Intact Perineum: What are the Predictive Factors in Spontaneous Vaginal Birth?

Occurrence and risk factors for second-degree perineal tears: A prospective cohort study using a detailed classification system

BACKGROUND

The amount of tissue trauma within second-degree perineal tears varies widely. Therefore, subcategorization of second-degree tears and a better understanding of their occurrence and risk factors are needed. The aim of this study was to assess the occurrence of perineal tears when second-degree tears were subcategorized. Furthermore, we aimed to assess the association between variables related to perineal anatomy and other potential risk factors, with second-degree tear subcategories.

METHODS

This prospective cohort study included 880 primiparous and multiparous women giving birth to one child vaginally. Perineal tears were categorized using the classification system recommended by the Royal College of Obstetricians and Gynaecologists. In addition, second-degree tears were subcategorized as 2A, 2B, or 2C according to the percentage of damage to the perineal body. Selected variables related to perineal anatomy were as follows: length of genital hiatus; perineal body length; and previous perineal trauma. Risk factors for second-degree tear subcategories were analyzed using a multinominal regression model.

RESULTS

Perineal tears occurred as follows: first-degree: 35.6% (n = 313), 2A: 16.3% (n = 143), 2B: 9.1% (n = 80), 2C: 6.6% (n = 58), and third- or fourth-degree: 1.6% (n = 14). In total, 169/880 participants underwent an episiotomy. When episiotomies were excluded, the risk for 2B, or 2C tears increased with smaller genital hiatus, larger perineal body, previous perineal trauma, primiparity, higher gestational age, instrumental vaginal delivery and fetal presentation other than occiput anterior.

CONCLUSION

The occurrence of second-degree tear subcategories was 16.3% for 2A tears, 9.1% for 2B tears, and 6.6% for 2C tears. Factors related to perineal anatomy increased the odds for experiencing a second-degree tear in a more severe subcategory.

Midwives' practices on perineal protection and episiotomy decision-making: A qualitative and descriptive study

INTRODUCTION

Perineal trauma is associated with both short- and long-term morbidity which in turn relates to the degree of trauma. The objective of this study was to understand midwives' practices regarding perineal protection during the second phase of labor, emphasizing decision-making to perform an episiotomy.

METHODS

A descriptive and explanatory study was conducted with an intentional sample of twenty-two midwives working in the labor ward of a tertiary hospital in a metropolitan location and in the public service, in Portugal. A semi-open interview was applied to collect the data from 5 to 15 January 2019. The computer software package, NVivo version 10, was used to perform the thematic analysis.

RESULTS

Four main themes arose from the midwives' data: 1) Factors affecting the application of perineal protection techniques', 2) Birth position, 3) Techniques for perineal protection, and 4) Episiotomy. The reasons for performing an episiotomy were the presence of tense perineum, large weight baby, previous obstetric anal sphincter injury, and Kristeller maneuver.

CONCLUSIONS

Midwives' practices regarding perineal protection techniques and reasons for performing an episiotomy were not all in line with the evidence. Perineal massage was not mentioned as a perineal protection technique.

Perineal massage and warm compresses - Randomised controlled trial for reduce perineal trauma during labor

OBJECTIVE

The aim of this study is to evaluate the effect of perineal massage and warm compresses technique on the perineum integrity during second stage of labor.

DESIGN AND SETTING

A single-center, prospective, randomized controlled trial was conducted between March 1st, 2019, and December 31st, 2020, at Hospital of Braga.

PARTICIPANTS

Women with 18 years or older, between 37 weeks and 41 weeks pregnant, in whom a vaginal birth of a fetus in the cephalic presentation was planned were recruited. Eight hundred forty-eight women were randomly assigned (Perineal massage and warm compresses group, n = 424 and control group, n = 424), and 800 women, both perineal massage and warm compresses group (n = 400) and control group (n = 400) were included in the strict per protocol analysis.

INTERVENTION

In the perineal massage and warm compresses group, women received perineal massage and warm compresses and in the control group, women received hands-on technique.

RESULTS

The incidence of intact perineum was significantly higher in the perineal massage and warm compresses group [perineal massage and warm compresses group: 47% vs control group: 26.3%; OR 2.53, 95% CI 1.86-3.45, p<0.001], whereas second-degree tears and episiotomy rate were significantly lower in this group [perineal massage and warm compresses group: 7.2% vs control group: 12.3%; OR 1.96, 95% CI 1.17-3.29, p = 0.010 and perineal massage and warm compresses group: 9.5% vs control group: 28.5%; OR 3.478, 95% CI 2.236-5.409, p<0.001, respectively]. Also, obstetric anal sphincter injury with and without episiotomy and second-degree tears with episiotomy were significantly lower in the perineal massage and warm compresses group [perineal massage and warm compresses group: 0.5% vs control group: 2.3%; OR 5.404, 95% CI 1.077-27.126, p = 0.040 and perineal massage and warm compresses group: 0.3% vs control group: 1.8%; OR 9.253, 95% CI 1.083-79.015, p = 0.042, respectively].

CONCLUSIONS

The perineal massage and warm compresses technique increased the incidence of intact perineum and reduced the incidence of second-degree tear, episiotomy and obstetric anal sphincter injury.

IMPLICATIONS FOR PRACTICE

Perineal massage and warm compresses technique is feasible, inexpensive and reproductible. Therefore, this technique should be taught and trained to midwives students and midwives team. Thus, women should have this information and have the option to decide whether they want to receive the perineal massage and warm compresses technique in the second stage of labor.

Efficacy of perineal massage during the second stage of labor for the prevention of perineal injury: A systematic review and meta-analysis

BACKGROUND

Numerous interventions to reduce perineal trauma during childbirth have been studied in recent years, including perineal massage.

OBJECTIVE

To determine the efficacy of perineal massage during the second stage of labor to prevent perineal damage.

SEARCH STRATEGY

Systematic search in PubMed, Pedro, Scopus, Web of Science, ScienceDirect, BioMed, SpringerLink, EBSCOhost, CINAHL, and MEDLINE with the terms Massage, Second labor stage, Obstetric delivery, and Parturition.

SELECTION CRITERIA

The articles must have been published in the last 10 years; the perineal massage was administered to the study sample; and the experimental design consisted of randomized controlled trial.

DATA COLLECTION AND ANALYSIS

Tables were used to describe both the studies' characteristics and the extracted data. The PEDro and Jadad scales were used to assess the quality of studies.

MAIN RESULTS

Of the 1172 total results identified, nine were selected. Seven studies were included in the meta-analysis and indicated a statistically significant decreased number of episiotomies in perineal massage.

CONCLUSIONS

Massage during the second stage of labor appears to be effective in preventing episiotomies and reducing the duration of the second stage of labor. However, it does not appear to be effective in reducing the incidence and severity of perineal tears.

The clinical characteristics of perineal tears: A study carried out on 14 pregnant women in a tertiary center: Case series

Background

The sheer quality of the female genital tract is not always respected at the time of childbirth because no protocol for the management of perineal tears exists in our services these days. The management remains dependent on a gynecologist and obstetrician. The study aimed to describe the characteristics of perineal tears.

Methods

Our cross-sectional, retrospective, and descriptive study focused on patients admitted for childbirth and hospitalized in the obstetrics department of the Saint Luc Tertiary Clinic for a period from March 2021 to March 2022. During this period, we recorded 111 deliveries with 14 perineal tears.

Results

A total of 111 deliveries were recorded with a 12.6% frequency of perineal tears. 64.3% of women aged between 26 and 35 and 71.4% of primiparous women were affected by perineal tears. For delivery, 64.3% of births were eutocic deliveries, with 42.9% of children born with a birth weight greater than 4 kg, and the cephalic presentation delivered 86% of children. For degrees of perineal tears, 64.3% of patients had first-degree perineal tears. For postpartum treatment of perineal tears, analgesics help calm the pain, and antibiotic therapy has been considered. For fourth and third-degree tears, episiotomy was performed as a surgical procedure.

Conclusion

Perineal tears are the trauma often encountered in obstetrics; the first few suffer from it essentially. The high birth weight of children is often the cause. They require immediate management to prevent or avoid infections.

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Women have a very complex anatomy, hence the high risk of trauma or tears of the perineum that are often unavoidable during childbirth. Young primiparous women are the most vulnerable to perineal tears with a very high prevalence.

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The high weight and cephalic presentation of children at delivery are the factors causing perineal tears in women. Vaginal delivery and the number of foetuses has an impact on the integrity of the perineum.

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During childbirth, perineal tears should be brought to the attention of obstetric providers to avoid complications for the woman.

A Hospital-Based Randomized Controlled Trial-Comparing the Outcome of Normal Delivery Between Squatting and Lying Down Positions During Labour

BACKGROUND

Labour is a physiological process. Before the seventeenth century, the upright birthing position was common in western countries. The supine position became popular because of the convenience for health professionals rather than the benefits for women.

AIMS AND OBJECTIVES

To compare the outcomes of normal deliveries between squatting and lying down positions and to assess the risks and benefits of squatting position during the second and third stages of labour and its comparison with the lying down position.

METHODOLOGY

A hospital-based prospective randomized controlled study was conducted in the Department of Obstetrics and Gynaecology in tertiary care centre carried over a period of 18 months among 212 female patients in labour assigned in Group A squatting position and Group B lying down position.

RESULTS

The mean age of patients in Group A was 23.30 ± 4.30 years and Group B was 23.81 ± 4.13 years. The mean duration of second and third stages of labour in both multigravida and primigravida patients was significantly lower in Group A (p < 0.05). The mean amount of blood loss in Group A was significantly higher compared to Group B (p < 0.05). The mean VAS score assessing severity of pain at second stage and third stage of labour was significantly lower in Group A compared to Group B (p < 0.05).

CONCLUSION

Squatting position was found much convenient for mothers in terms of less duration of second stage of labour, less number of patients administered oxytocin, lesser extension of episiotomy and greater maternal satisfaction on severity of pain.