Perineal injuries and birth positions among 2992 women with a low risk pregnancy who opted for a homebirth

The understanding of dynamic birth positions for women in labor and childbirth - A hybrid concept analysis

PROBLEM AND BACKGROUND

The assessment of advantages and drawbacks associated with varying birthing positions has predominantly centered around medical or technical considerations and few studies have accounted for a woman's ability to attune to her bodily instincts during labor and birth. The objective of this study was to define the concept of dynamic birth positions and its significance within the birthing process.

METHODS

This hybrid concept analysis consisted of three phases: theoretical, fieldwork, and analytical. Science Direct, PubMed and Google Scholar were searched with related terms in the theoretical phase. In the fieldwork phase, seven professionals and six mothers with the experience of dynamic birth positions were interviewed. After each interview, qualitative content analysis was conducted. During the final phase, descriptions and themes from the first two phases were combined.

RESULTS

In the theoretical phase, the definition of dynamic birth positions included descriptions answering the Who, What, When, Where, and Why questions. In the fieldwork phase, the results present two distinct categories that define dynamic birth positions: "Women's choice, women's power" and "A flow between rest and activity." The final analysis phase of this study indicated that dynamic birth positioning is characterized by the organic progression through a variety of postures that seamlessly merge rest and activity throughout the labor and birthing process, guided by the woman's individual preferences.

CONCLUSIONS

The definition of dynamic birth positions redefines birth as an evolving, dynamic journey characterized by a fluid interplay of movements and moments of rest, transcending conventional fixation on static positions.

Effects of flexible sacrum position at birth on maternal and neonatal outcomes: A retrospective cohort study

OBJECTIVE

To examine the differences in both maternal and neonatal outcomes between flexible and non-flexible sacrum positions at birth.

METHODS

A descriptive, cross-sectional, retrospective study was carried out on a sample of low-risk pregnant women. Univariate and multivariate logistic regressions and multivariate linear regressions were conducted to estimate the association between our discrete or continuous variables of interest. Maternal outcomes were perineal tear, maternal blood loss, second stage length; neonatal outcomes were Apgar scores and neonatal asphyxia. Results were adjusted for maternal age, neonatal birth weight, and epidural analgesia.

RESULTS

We considered for final analysis 2198 women. In primiparous women, women giving birth in the all-fours position were significantly more likely to have an intact perineum (P = 0.011) and a shorter length of the second stage of labor (P = 0.022). Maternal age (P = 0.005) and neonatal weight (P = 0.013) significantly increased perineal tearing; maternal age (P = 0.004) and neonatal birth weight (P < 0.001) were significantly associated with a higher amount of blood loss. Maternal age (P = 0.002) and neonatal weight (P < 0.001) significantly increased the length of the second stage of labor. For multiparous women, the side-lying position was significantly correlated with an intact perineum (P = 0.031); maternal age and intact perineum were statistically inversely associated. Epidural analgesia significantly increased the length of the second stage of labor in both nulliparous (P < 0.001) and pluriparous women (P < 0.001). No significant differences were found in neonatal outcomes.

CONCLUSION

Women with a low-risk labor should be free to choose their birth position as flexible sacrum positions are shown to increase maternal well-being and do not affect neonatal health.

Factors associated with the occurrence of upright birth in Brazil

OBJECTIVE

To identify the factors associated with Upright Delivery (UD) performed in hospitals linked to the Rede Cegonha (RC) in Brazil.

METHODS

Cross-sectional study with 3,073 parturients who had vaginal delivery in 606 health facilities in Brazil, located in health regions with a regional action plan approved in the RC. Socioeconomic, demographic, and obstetric characteristics of the parturients, organizational and management aspects of maternity hospitals, and work processes in childbirth care were evaluated. The multivariate logistic regression model with a hierarchical approach was adjusted to identify the variables associated with UD (outcome), estimating Odds Ratios (OR) with a significance level of 5%.

RESULTS

Of the evaluated parturient, 6.7% gave birth in the vertical position. The following were associated with a greater chance of PPV: being black (OR=2.07); having 13 or more years of study (OR=3.20); giving birth in a high-risk hospital (OR=1.58); giving birth in PPP rooms (which assisted with labor, delivery, and puerperium in the same environment) in Obstetric Centers (OR=2.07) or in-hospital Normal Delivery Centers (OR=1.62); being assisted by an obstetrician nurse (OR=1.64) or by a midwife (OR=7.62) when compared to a doctor; receiving massage during labor and delivery (OR=1.89); using a stool (OR=4.16) and among women who did not ask for/not receive analgesia (OR=3.15).

CONCLUSION

The UD is an event related to racial aspects and the education of the parturient, being stimulated in health establishments where good practices of childbirth care are implemented, with adequate ambiance, and with multidisciplinary teams comprising midwives and obstetric nurses.

Characteristics of Homebirth in Hungary: A Retrospective Cohort Study

Homebirth is legal and has been regulated by law in Hungary since 2012. Despite the obvious advantages of homebirth, it has not yet been broadly accepted, due to various opinions related to safety and risks associated with giving birth outside of a hospital. Our study aimed at exploring both real maternal and feto-neonatal characteristics associated with Hungarian homebirths. A total of 2997 cases were considered in support of our retrospective cohort study. In the examined period, there was a significant, continual rise in the number of homebirths by a rate of 0.22% on average per year. Aggregated maternal complications (primary uterine inertia, prolonged second stage labour, and third stage haemorrhage) were prevalent among homebirth cases (1.29% vs. 0.72%, p < 0.05) and were associated with an average of 11.77% rate of transfer to a health care institution. On the other hand, the rate of operative (vaginal or caesarean) delivery was 26.31% among institutionalized births. A slightly better Apgar score and relatively high rate (20%) of caesarean deliveries were correlated with institutionalized births (p < 0.05). However, the overall intervention rate was lower among homebirths (0.11% vs. 42.57%) than institutional birth cases (p < 0.001). Overall, homebirth is a reliable option for childbirth for healthy and low-risk mothers with uncomplicated pregnancies, which is reflected in the increasing number of deliveries at home in Hungary. Furthermore, utilizing the experiences of countries where homebirth is a long-established method may further improve the outcome of homebirths in Hungary.

Systematic review and meta-analysis to examine intrapartum interventions, and maternal and neonatal outcomes following immersion in water during labour and waterbirth

OBJECTIVES

Water immersion during labour using a birth pool to achieve relaxation and pain relief during the first and possibly part of the second stage of labour is an increasingly popular care option in several countries. It is used particularly by healthy women who experience a straightforward pregnancy, labour spontaneously at term gestation and plan to give birth in a midwifery led care setting. More women are also choosing to give birth in water. There is debate about the safety of intrapartum water immersion, particularly waterbirth. We synthesised the evidence that compared the effect of water immersion during labour or waterbirth on intrapartum interventions and outcomes to standard care with no water immersion. A secondary objective was to synthesise data relating to clinical care practices and birth settings that women experience who immerse in water and women who do not.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

A search was conducted using CINAHL, Medline, Embase, BioMed Central and PsycINFO during March 2020 and was replicated in May 2021.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Primary quantitative studies published in 2000 or later, examining maternal or neonatal interventions and outcomes using the birthing pool for labour and/or birth.

DATA EXTRACTION AND SYNTHESIS

Full-text screening was undertaken independently against inclusion/exclusion criteria in two pairs. Risk of bias assessment included review of seven domains based on the Robbins-I Risk of Bias Tool. All outcomes were summarised using an OR and 95% CI. All calculations were conducted in Comprehensive Meta-Analysis V.3, using the inverse variance method. Results of individual studies were converted to log OR and SE for synthesis. Fixed effects models were used when I2 was less than 50%, otherwise random effects models were used. The fail-safe N estimates were calculated to determine the number of studies necessary to change the estimates. Begg's test and Egger's regression risk assessed risk of bias across studies. Trim-and-fill analysis was used to estimate the magnitude of effect of the bias. Meta-regression was completed when at least 10 studies provided data for an outcome.

RESULTS

We included 36 studies in the review, (N=157 546 participants). Thirty-one studies were conducted in an obstetric unit setting (n=70 393), four studies were conducted in midwife led settings (n=61 385) and one study was a mixed setting (OU and homebirth) (n=25 768). Midwife led settings included planned home and freestanding midwifery unit (k=1), alongside midwifery units (k=1), planned homebirth (k=1), a freestanding midwifery unit and an alongside midwifery unit (k=1) and an alongside midwifery unit (k=1). For water immersion, 25 studies involved women who planned to have/had a waterbirth (n=151 742), seven involved water immersion for labour only (1901), three studies reported on water immersion during labour and waterbirth (n=3688) and one study was unclear about the timing of water immersion (n=215).Water immersion significantly reduced use of epidural (k=7, n=10 993; OR 0.17 95% CI 0.05 to 0.56), injected opioids (k=8, n=27 391; OR 0.22 95% CI 0.13 to 0.38), episiotomy (k=15, n=36 558; OR 0.16; 95% CI 0.10 to 0.27), maternal pain (k=8, n=1200; OR 0.24 95% CI 0.12 to 0.51) and postpartum haemorrhage (k=15, n=63 891; OR 0.69 95% CI 0.51 to 0.95). There was an increase in maternal satisfaction (k=6, n=4144; OR 1.95 95% CI 1.28 to 2.96) and odds of an intact perineum (k=17, n=59 070; OR 1.48; 95% CI 1.21 to 1.79) with water immersion. Waterbirth was associated with increased odds of cord avulsion (OR 1.94 95% CI 1.30 to 2.88), although the absolute risk remained low (4.3 per 1000 vs 1.3 per 1000). There were no differences in any other identified neonatal outcomes.

CONCLUSIONS

This review endorses previous reviews showing clear benefits resulting from intrapartum water immersion for healthy women and their newborns. While most included studies were conducted in obstetric units, to enable the identification of best practice regarding water immersion, future birthing pool research should integrate factors that are known to influence intrapartum interventions and outcomes. These include maternal parity, the care model, care practices and birth setting.

PROSPERO REGISTRATION NUMBER

CRD42019147001.

Comparison of perineal outcomes in Chinese women adopting lateral positions and lithotomy positions during the passive and active phases of the second stage of labour: An observational study

AIMS

To compare the effects of the adoption of lateral positions and lithotomy positions during the passive and active phases of the second stage of labour on perineal outcomes.

DESIGN

An observational study with prospectively collected data, conducted in three hospitals in China.

METHOD

Attending midwives recorded the perineal outcomes and characteristics of women giving birth between July-November 2020. Binary logistic regression was performed to explore the effects of lateral positions on perineal outcomes during different phases of the second stage of labour. The STROBE guidelines guided the reporting of this study.

RESULTS

Among primiparous women, when compared with those who adopted lateral positions during the passive phase of the second stage of labour and changed to lithotomy positions during the active phase, women who assumed lateral positions during both the passive and active phases had a higher rate of intact perineum/first-degree perineal tears and a reduced risk of episiotomy, and episiotomy/second-degree perineal tears. No significant difference was found in perineal outcomes between those who assumed lithotomy positions during the passive and active phases and those who adopted lateral positions during the passive phase and changed to lithotomy positions during the active phase. No significant difference was found in perineal outcomes among multiparous women, regardless of different positions adopted at the passive and/or the active phase.

CONCLUSION

Lateral positions during the active phase may have protective effects on the perineum in primiparous women. However, adopting lateral positions only during the passive phase did not promote better perineal outcomes, regardless of parity.

RELEVANCE TO CLINICAL PRACTICE

This study will provide a further reference for the use of lateral positions during different phases of the second stage of labour among primiparous and multiparous women in clinical practice, contributing to the perineal protection during childbirth.

Fatores associados à ocorrência de parto em posição vertical no Brasil

RESUMO Objetivo: Identificar os fatores associados aos partos na posição vertical realizados em hospitais vinculados à Rede Cegonha no Brasil. Métodos: Estudo transversal com 3.073 parturientes que tiveram parto vaginal em 606 estabelecimentos de saúde no Brasil, localizados em regiões de saúde com plano de ação regional aprovado na Rede Cegonha. Foram avaliadas características socioeconômicas, demográficas e obstétricas das parturientes, aspectos organizacionais e de gestão das maternidades e processos de trabalho na atenção ao parto. Modelo de regressão logística multivariada com abordagem hierarquizada foi ajustado para identificar as variáveis associadas ao parto na posição vertical (desfecho), estimando-se odds ratio (OR) com nível de significância de 5%. Resultados: Do total de parturientes avaliadas, 6,7% das mulheres tiveram parto na posição vertical. Estiveram associados à maior chance de ocorrência do parto na posição vertical: ser preta (OR=2,07); ter 13 ou mais anos de estudo (OR=3,20); parir em hospital de alto risco (OR=1,58); parir em quartos PPP (que dispunham de assistência ao trabalho de parto, parto e puerpério no mesmo ambiente) em centros obstétricos (OR=2,07) ou em centros de parto normal intra-hospitalares (OR=1,62); ser assistida por enfermeiro obstetra (OR=1,64) ou por obstetriz (OR=7,62) quando comparado ao médico; receber massagem durante o trabalho de parto e parto (OR=1,91); utilizar banqueta (OR=4,35) e entre mulheres que não pediram/não receberem analgesia (OR=3,33). Conclusão: O parto na posição vertical é um evento relacionado a aspectos raciais e à escolaridade da parturiente, sendo estimulado em estabelecimentos de saúde onde estão implantadas boas práticas de assistência ao parto, com ambiência adequada e com equipes multiprofissionais contendo obstetriz e enfermeiro obstetra.

Prevalence of Perineal Tear Peripartum after Two Antepartum Perineal Massage Techniques: A Non-Randomised Controlled Trial

Perineal massage increases elasticity of myofascial perineal tissue and decreases the burning and perineal pain during labour, thus optimising child birth, although an application protocol has not been standardised yet. The objective of this study is to determine the efficiency of massage in perineal tear prevention and identification of possible differences in massage application. Total of 90 pregnant participants were divided into three groups: perineal massage and EPI-NO^® device group, applied by an expert physiotherapist, self-massage group, where women were instructed to apply perineal massage in domestic household, and a control group, which received ordinary obstetric attention. Results: The results showed significant differences among the control group and the two perineal massage groups in perineal postpartum pain. Correlations in perineal postpartum pain, labour duration and the baby's weight were not statistically significant. Lithotomy posture was significantly less prevalent in the massage group than in the other two; this variable is known to have a direct effect on episiotomy incidence and could act as a causal covariate of the different incidence of episiotomy in the groups. Perineal massage reduces postpartum perineal pain, prevalence and severity of perineal tear during delivery.

[Normal childbirth: physiologic labor support and medical procedures. Guidelines of the French National Authority for Health (HAS) with the collaboration of the French College of Gynaecologists and Obstetricians (CNGOF) and the French College of Midwives (CNSF) - Maternal postures during the second stage of labour, delivery techniques and perineal protection]

OBJECTIVE

To assess maternal postures during the second stage of labour on course of labour, mode of delivery and maternal and neonatal morbidity. To describe the different techniques of spontaneous vaginal delivery and their influence on maternal and neonatal morbidity. To describe the different perineal protection techniques.

METHOD

Systematic review of the literature through consultation of Medline, Cochrane databases and international recommendations.

RESULTS

There is no particular posture that has demonstrated its superiority (Level of Evidence (LE) 2). In case of no contraindication and permanent maternal and fetal monitoring, it is recommended to encourage women to adopt the postures they consider most comfortable during the second stage of labour (Consensus agreement). There is insufficient evidence in the literature to recommend a technique for fetal head and shoulders delivery. There is not enough data in the literature to recommend the use of Ritgen maneuver (grade B), perineal massage (gradeC) or hot compresses (Consensus agreement). The abdominal expression must be abandoned (grade B).

CONCLUSION

The second stage of labour is a crucial time in labour that can lead to significant maternal and neonatal morbidity. It is necessary to take the greatest possible care in the supervision and management of women, especially for the perineal protection. The influence of non-medicinal techniques on the course of the second stage of labour should be studied.

Complications of planned home births in the Czech Republic between 2016‒2017

OBJECTIVE

This study aimed to analyze the complications of planned home births treated at healthcare facilities in the Czech Republic.

METHODS

This prospective cohort observational study is based on analysis of women hospitalized with complications related to planned home deliveries in the Czech Republic between 2016 and 2017. The data were collected using an online form made accessible to the directors of all maternity hospitals in the Czech Republic. The results were statistically evaluated.

RESULTS

We identified 45 complications during planned home deliveries. Complications occurred most often among women living in largely populated cities with higher levels of education. Overall, 40% of patients did not receive routine antenatal care, and 38% of women gave birth after the 41st week of pregnancy. In 60% of cases, no professionals attended the birth. Hospital transfer frequencies were 42% after delivery, 36% at third-stage labour, 11% first-stage labour, 9% second-stage labour, and 2% before delivery. We recorded four neonatal deaths and one severe newborn morbidity. There was one maternal death unrelated to the home-birthing process and six cases of severe maternal haemorrhagic shock requiring intensive care.

CONCLUSION

Complications of planned home births occurred more frequently in women living in largely populated cities and with higher education levels. Planned home births were also observed among women who were at a higher risk of complications. Risk factors included nulliparity, postdate pregnancy, and lack of prenatal care. Hospital transfers occurred most often in the third stage of labour and postpartum.

Effects of flexible sacrum positions during the second stage of labour on maternal and neonatal outcomes: A systematic review and meta-analysis

AIMS AND OBJECTIVES

To assess the effects of flexible sacrum positions on mode of delivery, duration of the second stage of labour, perineal trauma, postpartum haemorrhage, maternal pain, abnormal foetal heart rate patterns and Apgar scores based on published literature.

BACKGROUND

Maternal positions served as a nonmedical intervention may facilitate optimal maternal and neonatal outcomes during labour. Flexible sacrum positions are conducive to expanding pelvic outlet. Whether flexible sacrum positions have positive effects on maternal and neonatal well-being is a controversial issue under heated discussion.

DESIGN

We performed a systematic review and meta-analysis based on PRISMA guidelines.

METHODS

Randomised controlled trials (RCTs) comparing any flexible sacrum position with non-flexible sacrum position in the second stage of labour were included. PubMed, EMBASE, Cochrane Library, CINAHL, CNKI (China National Knowledge Infrastructure), SinoMed and Wanfang databases were searched from inception to 11 March 2019 for published RCTs. Risk of bias was assessed by the Cochrane criteria, and random-effects meta-analyses were conducted by RevMan 5.3.

RESULTS

Sixteen studies (3,397 women) published in English were included. Flexible sacrum positions in the second stage of labour could reduce the incidence of operative delivery, instrumental vaginal delivery, caesarean section, episiotomy, severe perineal trauma, severe pain and shorten the duration of active pushing phase in the second stage of labour. However, flexible sacrum positions may increase the incidence of mild perineal trauma. There was no significant difference in the duration of the second stage of labour, maternal satisfaction and other outcomes.

CONCLUSIONS

Flexible sacrum positions are superior in promoting maternal well-being during childbirth. However, several results require careful interpretation. More rigorous original studies are needed to further explore their effects.

RELEVANCE TO CLINICAL PRACTICE

The results support the use of flexible sacrum positions. Flexible sacrum positions are recommended to apply flexibly or tailor to individual woman's labour progress.

Predictive factors for time to cessation of urinary incontinence in primiparous adolescents after vaginal delivery

OBJECTIVE

To investigate predictive factors for the time to cessation of urinary incontinence (UI) and estimate the median time for its cessation in primiparous adolescents after vaginal delivery.

METHODS

A cohort study with 102 adolescents aged 10-19 years with UI after vaginal delivery was developed in the Physical Therapy Laboratory for Women's Health and Pelvic Floor at the Federal University of Pernambuco between June 2017 and December 2019. Participants responded to the assessment form, providing information on the outcome of interest and possible predictive factors. For statistical analysis, the Cox regression model and the Kaplan-Meier method were used.

RESULTS

Risk factors identified for the outcome of interest were: age 15-19 years (adjusted hazard ratio [HR_a ] 1.37, 95% confidence interval [CI] 0.11-2.8); non-instrumental delivery (HR_a 2.95. 95% CI 1.19-7.53); adoption of vertical position during the expulsion stage of delivery (HR_a 2.19, 95% CI 1.28-3.84); and absence of episiotomy (HR_a 2.01, 95% CI 1.2-3.44). The median time to cessation of UI was 16 months (10-29).

CONCLUSION

Health professionals should reflect on obstetric practices adopted during delivery in adolescents, especially among 10-14-year-olds, regarding the use of episiotomy, instrumental delivery, and parturient position during the expulsion stage of delivery.

Predictors of obstetric anal sphincter injury during waterbirth: a secondary analysis of a prospective observational study

INTRODUCTION AND HYPOTHESIS

Obstetric anal sphincter injury (OASI) during childbirth is associated with urino-genital pain and dysfunction. Waterbirth is a popular birth choice for women, but controversy remains around the risk of OASI during waterbirth. This study reports on the incidence of OASI, and factors associated with OASI, for a cohort of women who gave birth in water.

METHODS

This secondary analysis used prospectively collected data from 2,908 women who gave birth in water in a hospital setting. The incidence of OASI was calculated. Univariable and multivariable logistic regression analysis evaluated factors associated with OASI.

RESULTS

The incidence of OASI was 1.9% (95% confidence interval (CI) 1.4, 2.4) for all women. In nulliparae it was higher (3.2%, 95% CI 2.3, 4.3) than in multiparae (0.9%, 95% CI 0.5, 1.4). In the multivariable analysis, two variables were associated with OASI; multiparity was negatively associated with OASI (adjusted odds ratio [aOR] 0.24, 95% CI 0.12, 0.50, p < 0.001), and birth weight was positively associated with OASI (aOR 1.001, 95% CI 1.000, 1.002, p = 0.02). A "hands-on" technique was used during only 13% of births. A birth position supporting a flexible sacrum did not influence OASI risk.

CONCLUSIONS

A low incidence of OASI was found for this cohort of women. The low proportion of midwives using a hands-on technique suggests that it may not be required in waterbirth.

A pathway to establish a publicly funded home birth program in Australia

BACKGROUND

Home births provide women a birth choice where they may feel more comfortable and confident in their ability to give birth.

PROBLEM

Most women in Victoria do not have publicly funded access to appropriately trained health professionals if they choose to give birth at home.

METHODS

This paper describes the process of setting up a publicly funded home birth service and provide details of description of the set up and governance. We also report outcomes over 9 years with respect to parity, transfer to hospital, adverse maternal and neonatal outcomes.

RESULTS

Of the 191 women who were still booked into the home birth program at 36 weeks gestation, 148 (77.5%) women gave birth at home and 43 (22.5%) women were transferred into the hospital. The overall rate of vaginal birth was also high among the women in the home birth program, 185 (96.9%) with no added complications ascribed to home births. Such as severe perineal trauma [n=1] 0.6% PPH [n=4] 2.7%, Apgar score less than 7 at 5min [n=0] admissions post home birth to special care nursery [n=2] 1.35%.

DISCUSSION

This unique study provides a detailed road map of setting up a home birth practice to facilitate other institutions keen to build a publicly funded home birth service. The birth outcome data was found to be consistent with other Australian studies on low risk home births.

CONCLUSION

Well-designed home birth programs following best clinical practices and procedures can provide a safe birthing option for low risk women.

Coaching a slow birth with the woman in an empowered position may be less harmful than routine hands-on practice to protect against severe tears in birth - A discussion paper

BACKGROUND

Different hands-on interventions to protect women from severe perineal tears after birth have been widely implemented. Evidence to support the routine use of hands-on interventions to reduce severe tears is mainly based on aggregated data from observational studies.

AIM

To critically discuss the current evidence for the implementation of hands-on intervention as a routine practice to protect women from severe tears after birth.

DISCUSSION

Observational studies have been used to justify the routine use of hands-on intervention to protect women from severe perineal tears despite randomized controlled trials and systematic reviews showing lack of benefit. There is strong evidence supporting the slow speed at the time of birth to prevent severe perineal tears. While hands-on intervention does reduce the speed of birth, it may have a negative effect on the birth process, on neonatal outcomes and women's agency.

CONCLUSION

Evidence-based practice requires sufficient evaluation of interventions before being implemented in clinical practice as well as valuing the level of evidence when making clinical decisions. Evaluation of hands-on interventions to protect women from severe perineal tears must include not just one outcome of interest, but also an assessment of how the intervention interferes with the normal mechanism of birth, and how it affects neonatal outcomes and the autonomy of women.

Genital tract tears in women giving birth on a birth seat: A cohort study with prospectively collected data

BACKGROUND

Birth positions may influence the risk of tears in the genital tract during birth. Birth positions are widely studied yet knowledge on genital tract tears following birth on a birth seat is inconclusive.

AIM

The objective of this study was to describe the proportion of genital tract tears in women who gave birth on a birth seat compared to women who did not.

METHOD

An observational cohort study based on birth information collected prospectively. In total 10 629 live, singleton, non-instrumental births in cephalic presentation were studied.

RESULTS

Fewer women who gave birth on a birth seat experienced an overall intact genital tract compared to women who gave birth in any other position. Women who gave birth on a birth seat were less likely to have an episiotomy performed. Women who gave birth vaginally on a birth seat after a previous caesarean section may have an increased risk for sustaining a sphincter tear.

DISCUSSION

It is important to be aware of the decreased chance of an overall intact genital tract area when giving birth on a birth seat. Furthermore, there is a possibly increased risk of sphincter tear in women having a vaginal birth after caesarean. It is required and of importance to provide pregnant women with evidence-based information on factors associated with genital tract tears including birth positions.

[Which interventions during labour to decrease the risk of perineal tears? CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]

OBJECTIVE

The objective of this review was to evaluate whether interventions performed during labour could influence the risk of perineal tears.

METHODS

A separate keyword search for each medical intervention during labor was performed by selecting only studies evaluating perineal consequences, particularly the risk of obstetrical anal sphincter injury (LOSA). Interventions during pregnancy and during fetal expulsion have been specifically addressed in other chapters of the recommendations.

RESULTS

Maternal mobilisation and postures during the first stage of labour have not been shown to reduce the risk of OASIS (LE3). No particular posture has demonstrated its superiority over any other during the second stage of labour for preventing obstetric perineal lesions including OASIS and postnatal incontinence (urinary or faecal) (LE2). There is no reason to recommend one maternal posture rather than another during the first and the second stages of labour for the purpose of reducing the risk of OASIS (Grade C). Women should be allowed to choose the position most comfortable for them during the first and second stages of labour (Professional consensus). Posterior cephalic positions present the greatest risks of perineal injury (LE2). Manual rotation of cephalic posterior positions to the anterior during the second stage of labour may make it possible to reduce the risk of operative vaginal delivery, although no reduction in the risk of perineal injuries or OASIS has been clearly demonstrated (LE3). For fetuses in posterior cephalic positions, no data justifies a preference for manual rotation at full dilation to diminish the risk of perineal injury (Professional consensus). Urinary catheterisation is recommended for women with epidural analgesia during labour when spontaneous micturition is not possible (Professional consensus). Although current data does not justify a preference for continuous or intermittent urinary catheterisation (LE2), intermittent catheterisation nonetheless appears preferable in this situation (Professional consensus). During the second stage phase, delayed pushing does not modify the risk of OASIS (LE1). It does, however, increase the chances of spontaneous delivery (LE1). It is thus recommended that, when maternal and fetal status allow it, the start of pushing should be delayed (Grade A). There is no evidence to support preferring one pushing technique rather than another to diminish the risk of OASIS (grade B). Performing an operative vaginal delivery for the sole purpose of reducing the duration of the second stage of labour may increase the risk of OASIS (LE3). Perineal massage or the application of warm compresses during the second stage of labour appear to reduce the risk of OASIS (LE2). However, we have not made a determination about their use in clinical practice.

Factors associated with obstetric anal sphincter injuries in midwife-led birth: A cross sectional study

INTRODUCTION

Obstetric anal sphincter injurie (OASI) in vaginal births are a serious complication, and are associated with maternal morbidity. Focus on modifiable factors in midwives clinical skills and competences contributing to prevent the occurrence of OASI are essential. The objective of this study was to investigate the association between OASI and factors related to midwife-led birth such as manual support of perineum, active delivery of baby's shoulders, maternal birth position, and pushing and breathing techniques in second stage of labour.

METHODS

A prospective cross sectional study including primiparous (n = 129) and multiparous (n = 628) women in midwife-led non-instrumental deliveries with OASI (n = 96) or intact perineum (n = 661). Data were collected in a university hospital in Norway with two different birth settings: an alongside midwife-led unit with approximately 1500 births per year and an obstetrical unit with approximately 3500 births per year. In midwife-led births, there were a total of 2.6% OASI and 18.9% intact perineum.

RESULTS

The sample consisted of 757 women, 12.7% suffered OASI and 87.3% of participating women had an intact perineum. This selected sample compares the most serious outcome (OASI), and the optimal outcome (intact perineum).In primiparous women, 61 women suffered OASI and 68 women had intact perineum, while for multipara women, 35 women suffered OASI and 593 women had intact perineum. There was an increased risk of OASI if women actively pushed when the head was crowning compared to breathing the head out (adjusted OR: 3.10; 95% CI: 1.75 to 5.47). The maternal birth position associated with the lowest risk of OASI was kneeling position (adjusted OR: 0.15; 95% CI: 0.03 to 0.70), supine maternal birth position (adjusted OR: 2.52; 95% CI: 1.04 to 4.90) and oxytocin augmentation more than 30 min in second stage (OR: 1.93; 95% CI: 1.68 to 15.63) were associated with an increased risk of OASI, when adjusting for maternal, foetal, and obstetric factors.

CONCLUSION

Our study suggests that actively pushing when the baby's head is crowning, a supine maternal birth position and oxytocin augmentation more than 30 min in second stage, were associated with increased risk of OASI when compared to intact perineum. A kneeling maternal birth position was associated with a decreased risk of OASI.

Episiotomy and perineal tear risk factors in a group of 4493 women

Episiotomy belongs to the most frequent procedures carried out during delivery. Performing episiotomy should be reduced as there is scientific evidence indicating that it can cause pain, sexual problems, and serious, long-term health consequences. The aim of the researchers is to identify factors associated with episiotomy and the perineal tear. Analyses were performed using a model of a logistic regression. The study involved 4493 women. The episiotomy risk was related to: a birth weight exceeding 3500 grams, an instrumental delivery by means of forceps or vacuum extraction. The decrease of episiotomy rate increased the rate of perineal tear of first and second degree. The study has shown that episiotomy protects women from third- and fourth-degree perineal tear.

Perineal techniques during the second stage of labour for reducing perineal trauma

BACKGROUND

Most vaginal births are associated with trauma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including perineal massage, warm or cold compresses, and perineal management techniques have been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011.

OBJECTIVES

To assess the effect of perineal techniques during the second stage of labour on the incidence and morbidity associated with perineal trauma.

SEARCH METHODS

We searched Cochrane Pregnancy and Childbirth's Trials Register (26 September 2016) and reference lists of retrieved studies.

SELECTION CRITERIA

Published and unpublished randomised and quasi-randomised controlled trials evaluating perineal techniques during the second stage of labour. Cross-over trials were not eligible for inclusion.

DATA COLLECTION AND ANALYSIS

Three review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. We checked data for accuracy.

MAIN RESULTS

Twenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Overall, trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques.Most studies did not report data on our secondary outcomes. We downgraded evidence for risk of bias, inconsistency, and imprecision for all comparisons. Hands off (or poised) compared to hands onHands on or hands off the perineum made no clear difference in incidence of intact perineum (average risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.12, two studies, Tau² 0.00, I² 37%, 6547 women; moderate-quality evidence), first-degree perineal tears (average RR 1.32, 95% CI 0.99 to 1.77, two studies, 700 women; low-quality evidence), second-degree tears (average RR 0.77, 95% CI 0.47 to 1.28, two studies, 700 women; low-quality evidence), or third- or fourth-degree tears (average RR 0.68, 95% CI 0.21 to 2.26, five studies, Tau² 0.92, I² 72%, 7317 women; very low-quality evidence). Substantial heterogeneity for third- or fourth-degree tears means these data should be interpreted with caution. Episiotomy was more frequent in the hands-on group (average RR 0.58, 95% CI 0.43 to 0.79, Tau² 0.07, I² 74%, four studies, 7247 women; low-quality evidence), but there was considerable heterogeneity between the four included studies.There were no data for perineal trauma requiring suturing. Warm compresses versus control (hands off or no warm compress)A warm compress did not have any clear effect on the incidence of intact perineum (average RR 1.02, 95% CI 0.85 to 1.21; 1799 women; four studies; moderate-quality evidence), perineal trauma requiring suturing (average RR 1.14, 95% CI 0.79 to 1.66; 76 women; one study; very low-quality evidence), second-degree tears (average RR 0.95, 95% CI 0.58 to 1.56; 274 women; two studies; very low-quality evidence), or episiotomy (average RR 0.86, 95% CI 0.60 to 1.23; 1799 women; four studies; low-quality evidence). It is uncertain whether warm compress increases or reduces the incidence of first-degree tears (average RR 1.19, 95% CI 0.38 to 3.79; 274 women; two studies; I² 88%; very low-quality evidence).Fewer third- or fourth-degree perineal tears were reported in the warm-compress group (average RR 0.46, 95% CI 0.27 to 0.79; 1799 women; four studies; moderate-quality evidence). Massage versus control (hands off or routine care)The incidence of intact perineum was increased in the perineal-massage group (average RR 1.74, 95% CI 1.11 to 2.73, six studies, 2618 women; I² 83% low-quality evidence) but there was substantial heterogeneity between studies). This group experienced fewer third- or fourth-degree tears (average RR 0.49, 95% CI 0.25 to 0.94, five studies, 2477 women; moderate-quality evidence).There were no clear differences between groups for perineal trauma requiring suturing (average RR 1.10, 95% CI 0.75 to 1.61, one study, 76 women; very low-quality evidence), first-degree tears (average RR 1.55, 95% CI 0.79 to 3.05, five studies, Tau² 0.47, I² 85%, 537 women; very low-quality evidence), or second-degree tears (average RR 1.08, 95% CI 0.55 to 2.12, five studies, Tau² 0.32, I² 62%, 537 women; very low-quality evidence). Perineal massage may reduce episiotomy although there was considerable uncertainty around the effect estimate (average RR 0.55, 95% CI 0.29 to 1.03, seven studies, Tau² 0.43, I² 92%, 2684 women; very low-quality evidence). Heterogeneity was high for first-degree tear, second-degree tear and for episiotomy - these data should be interpreted with caution. Ritgen's manoeuvre versus standard careOne study (66 women) found that women receiving Ritgen's manoeuvre were less likely to have a first-degree tear (RR 0.32, 95% CI 0.14 to 0.69; very low-quality evidence), more likely to have a second-degree tear (RR 3.25, 95% CI 1.73 to 6.09; very low-quality evidence), and neither more nor less likely to have an intact perineum (RR 0.17, 95% CI 0.02 to 1.31; very low-quality evidence). One larger study reported that Ritgen's manoeuvre did not have an effect on incidence of third- or fourth-degree tears (RR 1.24, 95% CI 0.78 to 1.96,1423 women; low-quality evidence). Episiotomy was not clearly different between groups (RR 0.81, 95% CI 0.63 to 1.03, two studies, 1489 women; low-quality evidence). Other comparisonsThe delivery of posterior versus anterior shoulder first, use of a perineal protection device, different oils/wax, and cold compresses did not show any effects on perineal outcomes. Only one study contributed to each of these comparisons, so data were insufficient to draw conclusions.

AUTHORS' CONCLUSIONS

Moderate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent. Poor-quality evidence suggests hands-off techniques may reduce episiotomy, but this technique had no clear impact on other outcomes. There were insufficient data to show whether other perineal techniques result in improved outcomes.Further research could be performed evaluating perineal techniques, warm compresses and massage, and how different types of oil used during massage affect women and their babies. It is important for any future research to collect information on women's views.