term sexual dysfunction/relationship issues (27/40); (6) no postnatal assessment of injuries (36/40); (7) multiple symptoms of pelvic floor dysfunction (35/40); (8) "putting up" with injuries (36/40); (9) symptoms of post-traumatic stress disorder (PTSD) (27/40); (10) dismissive staff responses (26/40). Women who sustain LAM damage after vaginal birth have reduced quality of life due to psychological and somatic morbidities. PTSD symptoms are common. Clinicians may be unaware of the severity of this damage. Women report they feel traumatized and abandoned because such morbidities were not discussed prior to birth or postpartum.

The impact of anal sphincter injury on perceived body image

OBJECTIVE

Obstetric anal sphincter injury is common but the effect on body image is unreported. The aim of this study was to explore patient perceived changes in body image and other psychological aspects in women attending a perineal follow-up clinic.

STUDY DESIGN

This retrospective study analysed women's responses to a self-reported questionnaire. Consecutive women with anal sphincter injury who attended a United Kingdom Maternity Hospital perineal follow-up clinic between January 1999 and January 2012 were identified and the records obtained and reviewed. Multivariate regression analyses were performed to examine variables influencing self-reported change in body image.

RESULTS

Questionnaires and operation notes were analysed from 422 women who attended at a median of four months after delivery. 222 (53%) reported a change in body image with 80 (19%) reporting lower self-esteem and 75 (18%) a change in their personality due to the change in body image. 248 (59%) perceived an anatomical change due to the delivery. Factors associated with increased likelihood of reporting a change in body image were reporting a perceived change in anatomy due to the delivery, adjusted OR 6.11 (3.56-10.49), anal incontinence, OR 1.97 (1.16-3.36), and delivery by forceps, OR 2.59 (1.23-5.43).

CONCLUSIONS

This is the first study to quantify body image changes in women after anal sphincter injury sustained in childbirth. These were found to be very common, affecting up to 50% of women. The study has several limitations but it does highlight the significant psychosocial problems of negative self-esteem and personality changes associated with a perceived change in body image that has not previously been reported. It also outlines the further research questions that need to be addressed.

Migrant women's experiences, meanings and ways of dealing with postnatal depression: A meta-ethnographic study

Aim

To conduct a meta-ethnographic study of the experiences, meanings and ways of ‘dealing with’ symptoms or a diagnosis of postnatal depression amongst migrant women living in high income countries.

Background

Prevalence of postnatal depression is highest amongst women who are migrants. Yet many women do not seek help for their symptoms and health services do not always respond appropriately to migrant women’s needs. Studies have reported migrant women’s experiences of postnatal depression and it is timely to synthesise findings from these studies to understand how services can be improved.

Design

A meta-ethnographic synthesis of 12 studies reported in 15 papers

Data sources

Five databases were searched for papers published between January 1999 and February 2016

Review methods

The quality of included studies was assessed using the Critical Appraisal Skills Program tool. The synthesis process was guided by the seven steps of meta-ethnography outlined by Noblit and Hare.

Findings

Four key metaphors were identified: “I am alone, worried and angry—this is not me!”; ‘Making sense of my feelings’ ‘Dealing with my feelings’ and ‘What I need to change the way I feel!’. Primarily women related their feelings to their position as a migrant and as women, often living in poor socio-economic circumstances and they were exhausted keeping up with expected commitments. Many women were resourceful, drawing on their personal strengths and family / community resources. All the studies reported that women experienced difficulties in accessing appropriate services.

Conclusion

The meta-ethnographic study demonstrates the impact of migration on perinatal mental health, particularly for women lacking family support, who have no employment, a precarious migration status and/or relationship conflict. Migrant women are resourceful and this requires support through appropriate services. Further research is needed to evaluate effective support strategies for migrant women in the perinatal period.

Perineal resuturing versus expectant management following vaginal delivery complicated by a dehisced wound (PREVIEW): a nested qualitative study

OBJECTIVE

To explore women's lived experiences of a dehisced perineal wound following childbirth and how they felt participating in a pilot and feasibility randomised controlled trial (RCT).

DESIGN

A nested qualitative study using semistructured interviews, underpinned by descriptive phenomenology.

PARTICIPANTS AND SETTING

A purposive sample of six women at 6-9 months postnatal who participated in the RCT were interviewed in their own homes.

RESULTS

Following Giorgi's analytical framework the verbatim transcripts were analysed for key themes. Women's lived experiences revealed 4 emerging themes: (1) Physical impact, with sub-themes focusing upon avoiding infection, perineal pain and the impact of the wound dehiscence upon daily activities; (2) Psychosocial impact, with sub-themes of denial, sense of failure or self-blame, fear, isolation and altered body image; (3) Sexual impact; and (4) Satisfaction with wound healing. A fifth theme 'participating in the RCT' was 'a priori' with sub-themes centred upon understanding the randomisation process, completing the trial questionnaires, attending for hospital appointments and acceptability of the treatment options.

CONCLUSIONS

To the best of our knowledge, this is the first qualitative study to grant women the opportunity to voice their personal experiences of a dehisced perineal wound and their views on the management offered. The powerful testimonies presented disclose the extent of morbidity experienced while also revealing a strong preference for a treatment option.

TRIAL REGISTRATION NUMBER

ISRCTN05754020; results.

Prevalence of Perineal Lacerations in Women Giving Birth at Midwife-Led Birth Centers in Japan: A Retrospective Descriptive Study

INTRODUCTION

Perineal lacerations during birth can cause ongoing physical, psychological, and social problems. However, the prevalence of lacerations following normal spontaneous vaginal birth in women with low-risk pregnancies is unknown. We investigated the prevalence of perineal lacerations and factors associated with lacerations among low-risk Japanese women who had normal spontaneous vaginal births.

METHODS

Pregnant women who were cared for between January 1, 2008, and June 30, 2011, in 3 midwife-led birth centers in Tokyo, Japan, where invasive medical interventions are rarely applied, were included. We investigated the prevalence of perineal lacerations and conducted univariate and multivariate analyses on the relationship between the prevalence of lacerations and selected maternal and neonatal characteristics.

RESULTS

A total of 1881 pregnant women had initial antenatal care at one of the 3 study sites. Of these, 1521 were eligible for inclusion. Intact perineum rates were 49.5% (209/422) and 69.9% (768/1099) in nulliparous and multiparous women, respectively. First-degree lacerations occurred in 36.7% (155/422) of nulliparous women and 27.1% (298/1099) of multiparous women, and second-degree lacerations occurred in 13.5% (57/422) of nulliparous women and 3.0% (33/1099) of multiparous women. One multiparous woman experienced a third-degree laceration (0.1%). No women suffered fourth-degree or cervical lacerations. Logistic regression analyses showed that older age (≥ 35 years), the hands-and-knees position, and using a birthing chair during birth increased the risk of perineal laceration both in nulliparous and in multiparous women. In addition, waterbirths increased the risk of perineal laceration in multiparous women.

DISCUSSION

In normal spontaneous vaginal births among a low-risk population, it is possible to avoid episiotomy and achieve a high rate of intact perineum, with few second-degree and third-degree lacerations.

Autoethnography and severe perineal trauma--an unexpected journey from disembodiment to embodiment

BACKGROUND

There is a lack of research reporting on the physical and emotional experiences of women who sustain severe perineal trauma (third and fourth degree tears). When the researcher identifies with the group being researched, autoethnography can allow an insight into the experiences of the marginalised group through the telling of a personal story. The aim of this paper is to share the journey travelled by an autoethnographer who on examining the issue of severe perineal trauma came to understand the challenges and rewards she experienced through this reflective and analytic process.

METHODS

A transformative emancipatory approach guided the design, data collection and analysis of findings from this study. For this paper, a multivocal narrative approach was taken in presenting the findings, which incorporated the words of both the autoethnographer and the twelve women who were interviewed as a component of the study, all of whom had sustained severe perineal trauma.

RESULTS

As an autoethnographer, being a member of the group being researched, can be confronting as the necessary reflection upon one's personal journey may lead to feelings of vulnerability, sadness, and emotional pain. The transformation from disembodied to embodied self, resulted in a physical and emotional breakdown that occurred for this autoethnographer.

CONCLUSION

Autoethnographers may experience unexpected emotional and physical challenges as they reflect upon their experiences and research the experiences of others. When incorporating a transformative emancipatory framework, the hardships are somewhat balanced by the rewards of witnessing 'self-transformation' as a result of the research.

Postpartum sexual health: a principle-based concept analysis

AIM

The aim of this study is to report an analysis of the concept of postpartum sexual health.

BACKGROUND

Postpartum sexual health is a minimally understood concept, most often framed within physical/biological dimensions or as a 'checklist' task in postpartum information provision. This has the potential to leave women unprepared to manage transient or normative sexual health changes after childbirth. For meaningful discussions, clarity and understanding of postpartum sexual health is required.

DESIGN

A principle-based method of concept analysis.

DATA SOURCES

The databases of PubMed, CINAHL, Maternity and Infant Care, PsychInfo, Web of Science, EMBASE, SCOPUS and Social Science Index were systematically searched, from their earliest dates, using a combination of key terms, including; 'sexual health', 'sexual function', 'dyspareunia', 'sexuality', 'sexual desire', 'sexual dysfunction', 'postnatal' and 'postpartum', resulting in a final included dataset of 91 studies.

METHODS

Using the principle-based approach, postpartum sexual health was analysed under the four philosophical principles of epistemological, pragmatic, linguistic and logical.

RESULTS

Philosophically, postpartum sexual health is underdeveloped as a concept. A precise theoretical definition remains elusive and, presently, postpartum sexual health cannot be separated theoretically from sexuality and sexual function. Identified antecedents include an instrument free birth, an intact perineum and avoidance of episiotomy. Attributes include sexual arousal, desire, orgasm, sexual satisfaction and resumption of sexual intercourse. Outcomes are sexual satisfaction and a satisfying intimate relationship with one's partner.

CONCLUSION

Postpartum sexual health is conceptually immature with limited applicability in current midwifery practice.

Influence of the duration of the second stage of labor on the likelihood of obstetric anal sphincter injury

BACKGROUND

Duration of the second stage of labor has been suggested as an independent risk factor for clinically detectable obstetric anal sphincter injury in low-risk nulliparous women.

METHODS

A retrospective 5-year cohort study was conducted in a UK obstetrics center which included a high-risk delivery unit and a low-risk birthing center. The study included 4,831 nulliparous women with vertex-presenting, single, live-born infants at term, stratified according to spontaneous or instrumental delivery. Binary logistic regression models were used to examine the association between duration of second stage and sphincter injury.

RESULTS

Three-hundred twenty-five of 4,831 women (6.7%) sustained sphincter injuries. In spontaneously delivering women, no association between duration of the second stage and the likelihood of sphincter injury was recorded. Factors associated with increased likelihood of sphincter injury included older maternal age, higher birthweight, and Southeast Asian ethnicity. In contrast, for women undergoing instrumental delivery, a longer second stage was associated with an increased sphincter injury risk of 6 percent per 15 minutes in the second stage of labor before delivery.

CONCLUSIONS

For spontaneous vaginal deliveries, duration of the second stage of labor was not an independent risk factor for obstetric anal sphincter injury. The association between prolonged second stage and sphincter injury for instrumental deliveries is likely explained by the risk posed by the use of the instruments themselves or by delay in initiating instrumental assistance. Attempts to modify the duration of the second stage for prevention of sphincter injuries are unlikely to be beneficial and may be detrimental.

The impact of first birth obstetric anal sphincter injury on the subsequent birth: a population-based linkage study

BACKGROUND

With rising obstetric anal sphincter injury (OASI) rates, the number of women at risk of OASI recurrence is in turn increasing. Decisions regarding mode of subsequent birth following an OASI are complex, and depend on a variety of factors. We sought to identify the risk factors for OASI recurrence from first and subsequent births, and to investigate the effect of OASI birth factors on planned caesarean for the second birth.

METHODS

Using two linked population datasets from New South Wales, Australia, we selected women giving birth between 2001 and 2011 with a first birth OASI and a subsequent birth. Multivariable logistic regression was used to identify the association of first and second birth factors with OASI recurrence, and to determine which factors were associated with a planned pre-labour caesarean at the second birth.

RESULTS

Of 6,380 women with a first birth OASI who proceeded to a subsequent birth, 75.4% had a vaginal second birth, 19.4% a pre-labour caesarean, and 5.2% an intrapartum caesarean. Although the OASI recurrence rate of 5.7% was significantly higher than the first birth OASI rate of 4.5% (p < 0.01), this may not reflect a clinically significant increase. Following adjustment for first and second birth factors, first birth diabetes and second birthweight ≥3.5 kg were associated with increased likelihood of OASI recurrence, while first birthweight ≥4.0 kg and second gestation at 37-38 weeks were associated with decreased likelihood. A fourth degree tear at the first birth was the strongest factor associated with planned caesarean at the second birth, with other factors including epidural, spinal or general anaesthetic, birthweight, gestation, country of birth and maternal age.

CONCLUSIONS

Compared with previous reports, the low OASI recurrence rate (approximately one in twenty) may reflect appropriate decision-making about subsequent mode of delivery following first birth OASI. This assertion is supported by evidence of different risk profiles for women who have planned caesareans compared with planned vaginal births.

Midwives' lived experience of a birth where the woman suffers an obstetric anal sphincter injury--a phenomenological study

Background

The occurrence of obstetric anal sphincter injuries (OASIS) has increased in most high-income countries during the past twenty years. The consequences of these injuries can be devastating for women and have an impact on their daily life and quality of health. The aim of this study was to obtain a deeper understanding of midwives’ lived experiences of attending a birth in which the woman gets an obstetric anal sphincter injury.

Methods

A qualitative study using phenomenological lifeworld research design. The data were collected through in-depth interviews with 13 midwives.

Results

The essential meaning of the phenomenon was expressed as a deadlock difficult to resolve between a perceived truth among midwives that a skilled midwife can prevent severe perineal trauma and at the same time a coexisting more complex belief. The more complex belief is that sphincter injuries cannot always be avoided. The midwives tried to cope with their feelings of guilt and wanted to find reasons why the injury occurred. A fear of being exposed and judged by others as severely as they judged themselves hindered the midwives from sharing their experience. Ultimately the midwives accepted that the injury had occurred and moved on without any definite answers.

Conclusions

Being caught between an accepted truth and a more complex belief evoked various emotions among the midwives. Feelings of guilt, shame and the midwife’s own suspicion that she is not being professionally competent were not always easy to share. This study shows the importance of creating a safe working environment in which midwives can reflect on and share their experiences to continue to develop professionally. Further research is needed to implement and evaluate the effect of reflective practices in relation to midwifery care and whether this could benefit women in childbirth.

"A patchwork of services"--caring for women who sustain severe perineal trauma in New South Wales--from the perspective of women and midwives

BACKGROUND

Current research into severe perineal trauma (3rd and 4th degree) focuses upon identification of risk factors, preventative practices and methods of repair, with little focus on women's experiences of, and interactions with, health professionals following severe perineal trauma (SPT). The aim of this study is to describe current health services provided to women in New South Wales (NSW) who have experienced SPT from the perspective of Clinical Midwifery Consultants (CMC) and women.

METHODS

This study used a descriptive qualitative design and reports on the findings of a component of a larger mixed methods study. Data were collected through a semi-structured discussion group using a variety of non-directive, open-ended questions leading CMCs of NSW. A survey was distributed prior to the discussion group to collect further information and enable a more comprehensive understanding of services provided. Data from individual interviews with twelve women who had experienced SPT during vaginal birth is used to provide greater insight into their interactions with, and ease of access to, health service providers in NSW. An integrative approach was undertaken in reporting the findings which involved comparing and analysing findings from the three sets of data.

RESULTS

One overarching theme was identified: A Patchwork of Policy and Process which identified that current health services operate in a 'patchwork' manner when caring for women who sustain SPT. They are characterised by lack of consistency in practice and standardisation of care. Within the overarching theme, four subthemes were identified: Falling through the gaps; Qualifications, skills and attitudes of health professionals; Caring for women who have sustained SPT; and Gold standard care: how would it look?

CONCLUSION

The findings from this study suggest that current health services in NSW represent a 'patchwork' of service provision for women who have sustained SPT. It appeared that women seek compassionate and supportive care based upon a clear exchange of information, and this should be considered when reflecting upon health service design. This study highlights the benefits of establishing multi-disciplinary collaborative specialist clinics to support women who experience SPT and associated morbidities, with the aim of providing comprehensive physiological and psychological support.