Knowledge, attitude and experience of episiotomy practice among obstetricians and midwives: a cross-sectional study from China

Perineal massage and warm compresses-Implementation study of a complex intervention in health

OBJECTIVES

To determine the effect of using tailored and multifaceted strategies on the acceptability, appropriateness, feasibility and adoption of a perineal massage and warm compress intervention by midwives in a maternity ward of a tertiary hospital in Portugal.

METHODS

The complex intervention in health was developed based on the Medical Research Council framework and guided by the Theory of Change. Tailored and multifaceted strategies, including dissemination, integration and implementing process strategies, were applied. A mixed-methods approach was adopted, with a combination of qualitative (semi-open interviews) and quantitative (surveys, audits and electronic health records) methods. Surveys were applied to assess the acceptability, appropriateness and feasibility of the intervention. In order to evaluate adoption of the intervention, data from interviews were introduced into NVivo Version 10 to perform thematic analysis, and each audit checklist criterion was analysed using McNemar's exact test to determine differences in paired proportion.

RESULTS

This study found high acceptability (mean±standard deviation 4.28±0.45), high appropriateness (4.32±0.47) and high feasibility (4.26±0.43) of the intervention by midwives. Differences were reported for most topics between interviews conducted before and after implementation of the intervention. Pre-intervention, the midwives reported that the main factor affecting the application of perineal protection techniques was the lack of continuous presence of the midwife. The birth position was the alternative birth position (hands and knees, side-lying, squatting and semi-sitting), avoiding the lithotomy position. Techniques used for perineal protection were warm compresses, hands-on techniques, hands-off techniques and spontaneous pushing; and the reasons given for performing an episiotomy were large (high-birthweight) baby, Kristeller manoeuvre, tense perineum and previous obstetric sphincter injury. Post-intervention, the midwives reported that the presence of a second person increases the safety of professionals and women and improves working relations. The technique used for perineal protection was autonomy to adapt the intervention with perineal massage and warm compresses. A comfortable birth position for woman was used, and the rate of episiotomy reduced (only performed in the case of fetal distress). Regarding audits, significant differences (p < 0.05) were found for all audit criteria (pre- and post-intervention), which means that midwives adopted the intervention into their clinical practice.

CONCLUSION

Acceptability, appropriateness, feasibility and adoption of the intervention by midwives were high. Thus, tailored and multifaceted strategies were effective to achieve the implementation outcomes.

The effect of Camellia sinensis ointment on perineal pain and episiotomy wound healing in primiparous women: A triple-blind randomized clinical trial

BACKGROUND AND OBJECTIVE

Episiotomy is one of the most commonly performed procedures in obstetrics. complications of episiotomy are pain, bleeding, infection, pain in the sitting position, and difficulty in taking care of the baby. This study aimed to investigate the effect of Camellia sinensis ointment on perineal pain and episiotomy wound healing in primiparous women.

METHODS

This triple-blinded randomized clinical trial was conducted on 60 primiparous women who were referred to the maternity ward of Al-Hadi hospital in Shoushtar and Ganjovian hospital in Dezful, Iran, from 2020 to 2021. Participants were randomly assigned into two groups of intervention (Camellia sinensis extract ointment) and control (placebo) with a follow-up of 14 days. REEDA scale (redness, edema, ecchymosis, discharge, and approximation) was used to measure wound healing and the Visual Analog Scale (VAS) was used to measure the pain intensity.

RESULTS

There was no significant difference between two groups before intervention in terms of sociodemographic characteristics, pain intensity, and episiotomy wound status. Scores of pain intensity and wound healing reduced on days 7, 10, and 14 post-intervention in the intervention group compared to placebo. There was a significant decrease between the groups of intervention and control in terms of the mean score of pain intensity (VAS scale) on day 10 (1.33 ± 0.71, 1.77 ± 0.93) and day 14 (0.73 ± 0.74, 1.13 ± 0.81) post-intervention (P < 0.05). Also, on day 14 post-intervention, there was a significant decrease between the groups of intervention and control in terms of the mean score of episiotomy wound healing (REEDA index) (0.53 ± 0.77, 1.77 ± 1.46) (P < 0.05). The GLM test was applied for repeated measures. REEDA index and VAS scale changed during different times (time-variable) (p < .001). But, the studied groups (group variable) and the studied groups (interaction effect of group * time) did not affect the changes in the REEDA index (p = .292, p = .306) and VAS scale (p = .47) during different times.

CONCLUSION

Our study showed that Camellia sinensis extract ointment has a small effect on the healing process and pain reduction of episiotomy wounds. to confirm its effect, a study with a larger sample size should be conducted.

TRIAL REGISTRATION

This trial was registered in the Iranian Registry of Clinical Trials on 04/10/2019 with the IRCT ID: IRCT20190804044428N1. Participants were enrolled between 11 April 2020 and 20 January 2021. URL of registry: https://en.irct.ir/trial/41326.

Analysis of episiotomy incidence and risk factors in vaginal deliveries: a single-center

Introduction

Episiotomy is a surgical procedure involving the enlargement of the posterior vagina to facilitate the delivery of the baby. This study aims to further investigate the associated risk factors for episiotomy and the specific indications for its use in spontaneous labor.

Methodology

This institutional-based cross-sectional study was conducted among 349 vaginal births with a ratio of 1:4 from January 2020 to December 2020. We recruited study participants using consecutive sampling techniques. The sample size was calculated with a hypothesis test for two population proportions (one-sided test formula). Adjusted odds ratio with the corresponding 95% confidence interval was used to declare the significance of variables.

Results

In our multivariate analysis, it was found that pregnant women who underwent instrumental delivery (P-value=.00; OR=25.63; 95% CI: 5.76-114.0) and those with fetal birth weight >3,000 grams (P-value=.00; OR=11.31; 95% CI: 3.96-32.32) had the highest risk of undergoing an episiotomy. Subsequently, the duration of the second stage of labor >30 minutes (P-value=.049; OR=16.34; 95% CI: 1.01-264.48) was associated with a slightly increased risk of episiotomy. Fetal head circumference >34 cm was not found to be risk of an increased risk of episiotomy in this study. However, pregnant women aged >30 years (P-value=.049; OR=0.306; 95% CI: 0.94-0.99) showed a reduced risk of episiotomy.

Conclusion

The prevalence of episiotomy practice in this study exceeds the recommended threshold set by the World Health Organization (WHO). Instrumental delivery, high birth weight, and prolonged second-stage labor emerged as significant factors influencing episiotomy practice. Hence, further interventions are warranted to mitigate the prevalence of episiotomy practice.

Obstetric Interventions Among Native and Migrant Women: The (Over)use of Episiotomy in Portugal

Objective: Episiotomy, defined as the incision of the perineum to enlarge the vaginal opening during childbirth, is one of the most commonly performed surgical interventions in the world. We aimed to determine if migrant status is associated with episiotomy, and if individual characteristics mediate this association. Methods: We analyzed data from the Bambino study, a national, prospective cohort of migrant and native women giving birth at a public hospital in mainland Portugal between 2017 and 2019. We included all women with vaginal delivery. The association between migrant status and episiotomy was assessed using multivariable multilevel random-effect logistic regression models. We used path analysis to quantify the direct, indirect and total effects of migrant status on episiotomy. Results: Among 3,583 women with spontaneous delivery, migrant parturients had decreased odds of episiotomy, especially those born in Africa, compared to native Portuguese women. Conversely, with instrumental delivery, migrant women had higher odds of episiotomy. Disparities in episiotomy were largely explained by maternity units' factors, and little by maternal and fetal characteristics. Conclusion: Our results suggest non-medically justified differential episiotomy use during childbirth and highlight the importance of developing evidence-based recommendations for episiotomy use in a country with a high frequency of medical interventions during delivery.

Low-Value Surgical Procedures in Low- and Middle-Income Countries: A Systematic Scoping Review

Importance

Overuse of surgical procedures is increasing around the world and harms both individuals and health care systems by using resources that could otherwise be allocated to addressing the underuse of effective health care interventions. In low- and middle-income countries (LMICs), there is some limited country-specific evidence showing that overuse of surgical procedures is increasing, at least for certain procedures.

Objectives

To assess factors associated with, extent and consequences of, and potential solutions for low-value surgical procedures in LMICs.

Evidence Review

We searched 4 electronic databases (PubMed, Embase, PsycINFO, and Global Index Medicus) for studies published from database inception until April 27, 2022, with no restrictions on date or language. A combination of MeSH terms and free-text words about the overuse of surgical procedures was used. Studies examining the problem of overuse of surgical procedures in LMICs were included and categorized by major focus: the extent of overuse, associated factors, consequences, and solutions.

Findings

Of 4276 unique records identified, 133 studies across 63 countries were included, reporting on more than 9.1 million surgical procedures (median per study, 894 [IQR, 97-4259]) and with more than 11.4 million participants (median per study, 989 [IQR, 257-6857]). Fourteen studies (10.5%) were multinational. Of the 119 studies (89.5%) originating from single countries, 69 (58.0%) were from upper-middle-income countries and 30 (25.2%) were from East Asia and the Pacific. Of the 42 studies (31.6%) reporting extent of overuse of surgical procedures, most (36 [85.7%]) reported on unnecessary cesarean delivery, with estimated rates in LMICs ranging from 12% to 81%. Evidence on other surgical procedures was limited and included abdominal and percutaneous cardiovascular surgical procedures. Consequences of low-value surgical procedures included harms and costs, such as an estimated US $3.29 billion annual cost of unnecessary cesarean deliveries in China. Associated factors included private financing, and solutions included social media campaigns and multifaceted interventions such as audits, feedback, and reminders.

Conclusions and Relevance

This systematic review found growing evidence of overuse of surgical procedures in LMICs, which may generate significant harm and waste of limited resources; the majority of studies reporting overuse were about unnecessary cesarean delivery. Therefore, a better understanding of the problems in other surgical procedures and a robust evaluation of solutions are needed.

The Effects of Ginger (Zingiber officinale) Extract Ointment on Pain and Episiotomy Wound Healing in Nulliparous Women: A Randomized Clinical Trial

Introduction

Episiotomy is a usual midwifery surgery. Iran is a country with an abundant source of medicinal plants. This study aimed to investigate ginger extract ointment's effects on the pain and recovery of episiotomy incisions in nulliparous women.

Methods

This randomized clinical trial was conducted in a public hospital in Iran on 70 nulliparous women with an episiotomy incision. The women were randomly assigned to ginger extract ointment and placebo groups. The primary outcomes included pain and wound healing that were assessed using a visual analog scale (VAS), redness, edema, ecchymosis/bruising, discharge, and an approximation scale (REEDA). The participants were followed up before discharge from the hospital and 5×1 and 10×1 days after the intervention. The secondary outcome was the number of painkillers used during the study. Data were analyzed by chi-square, independent t test, and the Mann-Whitney U via SPSS-13. The significance levels were determined to be P≤0.05.

Results

There was no significant difference between participants treated with ginger extract ointment and placebo in the pain and wound healing scores before the intervention, 5×1 and 10×1 days after the intervention. But, the pain intensity decreased, and the recovery speed increased clinically. Also, regarding the secondary outcome of this study, no significant difference between the placebo and intervention groups in the number of painkillers participants took.

Conclusion

The ginger ointment could not significantly improve episiotomy wounds' pain and healing rate, but it was clinically helpful. So more studies with different doses of this ointment are needed.

Neonatal head circumference as a risk factor for obstetric anal sphincter injuries: a systematic review and meta-analysis

OBJECTIVE

Between 53% and 79% of women will sustain some degree of perineal laceration during vaginal delivery. Third- and fourth-degree perineal lacerations are known as obstetric anal sphincter injuries. Timely diagnosis and prompt treatment of obstetric anal sphincter injuries can help to prevent the development of severe consequences like fecal incontinence, urinary incontinence, and rectovaginal fistula. Neonatal head circumference is routinely measured postpartum but is often not mentioned as a risk factor for obstetric anal sphincter injuries in clinical guidelines. Thus far, no review article on the risk factors for obstetric anal sphincter injuries has discussed the role of neonatal head circumference. This study aimed to review and analyze the relationship between head circumference and the occurrence of obstetric anal sphincter injuries among previous studies to conclude whether head circumference should be recognized as an important risk factor.

DATA SOURCES

Through study screening on Google Scholar, PubMed, Scopus, and Science Direct for articles published between 2013 to 2023, followed by assessment of eligibility, this study ended up reviewing 25 studies, 17 of which were included in the meta-analysis.

STUDY ELIGIBILITY CRITERIA

Only studies that reported both the neonatal head circumference and the occurrence of obstetric anal sphincter injuries were included in this review.

METHODS

The included studies were appraised using the Dartmouth Library risk of bias assessment checklist. Qualitative synthesis was based on the study population, findings, adjusted confounding factors, and suggested causative links in each study. Quantitative synthesis was conducted using calculation and pooling of odds ratios and inverse variance using Review Manager 5.4.1.

RESULTS

A statistically significant association between head circumference and obstetric anal sphincter injuries was reported in 21 of 25 studies; 4 studies reported that head circumference was a true independent risk factor. A meta-analysis of the studies that reported neonatal head circumference as a dichotomous categorical variable with a cutoff point of 35±1 cm yielded statistically significant pooled results (odds ratio, 1.92; 95% confidence interval, 1.80-2.04).

CONCLUSION

The risk for obstetric anal sphincter injuries increased as the neonatal head circumference increased-this should be considered in decision-making during labor and postpartum management to attain the best outcome.

Prophylactic antibiotic use during labor and delivery in China: a nationwide, multicenter, hospital-based, cross-sectional study

BACKGROUND

Prophylactic antibiotic use during delivery is common in routine obstetric practice to prevent infection globally, especially in low- and middle-income countries. In China, however, little is currently known about the national estimates for prophylactic antibiotic use during delivery. Therefore, we aimed to describe the prevalence of prophylactic antibiotic use and guideline adherence using national data in China.

METHODS

This cross-sectional study analyzed a national dataset from the China Labor and Delivery Survey in 2015-2016. The primary outcomes were prophylactic antibiotic use and clinician adherence to WHO recommendations for the prevention and treatment of maternal peripartum infections. We estimated the weighted prevalence of the outcomes with Taylor series linearization and investigated the associated factors of the outcomes with logistic regression.

RESULTS

Of the 72,519 deliveries, the prevalence of antibiotic prophylaxis was 52.0%, varying from 92.8% in Shanxi to 17.3% in Hainan. The prevalence of clinician adherence to the WHO guideline was 79.9%, ranging from 93.4% in Shandong to 50.0% in Shanxi. Prophylactic antibiotic use was associated with cesarean delivery (AOR, 55.77; 95%CI, 25.74-120.86), operative vaginal delivery (AOR, 4.00; 95%CI, 1.64-9.78), preterm (AOR, 1.96; 95%CI, 1.60-2.41), premature rupture of membranes (PROM) (AOR, 2.80; 95%CI, 1.87-4.18), and meconium-stained amniotic fluid (AOR, 1.91; 95%CI, 1.30-2.81) in all deliveries and also episiotomy (AOR, 1.48; 95%CI, 1.02-2.16) in vaginal deliveries. Clinician adherence was positively associated with cesarean delivery (AOR, 5.72; 95%CI, 2.74-11.93) while negatively associated with operative vaginal delivery (AOR, 0.26; 95%CI, 0.11-0.61), PROM (AOR, 0.50; 95%CI, 0.35-0.70), and meconium-stained amniotic fluid (AOR, 0.66; 95%CI, 0.48-0.91) in all deliveries. In vaginal deliveries, clinician adherence was negatively associated with episiotomy (AOR, 0.67; 95%CI, 0.46-0.96) and severe perineal trauma (AOR, 0.09; 95%CI, 0.02-0.44). Besides, clinicians in general hospitals prescribed prophylactic antibiotics more likely (AOR, 2.79; 95%CI, 1.50-5.19) and had a lower adherence (AOR, 0.38; 95%CI, 0.20-0.71) than their peers in maternity hospitals.

CONCLUSIONS

We observed that about half of all deliveries in China received antibiotics for prophylaxis, and most deliveries were prescribed according to the WHO guideline. Furthermore, the two prevalence rates for prophylactic antibiotic use and clinician adherence varied widely across provinces of China.

Effect of Rosemary Cream on Episiotomy Wound Healing in Primiparous Women: A Randomized Clinical Trial

BACKGROUND

Delay in episiotomy wound healing can lead to infection. The application of natural antimicrobial agents isolated from herbal essences can be a good strategy to prevent the growth of bacteria and promote the wound healing process. Therefore, this study aimed to determine the effect of rosemary cream on episiotomy wound healing in primiparous women.

METHODS

This triple-blind randomized clinical trial was conducted on 80 primiparous pregnant women who were referred to the maternity ward of Shahid Motahari Hospital in Marvdasht, Iran, from September 2019 to March 2020. These women were randomly assigned into two groups of intervention (rosemary cream) and control (placebo), using variable quadruple blocks. Both groups applied the prescribed cream (in a dose of 2 cm) uniformly on the sutured area to cover it with the cream. The cream was applied twice a day for 10 consecutive days postpartum, and the rate of wound healing was evaluated by the researcher in the first 12 h and at days 4 and 10 postpartum using the REEDA scale. The data were analyzed using SPSS software (Version 19) through the Chi-square test, Mann-Whitney U test, student's t-test, and Fisher's test. A p-value less than 0.05 (P < 0.05) was considered statistically significant.

RESULTS

The mean ± SD REEDA score on the fourth day postpartum was obtained at 3.82 ± 0.93 and 4.25 ± 1.29 in the groups of rosemary cream and placebo, respectively (P = 0.17). However, the mean ± SD REEDA scores on the 10th day postpartum were determined at 0.75 ± 0.74 and 3.32 ± 2.54 in the rosemary cream and placebo groups, respectively, indicating a higher rate of episiotomy wound healing in the group of rosemary cream compared to placebo (P < 0.001).

CONCLUSION

Based on the obtained results, it seems that rosemary cream can be effective in healing episiotomy wounds in primiparous women. However, further studies are suggested to confirm the findings of this study.

TRIAL REGISTRATION

This trial was registered in the Iranian Registry of Clinical Trials in 24/08/2019 with the IRCT ID: IRCT20190308042971N1. The first participant enrolled in this trial in September 2019. URL of registry: https://en.irct.ir/trial/40092 .

A nationwide cross-sectional survey of episiotomy practice in China

Background

A restrictive use of episiotomy was recommended by the obstetric society in China, but limited information on the epidemiology and the effects of restrictive use of episiotomy on maternal and fetal outcomes have been published.

Methods

The China Labor and Delivery Survey is a cross-sectional investigation with a cluster random sampling scheme in 2015-2016 with the aim to describe detailed epidemiology of labor and delivery in China. We calculated the episiotomy rate by parity using the survey data. Associated factors of episiotomy were selected using mixed models with a random effect for the hospital-level clustering. Logistic regression models were fitted to examine the effects of mediolateral episiotomy on maternal and neonatal outcomes among the propensity score-matched women.

Findings

The episiotomy rate among vaginal births was 41·7% [95% confidence interval (CI): 40·1% - 43·2%] in nulliparae and 21·5% (95% CI: 19·4% - 23·5%) in multiparae in China. Associated factors of episiotomy included prepregnancy BMI, maternal diseases, and obstetric factors. More than half of episiotomies in nulliparae and one-fourth in multiparae had no indications. Mediolateral episiotomy without indicators increased the risk of 3^rd or 4^th degree perineal laceration [odds ratio (OR) =2·64, 95% CI: 1·08-6·48)] in nulliparae without neonatal benefits.

Interpretation

Episiotomy was performed more than medically necessary in China. Mediolateral episiotomy without indications more than doubled the risk of 3^rd and 4^th degree perineal laceration in nulliparae without neonatal benefits.

Funding

National Natural Science Foundation of China and Shanghai Health Commission Programme.