Childbirth Acquired Perineal Trauma study (CHAPTER): a UK prospective cohort study protocol

INTRODUCTION

Childbirth-related perineal trauma (CRPT) is the most common complication of childbirth affecting 80% of women overall after vaginal birth. There remains a lack of comprehensive evidence relating to the prevalence of subsequent health problems. Current evidence is related to short-term outcomes, for example, pain, but there is less known about longer-term outcomes such as infection, wound dehiscence, pelvic floor function and psychological outcomes. This is a protocol for a cohort study assessing outcomes of women after CRPT.

METHODS AND ANALYSIS

A multicentre, prospective UK cohort study aiming to include 1000 women. All women who have sustained CRPT will be eligible for inclusion and will be followed-up for 12 months after childbirth. The primary outcome will be perineal infection at 6 weeks post-birth. Secondary outcomes will include antibiotic use for perineal infection, wound breakdown, use of analgesia, the requirement for admission or surgical intervention, urinary and faecal incontinence, anxiety and depressive symptoms, sexual function and impact on daily activities. Outcomes will be measured at 6 weeks, 6 months and 12 months post partum, with some outcomes being measured at all time points and others at selected most appropriate time points only. Outcome data will be obtained from a review of clinical notes and from patient questionnaires. Simple descriptive statistics will be used to summarise characteristics and outcomes, with categorical variables expressed as percentages and continuous variables as mean averages, alongside the corresponding standard deviatons.

ETHICS AND DISSEMINATION

Ethical approval has been granted by the Research Ethics Council with reference 23/WA/0169. Data collected from the Childbirth Acquired Perineal Trauma (CHAPTER) cohort study will highlight the prevalence and type of complications after CRPT and which women are more at risk. After the conclusion of this study, findings will be used to work with governmental organisations and Royal Colleges to target resources and ultimately improve care.

The incidence of wound complications following primary repair of obstetric anal sphincter injury: a systematic review and meta-analysis

OBJECTIVE

We aimed to systematically determine the incidences of wound infection and dehiscence after primary obstetric anal sphincter injury repair.

DATA SOURCES

MEDLINE, Embase, CINAHL, EmCare, the Cochrane Library, and Trip Pro databases were searched from inception to February 2021.

STUDY ELIGIBILITY CRITERIA

We included observational clinical studies reporting the incidences of wound infection and dehiscence after primary obstetric anal sphincter injury repair. Case series and reports were excluded. Conference articles and observational study abstracts were included if they contained enough information regarding study design and outcome data.

METHODS

Data were analyzed as incidence (percentage) with 95% confidence intervals. Moreover, the prediction intervals were calculated to provide a predicted range for the potential incidence of wound complications when applied to an individual study setting. Study quality and risk of bias were assessed using the relevant tool from the Joanna Briggs Institute.

RESULTS

Of 956 studies found, 39 were selected for full-text review. Moreover, 10 studies (n=4767 women) were eligible and included in the meta-analysis. All 10 studies were conducted in high-income countries (Denmark [n=1], the United Kingdom [n=3], and the United States [n=6]). The incidences of wound infection (n=4593 women) and wound dehiscence (n=3866 women) after primary obstetric anal sphincter injury repair ranged between 0.1% to 19.8% and 1.9% to 24.6%, respectively. The overall incidences were 4.4% (95% confidence interval, 0.4-8.4) for wound infection and 6.9% (95% confidence interval, 1.6-12.2) for wound dehiscence. The prediction intervals were wide and suggested that the true incidences of wound infection and dehiscence in future studies could lie between 0.0% to 11.7% and 0.0% to 16.4%, respectively. Overall, 8 studies had a high or unclear risk of bias across ≥1 assessed element. None of the studies used the same set of clinical parameters to define wound infection or dehiscence. Furthermore, microbiological confirmation with wound swabs was never used as a diagnostic measure.

CONCLUSION

This was a systematic review and meta-analysis of wound infection and dehiscence incidences after primary obstetric anal sphincter injury repair. The incidence estimates from this review will be useful for clinicians when counseling women with obstetric anal sphincter injury and when consenting them for primary surgical repair.

Healing of disrupted perineal wounds after vaginal delivery: a poorly understood condition

Perineal injury following childbirth can result in complications such as wound infection and dehiscence. The reported incidence of these complications in the literature range between 0.1-23.6% and 0.2-24.6%, respectively. However, the healing of disrupted perineal wounds is poorly understood. In addition, it is a neglected area in maternity services. In this review, the authors explore the process of wound healing in the context of infected perineal wounds following childbirth. In addition, the authors describe the management of complications including hypergranulation, perineal pain and dyspareunia.

Surgical site infections following caesarean sections at Emirati teaching hospital: Incidence and implicated factors

The rate of delivery by caesarean sections is increasing globally and, therefore, the incidence of post-caesarean surgical site infections (SSIs) is probably also going to rise. The aim of the present study was to determine the incidence of SSIs after caesarean operations and to explore the factors associated with an increased risk of post-caesarean SSIs. A retrospective study was performed to assess all women who underwent caesarean sections from January 2016 to December 2017 at Al Ain Hospital in the United Arab Emirates (UAE). Backward multivariate logistic regression analysis was utilized to specify the variables that were significantly and independently connected with the development of post-caesarean SSIs. In total, 807 women underwent caesarean deliveries at the study site hospital during the two-year study period (January 2016-December 2017). Post-operative SSI was detected in 11 (1.4%) of the women who underwent caesarean operations. Of these, 11 (100%) women were diagnosed post-discharge, within 30 days after the date of the surgery. Multivariate logistic regression analysis showed that increased gestational age (P = 0.045) was significantly and independently associated with the development of post-caesarean SSI. Increased gestational age was found to be an independent predictor of post-caesarean SSIs. This identified risk factor should inform targeted health care policies to reduce the rate of SSIs.

The use of non-surgical glue to repair perineal first-degree lacerations in normal birth: A non-inferiority randomised trial

BACKGROUND AND PROBLEM

Surgical glue has been indicated for uncomplicated operatory wounds; however, it has a considerable cost. Non-surgical glue, a commercially available and cheaper product, has not been studied for repairing postpartum lacerations.

AIM

To compare non-surgical glue to traditional sutures on perineal first-degree lacerations after normal birth.

METHODS

In a prospective, open-label, non-inferiority, randomised controlled trial, we selected childbearing women who were admitted for normal term births and in whom skin lacerations occurred. They were assigned to laceration repair using either non-surgical glue (ethyl 2-cyanoacrylate; Glue group) or catgut sutures (Suture group). The primary endpoint was the occurrence of dehiscence >3mm. Secondary endpoints were procedure runtime, pain score, satisfaction level, and aspects of perineal repair by the REEDA score (hyperaemia, oedema, ecchymosis, exudation, and coaptation) immediately (T0), 24-48h (T1), and 7-10 days (T2) after childbirth.

FINDINGS

We included 126 women, 63 in each group, and found a non-inferiority dehiscence rate in the Glue Group compared to the Control group (T1=1.6% vs. 1.6%, P=0.999 and P<0.001 for non-inferiority; and T2=2.2% vs. 4.3%, P=0.557). In the Glue Group, the procedure runtime was shorter, pain score was lower, and women's satisfaction was greater. No women had any allergic reaction in the study.

CONCLUSIONS

Non-surgical glue was not inferior to traditional sutures to repair postpartum first-degree lacerations. In addition, non-surgical glue was associated with less pain and greater satisfaction. Brazilian Clinical Trials Registry (www.ensaiosclinicos.gov.br/rg/RBR-5Z8MKC).

Early re-suturing of dehisced obstetric perineal wounds: A 13-year experience

OBJECTIVES

To describe post-operative outcomes following early re-suturing of obstetric perineal wound dehiscence.

STUDY DESIGN

This was a retrospective series of 72 women who underwent re- suturing of a dehisced perineal wound at a tertiary urogynaecology department during a 13-year period (December 2006 - December 2019).

RESULTS

Seventy-two women with complete perineal wound dehiscence opted for secondary re-suturing. Other accompanying symptoms included purulent discharge from the wound (22.2 %), perineal pain (23.6 %) and both purulent discharge and pain (26.4 %). The median time taken for the wound to heal completely following re-suturing was 28 days (IQR 14.0-52.0); 49.2 % had healed completely by four weeks, 63.5 % by six weeks and 76.2 % by eight weeks. The median number of out-patient follow-up appointments required was 2 (IQR 1.0-3.0). No post-operative complications were experienced in 63.6 % of women, one complication occurred in 25.8 % and two complications in 10.6 %. Complications included skin dehiscence (33.3 %), granuloma (33.3 %), scar tissue (17.6 %), perineal pain (5.9 %) and sinus formation (5.9 %). Of the women who developed two complications, four developed skin dehiscence with granulation tissue and one had skin sinus formation. One developed granulation tissue with perineal pain. All complications were managed conservatively in an outpatient setting or surgically under local anaesthetic, without further complication. There was no significant difference (p = 0.443) in complication rates between the group (n = 10) with dehisced wounds with signs of wound infection (purulent discharge or the presence of both purulent discharge and pain) pre-operatively versus the group (n = 14) without signs of infection.

CONCLUSIONS

This study demonstrates the positive outcomes of early re-suturing of perineal wound dehiscence with faster healing, reduced follow-up requirements and few major complications. It provides information to clinicians who are uncertain about the effects of early re-suturing of perineal wounds which can be used to help counsel mothers with wound dehiscence on their management options.

Obstetric perineal tears: risk factors, wound infection and dehiscence: a prospective cohort study

PURPOSE

To assess risk factors for perineal tears, wound infection and dehiscence among primiparous women.

METHODS

A prospective cohort study at four Danish hospitals (Odense, Esbjerg, Aarhus and Kolding) among 603 primiparous women sampled in three groups: 203 with none/labia/1st degree, 200 with 2nd degree, and 200 with 3rd/4th degree tears included between July 2015 and January 2018. Baseline data were obtained and a clinical examination of perineal wound healing was performed 11-21 days postpartum. Main outcome measurements were as follows: degree of perineal tear, 1st to 4th, analyzed with a case-control approach, infection (purulent drainage or wound abscess), and wound dehiscence (a gap between wound edges > 0.5 cm).

RESULTS

Instrumental delivery and birthweight > 4000 g increased the risk of 3rd/4th degree tears (adjusted Odds Ratio [aOR] 13.7, 95% confidence interval [CI] 5.48-34.1 and aOR 3.27, 95% CI 1.52-7.04, respectively). BMI > 35 kg/m² increased the risk of wound infection and dehiscence (aOR 7.66, 95% CI 2.13-27.5 and aOR 3.46, 95% CI 1.10-10.9, respectively). Episiotomy tripled the risk of infection (aOR 2.97, 95% CI 1.05-8.41). Treatment with antibiotics during delivery and postpartum seemed to decrease the risk of dehiscence (aOR 0.32, 95% CI 0.15-0.70).

CONCLUSIONS

Instrumental delivery and high birth weight increased the risk of perineal tears. Severe obesity and episiotomy increased the risk of perineal wound complications. More focus on these women may be warranted postpartum. The use of prophylactic antibiotics among women in high risk of wound complications should be further investigated in interventional studies.

Student midwives' experiences in relation to assessment of maternal postnatal genital tract health: A case study analysis

OBJECTIVE

to explore student midwives' experiences of postnatal genital tract assessment within midwifery preregistration curricula.

DESIGN

a single, instrumental case study design was employed involving final year student midwives. Ethical approval was gained from the Higher Education Institution at the data collection site. Sampling was purposeful and data were collected using a survey (n = 25); narrative style in depth interviews (n = 11), review of programme documentation and a student midwife / researcher data workshop.

SETTING

one Higher Education Institution in the north of England.

FINDINGS

three themes were identified from the data analysis, awareness of assessment methods, accessing learning opportunities and actualisation of learning. The awareness theme highlights that most students were aware of potential signs and symptoms associated with genital tract assessment and health however; difficulties were identified concerning assessment of lochia, encountering sequential assessments and recognising potential for deterioration. This awareness was influenced by access to practice based learning opportunities. Access differed due to variation in postnatal provision, service pressures and variety in mentor practices regarding selecting and creating learning opportunities. This study suggests actualisation of learning and confidence in genital tract assessment was achieved when opportunities to integrate theory and practice occurred. Actualisation was hindered by limited allocation of curriculum time specifically for postnatal maternal assessment content and assessment strategies in comparison to other aspects of midwifery knowledge.

CONCLUSIONS

student midwives' experiences, awareness and learning actualisation varied in relation to the development of knowledge and confidence in maternal postnatal genital tract assessment. While clinical and theoretical learning opportunities were available, access and experience varied and limitations were identified. A number of recommendations are outlined to enhance the students learning experiences in practice and HEI settings, which address placement planning, mentor preparation, the student voice and supporting curricula documentation.

The effect of Achillea millefolium and Hypericum perforatum ointments on episiotomy wound healing in primiparous women

BACKGROUND

The purpose of this study was to assess the efficacy of Achillea millefolium and Hypericum perforatum ointments on episiotomy wound healing in primiparous women.

MATERIALS AND METHODS

This is a double-blind clinical trial study performed on 140 primiparous women. They were randomly divided into four groups, each group containing 35 women: 2control groups including nonintervention and placebo ointment; and 2 case groups including Hypericum perforatum ointment and Achillea millefolium ointment. Healing process was assessed by five specifications: redness, ecchymosis, edema, discharge and wound dehiscence on 7th, 10th, and 14th days after delivery; pain level was assessed by means of visual analog scale.

RESULTS

There was significant difference between groups in perineal pain level at 7th, 10th and 14th days postpartum, redness and edema at 7th and 10th days postpartum and ecchymosis at 7th day postpartum; the pain level, redness, edema and ecchymosis in groups who consume Hypericum perforatum and Achillea millefolium ointments were less than the control groups (p < 0.05). But, discharge and dehiscence incidence showed no significant difference between groups (p > 0.05).

CONCLUSIONS

Achillea millefolium and Hypericum perforatum ointments reduce perineal pain level, redness, edema and ecchymosis of episiotomy wound, so it seems that consuming them was useful for episiotomy treatment.

Incidencia de dehiscencias en el puerperio mediato de episiorrafias realizadas en el Centro de Salud Bárbara en San Juan Sacatepéquez en 2014-2015

Introducción: Episiotomía se define como una incisión quirúrgica que se realiza en el periné, región entre la vagina y el ano, para incrementar el diámetro vaginal en el momento del parto. Existen complicaciones derivadas de este procedimiento tales como edema, hematomas, dolor perineal y dehiscencia de episiorrafias. Las dehiscencias se consideran una complicación obstétrica poco común y, a pesar de que las estadísticas al respecto son limitadas, se han reportado tasas de 0.1 a 5.5% de dehiscencia. Objetivo: El objetivo del presente estudio fue evaluar la incidencia de dehiscencia en el puerperio mediato de las episiorrafias realizadas en Centro de Salud Bárbara, San Juan Sacatepéquez (CSB) en el período del 2014-2015 ya que, actualmente se carece de estadísticas al respecto y, aunque es una complicación poco común derivada de este procedimiento, puede tener secuelas importantes en las pacientes obstétricas. Metodología: Se realizó un estudio descriptivo de incidencia acumulada en el cual se utilizaron los expedientes de partos del CSB de los años 2014-2015. Se revisaron las notas de parto de cada una de las pacientes, posteriormente se seleccionaron las papeletas de las pacientes a quienes se les realizó episiotomía y re consultaron en la cita de control de puerperio mediato. Se revisó la nota de evolución en donde se pudo evidenciar la presencia o ausencia de una dehiscencia de episiorrafia. Resultados: Se revisaron 503 records correspondientes al total de partos en 2014 y 2015. Se realizó episiotomía a 171 pacientes (34%). Del total de pacientes a quienes se les realizó episiotomía únicamente 90 re consultaron durante el puerperio mediato, dando una tasa de re consulta de 53%. De las 90 pacientes que re consultaron, se documentó que 6 de ellas presentaban una dehiscencia de episiorrafia, dando una de 7.14 %. Conclusiones: Se concluyó que existe una incidencia de dehiscencia del 7 % durante ese período

Chronic wounds should be one of Australia's National Health Priority Areas

Chronic wounds are a poorly recognised chronic disease that cause pain and suffering and cost the Australian healthcare system A $2.85 billion dollars per annum. Unlike the highly profiled and relatively well-funded chronic diseases that comprise the Australian National Health Priority Areas, chronic wounds remain a largely hidden and poorly supported problem in the Australian community. This perspective article proposes that one approach to generate action to reduce the burden of chronic wounds is to better articulate the relationship between chronic wounds and the Australian National Health Priority Areas, and to establish a profile of chronic wounds as a chronic disease of national significance in its own right. This approach has the potential to raise awareness of the significance of chronic wounds and garner support from the public, healthcare sector, research funders and policy makers to improve the outcomes for people who are living with or at risk of developing this condition and to potentially reduce expenditure in this area.

Episiotomy healing assessment: Redness, Oedema, Ecchymosis, Discharge, Approximation (REEDA) scale reliability

OBJECTIVE

to analyse the Redness, Oedema, Ecchymosis, Discharge, Approximation (REEDA) scale reliability when evaluating perineal healing after a normal delivery with a right mediolateral episiotomy.

METHOD

observational study based on data from a clinical trial conducted with 54 randomly selected women, who had their perineal healing assessed at four time points, from 6 hours to 10 days after delivery, by nurses trained in the use of this scale. The kappa coefficient was used in the reliability analysis of the REEDA scale.

RESULTS

the results indicate good agreement in the evaluation of the discharge item (0.75< Kappa ≥0.88), marginal and good agreement in the first three assessments of oedema (0.16< Kappa ≥0.46), marginal agreement in the evaluation of ecchymosis (0.25< Kappa ≥0.42) and good agreement regarding redness (0.46< Kappa ≥0.66). For the item coaptation, the agreement decreased from excellent in the first assessment to good in the last assessment. In the fourth evaluation, the assessment of all items displayed excellent or good agreement among the evaluators.

CONCLUSION

the difference in the scores among the evaluators when applying the scale indicates that this tool must be improved to allow an accurate assessment of the episiotomy healing process.