Advantage or disadvantage of episiotomy compared with spontaneous perineal laceration

A novel obstetrical surgical intervention - New episiotomy: Case series study

OBJECTIVES

To establish anatomical structures responsible for creating a resistance force on a fetal head during vaginal delivery at term; to develop a new episiotomy to widen the vaginal outlet.

DESIGN

A prospective observational case series study.

SETTING

International centers.

POPULATION

Eighteen consecutive women at term during vaginal delivery.

METHODS

V-shape excision made on the hymeneal membrane, hymeneal ring, and hymeneal plate without extending an incision to the posterior perineal structures. Outlectorrhaphy (repairing the vaginal outlet to repair the surgical defect. Excisional specimens are subjected to histological examinations.

MAIN OUTCOME MEASURES

The primary maternal outcome measures were postpartum posterior perineum pain associated with vaginal outlectomy. The secondary outcomes measured a) complication of vaginal outlectomy; b) occurrence of dyspareunia after vaginal outlectomy; c) applicability of vaginal outlectomy; d) neonatal outcome measured by an APGAR score to show how the neonate tolerated the vaginal delivery process with vaginal outlectomy implementation.

RESULTS

The V-shape excision widened the vaginal outlet sufficiently for a vaginal delivery without a perineal incision. Outlectorrhaphy requires two or three simple interrupted sutures to close surgical defects and eliminate the vaginal gapping appearance. Eleven out of eighteen women were primigravida (61.1 %), and four multiparas (38.9 %) delivered a live newborn vaginally with a newly developed vaginal outlectomy. A median newborn's weight was 350 g ± 250 g, and APGAR scores at 5 min were median of 9 ± 1. One out of eighteen patients experienced extension of the skin, perineal fascia, and bulbospongiosus muscle. Bleeding from the extension tearing of vaginal outlectomy was heavier than from uncomplicated vaginal outlectomy but negligible. Immediately postpartum, patients reported no moderate or severe perineal pain. At a 3-month postpartum, none of the subjects reported superficial or deep dyspareunia. Histology from the vaginal outlectomy specimens described the direct connection of the longitudinal vaginal smooth muscles to the hymeneal plate and compact connective tissues (like cartilage) of the hymeneal ring. Additionally, the histological examination showed the absence of the perineal skeletal muscle within the vaginal outlectomy specimens.

CONCLUSIONS

The vaginal outlet is responsible for the most vital resistance force on a fetal head during delivery. Vaginal outlectomy widens the vaginal outlet sufficiently for a fetal vaginal birth with minimal bleeding and is easy to repair. No moderate-severe perineal pain or dyspareunia occurred in this study group.

TWEETABLE ABSTRACT

Vaginal outlectomy eliminates postpartum moderate-to-severe perineal pain and superficial dyspareunia. The posterior perineum creates no resistance force on the fetal head during vaginal delivery to warrant incision.

The Skin Antiseptic agents at Vaginal dElivery (SAVE) trial: study protocol for a randomized controlled trial

BACKGROUND

Cleansing of the vulva and perineum is recommended during preparation for vaginal delivery, and special attention is paid to cleansing before episiotomy because episiotomy is known to increase the risk of perineal wound infection and/or dehiscence. However, the optimal method of perineal cleansing has not been established, including the choice of antiseptic agent. To address this issue, we designed a randomized controlled trial to examine whether skin preparation with chlorhexidine-alcohol is superior to povidone-iodine for the prevention of perineal wound infection after vaginal delivery.

METHODS

In this multicenter randomized controlled trial, term pregnant women who plan to deliver vaginally after episiotomy will be enrolled. The participants will be randomly assigned to use antiseptic agents for perineal cleansing (povidone-iodine or chlorhexidine-alcohol). The primary outcome is superficial or deep perineal wound infection within 30 days after vaginal delivery. The secondary outcomes are the length of hospital stay, physician office visits, or hospital readmission for infection-related complications, endometritis, skin irritations, and allergic reactions.

DISCUSSION

This study will be the first randomized controlled trial aiming to determine the optimal antiseptic agent for the prevention of perineal wound infections after vaginal delivery.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05122169. First submitted date on 8 November 2021. First posted date on 16 November 2021.

Episiotomy practice and associated factors among mothers who gave birth at public health facilities in Metema district, northwest Ethiopia

BACKGROUND

Episiotomy is a surgical incision of the perineum to hasten the delivery. There is a scarce of information related to episiotomy practice, and its associated factors, in developing countries, including Ethiopia. Thus, this study was aimed to determine the level of episiotomy practice and to identify its determinants at public health facilities of Metema district, northwest, Ethiopia.

METHODS

Institutional-based cross sectional study was conducted among 410 delivered mothers from March 1 to April 30, 2020. We recruited study participants using systematic random sampling technique. Data were entered to Epi data version 3.1 and exported to STATA version 14 for statistical analysis. Stepwise backward elimination was applied for variable selection and model fitness was checked using Hosmer and Lemshows statistics test. Adjusted odds ratio with the corresponding 95% confidence interval was used to declare the significance of variables.

RESULTS

In this study, the magnitude of episiotomy practice was found 44.15% (95% CI 39.32-48.97). Vaginal instrumental delivery (AOR 3.04, 95% CI 1.36-6.78), perineal tear (AOR 3.56, 95% CI 1.68-7.55), age between 25 and 35 (AOR 0.11, 95% CI 0.05-0.25), birth spacing less than 2 years (AOR 4.76, 95% CI 2.31-9.83) and use of oxytocin (AOR 2.73, 95% CI 1.19-6.25) were factors significantly associated with episiotomy practice.

CONCLUSIONS

Magnitude of episiotomy practice in this study is higher than the recommended value of World Health Organization (WHO). Instrumental delivery, age, oxytocin, birth spacing and perineal tear were significant factors for episiotomy practice. Thus, specific interventions should be designed to reduce the rate of episiotomy practice. Plain English summary The routine use of episiotomy practice is not recommended by WHO. A study that compares routine episiotomy with restrictive episiotomy suggests that the latter is associated with less posterior perineal trauma, less need for suturing, and fewer complications related to healing. In addition, though, the rate of episiotomy has been declined in developed countries, still it remains high in less industrialized countries. The data for this study were taken at public health facilities of Metema district, northwest, Ethiopia. We included a total of 410 delivered mothers. The magnitude of episiotomy practice was found 44%. This result was higher than the recommended value of WHO. The WHO recommends an episiotomy rate of 10% for all normal deliveries. The result of this study showed that episiotomy practice is common among mothers whose age group are 18-24. In addition, mothers whose labor were assisted by instrumental vaginal delivery are more likely to have episiotomy as compared to those delivered by normal vaginal delivery. Laboring mothers who had used oxytocin were about three times more likely to be exposed for episiotomy than laboring mothers who did not use oxytocin drug. Moreover, episiotomy practice was nearly five times more likely among mothers who had birth spacing of 2 years and less as compared to mothers who had birth spacing of more than 2 years.

Episiotomy and Initiation of Human Milk Feeds: A Retrospective Observational Study

Objective: To investigate the association, in the United Kingdom, between having an episiotomy during childbirth and giving human milk by any modality as an infant's first feed. We also identified maternal demographic factors and perinatal experiences associated with increased chance of the infant's first feed being human milk. Study Design: Retrospective observational cohort study at two large maternity units within district general hospitals in the United Kingdom. Population: Mothers giving birth vaginally to singleton babies at ≥34 weeks and ≥1,800 g. Methods and Main Outcome Measures: Deidentified data from hospital records were analyzed. The odds ratio (OR) of a mother giving human milk for an infant's first feed after episiotomy versus no episiotomy was calculated using a chi-squared test. Logistic regression was used to investigate and then control for confounders known to affect breastfeeding. Results: A total of 13,906 women met the inclusion criteria (2,113 had had an episiotomy and 11,793 had not). Human milk was given as a first feed to 70% of infants in the study population. Women whose infants received their first feed as human milk were on average older, had lower body mass index, lived in an area of less socioeconomic deprivation, and had fewer previous births than those women who gave formula milk as the first feed to their infant. The occurrence of an episiotomy during delivery was not associated with a change in the odds of the infant receiving human milk for the first feed (OR: 1.12 [confidence interval, CI: 0.96-1.38]). Where a woman had skin-to-skin care with her infant straight after birth, the infant was more likely to receive human milk as a first feed (OR: 4.23 [CI: 3.59-4.98]). Conclusion: There is no link between episiotomy during delivery and the odds of a woman giving human milk as the first feed to her infant.

Episiotomy: history, present and future - a review

Childbirth has always carried traumatic stress to the woman's body. To deliver with less perineal trauma, obstetricians have used episiotomies. Episiotomy is still a common practice despite the controversy regarding its use. Weighing the risks and benefits, the scientific literature supports its selective use. With the worldwide trend to reduce the rate of episiotomy, several techniques have been proposed to achieve that. However, further research is still needed to prove their efficacy. This review will shed light on the historical background of episiotomy, its different techniques, indications, and the future of its practice.

Prevalence and risk factors for postpartum urinary retention after vaginal delivery in Japan: A case-control study

AIM

This study aimed to clarify the prevalence and risk factors of postpartum urinary retention after vaginal delivery. It also described the healing process of women who had postpartum urinary retention.

METHODS

In this case-control study, 77 women who had postpartum urinary retention were matched by age and parity with 385 women as controls. Data were analyzed by conditional logistic regression analysis. Data were collected from the women in the case group regarding their healing process and conditions for urinary retention (overt or covert urinary retention).

RESULTS

The prevalence of postpartum urinary retention was 1.2%. The adjusted odds ratio and the 95% confidence intervals for risk factors were as follows: epidural analgesia 4.72, 95% CI 2.38, 9.39; episiotomy 2.68, 95% CI 1.40, 5.13; length of second stage of labor 1.85, 95% CI 0.98, 3.49; labor augmentation 1.78, 95% CI 0.90, 3.51; instrument delivery 0.96, 95% CI 0.43, 2.17; and Kristeller maneuver 0.93, 95% CI 0.37, 2.37. Among 59 women with overt urinary retention, 29 (49.2%) transitioned to covert urinary retention within 10 days after delivery. More than half of the women were normal within 72 hr, but there were five women whose urinary retention did not resolve 11 days following delivery.

CONCLUSIONS

The statistically significant risk factors for postpartum urinary retention were epidural analgesia and episiotomy. Initiatives for the prevention and management of postpartum urinary retention are necessary.

The Effect of Warm Compress Bistage Intervention on the Rate of Episiotomy, Perineal Trauma, and Postpartum Pain Intensity in Primiparous Women with Delayed Valsalva Maneuver Referring to the Selected Hospitals of Shiraz University of Medical Sciences in 2012-2013

BACKGROUND

Genital trauma during vaginal delivery may result from episiotomy, spontaneous perineal tears (perineum, vagina), or both. In 2012, this study aimed to investigate the effect of warm compress bistage intervention on the rate of episiotomy, perineal trauma, and postpartum pain intensity in the primiparous woman with delayed Valsalva maneuver.

METHODS

In this randomized clinical trial, which was performed in hospitals in Shiraz, Iran, in 2012-2013, 150 women were randomly divided into 2 groups: 1 intervention and 1 control. The intervention group received warm compress bistage intervention at 7-cm and 10-cm dilatation and zero position during the first and second stages of labor for 15 to 20 minutes, whereas the control group received the hospitals' routine care. After delivery, the prevalence of episiotomy; intact perineum; location, degree, and length of rupture; and postpartum pain intensity were assessed in the 2 groups. Following that, the data were analyzed with SPSS statistical software (version 16) using χ test, t test, and odds ratio.

RESULTS

The results revealed a significant difference between the intervention and control groups regarding the frequency of intact perinea (27% vs 6.7%) and the frequency of episiotomy (45% vs 90.70%). In addition, the frequency of the location of rupture (P = .019), mean length of episiotomy incision (P = .02), and mean intensity of pain the day after delivery (P < .001) were significantly lower in the intervention group compared with the control group. However, the rate of ruptures was higher in the intervention group.

CONCLUSIONS

Warm compress bistage intervention was effective in reducing episiotomies and the mean length of episiotomy incision, reducing pain after delivery, and increasing the rate of intact perinea. However, the rate of ruptures slightly increased in the intervention group compared with the control group.

Sexual activity and dyspareunia the first year postpartum in relation to degree of perineal trauma

INTRODUCTION AND HYPOTHESIS

Knowledge on sexual complaints and time to sexual resumption after obstetric anal sphincter injury (OASI) is scarce. The aim of the study was to investigate self-reported sexual activity and coital problems 1 year postpartum in relation to perineal trauma, in addition to delivery mode.

METHODS

Among 2,846 women recruited during pregnancy, all women who delivered with OASI (n = 42, all third-degree perineal tears), in addition to 20 randomly selected controls per OASI case, a total of 882 women, were sent a self-administered questionnaire addressing time to coital resumption after delivery and potential coital difficulty 1 year postpartum.

RESULTS

By 8 weeks, half of the 561 responders (51.4 %) had resumed intercourse, increasing to 75.2 % by 12 weeks and 94.7 % 1 year postpartum. In multivariate regression analysis OASI was the strongest predictor for postponed coital onset, defined as after 8 weeks (aOR 5.52, CI 1.59-19.16). OASI was also the only significant predictor for dyspareunia 1 year after delivery (aOR 3.57, CI 1.39-9.19). Episiotomy was neither a risk factor for postponed coital onset nor for dyspareunia. There were no differences between episiotomy and second-degree laceration injury groups regarding postponed coital onset (p = 0.45) or dyspareunia (p = 0.67) 1 year postpartum.

CONCLUSIONS

Obstetric anal sphincter injury was a strong and independent predictor for both postponed coital resumption after delivery and for dyspareunia 1 year postpartum, whereas episiotomy and spontaneous second-degree lacerations were not. Our main finding of affected sexual activity after OASI further supports the need to reduce the rates of this obstetric injury to a minimum.

The Development of a New Medical Device for Standardized Episiotomy: A Pre-Clinical Validation Study

BACKGROUND

The aim of this study was to present the validation and optimization process for a new innovative medical device to create a standardized episiotomy.

DESIGN

We performed a preclinical validation study.

SETTING

This study was performed at the University hospital.

SAMPLE

Animal, cadaver.

METHODS

Together with technical engineers, we designed a new medical device that involves a knife and cuts back from buttock toward introitus, in contrast to the conventional episiotomy. We optimized the design and its performance in consecutive animal and cadaver studies.

MAIN OUTCOME MEASURES

Ability to perform a standardized incision, ease of use.

RESULTS

After multiple adjustments, based on the results of multiple animal and cadaver studies, a medical device was developed to perform a standardized clean-cut episiotomy of 4-6 cm length.

CONCLUSION

We have shown that optimizing the technical performance and safety of an innovative device in animals, prior to opposing patients to its potential hazards, is feasible. Our design optimizing study can be used as a model for the pre-clinical validation of future innovative medical devices.

Rates and Indicators for Episiotomy in Modern Obstetrics - a study from Saudi Arabia

BACKGROUND

This observational study aimed to describe the rates and indicators for practice of episiotomy during normal labour and to compare them between women who have had one pregnancy (PG) and women who have already delivered two or more children (G2 and above).

METHODS

The study was conducted at Mother and Child Hospital, Buraidah from October- December 2013 as a descriptive cross sectional study.

RESULTS

Overall rate of Episiotomy was 51.20%. Amongst the Primigravidas all went through episiotomies however in G2 and above only 7 patients (4.69%) delivered with episiotomy. Proportions tests revealed that there were significant differences between gravidity groups on two indications of episiotomy (vaginal breech p <0.001 and previous history of perineal tear p < 0.001). G2 and above had episiotomy for breech delivery (1 of 7 = 14.29%) significantly more often than PG participants (0 of 142 = 0.0%). And G2 and above participants experienced episiotomy for previous perineal tear (2 of 7 = 28.5% as compared to none in PG No other significant differences were found on indications of episiotomy.

CONCLUSION

Episiotomy is a very common obstetric intervention (51.20%). The PG experience episiotomy significantly more often than G2 and above women. Efforts should be made to reduce its rates. This can be done by reviewing the indications and rates at repeated intervals and setting guidelines for these indications.

Risk of episiotomy and perineal lacerations recurring after first delivery

BACKGROUND

To assess whether the presence of an episiotomy or spontaneous perineal trauma at the first delivery increases the risk of perineal trauma at the following one.

METHODS

We studied 2,695 women who gave birth twice at Virgen de las Nieves University Hospital of Granada, Spain. All second deliveries were from 2004 to 2011 and prenatal database records were used to obtain information about the first deliveries. All births, first and second, were single, vaginal, unassisted, and in a cephalic presentation. Two groups were made as follows: Intact perineum (no perineal trauma or first-degree spontaneous tear at the first delivery) and perineal trauma (episiotomy or second-degree or higher spontaneous tear at the first delivery). Both groups were compared according to the degree of perineal trauma at the second delivery.

RESULTS

Women included in the perineal trauma group were significantly older and a higher proportion was attended by a midwife with an obstetrician present in the delivery room. No differences were observed according to gestational age, epidural analgesia or fetal birth weight. Adjusting for these possible compounding factors and the year of birth, the risk of undergoing a second-degree or higher spontaneous tear at their next delivery was fivefold (adjusted OR 5.15, 95% CI 3.11-8.54), and the risk of undergoing an episiotomy in the second delivery was threefold (adjusted OR 3.20, 95% CI 2.19-4.69) for the perineal trauma group.

CONCLUSION

The risk of undergoing a spontaneous perineal tear or an episiotomy in the second delivery is increased by the practice of episiotomy in the first one.

Surgical repair of spontaneous perineal tears that occur during childbirth versus no intervention

BACKGROUND

Perineal tears commonly occur during childbirth. They are sutured most of the time. Surgical repair can be associated with adverse outcomes, such as pain, discomfort and interference with normal activities during puerperium and possibly breastfeeding. Surgical repair also has an impact on clinical workload and human and financial resources.

OBJECTIVES

To assess the evidence for surgical versus non-surgical management of first- and second-degree perineal tears sustained during childbirth.

SEARCH STRATEGY

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (1 May 2011), CENTRAL (The Cochrane Library 2011, Issue 2 of 4) and MEDLINE (Jan 1966 to 2 May 2011). We also searched the reference lists of reviews, guidelines and other publications and contacted authors of identified eligible trials.

SELECTION CRITERIA

Randomised controlled trials (RCTs) investigating the effect on clinical outcomes of suturing versus non-suturing techniques to repair first- and second-degree perineal tears sustained during childbirth.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion and assessed trial quality. Three review authors independently extracted data.

MAIN RESULTS

We included two RCTs (involving 154 women) with a low risk of bias. It was not possible to pool the available studies. The two studies do not consistently report outcomes defined in the review. However, no significant differences were observed between the two groups (surgical versus non-surgical repair) in incidence of pain and wound complications, self-evaluated measures of pain at hospital discharge and postpartum and re-initiation of sexual activity. Differences in the use of analgesia varied between the studies, being high in the sutured group in one study. The other trial showed differences in wound closure and poor wound approximation in the non-suturing group, but noted incidentally also that more women were breastfeeding in this group.

AUTHORS' CONCLUSIONS

There is limited evidence available from RCTs to guide the choice between surgical or non-surgical repair of first- or second-degree perineal tears sustained during childbirth. Two studies find no difference between the two types of management with regard to clinical outcomes up to eight weeks postpartum. Therefore, at present there is insufficient evidence to suggest that one method is superior to the other with regard to healing and recovery in the early or late postnatal periods. Until further evidence becomes available, clinicians' decisions whether to suture or not can be based on their clinical judgement and the women's preference after informing them about the lack of long-term outcomes and the possible chance of a slower wound healing process, but possible better overall feeling of well being if left un-sutured.

Episiotomy pain relief: Use of Lavender oil essence in primiparous Iranian women

INTRODUCTION

Post-episiotomy discomfort and its consequences can affect maternal quality of life and mental health as well as the mother and baby relationship. Complementary medicine is increasingly used and Lavender oil is frequently prescribed due to its antiseptic and healing properties.

METHOD

This clinical trial involved 60 qualified primiparous women admitted for labor in Kamali Hospital in Karaj, Iran. They were randomly categorized into two groups: case (using Lavender oil) and control (usual hospital protocol). Participants pain and discomfort were recorded using a Visual Analogue Scale (VAS) and a Redness, Edema, Ecchymosis, Discharge Scale (REEDA). Pain was evaluated at 4 h, 12 h and 5 days following episiotomy. Collected data was analyzed in SPSS 14 using an independent t-test and chi-square.

RESULTS

There was a statistical difference in pain intensity scores between the 2 groups after 4 h (p = 0.002, and 5 days (p = 0.000) after episiotomy. However, differences in pain intensity between the two groups, at 12 h post-surgery, were not significant (p = 0.066). The REEDA score was significantly lower in the experimental group (Lavender oil group) 5 days after episiotomy (p = 0.000).

CONCLUSION

According to these findings, use of Lavender oil essence can be effective in reducing perineal discomfort following episiotomy. It is suggested that Lavender oil essence may be preferably to the use of Betadine for episiotomy wound care.

The use of liquid petroleum jelly in the prevention of perineal lacerations during birth

Most of vaginal births are accompanied by lacerations in the genital tract. This was a randomized study carried out in a Birth Center located in São Paulo city to evaluate the efficacy of liquid petroleum jelly in reducing perineal laceration. The sample was composed of 38 nulliparous women per group (experimental and control). In the experimental group was used 30 ml of the petroleum jelly in the perineal region during the expulsive period. The parturient were allowed to push spontaneously during the delivery and remained in the left side position. The frequency of perineal laceration was similar in both groups (experimental 63.2% versus control 60.5%). The posterior perineum region presented the highest frequency of trauma (53.2%). Of the total cases of perineal trauma, 72.3% were first-degree lacerations. The use of liquid petroleum jelly of perineal protection does not reduce the frequency neither the degree of lacerations in childbirth.

Evaluation of postpartum perineal pain and dyspareunia—A prospective study

OBJECTIVE

Postpartum perineal pain and dyspareunia have been reported to affect 42% of women within the first 2 weeks after their first vaginal delivery. We aimed to determine the prevalence of dyspareunia and perineal pain using validated pain scores following accurate classification of perineal trauma according to the guidelines of the Royal College of Obstetricians and Gynaecologists.

STUDY DESIGN

Prospective study of women having their first vaginal delivery. All women had a perineal and rectal examination. Pain was assessed with a 4-point Verbal Rating Score and an 11-point visual analogue scale on day 1, day 5 and 2 months after delivery.

RESULTS

Two hundred and fifty-four women were invited and 95% participated. Ninety-two percent experienced perineal pain on day one, resolving in 88% (p<0.001) at 2 months. Compared to an intact perineum or first degree tear significantly more women experienced perineal pain after a second, third or fourth degree tear. Forty percent resumed coitus within 2 months regardless of whether perineal trauma occurred or not. Five days after delivery, uncomplicated episiotomies resulted in more perineal pain than second degree tears.

CONCLUSIONS

Although perineal pain affected 92% of mothers, it resolved in the majority within 2 months of delivery. Obstetric anal sphincter injury is associated with more perineal pain than other perineal trauma. Spontaneous second degree tears cause less perineal pain than episiotomies. The 11-point visual analogue scale may be more sensitive than the 4-point Verbal Rating Score.

Sexuality after delivery with episiotomy: a long-term follow-up

AIM

To investigate the quality of women's sex life 12-18 months after first, episiotomy-assisted childbirth and risk factors for long-term dyspareunia after childbirth.

METHODS

Two hundred and six women who gave birth vaginally at the Karolinska University Hospital between September 1997 and February 1998 and from June 1998 to January 1999 received postal questionnaires at 12-18 months postpartum. Obstetrical, psychological and sexological data, concerning 110 primiparae who underwent episiotomy and 153 age-matched women who did not, were compared. Possible risk factors for postpartum dyspareunia were investigated in the entire sample.

RESULTS

Women who underwent episiotomy experienced a more complicated and emotionally difficult delivery. They reported a higher frequency of dyspareunia and insufficient lubrication than women who had given birth without episiotomy. Arousal, orgasm and satisfaction with sex were not affected. Episiotomy, perineal lacerations, fundal pressure at delivery and a history of dyspareunia were independent risk factors for dyspareunia 12-18 months postpartum.

CONCLUSION

Episiotomy may affect women's sex life during the second year post partum with more frequent pain and vaginal dryness at intercourse. Other obstetrical factors and pain history may also influence the propensity for dyspareunia.

The prevalence of enduring postnatal perineal morbidity and its relationship to perineal trauma

OBJECTIVE

to investigate the prevalence of enduring postnatal perineal morbidity and its relationship to perineal trauma.

DESIGN

a retrospective cross-sectional community survey of postnatal women.

PARTICIPANTS AND SETTING

a total population sample of 2100 women were surveyed from two maternity units within Birmingham. Women were identified from the Trust's computerised Maternity Information System (MIS).

METHODS

Women were surveyed using a self-administered postal questionnaire 12 months after birth. The questionnaire included self-assessment of perineal pain, perineal healing, urinary incontinence, flatus incontinence, faecal incontinence, sexual morbidity and dyspareunia.

FINDINGS

a response rate of 23.3% was achieved (n=482). A high level of perineal morbidity was reported (53.8% stress urinary incontinence, 36.6% urge urinary incontinence, 9.9% liquid faecal incontinence, 54.5% with at least one index of sexual morbidity). Women with perineal trauma reported significantly more morbidity (sexual morbidity, dyspareunia, stress and urge urinary incontinence) than women with an intact perineum. Women with perineal trauma also resumed sexual intercourse later than women with an intact perineum. Women with a first- or second-degree tear reported significantly more perineal morbidity (stress incontinence, sexual morbidity) than women with an intact perineum, and resumed sexual intercourse later. However, a high percentage of women with an intact perineum also reported new-onset perineal morbidity: stress urinary incontinence (34.8%); urge urinary incontinence (19.5%); flatus incontinence (13.8%); and dyspareunia (25.3%), highlighting that enduring perineal morbidity can occur irrespective of perineal trauma.

CONCLUSION

enduring postnatal perineal morbidity is common in women with all types and grades of perineal trauma and intact perineum after childbirth. This highlights the need for further debate and research into the prevalence and experience of postnatal morbidity.

The outcomes of midline versus medio-lateral episiotomy

BACKGROUND

Episiotomy is the surgical enlargement of the vaginal orifice by an incision of the perineum during the second stage of labor or just before delivery of the baby. During the 1970s, it was common to perform an episiotomy for almost all women having their first delivery, ostensibly for prevention of severe perineum tears and easier subsequent repair. However, there are no data available to indicate if an episiotomy should be midline or medio-lateral. We compared midline versus medio-lateral episiotomy for complication such as extended perineal tears, pain scores, wound infection rates and other complications.

METHODS

We conducted a prospective cohort including 1,302 women, who gave birth vaginally between April 2005 and February 2006 at Srinagarind Hospital - a tertiary care center in Northeast Thailand. All women included had low risk pregnancies and delivered at term. The outcome measures included deep perineal tears (including perineal tears with anal sphincter and/or rectum tears), other complications, and women's satisfaction at 48 hours and 6-weeks postpartum.

RESULTS

In women with midline episiotomy, deep perineal tears occurred in 14.8%, which is statistically significantly higher compared to 7% in women who underwent a medio-lateral episiotomy (p-value < 0.05). There was no difference between the groups for other outcomes (such as blood loss, vaginal hematoma, infection, pain, dyspareunia, and women's satisfaction with the method). The risk factors for deep perineal tears were: midline episiotomy, primiparity, maternal height < 145 cm, fetal birth weight > 3,500 g and forceps extraction.

CONCLUSION

Midline compared to medio-lateral episiotomy resulted in more deep perineal tears. It is more likely deep perineal tears would occur in cases with additional risk factors.

Freqüência e critérios para indicar a episiotomia

Trata-se de estudo exploratório com o objetivo de identificar a freqüência, os tipos e os critérios adotados para indicar a episiotomia. Foram entrevistados 12 médicos e 12 enfermeiras que prestam assistência à parturiente no Hospital Universitário da Universidade de São Paulo. A episiotomia ocorreu em 76,2% dos partos normais; as indicações mais freqüentes foram: rigidez perineal (28,7%), primiparidade (23,7%), feto macrossômico (11,9%), prematuridade (10,2%). O tipo mais citado foi médio-lateral direito (92,0%), justificado por: aprendizado durante a formação acadêmica (25,9%), ser adotada rotineiramente (19,4%), menor chance de lesar o esfíncter anal (16,1%), menor risco de complicações (16,1%). É necessário rever as práticas de atendimento à parturiente, considerando as evidências científicas e condutas individualizadas.

Compliance as strategy: the importance of personalised relations in obstetric practice

This paper highlights the importance of personalised relations in institutionalised obstetric care. It seeks to explore the link between objectification and agency, by examining the way in which women find a new subjectivity in motherhood within the walls of the obstetric institution. The paper focuses on obstetric encounters through the lens of labour and intrapartum routine procedures, and argues that when expectant women enter the obstetric institution, a series of relations ensue through their efforts to become connected with the official obstetric system. The hospital organisation and network of relations that originate in it reflect and reproduce a passive role for expectant women and mothers; however, it would be misleading to represent their behaviour as simply "compliant". Expectant mothers value the connectedness with the obstetric system exemplified by personalised patient-practitioner relations because it is a guarantee of safety. They are happy to follow clinicians' instructions, even when this implies significant sacrifice or suffering because they are projected towards fulfilling their parenting desires. Compliance, like resistance then, is here intended to be understood as yet another maternal strategy, and as such it is the most widespread, deployed by women in order to achieve their ideals and desires.

Clinical approach to dyspareunia

Dyspareunia needs to be addressed from an integrated patient-centered perspective. This review analyzes the organic causes of pain during intercourse. Factors that are often underevaluated in the clinical setting include hormonal, inflammatory, muscular, iatrogenic, neurologic, vascular, connective, and immunitary causes. Psychosexual factors, such as vaginismus, loss of libido, arousal disorders and sexual pain-related disorders, often overlap. A preliminary clinical approach aimed at integrating different biological and psychosexual etiologies in a comprehensive manner is discussed in this article.

Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women

OBJECTIVE

Our goal was to evaluate the relationship between obstetric perineal trauma and postpartum sexual functioning.

STUDY DESIGN

Our study was carried out with a retrospective cohort design in 3 groups of primiparous women after vaginal birth: Group 1 (n = 211) had an intact perineum or first-degree perineal tear; group 2 (n = 336) had second-degree perineal trauma; group 3 (n = 68) had third- or fourth-degree perineal trauma. These sample sizes reflect a 70% response rate. Outcomes were time to resuming sexual intercourse, dyspareunia, sexual satisfaction, sexual sensation, and likelihood of achieving orgasm.

RESULTS

At 6 months post partum about one quarter of all primiparous women reported lessened sexual sensation, worsened sexual satisfaction, and less ability to achieve orgasm, as compared with these parameters before they gave birth. At 3 and 6 months post partum 41% and 22%, respectively, reported dyspareunia. Relative to women with an intact perineum, women with second-degree perineal trauma were 80% more likely (95% confidence interval, 1.2--2.8) and those with third- or fourth-degree perineal trauma were 270% more likely (95% confidence interval, 1.7--7.7) to report dyspareunia at 3 months post partum. At 6 months post partum, the use of vacuum extraction or forceps was significantly associated with dyspareunia (odds ratio, 2.5; 95% confidence interval, 1.3--4.8), and women who breast-fed were > or = 4 times as likely to report dyspareunia as those who did not breast-feed (odds ratio, 4.4; 95% confidence interval, 2.7--7.0). Episiotomy conferred the same profile of sexual outcomes as did spontaneous perineal lacerations.

CONCLUSIONS

Women whose infants were delivered over an intact perineum reported the best outcomes overall, whereas perineal trauma and the use of obstetric instrumentation were factors related to the frequency or severity of postpartum dyspareunia, indicating that it is important to minimize the extent of perineal damage incurred during childbirth.

Minimizing postpartum pain: a review of research pertaining to perineal care in childbearing women

This paper provides a review of literature that relates to perineal pain and care. Articles evaluated include systematic reviews and research papers from the disciplines of midwifery, physiotherapy and obstetrics. The major themes to emerge from the literature and be reviewed are the need for episiotomy, suturing methods and materials, assessment of perineal trauma, treatment of perineum in the postpartum period, and postpartum recovery. Research has highlighted that many practices relating to perineal care remain un-researched and therefore the need for evaluation is urgent. Further postpartum morbidity has been seen to affect many women, but is often unrecognized by practitioners. It is also a topic that requires further evaluation through well-designed and implemented research.

Is it necessary to suture all lacerations after a vaginal delivery?

BACKGROUND

Midwives tend to leave minor perineal lacerations to heal spontaneously, and clinical experience and studies show that women can suffer from their stitched lacerations. The study purpose was to determine any differences in the healing process and experience of minor perineal lacerations when they were sutured or not sutured.

METHODS

Eighty term pregnant primiparas with minor perineal lacerations of grades I-II were randomized after childbirth. The experimental group was nonsutured and the control group was sutured. A follow-up examination was performed at 2 to 3 days, 8 weeks, and 6 months after the delivery. Participants were asked about the type of discomfort, and the effect of the laceration on breastfeeding and sexual intercourse.

RESULTS

No significant differences were found in the healing process. The type of pain differed between the groups, but the amount of discomfort was the same. The sutured group had to visit the midwife more often because of discomfort from the stitches. Sixteen percent of the women in the sutured group, but none in the nonsutured group (p = 0.0385), considered that the laceration had had a negative influence on breastfeeding.

CONCLUSIONS

Minor perineal lacerations can be left to heal spontaneously. The benefits for the woman include the possibility of having a choice, avoiding the discomfort of anesthesia and suturing, providing positive affects on breastfeeding.

Severe perineal lacerations during vaginal delivery: the University of Miami experience

OBJECTIVE

After childbirth-related third- or fourth-degree perineal lacerations, the estimated incidence of wound disruption, fecal incontinence, or fistula ranges from 1% to 10%. Risk factors associated with severe laceration were analyzed at a single large teaching institution.

STUDY DESIGN

This study consisted of an analysis of data from the delivery database of Jackson Memorial Hospital, University of Miami, from 1989 through 1995. Included were vaginal deliveries for which complete information was available on maternal age, parity, ethnicity (white, black, or Hispanic), birth weight, episiotomy versus no episiotomy, type of episiotomy, and delivery (normal spontaneous, vacuum, or forceps). Multiple gestations, cases of shoulder dystocia, cesarean deliveries, patients with a history of cesarean delivery, and babies weighing <500 g at birth were excluded from this study. Both univariate and multivariate analyses were performed with variables such as maternal age, race, birth weight, type of episiotomy if any, and type of vaginal delivery.

RESULTS

Among the 71,959 women who were delivered at our institution during the 7-year study period, 50,210 met the inclusion criteria. Through time there had been a decline in the use of episiotomy in general and of midline episiotomy in particular. The annual total number of deliveries also decreased. The episiotomy procedure per se and the type of episiotomy as well as birth weight, assisted vaginal delivery, and older maternal age were identified as independent risk factors associated with third- and fourth-degree perineal lacerations.

CONCLUSION

Although episiotomy is an important risk factor for severe lacerations after vaginal delivery, there are other significant independent risk factors, such as maternal age, birth weight, and assisted vaginal delivery, that should be considered in counseling and making decisions regarding delivery modality. Older patients who are being delivered of a first child are at higher risk for severe laceration. Midline episiotomy and assisted vaginal delivery should therefore be avoided in this population whenever possible, especially in the presence of a large baby.

Routine use of episiotomy in modern obstetrics. Should it be performed?

Episiotomy continues to be a frequently used procedure in obstetrics despite little scientific support for its routine use. Although episiotomy does decrease the occurrence of anterior lacerations, it fails to accomplish the majority of goals stated as reasons for its use. Episiotomy does not decrease damage to the perineum but rather increases it. The midline episiotomy increases the risk for third-degree and fourth-degree lacerations. Episiotomy fails to prevent the development of pelvic relaxation and its attendant complications. Rather than decreasing maternal morbidity, episiotomy increases blood loss and is related to greater initial postpartum pain and dyspareunia. It has been associated with a more difficult and lengthy repair as measured by the need for suture material and operating room time. The claims of a protective effect on the fetus in shortening the second stage of labor, improving Apgar scores, and preventing perinatal asphyxia have not been borne out. The value of episiotomy use on a routine basis bears scientific examination in prospective, randomized, controlled trials. These types of trials are certainly achievable, ethically correct, and much needed. Until these trials are completed and published, obstetricians should not routinely perform the procedure but rather determine the need for episiotomy on a case-by-case basis.

Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy

OBJECTIVE

The aim of the study was to evaluate the effectiveness of perineal massage during pregnancy for the prevention of perineal trauma at birth.

STUDY DESIGN

Pregnant women with (n = 493) and without (n = 1034) a previous vaginal birth from 5 hospitals in the province of Québec, Canada, participated in this single-blind, randomized, controlled trial. All participants received oral and written information on the prevention of perineal trauma. Women in the experimental groups were requested to perform a 10-minute perineal massage daily from the 34th or 35th week of pregnancy until delivery.

RESULTS

Among participants without a previous vaginal birth, 24.3% (100/411) from the perineal massage group and 15.1% (63/417) from the control group were delivered vaginally with an intact perineum, for a 9.2% absolute difference (95% confidence interval 3.8%-14.6%). The incidence of delivery with an intact perineum increased with compliance with regular practice of perineal massage (chi2 for trend 13.2, P = 0.0003). Among women with a previous vaginal birth, 34.9% (82/235) and 32.4% (78/241) in the massage and control groups, respectively, were delivered with an intact perineum, for an absolute difference of 2.5% (95% confidence interval -6.0% to 11.0%). There were no differences between the groups in the frequency of sutured vulvar and vaginal tears, women's sense of control, and satisfaction with the delivery experience.

CONCLUSION

Perineal massage is an effective approach to increasing the chance of delivery with an intact perineum for women with a first vaginal delivery but not for women with a previous vaginal birth.

Distribution of genital tract trauma in childbirth and related postnatal pain

BACKGROUND

The full extent of genital tract trauma in spontaneous births is not well documented. The purpose of this study was to describe the range and extent of childbirth trauma and related postnatal pain using data from a large randomized clinical trial of perineal management techniques (n = 5471).

METHODS

Descriptive analysis was conducted on trial participants who delivered spontaneously at term and were examined by their midwife after birth (n = 5404). Data are reported for sites of trauma, and the relation to episiotomy, suturing, and maternal reports of pain at 2 days, 10 days, and 3 months after birth.

RESULTS

Eighty-five percent of all women experienced some form of trauma, with first- or second-degree perineal lacerations occurring in two-thirds of women and outer vaginal tears occurring in one-half. Tears to the rectum and vaginal vault were more common with episiotomy. Nearly all unsutured trauma was restricted to perineal first- or second-degree, outer vaginal, and labial sites. Pain declined over time, and a gradient in pain was observed according to the site and complexity of trauma.

CONCLUSIONS

Genital tract trauma is extremely common with spontaneous vaginal birth. Effective measures to prevent or reduce its occurrence would benefit many new mothers.

Influence of the position of the mother at delivery over some maternal and neonatal outcomes

OBJECTIVE

Evaluate possible advantages or disadvantages of the sitting over the horizontal position during the second stage of labor.

DESIGN AND METHODS

Clinical trial randomly selecting 127 volunteers for the sitting position and 121 for the horizontal position during the second stage of labor. Duration of the second stage and of expulsion of the placenta, vulvo vaginal and perineal lacerations, blood lost and Apgar score were evaluated.

RESULTS

There was a non-significant decrease of 3.4 min in the duration of the second period in the vertical position in comparison with the horizontal position. There was a similar difference in the duration of delivery of the placenta, but also non-significant. Blood loss was slightly greater among women delivering in vertical position, but the difference did not reach significance. Breastfeeding did not show any influence on blood loss and on the time for delivering the placenta. The incidence of perineal trauma was 44.1% for vertical position and 47% for horizontal position in the whole group and of 47.8% and 71.2% in the group with history of episiotomy. This last difference was statistically significant. The results of this study are in the line of other studies that suggest some advantages and possible disadvantages of the vertical position.

CONCLUSIONS

Mothers should be given the choice of the posture to be assumed during parturition. The supine position should not be imposed and episiotomy should not be a routine.

Nurse advocacy for selective versus routine episiotomy

Although episiotomy is one of the most commonly performed surgeries, little scientific support exists for this procedure. Furthermore, the suggested advantages of routine episiotomy are challenged easily and the surgery is not without risks. Adverse effects arising from episiotomy include an increased incidence of severe lacerations, blood loss, pain, delayed healing, dyspareunia, psychologic trauma, and medical cost. Nurses can assist women in avoiding perineal trauma resulting from unnecessary episiotomy through patient education, patient advocacy, and direct care.

Benefits and risks of episiotomy: a review of the English-language literature since 1980. Part II

Mediolateral and, to a lesser degree, midline episiotomies substantially increase the amount of blood loss at delivery; in fact, simple avoidance of episiotomy may be the most powerful means the delivery attendant has to prevent excessive intrapartum hemorrhage. The long-term morbidity of the anal sphincter damage induced by episiotomy, particularly midline, has generally been underestimated in both its frequency and severity. Other potential fetal and maternal complications of episiotomies, although rare, are numerous and serious. The overall degree of risk that accompanies this procedure could only be justified by a clear and overriding benefit, which, as discussed under "Benefits" earlier in this review, does not appear to exist.

Benefits and risks of episiotomy: a review of the English-language literature since 1980. Part I

The professional literature on the benefits and risks of episiotomy was last reviewed critically in 1983, encompassing material published through 1980. This paper reviews the evidence accumulated since then. (Part II follows in this issue.) It is concluded that episiotomies prevent anterior perineal lacerations (which carry minimal morbidity), but fail to accomplish any of the other maternal or fetal benefits traditionally ascribed, including prevention of perineal damage and its sequelae, prevention of pelvic floor relaxation and its sequelae, and protection of the newborn from either intracranial hemorrhage or intrapartum asphyxia. In the process of affording this one small advantage, the incision substantially increases maternal blood loss, the average depth of posterior perineal injury, the risk of anal sphincter damage and its attendant long-term morbidity (at least for midline episiotomy), the risk of improper perineal wound healing, and the amount of pain in the first several postpartum days.

Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation

OBJECTIVE

Our purpose was to compare consequences for women of receiving versus not receiving median episiotomy early and 3 months post partum on the outcomes perineal pain, urinary and pelvic floor functioning by electromyography, and sexual functioning and to analyze the relationship between episiotomy and third- and fourth-degree tears.

STUDY DESIGN

A secondary cohort analysis was performed of participants within a randomized clinical trial, analyzed by type of perineal trauma and pain, pelvic floor, and sexual consequences of such trauma, while controlling for trial arm. The study was conducted in three university or community hospitals; 356 primiparous and 341 multiparous women were studied.

RESULTS

Early and 3-month-postpartum perineal pain was least for women who gave birth with an intact perineum. Spontaneous perineal tears were less painful than episiotomy. Sexual functioning was best for women with an intact perineum or perineal tears. Postpartum urinary and pelvic floor symptoms were similar in all perineal groups. At 3 months post partum those delivered with an intact perineum had the strongest pelvic floor musculature, those with episiotomy the weakest. Among primiparous women third- and fourth-degree tears were associated with median episiotomy (46/47). After forceps births were removed and 21 other variables potentially associated within such tears were controlled for, episiotomy was strongly associated with third- and fourth-degree tears (odds ratio +22.08, 95% confidence interval 2.84 to 171.53). Physicians using episiotomy at high rates also used other procedures, including cesarean section, more frequently.

CONCLUSION

Perineal and pelvic floor morbidity was greatest among women receiving median episiotomy versus those remaining intact or sustaining spontaneous perineal tears. Median episiotomy was causally related to third- and fourth-degree tears. Those using episiotomy at the highest rates were more likely use other interventions as well. Episiotomy use should be restricted to specified fetal-maternal indications.

Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair

OBJECTIVES

To determine (i) risk factors in the development of third degree obstetric tears and (ii) the success of primary sphincter repair.

DESIGN

(i) Retrospective analysis of obstetric variables in 50 women who had sustained a third degree tear, compared with the remaining 8553 vaginal deliveries during the same period. (ii) Women who had sustained a third degree tear and had primary sphincter repair and control subjects were interviewed and investigated with anal endosonography, anal manometry, and pudendal nerve terminal motor latency measurements.

SETTING

Antenatal clinic in teaching hospital in inner London.

SUBJECTS

(i) All women (n = 8603) who delivered vaginally over a 31 month period. (ii) 34 women who sustained a third degree tear and 88 matched controls.

MAIN OUTCOME MEASURES

Obstetric risk factors, defecatory symptoms, sonographic sphincter defects, and pudendal nerve damage.

RESULTS

(i) Factors significantly associated with development of a third degree tear were: forceps delivery (50% v 7% in controls; P = 0.00001), primiparous delivery (85% v 43%; P = 0.00001), birth weight > 4 kg (P = 0.00002), and occipito-posterior position at delivery (P = 0.003). No third degree tear occurred during 351 vacuum extractions. Eleven of 25 (44%) women who were delivered without instruments and had a third degree tear did so despite a posterolateral episiotomy. (ii) Anal incontinence or faecal urgency was present in 16 women with tears and 11 controls (47% v 13%; P = 0.00001). Sonographic sphincter defects were identified in 29 with tears and 29 controls (85% v 33%; P = 0.00001). Every symptomatic patient had persistent combined internal and external sphincter defects, and these were associated with significantly lower anal pressures. Pudendal nerve terminal motor latency measurements were not significantly different.

CONCLUSIONS

Vacuum extraction is associated with fewer third degree tears than forceps delivery. An episiotomy does not always prevent a third degree tear. Primary repair is inadequate in most women who sustain third degree tears, most having residual sphincter defects and about half experiencing anal incontinence, which is caused by persistent mechanical sphincter disruption rather than pudendal nerve damage. Attention should be directed towards preventive obstetric practice and surgical techniques of repair.