A systematic mixed studies review of women's experiences of perineal trauma sustained during childbirth

'Plan Z and then off the edge of a cliff': An interpretative phenomenological analysis of mothers' experience of living with a slow-to-heal Caesarean wound

BACKGROUND

Studies indicate that complex postsurgical wound healing can significantly alter biopsychological markers responsible for recovery. Yet, there is a lack of research investigating women's experience of living with slow-to-heal Caesarean birth wounds. This is an important area of investigation considering the increase of factors associated with surgical births and poor wound healing in the UK and globally.

AIM

The aim of this study was to explore women's experiences of living with a slow-to-heal Caesarean wound.

METHOD

Semi-structured interviews were conducted with seven women who had lived experience of slow-to-heal Caesarean wounds. Narratives were analysed using Interpretative Phenomenological Analysis (IPA) approach.

RESULTS

Analysis of women's narratives revealed three interlinking superordinate themes of 1) 'Tied to that event': healing physical and emotional wounds, 2) The 'good mother' and the 'good patient': negotiating being a carer and being cared for, and 3) 'Adjusting to a new normality'. Overall, slow-to-heal wounds embodied women's perceptions of agency over their Caesarean birth experience and achievement of a new motherhood identity. Wherein, successful healing would encompass a sense of normality defined by subjective notions of regaining expected roles and daily activities, previous bodily functions, and maternal status within their families that became disrupted due to delayed wound healing.

CONCLUSION

Women's narratives support discourse surrounding Caesarean birth and recovery as a biopsychosocial phenomenon. This has important ramifications regarding research and treatment programmes for postnatal women with complex healing that are largely described as 'invisible'.

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.

Optimising recovery after perineal trauma: Implementation of an evidence-based patient-centred care and clinical practice guideline

BACKGROUND

Perineal trauma and pain can affect the quality of life of women who experience vaginal birth.

AIM

To investigate the effect of perineal care and pain management on women's postpartum recovery.

METHODS

This was a Quasi-experimental study. In Phase 1 women were treated using our old postnatal perineal care management guideline. In Phase 2 an updated guideline was introduced (regular administration of icepacks and analgesia during the first 24-48 h postpartum). During Phase 1, pregnant women planning a vaginal birth completed a baseline questionnaire. Those who sustained perineal trauma completed a survey at 24-48 h, seven days and 12 weeks after birth. In Phase 2 we continued recruiting participants, using the same procedure, and investigated the efficacy of pain relief approaches using the new guideline.

RESULTS

In Phase 1, 111 women (Group 1), and Phase 2, 146 women (Group 2) were recruited. No statistically significant differences were found between the two groups in terms of the women's pain catastrophising, their partner's responses to pain behaviours, or birth outcomes. At 24-48 h and seven days postpartum, women in Group 2 were less likely than women in Group 1 to be bothered by back or perineal pain, headache, sleeping difficulties and dizziness (p < 0.05). More women in Group 2 received regular paracetamol and perineal icepacks during their hospital stay, with less use of oxycodone in Group 2 than Group 1.

CONCLUSION

The implementation of the guideline's recommendations was associated with decrease back and perineal pain, headache, sleeping difficulties and dizziness during the first seven days postpartum.

Key dimensions of women's and their partners' experiences of childbirth: A systematic review of reviews of qualitative studies

BACKGROUND

The World Health Organization 2018 intrapartum guideline for a positive birth experience emphasized the importance of maternal emotional and psychological well-being during pregnancy and the need for safe childbirth. Today, in many countries birth is safe, yet many women report negative and traumatic birth experiences, with adverse effects on their and their families' well-being. Many reviews have attempted to understand the complexity of women's and their partners' birth experience; however, it remains unclear what the key dimensions of the birth experience are.

OBJECTIVE

To synthesize the information from reviews of qualitative studies on the experience of childbirth in order to identify key dimensions of women's and their partners' childbirth experience.

METHODS

Systematic database searches yielded 40 reviews, focusing either on general samples or on specific modes of birth or populations, altogether covering primary studies from over 35,000 women (and >1000 partners) in 81 countries. We appraised the reviews' quality, extracted data and analysed it using thematic analysis.

FINDINGS

Four key dimensions of women's and partners' birth experience (covering ten subthemes), were identified: 1) Perceptions, including attitudes and beliefs; 2) Physical aspects, including birth environment and pain; 3) Emotional challenges; and 4) Relationships, with birth companions and interactions with healthcare professionals. In contrast with the comprehensive picture that arises from our synthesis, most reviews attended to only one or two of these dimensions.

CONCLUSIONS

The identified key dimensions bring to light the complexity and multidimensionality of the birth experience. Within each dimension, pathways leading towards negative and traumatic birth experiences as well as pathways leading to positive experiences become tangible. Identifying key dimensions of the birth experience may help inform education and research in the field of birth experiences and gives guidance to practitioners and policy makers on how to promote positive birth experiences for women and their partners.

The effects of warm perineal compress on perineal trauma and postpartum pain: a systematic review with meta-analysis and trial sequential analysis

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.

The postnatal effects of perineal trauma on maternal psychological and emotional wellbeing: A longitudinal study

OBJECTIVE

To examine the postnatal psychological health and parenting adjustment of primiparous women experiencing perineal trauma.

STUDY DESIGN

Longitudinal cohort study assessing body image, perceptions of traumatic birth, psychological distress, perineal pain, impact upon parental tasks and mother-infant bonding at 6-12 weeks (n = 103) and 6-10 months postnatally (n = 91). Primiparous women were recruited following vaginal birth and perineal suturing in a UK-based maternity hospital. al. Comparisons made according to the objective classification of perineal trauma experienced; 1st/2nd degree tear, episiotomy, and Obstetric Anal Sphincter Injuries (OASI).

RESULTS

At 6-12 weeks women with an episiotomy reported a more negative perception of their body image than those with OASI. Women with OASI or an episiotomy were more likely to have experienced birth as traumatic, and those with OASI reported more avoidance symptoms of post-traumatic stress and a greater negative impact on parenting tasks. At 6-10 months significantly more avoidance symptoms continued to be reported by those with OASI, whereas those with an episiotomy reported more anxiety related symptoms in general than those with OASI.

CONCLUSIONS

OASI, whilst associated with traumatic birth and some early parenting impacts, may not be linked to general negative psychological outcomes when specialist routine follow-up care is provided. Psychological impacts for women with episiotomy may merit further input than currently provided. Consideration should be given with regards to widening the access to postnatal perineal care by extending the criteria for specialist follow up beyond those sustaining OASI.

Perineal repair performed by midwives in Australia: A cross-sectional survey study of education and practice

PROBLEM

Perineal repair is generally not a widely practiced skill amongst Australian midwives, the reasons for this are uncertain and may result in technique variations.

BACKGROUND

Many birthing women experience perineal tears that require suturing. As midwives attend the majority of vaginal births, they would be ideally placed to undertake perineal repair.

AIM

To describe the current level of midwifery perineal repair skill acquisition, knowledge, techniques and utilization by Australian midwives.

METHODS

An online survey was distributed to Australian College of Midwives members and shared via social media. Data on demographics, suturing techniques, reasons why midwives did or did not suture and barriers to skill acquisition were collected. Descriptive statistics were calculated for all variables including percentages, mean, standard deviation, median and range as appropriate.

FINDINGS

375 completed surveys were received between April and May 2023. 197 midwives indicated current suturing practice and 178 did not suture. Contributing to continuity of care was the most common motivating factor. The use of a continuous suturing technique for all layers of a perineal injury was reported by the majority of suturing midwives. There was greater variation in the management of labial tears. Low numbers of skilled midwives to support attaining competency and high workloads were the main barriers to attaining suturing skills.

DISCUSSION

Australian midwives view perineal suturing as a valid midwifery skill that can contribute to continuity of care. Largely organisational barriers exist to skill development and greater utilisation.

CONCLUSION

Perineal repair should be prioritised as a fundamental midwifery skill.

The relationship between perineal trauma and postpartum psychological outcomes: a secondary analysis of a population-based survey

BACKGROUND

Perineal trauma, involving either naturally occurring tears or episiotomy, is common during childbirth but little is known about its psychological impact. This study aimed to determine the associations between childbirth related perineal trauma and psychological outcomes reported by women three months after giving birth and to explore factors that could mediate relationships between perineal trauma and maternal psychological outcomes.

METHODS

This study was a secondary analysis of data from a cross-sectional population-based survey of maternal and infant health. A total of 4,578 women responded to the survey, of which 3,307 had a vaginal birth and were eligible for inclusion into the analysis. Symptoms of depression, anxiety, and post-traumatic stress (PTS) symptoms were assessed using validated self- report measures. Physical symptoms were derived from a checklist and combined to produce a composite physical symptoms score. Regression models were fitted to explore the associations.

RESULTS

Nearly three quarters of women experienced some degree of perineal trauma. Women who experienced perineal trauma reported having more postnatal physical symptoms (adjusted proportional odds ratio 1.47, 95%CI 1.38 to 1.57, p-value < 0.001), were more likely to report PTS symptoms (adjusted OR 1.19, 95%CI 1.04 to 1.36, p-value 0.010), and there was strong evidence that each unit increase in the physical symptoms score was associated with between 38 and 90% increased adjusted odds of adverse psychological symptoms. There was no evidence of association between perineal trauma and satisfaction with postnatal care, although there was strong evidence that satisfaction with labour and birth was associated with 16% reduced adjusted odds of depression and 30% reduced adjusted odds of PTS symptoms.

CONCLUSIONS

Women who experienced perineal trauma were more likely to experience physical symptoms, and the more physical symptoms a woman experienced the more likely she was to report having postnatal depression, anxiety and PTS symptoms. There was some evidence of a direct association between perineal trauma and PTS symptoms but no evidence of a direct association between perineal trauma and depression or anxiety. Assessment and management of physical symptoms in the postnatal period may play an important role in reducing both physical and psychological postnatal morbidity.

Disempowering women-a mixed methods study exploring informational support about pain persisting after childbirth and its consequences

Background

Access to information is essential to achieving individual empowerment; meaning the ability to exercise control, manage one’s own condition and make informed decisions. However, studies have shown that information provided to women regarding physiological changes during the postpartum period and postpartum health was inadequate, incorrect, or inconsistent.

Methods

The aim of this study was to explore informational support about pain persisting after childbirth and its consequences. A sequential explanatory mixed methods design was used. In the first, quantitative phase, 1,171 women, who gave birth eight months earlier, completed a self-administered questionnaire. In the second, qualitative phase, 20 women who experienced chronic pain were interviewed. Descriptive statistics and qualitative content analysis were used to analyse the data.

Results

The majority of the women did not receive information about pain persisting after childbirth, or the information was insufficient or incorrect. They did not know when and where to seek help and did not consult health care professionals. In addition, the lack of information had a negative impact on women’s psychological well-being. All women expressed the need to be informed by health care professionals, irrespective of the individual risk of developing chronic pain.

Conclusions

Health services should ensure availability of information to give the women opportunity to achieve empowerment to make good health decisions, increase control over their health and well-being as well as to enhance their self-efficacy. We propose that a booklet or leaflet with relevant information about the risk of developing chronic pain, symptoms and treatment, along with advice about appropriate health care settings should be provided as part of antenatal or postnatal care.

The effects of perineal trauma on immediate self-reported birth experience in first-time mothers

INTRODUCTION

Childbirth can sometimes be stressful or traumatic, and previous research has considered how birth complications and interventions may contribute to a negative birth experience. One of the most frequent complications during birth is trauma to the perineum. The aim of this study was to investigate whether different levels of perineal trauma were associated with differences in women's evaluation of their birth experience.

MATERIALS AND METHODS

As part of a longitudinal cohort study, the self-reported birth experiences of 202 primiparous women were compared based on the degree of perineal trauma they had experienced. Women who had given birth for the first time, vaginally and within the last 48 h in a large tertiary maternity unit in England were invited to take part. Data were collected from their hospital records with their consent and using the Childbirth Experience Questionnaire (CEQ), Experience of Birth Scale (EBS) and a perineal pain Visual Analogue Scale (VAS).

RESULTS

Women with an obstetric anal sphincter injury (OASI) or episiotomy reported a more negative overall birth experience and perceived themselves as having less ability to give birth compared to those with a 1st/2nd degree sutured tear. Those with an episiotomy also reported feeling less involved in decision making processes during their birth. Significant differences remained between the OASI and 1st/2nd degree tear groups when controlling for factors known to affect birth experience, highlighting severe perineal trauma as a potential contributor to more negative birth experience.

CONCLUSIONS

Perineal trauma may affect a woman's birth experience. Experiencing an episiotomy should not be overlooked as a potential contributor, especially during instrumental birth and in the absence of involved decision making. Further research is needed to disentangle the effects of episiotomy on birth experience, to explore the care needs of women with different degrees of perineal trauma and to explore how a negative birth experience may contribute to poor psychological health in the longer term.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

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.

Earning the Trust of African American Communities to Increase Representation in Dementia Research

Black/African American populations are underrepresented as participants in dementia research. A major barrier to participation of African American older adults in dementia research is a tendency to distrust research institutions owing to both historical and contemporary racism. Building on the Ford framework, the objective of our study was to examine factors that influence participation in dementia research among African American older adults and caregivers, with an emphasis on understanding factors related to trust. Data were collected during January 2019 and March 2020 from 10 focus groups with African American older adults (n=91), 5 focus groups with caregivers (n=44), and interviews with administrators of community-based organizations (n=11), and meetings with our Community Advisory Board. Inductive/deductive content analysis was used to identify themes. The results identified an overall tension between distrust of researchers and a compelling desire to engage in dementia research. This overarching theme was supported by six themes that provided insights about the multiple layers of distrust, as well as expectations about the appropriate conduct of researchers and academic institutions. Strong commitment to the community was identified as a priority. The findings suggest that a paradigm shift is needed to increase the representation of African Americans in dementia research. In this new paradigm, earning the trust of African American communities becomes a systemic endeavor, with academic, state, and national institutions deeply committed to earning the trust of African American communities and guiding researchers in this endeavor. The findings also generated actionable recommendations to help improve representation of African American older adults in dementia research.

Multi-cultural perspectives on group singing among diverse older adults

Group choir singing has been shown to have health benefits for older adults. However, because most studies have included predominantly white participants, it is unknown whether findings generalize to older adults from more diverse backgrounds. This multi-site qualitative study assessed perceived benefits of group singing for socioeconomically and racially/ethnically diverse older adults. We interviewed 31 choir participants, 6 music professionals and 6 administrators involved in a large, cluster-randomized trial. We used content analysis to identify themes. Psychosocial engagement was most commonly reported, with six components: emotional well-being, self-esteem, self-confidence, social connection and support, decreased loneliness, and cultural identity and multi-cultural appreciation. A few reported cognitive and physical benefits. They also suggest that group singing among ethnically diverse older adults can have multiple psychosocial benefits and enhance a sense of cultural identity and appreciation of other cultures. These findings can help in selecting structured outcome measures for choir interventions.

Women's experience of episiotomy: a qualitative study from China

OBJECTIVE

To describe women's experience of episiotomy in urban China.

DESIGN

This is a semistructured, indepth interview with women after episiotomy. We analysed transcriptions using thematic analysis in Chinese. Emerging themes were debated in English to finalise interpretation.

SETTING

Two community health centres and four hospitals in Shanghai, China.

PARTICIPANTS

Purposive sampling of 30 postpartum women who had experienced episiotomy; 25 were primiparous and 4 had deliveries by forceps. We interviewed health providers to complement the data.

RESULTS

We identified four main themes: (1) women's views of the procedure vary considerably; (2) pain interferes with daily life for weeks; (3) long-term anxiety is a consequence for some, described as a 'psychological shadow'; and (4) societal norms assume women will not complain.

CONCLUSION

Women receive little information in advance about episiotomy, yet the procedure has a wide range of physical and psychological consequences. This includes long-term anxiety about the damage done to them as women.

The effects of a severe perineal trauma prevention program in an Australian tertiary hospital: An observational study

BACKGROUND

Severe perineal trauma during childbirth is associated with significant morbidity and rates internationally, are on the rise.

AIMS

To determine the impact of a prevention program on severe perineal trauma in a nulliparous population at a tertiary hospital in Australia.

METHODS

Routinely collected maternity data were used comparing outcomes in two time periods; two years before and two years after the introduction of the program. Categorical data were compared using the Chi Squared statistic and continuous data Student's t-test. Logistic regression examined the association between independent and dependent variables using unadjusted and adjusted odds ratios, with 95% confidence intervals and p -values with significance set at 0.05. The main outcome of interest is severe perineal trauma.

RESULTS

The proportion of women in this nulliparous population experiencing severe perineal trauma during vaginal birth decreased from 8.8% in the first time period to 5.6% in the second. Reductions were achieved in all modes of vaginal birth but were most pronounced in vacuum births. Rates of episiotomy increased between time periods and further analysis found that this was protective of severe perineal trauma in all modes of birth for women of Asian country of birth and only in forceps birth for non-Asian women. Factors found to contribute to severe perineal trauma in this population were Asian country of birth, neonatal weight ≥4000gm, forceps birth and maternal age.

CONCLUSIONS

The prevention program is associated with reduced rates of severe perineal trauma. The challenge for the service is to maintain this positive change.