Midline and Mediolateral Episiotomy: Risk Assessment Based on Clinical Anatomy

Evaluation of perineal wound healing and pain outcomes after low-angle mediolateral episiotomy in women undergoing vaginal childbirth: A systematic review and meta-analysis

The efficacy of episiotomy, particularly the angle of incision in mediolateral episiotomies, remains a significant area of inquiry in obstetrics. This meta-analysis aimed to evaluate the impact of low-angle mediolateral episiotomy on perineal wound healing and pain outcomes in women undergoing vaginal childbirth. Adhering to PRISMA guidelines, a systematic review was conducted using the PICO framework. Studies were selected based on predefined inclusion and exclusion criteria, focusing on randomised controlled trials (RCTs) involving low-angle mediolateral episiotomies. Comprehensive literature searches were performed across major electronic databases including PubMed, Embase, Web of Science and Cochrane Library. Data extraction and quality assessments were meticulously carried out by independent reviewers, employing the Cochrane Collaboration's risk of bias tool. A total of 1246 articles were initially identified, with 8 articles meeting the strict inclusion criteria for the final analysis. The meta-analysis revealed significant heterogeneity among studies regarding postoperative pain (p < 0.0001, I2 = 77.5%), and employed a random-effects model. Results showed that low-angle episiotomies significantly reduced postoperative pain (OR = 0.27, 95% CI: 0.17-0.42, p < 0.001), and increased first-degree healing rates (OR = 2.95, 95% CI: 2.20-3.96, p < 0.001) compared to traditional angles. Sensitivity analyses confirmed the stability of these findings, and no significant publication bias was detected. The analysis suggests that low-angle episiotomies can potentially reduce postoperative perineal pain and enhance wound healing. However, the limited number and varying quality of the included studies warrant cautious interpretation of these results. Further well-designed studies are needed to corroborate these findings and guide clinical practice.

A pre-post implementation study of a care bundle to reduce perineal trauma in unassisted births conducted by midwives

PROBLEM

The perineal-bundle is a complex intervention widely implemented in Australian maternity care facilities.

BACKGROUND

Most bundle components have limited or conflicting evidence and the implementation required many midwives to change their usual practice for preventing perineal trauma.

AIM

To measure the effect of perineal bundle implementation on perineal injury for women having unassisted births with midwives.

METHODS

A retrospective pre-post implementation study design to determine rates of second degree, severe perineal trauma, and episiotomy. Women who had an unassisted, singleton, cephalic vaginal birth at term between two time periods: January 2011 - November 2017 and August 2018 - August 2020 with a midwife or midwifery student accoucheur. We conducted logistic regression on the primary outcomes to control for confounding variables.

FINDINGS

data from 20,155 births (pre-implementation) and 6273 (post-implementation) were analysed. After implementation, no significant difference in likelihood of severe perineal trauma was demonstrated (aOR 0.86, 95% CI 0.71-1.04, p = 0.124). Nulliparous women were more likely to receive an episiotomy (aOR 1.49 95% CI 1.31-1.70 p < 0.001) and multiparous women to suffer a second degree tear (aOR 1.18 95% CI 1.09-1.27 p < 0.001).

DISCUSSION

This study adds to the growing body of literature which suggests a number of bundle components are ineffective, and some potentially harmful. Why, and how, the bundle was introduced at scale without a research framework to test efficacy and safety is a key concern.

CONCLUSION

Suitably designed trials should be undertaken on all proposed individual or grouped perineal protection strategies prior to broad adoption.

Case-Based Serious Gaming for Complication Management in Colorectal and Pancreatic Surgery: Prospective Observational Study

BACKGROUND

The potential risk and subsequent impact of serious complications after pancreatic and colorectal surgery can be significantly reduced through early recognition, correct assessment, and timely initiation of appropriate therapy. Serious gaming (SG) is an innovative teaching method that combines play with knowledge acquisition, increased concentration, and quick decision-making and could therefore be used for clinically oriented education.

OBJECTIVE

This study aims to develop a case-based SG platform for complication management in pancreatic and colorectal surgery, validate the application by comparing game courses of various professional groups in the health care sector, and test the acceptance of the developed platform in the context of clinical education by measuring levels of usability and applicability within the framework of a validity and usefulness analysis.

METHODS

In this observational trial, a novel SG for management of postoperative complications was developed and prospectively validated in a cohort of 131 human caregivers with varying experience in abdominal surgery. A total of 6 realistic patient cases were implemented, representing common complications after pancreatic and colorectal surgery. Cases were developed and illustrated using anonymized images, data, and histories of postoperative patients. In the prospective section of this study, following a brief case presentation, participants were asked to triage the virtual patient, make an initial suspected diagnosis, and design a 3-step management plan, throughout which the results of selected diagnostic and therapeutic actions were presented. Participants' proposed case management was compared to ideal case management according to clinical guidelines. Usability, applicability, validity, and acceptance of the application were assessed using the Trier Teaching Evaluation Inventory as part of a noncomparative analysis. In addition, a comparative analysis of conventional teaching and learning formats was carried out.

RESULTS

A total of 131 cases were answered. Physicians selected more appropriate therapeutic measures than nonphysicians. In the Trier Teaching Evaluation Inventory, design, structure, relevance, timeliness, and interest promotion were predominantly rated positively. Most participants perceived the application to be superior to conventional lecture-based formats (training courses, lectures, and seminars) in terms of problem-solving skills (102/131, 77.9%), self-reflection (102/131, 77.9%), and usability and applicability (104/131, 79.4%).

CONCLUSIONS

Case-based SG has educational potential for complication management in surgery and could thereby contribute to improvements in postoperative patient care.

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.

Prevalence of episiotomy practice and factors associated with it in Ethiopia, systematic review and meta-analysis

An episiotomy is one of the most commonly performed obstetrics surgeries indicated in emergencies during the second stage of labor like fetal distress, dystocia, and tight perineum. As a result, this systematic review and meta-analysis aimed to assess the prevalence of episiotomy practice and associated factors in Ethiopia. Ten cross-sectional studies with a total population of 3718 were included in this study. The search was done using online databases like PubMed, HINARI, Web of Science, other gray, and online repositories of Universities. All the included papers were extracted and appraised using the standard extraction sheet format of JOANNA Briggs Institute. The Cochran Q-test and I² statistics test were used to test the heterogeneity of studies. To detect the publication bias of the included studies, a funnel plot and Egger's test were used. The pooled prevalence of episiotomy practice and the odds ratio with a 95% confidence interval were presented using forest plots. The overall pooled prevalence of episiotomy practice was 45.11% (95% CI; 37.04-53.18; I² = 96.3%). Prolonged second stage of labor (OR: 4.79, 95% CI: 3.03, 7.57), face presentation (OR: 4.26, 95% CI: 1.21, 15.07), birth weight > 4000 g (OR: 6.71, 95% CI: 3.14-14.33), instrumental delivery (OR: 4.26, 95% CI 2.95, 6.14), and primiparity (OR: 3.70, 95% CI: 1.90, 7.2) were factors associated with episiotomy practice. The overall prevalence of episiotomy practice was higher in Ethiopia compared to studies conducted in other countries. The prolonged second stage of labor, face presentation, birth weight > 4000 g, instrumental delivery, and primiparity of women were the factors associated with episiotomy practice. Therefore, efforts should be made to prevent routine episiotomy practice through creating awareness, adjusting national guidelines, affecting the World Health Organization episiotomy policy, and monitoring the activities of the health care facilities in executing the protocols.