Midwives' approach to the prevention and repair of obstetric perineal trauma in Spain

AIM

Different clinical practice guidelines include recommendations on how to prevent and repair obstetric perineal trauma, as well as the use of episiotomy. To evaluate the variability in midwives' professional practices for preventing and repairing perineal trauma, as well as the professional factors that may be associated with the restrictive use of episiotomy.

DESIGN

Observational cross-sectional study.

METHODS

Three hundred five midwives completed an anonymous questionnaire developed by the authors and distributed across various midwifery scientific societies. The main outcomes measured were the frequencies of adopting specific practices related to perineal injury prevention and repair, episiotomy technique and restrictive episiotomy use (<10%). Odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals were estimated.

RESULTS

Intrapartum perineal massage was not normally used by 253 (83%) of midwives, and 186 (61%) applied compresses soaked in warm water to the perineum. Regarding episiotomy, there was a great deal of variability, noting that 129 (42.3%) adopted a restrictive use of this procedure, 125 (41%) performed it between 10% and 20%, while 51 midwives (16.7%) performed it in more than 20% of cases. In addition, 165 (54.1%) midwives followed an incision angle of 60º. Concerning tears, 155 (50.8%) usually sutured first-degree tears and 273 (89.5%) always sutured second-degree tears. Midwives attending home births (aOR = 6.5; 95% CI: 2.69-15.69), working at a teaching hospital (aOR = 3.69; 95% CI: 1.39-9.84), and the ones who recently completed their professional training (aOR = 3.58; 95% CI: 1.46-8.79) were significantly more likely to adopt a restrictive use of episiotomy.

CONCLUSIONS

There is a significant variability in Spanish midwives' practices for preventing and repairing perineal tears. Moreover, the restrictive use of episiotomy is associated with midwives attending home births, working in teaching hospitals and having recent professional training.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

The effects of warm perineal compress on perineal trauma and postpartum pain: a systematic review with meta-analysis and trial sequential analysis

BACKGROUND

In order to reduce the complications of perineal damage and the pain caused by it for the mother, this study was conducted to determine the effect of warm perineal compress on perineal trauma (1st-, 2nd-, 3rd-, and 4th-degree perineal tears), postpartum pain, intact perineum (primary outcomes), episiotomy, length of the second stage, and APGAR score at 1 and 5 min after childbirth (secondary outcome).

METHODS

PubMed, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, Web of Science, SID, Magiran, and ClinicalTrials.gov were searched to identify the relevant articles from inception to November 1, 2022, with language restriction (only English and Persian). A manual search was also performed. Risk of bias 2 (RoB2) and ROBIN-I were employed to evaluate the quality of the included papers. Meta-analysis was conducted using RevMan 5.3. Heterogeneity was assessed using I2. In cases with high heterogeneity, subgroup analysis was utilized based on the parity and ethnicity, and time of pain measurement after delivery also a random-effects model was used instead of a fixed-effects model. Trial sequential analysis (TSA) was performed for the primary outcomes. The certainty of evidence was assessed using the GRADE approach.

RESULTS

A total number of 228 articles were found in databases. Of these articles, eighty-six were screened by title, 27 by abstract, and 21 by full text. Finally, 14 articles were included, of which ten were RCT and four were non-RCT. Meta-analysis results revealed that warm perineal compress significantly reduced perineal pain (RR 0.23, 95% CI 0.08-0.66; P = 0.0006), average pain (SMD - 0.73, 95% CI 1.23 to - 0.23; P = 0.004), second-degree perineal tear (RR 0.65, 95% CI 0.54-0.79; P˂0.00001), third-degree perineal tear (RR 0.32, 95% CI 0.15-0.67; P = 0.003), fourth-degree perineal tear (RR 0.11, 95% CI 0.01-0.87; P = 0.04), episiotomy (RR 0.63, 95% CI 0.46-0.86; P = 0.004), and intact perineum significantly increased (RR 3.06, 95% CI 1.79-5.22; P < 0.0001) compared to the control group. However, there was no statistically significant difference in terms of first-degree tear (RR 1.04, 95% CI 0.86-1.25; P = 0.72), length of the second stage of labor (MD - 0.60, 95% CI - 2.43 to 1.22; P = 0.52), the first minute (MD - 0.03, 95% CI - 0.07 to 0.02; P = 0.24) and the fifth minute Apgar score (MD - 0.02, 95% CI - 0.07 to 0.03; P = 0.46) between the two groups.

CONCLUSION

Warm perineal compress administered during the second stage of labor reduce postpartum pain, second and third-degree perineal tears, and episiotomy rate while it increases the incidence of intact perineum compared to the control group.

Is water delivery a good idea to prevent obstetric anal sphincter injuries in low risk primiparae? An exploratory study in a Swiss public teaching hospital

OBJECTIVE

Obstetric anal sphincter injuries are feared perineal injuries that are associated with increased pelvic floor disorders. The knowledge of influencing factors as the mode of delivery is therefore important. The aim of this study is to compare the rate of obstetric anal sphincter injuries in primiparae after water and bed deliveries.

STUDY DESIGN

In this retrospective cohort study 3907 primiparae gave birth in water or on a bed in a Swiss teaching hospital. The diagnosis of obstetric anal sphincter injuries was confirmed by a consultant of obstetrics and gynecology and treated by them. The rates of these injuries after water and bed births were compared. Subgroup analysis was performed to detect possible associative factors, such as birth weight, episiotomy, use of oxytocin in first and second stage of labor.

RESULTS

1844 (47.2 %) of the primiparae had a water delivery and 2063 (52.8 %) a bed delivery. 193 (4.94 %) were diagnosed with obstetric anal sphincter injuries, of which 68 (3.7 %) had a water delivery and 125 (6.1 %) a bed delivery, p < 0.001. Subgroup analysis revealed that, in the first and second stage of labor, the rate of obstetric anal sphincter injuries with oxytocin was significantly lower in water than in bed deliveries; p = 0.025, p < 0.017, respectively. The rate of obstetric anal sphincter injuries in the birth weight or episiotomy subgroups did not reach significance.

CONCLUSIONS

In a teaching hospital setting with standardized labor management, primiparae with a water delivery have the lowest risk for obstetric anal sphincter injuries.

The prevention of perineal trauma during vaginal birth

Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%. The incidence of obstetrical anal sphincter injury is approximately 3%, with a significantly higher rate in primiparous than in multiparous women (6% vs 2%). Obstetrical anal sphincter injury is a significant risk factor for the development of anal incontinence, with approximately 10% of women developing symptoms within a year following vaginal birth. Obstetrical anal sphincter injuries have significant medicolegal implications and contribute greatly to healthcare costs. For example, in 2013 and 2014, the economic burden of obstetrical anal sphincter injuries in the United Kingdom ranged between £3.7 million (with assisted vaginal birth) and £9.8 million (with spontaneous vaginal birth). In the United States, complications associated with trauma to the perineum incurred costs of approximately $83 million between 2007 and 2011. It is therefore crucial to focus on improvements in clinical care to reduce this risk and minimize the development of perineal trauma, particularly obstetrical anal sphincter injuries. Identification of risk factors allows modification of obstetrical practice with the aim of reducing the rate of perineal trauma and its attendant associated morbidity. Risk factors associated with second-degree perineal trauma include increased fetal birthweight, operative vaginal birth, prolonged second stage of labor, maternal birth position, and advanced maternal age. With obstetrical anal sphincter injury, risk factors include induction of labor, augmentation of labor, epidural, increased fetal birthweight, fetal malposition (occiput posterior), midline episiotomy, operative vaginal birth, Asian ethnicity, and primiparity. Obstetrical practice can be modified both antenatally and intrapartum. The evidence suggests that in the antenatal period, perineal massage can be commenced in the third trimester of pregnancy to increase muscle elasticity and allow stretching of the perineum during birth, thereby reducing the risk of tearing or need for episiotomy. With regard to the intrapartum period, there is a growing body of evidence from the United Kingdom, Norway, and Denmark suggesting that the implementation of quality improvement initiatives including the training of clinicians in manual perineal protection and mediolateral episiotomy can reduce the incidence of obstetrical anal sphincter injury. With episiotomy, the International Federation of Gynecology and Obstetrics recommends restrictive rather than routine use of episiotomy. This is particularly the case with unassisted vaginal births. However, there is a role for episiotomy, specifically mediolateral or lateral, with assisted vaginal births. This is specifically the case with nulliparous vacuum and forceps births, given that the use of mediolateral or lateral episiotomy has been shown to significantly reduce the incidence of obstetrical anal sphincter injury in these groups by 43% and 68%, respectively. However, the complications associated with episiotomy including perineal pain, dyspareunia, and sexual dysfunction should be acknowledged. Despite considerable research, interventions for reducing the risk of perineal trauma remain a subject of controversy. In this review article, we present the available data on the prevention of perineal trauma by describing the risk factors associated with perineal trauma and interventions that can be implemented to prevent perineal trauma, in particular obstetrical anal sphincter injury.

Prevention of obstetric anal sphincter injuries with perineal support and lateral episiotomy: A historical cohort study

INTRODUCTION

There are many risk factors for obstetric anal sphincter injury (OASIS) and the interaction between these risk factors is complex and understudied. The many observational studies that have shown a reduction of OASIS rates after implementation of perineal support have short follow-up time. We aimed to study the effect of integration of active perineal support and lateral episiotomy on OASIS rates over a 15-year period and to study interactions between risk factors known before delivery.

MATERIAL AND METHODS

We performed a historical cohort study over the periods 1999-2006 and 2007-2021 at Stavanger University Hospital, Norway. The main outcome was OASIS rates. Women without a previous cesarean section and a live singleton fetus in cephalic presentation at term were eligible. The department implemented in 2007 the Finnish concept of active perineal protection, which includes support of perineum, control of fetal expulsion, good communication with the mother and observation of perineal stretching. The practice of mediolateral episiotomy was replaced with lateral episiotomy when indicated. We analyzed the OASIS rates in groups with and without episiotomy stratified for delivery mode, fetal position at delivery and for parity, and adjusted for possible confounders (maternal age, gestational age, oxytocin augmentation and epidural analgesia).

RESULTS

We observed a long-lasting reduction in OASIS rates from 4.9% to 1.9% and an increase in episiotomy rates from 14.4% to 21.8%. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with instrumental vaginal deliveries and occiput anterior (OA) position; 3.4% vs 10.1% (OR 0.31; 95% CI: 0.24-0.40) and 6.1 vs 13.9% (OR 0.40; 95% CI: 0.19-0.82) in women with occiput posterior (OP) position. Lateral episiotomy was also associated with lower OASIS rates in nulliparous women with spontaneous deliveries and OA position; 2.1% vs 3.2% (OR 0.62; 95% CI: 0.49-0.80). The possible confounders had little confounding effects on the risk of OASIS in groups with and without episiotomy.

CONCLUSIONS

We observed a long-lasting reduction in OASIS rates after implementation of preventive procedures. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with an instrumental delivery. Special attention should be paid to deliveries with persistent OP position.

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.

Episiotomy: Evolution of a Common Obstetric Practice at a Public Hospital

OBJECTIVE

 This study aimed to evaluate the rate and impact of episiotomy on maternal and newborn outcomes before and after restricted use of episiotomy.

STUDY DESIGN

 This population-based observational study used an obstetric database of all deliveries since 1990 that has been maintained with quality checks. Inclusion criteria were vaginal deliveries at ≥37 weeks. Exclusion criteria included fetal malformations, multifetal gestations, or fetal deaths known on arrival to Labor and Delivery. The primary outcomes of interest were episiotomy, perineal lacerations, and newborn outcomes. To evaluate the impact of restrictive episiotomy, data from 1990 to 1997 (35% overall episiotomy rate) were compared with data from 2010 to 2017 (2.5% overall episiotomy rate). Univariable analysis of maternal and infant outcomes were performed comparing the two-time epochs with the Pearson's Chi-squared test.

RESULTS

 Overall, 268,415 women met inclusion criteria and 49,089 (18.2%) had an episiotomy. The rate of episiotomy decreased from 37% of deliveries in 1990 to 2% in 2017. A total of 82,082 deliveries occurred in the 1990 to 1997 epoch and 57,183 in 2010 to 2017. Indicated use of episiotomy was associated with a significant decrease in third and fourth degree lacerations. Immediate newborn condition (5-minute Apgar's score ≤3 and umbilical artery pH <7.1) and neonatal outcomes (intraventricular hemorrhage [IVH] grade 3/4, positive culture sepsis, neonatal seizures, and neonatal demise) were not significantly different.

CONCLUSION

 Selective, indicated use of episiotomy compared with routine was associated with lower rates of third/fourth-degree lacerations with no change in neonatal outcomes. The common obstetric practice of routinely performing episiotomy, presumably to prevent perineal trauma, proved untrue when analyzed over almost three decades.

KEY POINTS

· Episiotomy use decreased overtime at our institution.. · Decreased episiotomy use was associated with significant improvement in maternal outcomes.. · Neonatal outcomes were unchanged suggesting no deleterious effects with restricted episiotomy..

Is an episiotomy always necessary during an operative vaginal delivery with vacuum? A longitudinal study

Objective: The use of episiotomy during operative vaginal birth (OVB) is rather debated among operators and in literature. It is also important to evaluate the indications for which episiotomy is performed. In fact, the consequences of an episiotomy can be invalidating for patients with long-lasting results. The aim of this study is the evaluation of the role of episiotomy during OVB with the vacuum extractor and its correlation with Obstetric Anal Sphincter Injuries (OASIs).Methods: On of 9165 vaginal births, a total of 498 OVB (5.4%) were enrolled in a longitudinal prospective observational study. The incidence of OASIs was evaluated in our population after OVB performed with the vacuum extractor, during which the execution of episiotomy was performed indicated by clinician in charge.Results: OASIs occurred in 4% of the patients (n = 20). Episiotomy was performed in 39% of them (n = 181). OASIs incidence was 6% (n = 17) in the No Episiotomy and 1.8% (n = 3) in Episiotomy group (p<.001). Performance of episiotomy during OVB determined a protective effect against OASIs (p = 0.025 in full cohort and p = 0.013 in the primiparous group). An expulsive phase under one hour was an almost significant protective factor (p = 0.052).Conclusions: The use of episiotomy during OVB was associated with much lower OASIs rates in nulliparous women with a vacuum extraction; OR 0.23 (CI 95% 0.07-0.81) p = 0.037 in nulliparous women and the number necessary to treat was 18 among nulliparous women to prevent 1 OASIs. A further risk factor that emerged from the analysis is a prolonged expulsive period, whereas fundal pressure does not seem to have a statistically significant influence.

Trends in obstetric anal sphincter injury in spontaneous vaginal delivery versus operative vaginal delivery over a 10-year period: Lessons learned

OBJECTIVE

To evaluate trends in the incidence of women with obstetric anal sphincter injuries (OASIS) over a 10-year period comparing spontaneous vaginal delivery (SVD) and operative vaginal delivery (OVD).

METHODS

A retrospective study was performed in which all women who underwent vaginal delivery over a 10-year period (n = 86 242, 2009-2018) at the Rotunda Hospital were reviewed. The overall incidence of OASIS was compared with incidence rates stratified by parity and type of vaginal birth.

RESULTS

The 10-year vaginal delivery rate was 69% (n = 59 187) where 24 580 women (42%) were primiparous and 34 607 women (58%) were multiparous. SVD rate was 74% and OVD rate was 26%. The overall incidence of OASIS was 2.9%. The incidence of OASIS in OVD was 5.5% and the incidence in SVD was 2%. Of 498 multipara who sustained OASIS, 366 (73%) had an SVD without episiotomy compared with 14 (3%) who had an episiotomy. There was a significant reduction of OASIS over the 10-year period in primipara who had an OVD but no reduction in the other groups.

CONCLUSION

The primiparous OVD group had a significant reduction of OASIS. Continued education around perineal protection and episiotomy at SVD could positively impact further reduction in OASIS, particularly in the SVD groups.

Magnitude and factors associated with birth preparedness and complication readiness among pregnant women in Wolaita Zone, Ethiopia

OBJECTIVE

To assess the magnitude and factors associated with birth preparedness and complication readiness (BPCR) among pregnant women in Humbo district, Wolaita Zone, Ethiopia.

METHODS

A community-based cross-sectional study was conducted from August 1 to 30, 2020. A total of 506 pregnant women were randomly selected and interviewed using a questionnaire. Data were entered using EpiData version 4.6.0, and analysis was made using SPSS version 24. An adjusted odds ratio (aOR) with a 95% confidence interval (CI) was calculated.

RESULTS

The magnitude of BPCR in the Humbo district was 26.0%. The odds of being prepared for birth and its complications were higher among women who had a history of obstetric complications (aOR 2.77; 95% CI 1.18-6.52), participated in pregnant women's conferences (aOR 3.84; 95% CI 2.13-6.93), received advice on BPCR (aOR 2.39; 95% CI 1.36-4.22), and were knowledgeable on labor and childbirth danger signs (aOR 2.64; 95% CI 1.55-4.49).

CONCLUSION

The magnitude of birth preparedness and complication readiness was low in the study area. The healthcare provider should encourage the women to participate in conferences and provide continuous counseling during their prenatal care visits.

Knowledge, attitude and acceptability regarding antenatal perineal massage in Thai pregnant women

INTRODUCTION AND HYPOTHESIS

Antenatal perineal massage for obstetric anal sphincter injury prevention is not routinely performed in Thailand. Due to the cultural conservatism in the country, attitudes and acceptability need to be evaluated before procedure implementation. This research was conducted to evaluate knowledge, attitudes, and acceptability of antenatal perineal massage and identify associated factors for acceptability in antenatal perineal massage among Thai pregnant women.

METHODS

A cross-sectional study was conducted in the antenatal clinic at King Chulalongkorn Memorial Hospital, Bangkok, Thailand between July 2021 and June 2022. Thai women with singleton pregnancies at 22 weeks or more of gestation without an indication for cesarean section were enrolled. Knowledge, attitudes, and acceptability of antenatal perineal massage were assessed using a self-administered questionnaire. In-depth interviews with pregnant women who were not interested in antenatal perineal massage were also completed.

RESULTS

A total of 144 pregnant women were enrolled with 119 participants (83%) having an accepting attitude about antenatal perineal massage. Results on knowledge included 22 (15%) participants aware of this practice, 46 participants (31.9%) knew it should be practiced after GA 34 weeks, 52 participants (36.1%) knew the massage should be maintained for 5-10 min, and 37 participants (25.7%) knew it should be performed daily. Factors associated with acceptability of antenatal perineal massage were prior interest in perineal massage and trust in the benefit of the perineal massage in facilitating vaginal delivery. Reasons for disagreeing in antenatal perineal massage included never hearing of perineal massage, concern about pregnancy complications, fear of pain, believing it to be a useless procedure, and previous successful vaginal delivery.

CONCLUSIONS

We found high acceptability for antenatal perineal massage. This program should be routinely explained and offered to Thai pregnant women to prevent severe perineal trauma and postpartum complications.

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 effectiveness of interventions in the prevention of perineal trauma in parturients: A systematic review with meta-analysis

AIM

To investigate the effectiveness of interventions to prevent the occurrence of perineal trauma in parturients.

METHODS

A bibliographic search was carried out in Cochrane Library, MEDLINE via PUBMED, LILACS via Virtual Health Library (VHL), Embase, Scopus, CINAHL, Scielo, Web of Science, and PEDro databases. Randomized clinical trials evaluating the effects of any intervention to prevent perineal trauma during pregnancy and/or childbirth were included. There were no temporal or language restrictions. The risk of bias assessment was performed using the Revised Cochrane Risk-of-bias Tool for Randomized Trials.

RESULTS

Fifty studies, with a total of 17,221 participants, were included in this meta-analysis. No intervention during childbirth was effective for the prevention of perineal trauma (RR = 1.07, 95% CI [0.98.1.18], p < 0.01, I² = 83%) when compared to no intervention. However, a lower risk of perineal laceration was verified with techniques performed during pregnancy, when compared to no intervention (RR = 0.81, 95% CI [0.71, 0.93], p = 0.05, I² = 47%). Among them, highlight the effects of perineal massage in preventing lacerations (RR = 0.69, 95% CI [0.54, 0.87], p < 0.01) when compared to no intervention.

CONCLUSIONS

The techniques performed during pregnancy, especially perineal massage, are associated with a lower risk of perineal laceration.

Efficacy of warm compresses in preserving perineal integrity and decreasing pain during normal labor: A systematic review and meta-Analysis

The objective of the study was to assess the effect of warm compresses in preserving perineal integrity in women who delivered a single baby vaginally with cephalic presentation. We searched PubMed, Scopus, and the ISI Web of Science databases. Two researchers worked independently and conducted the study's search, selection, and extraction. We calculated the pooled risk ratio (R.R.)- for our categorical outcomes- and mean difference (M.D.)-for our continuous outcomes- using random or fixed-effect meta-analysis according to heterogenicity status. I2 test was used to detect heterogenicity. Studies were assessed for methodological quality using the Cochrane risk of bias assessment tool. Our study analyzed 13 controlled trials (n= 3947) to compare warm compresses versus not using it during vaginal delivery. The analysis revealed that warm compresses group had better outcomes regarding episiotomy, degree of perineal trauma (third and fourth degree), perineal trauma requiring suturing, and also in behavioral pain scales (severe muscle tense, being very restless, and constant grimacing) with the following R.R. and confidence intervals: (R.R.= 0.56, 95% C.I.[0.23, 1.37]), (R.R.= 0.69, 95% C.I.[0.54, 0.89], p= 0.004),( (R.R.= 0.37, 95% C.I.[0.18, 0.77], p= 0.004), and ( (R.R.= 0.42, 95% C.I.[0.23, 0.78], p= 0.006) respectively. We conclude that among primiparous women, warm compresses group showed better outcome in improving perineal comfort than a the good of women who did not receive warm compresses after delivery.

Effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women: A systematic review and meta-analysis

BACKGROUND

Perineal massage during childbirth has been recommended as an effective measure to prevent perineal injury. However, the overall effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women remain inconclusive. Particularly, the effects of perineal massage begun during different stages of labor need to be further investigated.

OBJECTIVES

To comprehensively review the effects of perineal massage during childbirth on primiparous health outcomes, including perineal-related outcomes, duration of labor, hemorrhage and postpartum perineal pain, and neonatal outcomes, including Apgar scores and neonatal complications, and to further explore the effects of perineal massage begun during different stages of labor.

DESIGN

A systematic review and meta-analysis following the Cochrane Handbook guidelines and PRISMA2020.

METHODS

A systematic search strategy was developed following the three-phase search approach, and the literature search was conducted in electronic databases and clinical trial registers from inception to 7th January 2022. Study selection and data extraction were completed independently by two researchers. The updated Cochrane risk of bias 2.0 tool for randomized trials was chosen to evaluate the quality of included studies. Data analyses were conducted using the Revman5.4 software, and subgroup analyses were performed based on the different start times of perineal massage. Furthermore, the certainty of body of evidence for each outcome was assessed utilizing the GRADEpro online tool.

RESULTS

Seventeen randomized controlled trials involving 3248 primiparous women were included in the review. The pooled results of meta-analyses indicated that perineal massage begun during the second stage of labor significantly increased the occurrence of intact perineum (RR = 2.78, 95 % CI: [1.52, 5.05], P < 0.001), reduced the rate of second- and third-degree perineal lacerations (P < 0.05), and decreased the incidence of episiotomy (RR = 0.63, 95 % CI: [0.50, 0.79], P < 0.001), while perineal massage during the first stage of labor effectively shortened the duration of the first and second stages of labor (P < 0.05). The available evidence also suggests the potential role of perineal massage on hemorrhage and long-term postpartum perineal pain (P < 0.05). However, the aggregated results failed to demonstrate the beneficial effects of perineal massage on neonatal outcomes (P > 0.05).

CONCLUSIONS

Perineal massage begun during the second stage of labor effectively improves the perineal-related outcomes in primiparous women, while perineal massage during the first stage of labor significantly shortens the duration of labor. High-quality studies exploring the standardized procedure for perineal massage and the short- and long-term effects of perineal massage are warranted.

REGISTRATION NUMBER

CRD42022302336 (PROSPERO).

Birth preparedness and complication readiness practice and associated factors among pregnant women in Central Ethiopia, 2021: A cross-sectional study

Background

Birth preparedness and complication readiness (BP/CR) is an intervention designated by the World Health Organization (WHO) as an essential element of the antenatal (ANC) package with a concept of a global strategy to reduce maternal mortality. In Ethiopia, the proportion of pregnant women preparing for birth and related complications has remained low. Whereas, the need for additional study is indicated to add more evidence to the country’s efforts to end preventable maternal death.

Methods

A facility-based cross-sectional study was conducted from March 01 to May 01, 2021. A systematic random sampling technique was applied to recruit 422 pregnant women. Bivariable and multivariable binary logistic regression was fitted to identify factors associated with BP/CR practice. Variables with a p-value ≤ 0.25 on the bivariable analysis were included in multivariable analysis. Adjusted odds ratios (AOR) with the respective 95% confidence interval (CI) and a p-value <0.05 was used to set statistically significant variables in the multivariable analysis.

Results

A total of 414 pregnant women have participated in the study. The overall BP/CR practice level was 44.9% (95% CI: 40.1, 49.7). Preconception care utilization (PCC) (AOR = 2.31; 95% CI:1.38–3.86), urban residents (AOR = 2.00; 95% CI:1.21–3.31), knowledge of BP/CR (AOR = 2.29; 95% CI:1.27–3.47), knowledge of danger signs during pregnancy (AOR = 2.05; 95% CI:1.21–3.47), knowledge of danger signs in newborns (AOR = 2.06; 95% CI:1.21–3.47), starting ANC visits in the 1^st and 2^nd trimester (AOR = 2.52; 95% CI:1.40–4.52), number of ANC visit ≥ three (AOR = 1.66; 95% CI;1.01–2.74), knowing Expected Date of Delivery (EDD) (AOR = 3.71; 95% CI:2.01–6.82), and joint decision-making on obstetric services (AOR = 3.51; 95% CI;1.99–6.20) were factors significantly associated with BP/CR practice.

Conclusion

Based on the WHO standard, this study revealed a low level of BP/CR practice among pregnant women, with only less than half of women adequately prepared for childbirth and its complications. Moreover, it has been shown that BP/CR practice is influenced by socio-economic, maternal knowledge, and health service-related factors. Therefore, improving the status of BP/CR practice by expanding awareness creation opportunities, strengthening PCC and early ANC initiation by improving pregnant women’s understanding, and promoting joint decision-making on obstetric services are recommended.

Perineal Massage during Pregnancy for the Prevention of Postpartum Urinary Incontinence: Controlled Clinical Trial

Background and objectives: Urinary incontinence is any involuntary loss of urine. It may result in anxiety, depression, low self-esteem and social isolation. Perineal massage has spread as a prophylactic technique for treating complications during labor. Acknowledged effects of perineal massage are reduction of incidence and severity of perineal tear and use of equipment directly related to the intrapartum perineal trauma. The aim of this study was to determine the effectiveness of massage in urinary incontinence prevention and identification of possible differences in its form of application (self-massage or by a physiotherapist), with the previous assumption that it is effective and that there are differences between the different forms of application. Materials and Methods: A controlled clinical trial with a sample of 81 pregnant women was conducted. The participants were divided into three groups: a group that received the massage applied by a specialized physiotherapist, another group that applied the massage to themselves, and a control group that only received ordinary obstetric care. Results: No differences were identified in the incidence or severity of urinary incontinence among the three groups. The severity of the incontinence was only affected by the body mass index and the weight of the baby at the time of delivery. Conclusions: A relationship between perineal massage interventions and development of urinary incontinence has not been observed.

Partograph utilization and associated factors among obstetric care givers in governmental health institutions of Jigjiga and Degehabur towns, Somali region, Ethiopia: A cross-sectional study

Background

Partograph is a simple, inexpensive & economical tool that provides a continuous graphical overview of labour and prevents prolonged and obstructed labor. The purpose of the study is to assess partograph utilization and associated factors among obstetric care givers in governmental health institutions of Jigjiga and Degehabur Towns, Somali Region, Ethiopia.

Methods

An institution based cross-sectional quantitative study was carried out among obstetric care givers who were working in governmental health institutions. Systematic random sampling with proportional to size allocation was used to recruit a total of 235 study participants. Self-administered questionnaire was used to collect data in this study. Three data collectors and one supervisor were recruited and trained to facilitate the data collection activities. Data were entered into Epi data software and exported into SPSS (23.0) for analysis. Descriptive statistics, bivariate and multivariate logistic regression were computed to determine proportions and significant association with partograph utilization among obstetric care givers.

Result

Less than half of obstetric care givers, 41% (95%CI: 34.5–46.9) had good partograph utilization to monitor progress of labor. Being female [AOR = 2.36, 95%CI:(1.03–5.44)], availability of partograph [AOR = 4.633, 95%CI: (1.698–12.640)], having good knowledge [AOR = 6.90, 95%CI:(2.62–18.18)], receiving on job training [AOR = 15.46, 95%CI:(6.95–34.42)] and positive attitude towards partograph [AOR = 2.99, 95%CI:(1.25–7.14)] were significantly associated with partograph utilization.

Conclusion

Partograph utilization in this study was low. Especial emphasizes and interventions should be given to periodic on job training that improve knowledge and attitude of obstetric care givers to increase partograph utilization.

Intrapartum group B Streptococcal prophylaxis and childhood weight gain

OBJECTIVE

To determine the difference in rate of weight gain from birth to 5 years based on exposure to maternal group B streptococcal (GBS) intrapartum antibiotic prophylaxis (IAP).

DESIGN

Retrospective cohort study of 13 804 infants.

SETTING

Two perinatal centres and a primary paediatric care network in Philadelphia.

PARTICIPANTS

Term infants born 2007-2012, followed longitudinally from birth to 5 years of age.

EXPOSURES

GBS IAP defined as penicillin, ampicillin, cefazolin, clindamycin or vancomycin administered ≥4 hours prior to delivery to the mother. Reference infants were defined as born to mothers without (vaginal delivery) or with other (caesarean delivery) intrapartum antibiotic exposure.

OUTCOMES

Difference in rate of weight change from birth to 5 years was assessed using longitudinal rate regression. Analysis was a priori stratified by delivery mode and adjusted for relevant covariates.

RESULTS

GBS IAP was administered to mothers of 2444/13 804 (17.7%) children. GBS IAP-exposed children had a significantly elevated rate of weight gain in the first 5 years among vaginally-born (adjusted rate difference 1.44% (95% CI 0.3% to 2.6%)) and caesarean-born (3.52% (95% CI 1.9% to 5.2%)) children. At 5 years, the rate differences equated to an additional 0.24 kg among vaginally-born children and 0.60 kg among caesarean-born children.

CONCLUSION

GBS-specific IAP was associated with a modest increase in rate of early childhood weight gain. GBS IAP is an effective intervention to prevent perinatal GBS disease-associated morbidity and mortality. However, these findings highlight the need to better understand effects of intrapartum antibiotic exposure on childhood growth and support efforts to develop alternate prevention strategies.

Mode of delivery of women with Swyer syndrome in a German case series

OBJECTIVES

For women with Swyer Syndrome, a 46,XY gonadal dysgenesis, full term pregnancies are possible after oocyte donation. According to literature, mode of delivery is almost always by Caesarean section for various reasons. Medical indications are multiple pregnancies and related complications, preeclampsia, an androgynous shaped pelvis and failed induction of labor. Elective Caesarean sections were performed based on maternal request and medical recommendation.

METHODS

Following careful examination and shared decision making, we planned a spontaneous delivery with a patient with Swyer syndrome and tested the different hypotheses regarding anatomical and functional features according to literature. In addition, deliveries of women with Swyer Syndrome were analyzed in a German multicenter case series.

RESULTS

A total of seven women with Swyer syndrome with a total of 10 pregnancies were identified, who later gave birth to twelve live-born children. Seven out of 10 births were performed by elective and non-elective Caesarean section, three births took place vaginally.

CONCLUSIONS

In summary, the risk of Caesarean section delivery has increased, but spontaneous delivery can be attempted in the event of inconspicuous findings.

Anesthesia in Parturients Presenting with Marfan Syndrome

BACKGROUND

Pregnant women with Marfan syndrome (MS) have a high risk of aortic dissection around delivery and their optimal management requires a multi-disciplinary approach, including proper cardio-obstetric care and adequate pain management during labor, which may be difficult due to the high prevalence of dural ectasia (DE) in these patients.

OBJECTIVES

To evaluate the multidisciplinary management of MS patients during labor.

METHODS

Nineteen pregnant women (31 pregnancies) with MS were followed by a multi-disciplinary team (cardiologist, obstetrician, anesthesiologist) prior to delivery.

RESULTS

Two patients had kyphoscoliosis; none had previous spine surgery nor complaints compatible with DE. In eight pregnancies (7 patients), aortic root diameter (ARd) before pregnancy was 40 to 46 mm. In this high-risk group, one patient underwent elective termination, two underwent an urgent cesarean section (CS) under general anesthesia, and five had elective CS; two under general anesthesia (GA), and three under spinal anesthesia. In 23 pregnancies (12 patients), ARd was < 40 mm. In this non-high-risk group three pregnancies (1 patient) were electively terminated. Of the remaining 20 deliveries (11 patients), 14 were vaginal deliveries, 9 with epidural analgesia and 5 without. Six patients had a CS; four under GA and two2 under spinal anesthesia. There were no epidural placement failures and no failed responses. There were 2 cases of aortic dissection, unrelated to the anesthetic management.

CONCLUSIONS

The optimal anesthetic strategy during labor in MS patients should be decided by a multi-disciplinary team. Anesthetic complications due to DE were not encountered during neuraxial block.

Clinical evaluation of labor: an evidence- and experience-based approach

During labor mother and fetus are evaluated at intervals to assess their well-being and determine how the labor is progressing. These assessments require skillful physical diagnosis and the ability to translate the acquired information into meaningful prognostic decision-making. We describe a coordinated approach to the assessment of labor. Graphing of serial measurements of cervical dilatation and fetal station creates "labor curves," which provide diagnostic and prognostic information. Based on these curves we recognize nine discrete labor abnormalities. Many may be related to insufficient or disordered contractile mechanisms. Several factors are strongly associated with development of labor disorders, including cephalopelvic disproportion, excess analgesia, fetal malpositions, intrauterine infection, and maternal obesity. Clinical cephalopelvimetry involves assessing pelvic traits and predicting their effects on labor. These observations must be integrated with information derived from the labor curves. Exogenous oxytocin is widely used. It has a high therapeutic index, but is easily misused. Oxytocin treatment should be restricted to situations in which its potential benefits clearly outweigh its risks. This requires there be a documented labor dysfunction or a legitimate medical reason to shorten the labor. Normal labor and delivery pose little risk to a healthy fetus; but dysfunctional labors, especially if stimulated excessively by oxytocin or terminated by complex operative vaginal delivery, have the potential for considerable harm. Conscientiously implemented, the approach to the evaluation of labor outlined in this review will result in a reasonable cesarean rate and minimize risks that may accrue from the labor and delivery process.

The knowledge of danger signs of obstetric complications among women in rural India: evaluating an integrated microfinance and health literacy program

BACKGROUND

Maternal mortality can be prevented in low-income settings through early health care seeking during maternity complications. While health system reforms in India prioritised institutional deliveries, inadequate antenatal and postnatal services limit the knowledge of danger signs of obstetric complications to women, which delays the recognition of complications and seeking appropriate health care. Recently, a novel rapidly scalable community-based program combining maternal health literacy delivery through microfinance-based women-only self-help groups (SHG) was implemented in rural India. This study evaluates the impact of the integrated microfinance and health literacy (IMFHL) program on the knowledge of maternal danger signs in marginalised women from one of India's most populated and poorer states - Uttar Pradesh. Additionally, the study evaluates the presence of a diffusion effect of the knowledge of maternal danger signs from SHG members receiving health literacy to non-members in program villages.

METHODS

Secondary data from the IMFHL program comprising 17,232 women from SHG and non-member households in rural Uttar Pradesh was included. Multivariate logistic regression models were used to identify the program's effects on the knowledge of maternal danger signs adjusting for a comprehensive range of confounders at the individual, household, and community level.

RESULTS

SHG member women receiving health literacy were 27% more likely to know all danger signs as compared with SHG members only. Moreover, the results showed that the SHG network facilitates diffusion of knowledge of maternal danger signs from SHG members receiving health literacy to non-members in program villages. The study found that the magnitude of the program impact on outcome remained stable even after controlling for other confounding effects suggesting that the health message delivered through the program reaches all women uniformly irrespective of their socioeconomic and health system characteristics.

CONCLUSIONS

The findings can guide community health programs and policy that seek to impact maternal health outcomes in low resource settings by demonstrating the differential impact of SHG alone and SHG plus health literacy on maternal danger sign knowledge.

Perineal management: Midwives' confidence and educational needs

OBJECTIVE

The overall aim of this study was to collate information to inform the updating of a perineal management educational programme for midwives. This paper explores midwives' confidence and educational needs in managing the woman's perineum during the second stage of labour, focusing on future quality initiatives to improve midwives' experiences and expertise in the prevention of perineal trauma during birth.

DESIGN

A mixed-methods sequential exploratory design was used.

PARTICIPANTS AND SETTING

Midwives and clinical midwife managers assisting with births in the labour ward of a large urban university stand-alone maternity hospital in the Republic of Ireland with approximately 9,000 births per year participated in the study.

MEASUREMENTS

A questionnaire and two focus groups were used to collect the data.

FINDINGS

Fifty-two midwives from a total of 64 eligible labour ward midwives completed the questionnaire, a response rate of 81.2%. Midwives indicated that perineal management workshops did not cover prevention of perineal trauma, and mainly focused on suturing and repair of the perineum. The majority of midwives (85%) indicated that they would like further education on the prevention of perineal trauma. Higher levels of confidence in making a decision to perform an episiotomy, infiltrating the perineum and at performing an episiotomy were reported in experienced midwives. Midwives want improved and additional education in the management of women's perinea during the second stage of labour and made various recommendations regarding the content, format, timing and frequency of the workshop. Suggestions for further education included techniques for preventing perineal trauma during labour and birth and how to perform an episiotomy.

KEY CONCLUSIONS

This study provides key insights into midwives' confidence and educational needs in relation to managing the woman's perineum during the second stage of labour. The findings from this study demonstrates the appetite of midwives for additional education in the area of perineal management, particularly prevention strategies.

IMPLICATIONS FOR PRACTICE

Midwives play an essential role in reducing the rates of perineal trauma through regular education. It is therefore important that midwives keep up to date with the best available evidence. Updating existing perineal management educational programmes that are tailor made to midwives' needs could not only improve clinical skills and perineal protection techniques but also midwives' confidence in decision making. The overall aim is to reduce perineal trauma in women having a spontaneous vaginal birth.

Partograph Utilization and Associated Factors among Obstetric Care Providers Working in Public Health Facilities of Wolaita Zone, 2017

BACKGROUND

Obstructed or prolonged labor is a major cause of maternal deaths. Prolonged and obstructed labor contributed to 13% of global maternal deaths which can be reduced by proper utilization of a partograph during labor. Obstetric caregivers' use of the partograph during labor has paramount importance in identifying any deviation during labor. Even though partograph use is influenced by different factors as obtained from the literatures, the magnitude of partograph utilization and the factors associated with its use are not well determined in the health facilities of Wolaita Zone.

OBJECTIVE

To assess the magnitude of partograph utilization and factors that affect its utilization among obstetric caregivers in public health facilities of Wolaita Zone, Ethiopia, 2017.

METHODS

An institution-based cross-sectional study was conducted on obstetric caregivers. A pretested and structured questionnaire was used to collect data. Data was entered to EpiData version 3.01 and exported to SPSS version 23.0 for further analysis. Logistic regression analyses were used to see the association of different variables.

RESULT

A total of 269 obstetric caregivers participated in the study. Among those who were utilizing the partograph, 193 (71.7%) routinely used it for all laboring mothers and 76 (28.3%) of participants reported that they do not routinely utilize it. Greater number of service years (AOR = 4.93, 95% CI: 1.53-15.88), on-the-job training (AOR = 0.16, 95% CI: 0.06-0.43), good knowledge (AOR = 3.35, 95% CI: 1.61-6.97), and favorable attitude towards partograph utilization (AOR = 2.99, 95% CI: 1.28-7.03) were significantly associated with partograph utilization. Conclusion and Recommendation. Partograph utilization among obstetric caregivers in the public health facilities was good. Greater years of work experience, in-service training, having good knowledge, and favorable attitude towards partograph utilization among obstetric caregivers independently determined partograph utilization. Provision of on-the-job training to make obstetric caregivers improve knowledge and skill on partograph utilization, maintaining caregivers' retention to decrease turnover by providing different incentives to more experienced obstetric care providers, and establishing favorable attitude could improve the proper use of the tool.

Influence of non-pharmacological obstetric interventions on adverse outcomes of childbirth under regional analgesia

Background We examined the influence of companionship and the use of complementary therapies on adverse outcomes in parturients under regional analgesia. Methods This study is a single-center retrospective cohort of 986 term pregnant women, and it was based on data from medical records (hospitalization period: November 2012-November 2018). The women were in the active phase of labor under regional analgesia. A statistical program was used to search for an association between companionship and the use of complementary therapies with sample data. Bi- and multivariate logistic regressions based on significant associations were used to analyze the potential intervening variables in the adverse outcomes. Results Models were constructed for each of the maternal adverse outcomes. Childbirth complications were significantly associated with complementary therapies [adjusted odds ratio (AOR) = 0.42; 95% confidence interval (CI) = 0.28-0.63; P < 0.001] and companionship (AOR = 0.36; 95% CI = 0.22-0.57; P < 0.001). Prolonged maternal hospitalization was significantly associated with companionship (AOR = 0.57; 95% CI = 0.36-0.92; P < 0.05). Unplanned cesarean section showed a significant association with complementary therapies (AOR = 0.05; 95% CI = 0.01-0.47; P < 0.01). Conclusion The likelihood of childbirth complications and prolonged maternal hospitalization is reduced by companionship, whereas the likelihood of childbirth complications and cesarean section rates is reduced by the use of complementary therapies.

Proactive versus standard support of labour in nulliparous women; study protocol for a randomized, controlled trial

BACKGROUND

Prolonged latent phase of labour often results in a traumatic birth experience. Prolonged labour is associated with more operative deliveries, haemorrhage, fetal asphyxia and poor birth experience. Women with prolonged labour in a former pregnancy more often demand caesarean section in the next, due to their negative birth experience. "Proactive support of labour" is an alternative method, developed to counteract prolonged labour. There are little research and no randomized controlled study that compare proactive to standard labour support.

METHODS/DESIGN

A prospective, non-blinded, randomized, single-centre, clinical trial where we compare proactive support to standard support of labour in a university hospital setting.

INCLUSION CRITERIA

latent phase of labour, non-pathologic pregnancy. Robson group 1, with painful contractions, and fully effaced cervix, with 1-3 cm dilatation.

EXCLUSION CRITERIA

induction of labour, breech presentation, twin pregnancy, multi-parity, conditions that require extended surveillance before and/or during labour.

PRIMARY OUTCOME

spontaneous, uncomplicated vaginal delivery. After inclusion, women randomized to proactive support of labour will stay at the hospital and have one-to-one midwife support. If no progression during the next 1-2 hours, amniotomy and/or oxytocin stimulation will be started. The control group will adhere to the standard procedures for labour support: expectance until established regular contractions and 4-5 cm cervical dilatation, and then one-to-one midwife support.

DISCUSSION

The idea of proactive support of labour is to initiate early intervention when there are signs of slow progress in order to avoid protracted labour with exhaustion of the mother, the uterus and prolonged stress of the foetus. Proactive support of labour may represent a useful method to improve labour support in nulliparous women. However, evidence based on randomized controlled trials are needed in order to know whether proactive support of labour is comparable or superior to standard care. A randomized, controlled trial is described; challenges and possible clinical implications are discussed.

TRIAL REGISTRATION

The Proactive Support of Labor Study (PAF) ClinicalTrials, NCT03056313. Registered on February 17, 2017.

Prevalence and risk factors of obstetric fistula: implementation of a need-based preventive action plan in a South-eastern rural community of India

BACKGROUND

The study was conducted to estimate the prevalence and risk factors of obstetric fistula in the rural area of the south eastern community of India and the training of community health workers for its prevention.

METHODS

A population-based cross-sectional analytical study was conducted in the south eastern rural community of India. A total of 3939 women were included in the study and Probability proportional to size sampling was used in the study. Frequency distribution and logistic regression were computed to analyse the data using STATA version 11.2.

RESULTS

Out of 3939 participants interviewed, 23.7% women reported obstetric fistula symptoms whereas after clinical diagnosis and speculum examination the obstetric morbidity pattern was: Obstetric fistula 0.3%, stress urinary incontinence 20.0%, pelvic inflammatory diseases 1.2%, uterine prolapse 1.4% and urinary tract infection 3.8%. The awareness level of the rural women regarding the obstetric fistula was assessed by a structured knowledge questionnaire and found to be very poor, hence community based fistula training was implemented among community health workers as a health system based strategy for its prevention. Obstetric fistula found to be more prevalent among women of poor educational level, low socioeconomic status, less no of antenatal visits, delay in accessing the emergency obstetric care and prolonged labour (p ≤ 0.05).

CONCLUSION

Finding of the study indicated that the prevalence and risk of developing obstetric fistula was associated with less number of antenatal visits, prolonged labour, delay in timely intervention, delay in accessing emergency obstetric care and more number of movements from home to the delivery place. Finally, our study suggests that emphasis needs to be placed on training of community health workers to facilitate early screening for identification and referral of women with obstetric fistula.

Vaginal delivery is safely achieved in pregnancies complicated by spinal cord injury: a retrospective 25-year observational study of pregnancy outcomes in a national spinal injuries centre

BACKGROUND

Women with spinal cord injuries (SCI) represent a high risk population during pregnancy with comparatively few studies in the literature regarding their management and pregnancy outcomes, due to the relative rarity of the condition. Our objective was to assess pregnancy outcomes in women with spinal cord injury.

METHODS

We performed a retrospective observational study of pregnancy outcomes by reviewing maternity records of all pregnant women with SCI attending the National Spinal Injury Centre at Buckinghamshire NHS Trust between 1991 and 2016. The outcome measures were Maternal demographic data, antenatal complications, method of anaesthetic, intrapartum data (gestation at delivery, onset of labour, mode of delivery, indication for obstetric intervention) and neonatal outcomes (low birth weight, stillbirth, neonatal death).

RESULTS

Fifty women with a total of 68 pregnancies were identified. Five patients sustained SCI during pregnancy and the remaining 63 pregnancies were conceived at least 1 year after SCI, of which 45 pregnancies had a SCI at T10 or above (73%) and 23 pregnancies at T11 or below (27%). The most common antenatal complications in SCI patients were worsening of spasms (38%) and urinary tract infection (24%). Preterm delivery occurred in 18% of women. Vaginal delivery was achieved in 77% of pregnancies, including 14% instrumental delivery rate and 23% Caesarean delivery rate.

CONCLUSIONS

Our findings support the current evidence that pregnancy outcomes are generally successful and that vaginal delivery can be safely achieved in the majority of women, independent of the level of SCI.

Utilization of Partograph and its associated factors among midwives working in public health institutions, Addis Ababa City Administration,Ethiopia,2017

BACKGROUND

Partograph is cost effective and affordable tool designed to provide a continuous pictorial overview and labour progress used to prevent prolonged and obstructed labour. It consists of key information about progress of labour, fetal condition and maternal condition. Its role is to improve outcomes and predict the progress of labour. The aim of this study was to assess utilization of partograph and its predictors among midwives working in public health facilities, Addis Ababa city administration, Ethiopia, 2017.

METHODS

An institution based cross-sectional study design was conducted in Addis Ababa, Ethiopia from 15/10/2017-15/12/2017.Simple random sampling under multistage sampling technique was applied to select a total of 605 midwives working in maternity unit of selected public health facilities. Data were collected using structured self-administered questionnaire. Checklist based direct observations were made to all midwife participants to determine the actual practical use of partograph. Data first entered in to EpiInfo version 3.5.1 and transported to SPSS Version 21.Descriptive statistics such as frequency, percentage, mean, and median were calculated. Biviriate and multivariable logistic regression analysis were applied. Any personal identification of the study participants was not recorded during data collection to ensure confidentiality of information.

RESULTS

In this study, the utilization of partograph was 409(69%) out of 594 study participants. Being mentored(AOR = 3.1; 95% CI: 1.7, 5.3),received training (AOR = 2.4; 95% CI:1.5,3.6),being knowledgeable about partograph (AOR = 1.6; 95% CI: 1.1, 2.5), health center workers(AOR = 12.6; 95% CI:5.1,31.6),supportive supervision 4 times per year (AOR = 18.6; 95% CI: 6.6,25),supportive supervision twice per a year (AOR = 4.7; 95% CI: 1.9, 11.3),supportive supervision once per year (AOR =3.8;95% CI:1.7,8.8) were positive predictors of partograph utilization. Two midwives per shift (AOR = 0.101; 95% CI: 0.05, 0.65), and 4 per shift (AOR = 0.105, 95% CI: 0.03, 0.40) were protective predictors of partograph utilization.

CONCLUSIONS

More than half of the respondents utilized partograph. All public health institutions avail partograph in their laboring room but didn't utilize it according to WHO recommended standard. Working facility, supportive supervision, mentoring, training on partograph, number of midwives working per shift, and knowledge were factors affecting partograph utilization. Encouraging interventions are recommended to the response of the above significantly associated factors.

Preventing Cesarean Birth in Women with Obesity: Influence of Unit-Level Midwifery Presence on Use of Cesarean among Women in the Consortium on Safe Labor Data Set

INTRODUCTION

Maternal obesity is associated with slow labor progression and unplanned cesarean birth. Midwives use fewer medical interventions during labor, and the women they care for have lower cesarean birth rates, compared with low-risk, matched groups of women cared for by physicians. The primary aim of this study was to examine associations between midwifery unit-level presence and unplanned cesarean birth in women with different body mass index (BMI) ranges. Unit-level presence of midwives was analyzed as a representation of a unique set of care practices that exist in settings where midwives work.

METHODS

A retrospective cohort study was conducted using Consortium on Safe Labor data from low-risk, healthy women who labored and gave birth in medical centers with (n = 9795) or without (n = 13,398) the unit-level presence of midwives. Regression models were used to evaluate for associations between unit-level midwifery presence and 1) the incidence of unplanned cesarean birth and 2) in-hospital labor durations with stratification by maternal BMI and adjustment for maternal demographic and pregnancy factors.

RESULTS

The odds of unplanned cesarean birth among women who gave birth in centers with midwives were 16% lower than the odds of cesarean birth among similar women at who gave birth at centers without midwives (adjusted odds ratio, 0.84; 95% CI, 0.77-0.93). However, women whose BMI was above 35.00 kg/m2 at labor admission had similar odds of cesarean birth, regardless of unit-level midwifery presence. In-hospital labor duration prior to unplanned cesarean was no different by unit-level midwifery presence in nulliparous women whose BMI was above 35.00 kg/m2 .

DISCUSSION

Although integration of midwives into the caregiving environment of medical centers in the United States was associated with overall decrease in the incidence of cesarean birth, increased maternal BMI nevertheless remained positively associated with these outcomes.

Healthcare providers' perception of the referral system in maternal care facilities in Aceh, Indonesia: a cross-sectional study

OBJECTIVES

Our study investigates the barriers perceived by staff in the referral systems in maternal healthcare facilities across Aceh province in Indonesia.

DESIGN

With a cross-sectional approach, two sets of surveys were administered during September to October 2016 in 32 sampling units of our study. We also collected referral data in the form of the frequency of ingoing and outgoing referral cases per facility.

SETTING

In three districts, Aceh Besar, Banda Aceh and Bireuen, a total of 32 facilities including hospitals, community health centres, and private midwife clinics that met the criteria of providing at least basic emergency obstetric and neonatal care (BEonC) were covered.

PARTICIPANTS

Across the 32 healthcare centres, 149 members of staff (mainly midwives) agreed to participate in our surveys.

PRIMARY AND SECONDARY OUTCOME MEASURES

The first survey consisted of 65 items focusing on organisational measures as well as case numbers for example, patient counts, mortality rate and complications. The second survey with 68 items asked healthcare providers about a range of factors including attitudes towards the referral process in their facility and potential barriers to a well-functioning system in their district.

RESULTS

Overall, mothers'/families' consent as well as the complex administration process were found to be the main barriers (36% and 12%, respectively). Healthcare providers noted that information about other facilities has the biggest room for improvement (37%) rather than transport, timely referral of mothers and babies, or the availability of referral facilities.

CONCLUSIONS

The largest barrier perceived by healthcare providers in our study was noted to be family consent and administrative burden. Moreover, lack of information about the referral system itself and other facilities seemed to be affecting healthcare providers and mothers/families alike and improvements perhaps through a shared information system is needed.

Utilization of the partograph and its associated factors among obstetric care providers in the Eastern zone of Tigray, Northern Ethiopia, 2017: a cross-sectional study

INTRODUCTION

the partograph is a pre-printed paper form used in monitoring the progress labor. It was initially introduced by Philpot; and endorsed by the World Health Organization as a simple and accurate instrument for early recognition of complications of labor. Our study was conducted to evaluate the utilization of the partograph and associated factors among obstetric care providers in the Eastern zone of Tigray, Northern Ethiopia 2017.

METHODS

a cross-sectional study was conducted in the Eastern zone of Tigray. Four hundred and fourteen participants were randomly selected from the Eastern zone weredas (districts). Data were collected using a self-administered questionnaire. The data were entered into epi data version 3.5 and exported to SPSS V-20 for analysis. Bivariate and multivariate analysis were done to determine the association between a dependent variable and independent variables at P-value <0.05.

RESULTS

of the 406 obstetric care providers, 83% of them had utilized the partograph to monitor labor. In addition, utilization of the partograph were statistically associated with being female (AOR=2.09, 95%CI= (1.11, 3.93), age group of 20-25 (AOR=0.25, 95%CI= (0.07, 0.88), being a diplomat midwives (AOR=0.01, 95%CI= (0.00, 0.28)) and having qualified from pre-service training (AOR=0.01, 95%CI= (0.02, 0.05)).

CONCLUSION

participants' utilization of the partograph was generally good. However, most of them were using it incorrectly. Age, gender, level of educational, year of qualification from pre-service training were the variables that showed association with the utilization of the partograph. The provision of on-the-job training on the partograph is recommended to improve partograph utilization.

Effects of physical exercise during pregnancy on mothers' and neonates' health: a protocol for an umbrella review of systematic reviews and meta-analysis of randomised controlled trials

INTRODUCTION

A growing interest has emerged on the effects of exercise during gestation. Several systematic reviews and meta-analyses have shown that prenatal exercise could reduce the mothers' risk for some disorders. Despite this, evidence regarding the risk of caesarean section, birth weight or Apgar score at delivery is still controversial. Furthermore, practitioners are reluctant to recommend exercise to pregnant women suffering from some disorders, such as hypertension, pre-eclampsia or pregnant women with obesity. Moreover, the scarcity of studies addressing the risks and benefits of exercise at higher intensity prevent practitioners from recommending it at higher dosages. Umbrella reviews represent an appropriate design to elucidate the reasons behind the contradictory findings of previous systematic reviews.

METHODS

This protocol was developed according to the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols and the Cochrane Collaboration Handbook. Medline, EMBASE, Web of Science, Cochrane database of systematic reviews, Epistemonikos, Prospero register and SPORTDiscuss databases will be searched to identify systematic reviews, meta-analyses and randomised controlled trials that examine the effect of exercise on pregnancy outcomes from inception to August 2019. Searches will be conducted from September to November 2019.

STATISTICAL ANALYSIS

Methodological quality will be evaluated using the AMSTAR 2 tool. The certainty of evidence and strength of recommendations for meta-analyses will be assessed by the Grading of Recommendations Assessment, Development and Evaluation framework. The summary effect sizes will be calculated through the use of random-effects and fixed-effects models. Heterogeneity among studies will be assessed using the I2 statistic, and evidence of excess significance bias and evidence of small study effects will also be evaluated.

ETHICS AND DISSEMINATION

Ethical approval will not be needed for this review protocol. The results will be disseminated to academic audiences by peer-reviewed publications. Furthermore, results will be disseminated to clinical audiences through professionals' associations and social networks, and may influence guidelines developers in order to improve outcomes in mothers and offspring.

PROSPERO REGISTRATION NUMBER

CRD42019123410.

Warm perineal compresses during the second stage of labor for reducing perineal trauma: A meta-analysis

OBJECTIVE

Perineal trauma may have a negative impact on women's lives as it has been associated with perineal pain, urinary incontinence and sexual dysfunction. The aim of this systematic review and meta-analysis of randomized controlled trials was to evaluate the effectiveness of warm compresses during the second stage of labor in reducing perineal trauma.

METHODS

Electronic databases were searched from inception of each database to May 2019. Inclusion criteria were randomized trials comparing warm compresses (i.e. intervention group) with no warm compresses (i.e. control group) during the second stage of labor. Types of participants included pregnant women planning to have a spontaneous vaginal birth at term with a singleton in a cephalic presentation. The primary outcome was the incidence of intact perineum. Meta-analysis was performed using the Cochrane Collaboration methodology with results being reported as relative risk (RR) with 95% confidence interval (CI).

RESULTS

Seven trials, including 2103 participants, were included in this meta-analysis. Women assigned to the intervention group received warm compresses made from clean washcloths or perineal pads immersed in warm tap water. These were held against the woman's perineum during and in between pushes in second stage. Warm compresses usually started when the baby's head began to distend the perineum or when there was active fetal descent in the second stage of labor. We found a higher rate of intact perineum in the intervention group compared to the control group (22.4% vs 15.4%; RR 1.46, 95% CI 1.22 to 1.74); a lower rate of third degree tears (1.9% vs 5.0%; RR 0.38, 95% CI 0.22 to 0.64), fourth degree tears (0.0% vs 0.9%; RR 0.11, 95% CI 0.01 to 0.86) third and fourth degree tears combined (1.9% vs 5.8%; RR 0.34, 95% CI 0.20 to 0.56) and episiotomy (10.4% vs 17.1%; RR 0.61, 95% CI 0.51 to 0.74).

CONCLUSION

Warm compresses applied during the second stage of labor increase the incidence of intact perineum and lower the risk of episiotomy and severe perineal trauma.

Community perceptions of obstetric fistula in Malawi

It is well-documented that obstetric fistula, a severe birth injury, is caused by a prolonged obstructed labour that has not been relieved on time. Lay people often understand causation differently. This study sought to explore the awareness and local meanings attached to obstetric fistula in the rural parts of Malawi. We conducted interviews with key informants and focus group discussions with community members in purposively selected communities in the central region of Malawi. We categorised data using Nvivo 10 and conducted a thematic analysis. Findings indicate that there is considerable awareness about fistula in local communities; however, community members have very limited knowledge about its causes. Participants associated obstetric fistula with sexually transmitted diseases, the woman's laziness to push during labour, witchcraft and the husband's infidelity, which contributed to the isolation of the affected women. Strategies to eradicate obstetric fistula in general, and its social consequences in particular, should include more information on causes and prevention. This may help to dispel misconceptions about fistula, increase acceptance and support for women with fistula, and subsequently improve the quality of their lives and the lives of girls and women who may suffer from this condition in the future.

Automated early detection of obstetric complications: theoretic and methodologic considerations

Compared with adults who are admitted to general medical-surgical wards, women who are admitted to labor and delivery services are at much lower risk of experiencing unexpected critical illness. Nonetheless, critical illness and other complications that put either the mother or fetus at risk do occur. One potential approach to prevention is to use automated early warning systems, such as those used for nonpregnant adults. Predictive models that use data extracted in real time from electronic records constitute the cornerstone of such systems. This article addresses several issues that are involved in the development of such predictive models: specification of temporal characteristics, choice of denominator, selection of outcomes for model calibration, potential uses of existing adult severity of illness scores, approaches to data processing, statistical considerations, validation, and options for instantiation. These have not been addressed explicitly in the obstetrics literature, which has focused on the use of manually assigned scores. In addition, this article provides some results from work in progress to develop 2 obstetric predictive models with the use of data from 262,071 women who were admitted to a labor and delivery service at 15 Kaiser Permanente Northern California hospitals between 2010 and 2017.

Assessment of maternal referral systems used for a rural Zambian hospital: the development of setting specific protocols for the identification of complications

Background

In resource-limited countries, it is estimated that up to 75% of maternal deaths are preventable. Maternal referral systems are an effective measure to help prevent these deaths.

Objective

The objective of this study was to delineate criteria that health care workers use to identify obstetrical emergencies and make referrals, in order to evaluate the effectiveness of the established referral system and to implement improvements to this system.

Methods

Using a qualitative study design, the individuals with the highest level of formal obstetrics training at 10 health posts that refer to a rural Zambian hospital were surveyed using semi-structured interviews regarding their referral protocols. Data were analyzed through open-coding. At the conclusion of the interview, standardized referral protocols for obstetric emergencies derived from published guidelines and local practices were distributed.

Results

Identified complications resulting in referral most commonly included post-partum hemorrhage (70%), prolonged labor (70%), malpresentation (50%), antepartum hemorrhage (40%), and retained placenta (40%). While numerous reasons for referral were identified, there was little consensus on the referral protocol used for each complication. Obstacles to successful referral most commonly included cellular network disruptions (70%), distance (50%), and lack of transportation (30%).

The referral protocols distributed to health posts covered only 11 of the 23 complications cited as the most common reason for referral.

Conclusion

The referral criteria and protocols were updated to include all of the reported complications. We propose this document for others working in resource-limited settings attempting to establish or evaluate a maternal referral systems.

Impact of electronic and blended learning programs for manual perineal support on incidence of obstetric anal sphincter injuries: a prospective interventional study

BACKGROUND

Obstetric anal sphincter injuries (OASIS) are associated with anal incontinence, dyspareunia and perineal pain. Bimanual perineal support technique (bPST) prevents OASIS. The aim of this study was to assess the effect of two different bPST training-methods on OASIS incidence.

METHODS

This is a prospective-interventional quality improvement study conducted in two Palestinian maternity units between June 1 2015 and December 31 2016. Women having spontaneous or operative vaginal-delivery at ≥24 gestational-weeks or a birthweight of ≥1000 g (n = 1694) were recruited and examined vaginally and rectally immediately after vaginal birth by a trained assessor. Data on baseline OASIS incidence were collected during Phase-1 of the study. Subsequently, birth attendants in both maternity units were trained in bPST using two training modalities. A self-directed electronic-learning (e-learning) using an animated video was launched in phase-2 followed by a blended learning method (the animated e-learning video+ structured face-to-face training) in phase-3. OASIS incidence was monitored during phases-2 and 3. Variations in OASIS incidence between the three phases were assessed using Pearson-χ²-test (or Fisher's-Exact-test). The impact of each training-method on OASIS incidence was assessed using logistic-regression analysis.

RESULTS

A total of 1694 women were included; 376 in phase-1, 626 in phase-2 and 692 in phase-3. Compared to Phase-1, OASIS incidence was reduced by 45% (12.2 to 6.7%, aOR: 0.56, CI; 0.35-0.91, p = 0.018) and 74% (12.2 to 3.2%, aOR, 0.29, CI; 0.17-0.50, p < 0.001) in phases-2 and 3, respectively. There was also a significant reduction in OASIS incidence by 52% from phase-2 to phase-3 (6.7% (42/626) to 3.2% (22/692), p = 0.003). These reductions reached statistical significance among parous-women only (aOR: 0.18, CI; 0.07-0.49, p = 0.001) after the first training method tested in phase-2. However, the reduction was significant among both primiparous (aOR: 0.39, CI; 0.21-0.74, p = 0.004) and parous-women (aOR: 0.11, CI; 0.04-0.32, p < 0.001) after implementing the blended learning method in phase-3.

CONCLUSION

The animated e-learning video had a positive impact on reducing OASIS incidence. However, this reduction was enhanced by the use of a blended learning program combining both e- learning and face-to-face training modalities.

STUDY REGISTRATION NUMBER

ClinicalTrialo.gov identifier: NCT02427854 , date: 28 April 2015.

Counseling and Knowledge of Danger Signs of Pregnancy Complications in Haiti, Malawi, and Senegal

Objectives Providing counseling on danger signs of pregnancy complications as part of visits for antenatal care (ANC) can raise expecting women's awareness so that if danger signs occur they can seek assistance in time. The study examines the level of agreement in counseling on danger signs between observation of the provider during the ANC visit and the client's report in the exit interview, and the association of this agreement with the client's level of knowledge on danger signs. Methods The analysis used data from service provision and assessment (SPA) surveys in Haiti, Malawi, and Senegal. Agreement between the observation and client's report was measured by Cohen's kappa and percent agreement. Regressions were performed on the number of danger signs the client knew, with the level of agreement on the counseling on danger signs as the main independent variable. Results The study found little agreement between the observation of counseling and the client's report that the counseling occurred, despite the fact that the exit interview with the client was performed immediately following the ANC visit with the provider. The level of positive agreement between observation and client's report was 17% in Haiti, 33% in Malawi, and 23% in Senegal. Clients' overall knowledge of danger signs was low; in all three countries the mean number of danger signs known was 1.5 or less. The regression analysis found that, in order to show a significant increase in knowledge of danger signs, it was important for the client to report that it took place. Conclusions Ideally, there should be 100% positive agreement that counseling occurred. To achieve this level requires raising both the level of counseling on danger signs of pregnancy complications and its quality. While challenges exist, providing counseling that is more client-centered and focuses on the client's needs could improve quality and thus could increase the client's knowledge of danger signs.

[Pregnancy and lever cirrhosis: a high-risk combination]

BACKGROUND

Pregnancy rarely occurs in women with liver cirrhosis. However, for those who do become pregnant there are substantial maternal and foetal risks.

CASE DESCRIPTION

A 29-year-old pregnant woman with fully compensated liver cirrhosis was referred to a tertiary centre. No oesophageal or stomach varices were identified, nor indications for decompensation of the liver disease. Following an uneventful pregnancy, she gave (vaginal) birth at term to a healthy son.

CONCLUSION

The risk of complications in pregnant patients with liver cirrhosis is related to the degree of liver dysfunction and the presence of portal hypertension, emphasizing the importance of individualised preconception counselling. Oesophageal or stomach variceal bleeding during pregnancy carries a considerable risk of mortality. Therefore, screening endoscopy in the second trimester is advised to facilitate primary prophylaxis of variceal bleeding. Although the risk of variceal bleeding is increased during delivery, elective caesarean sections are not routinely performed because of an increased risk of bleeding due to abdominal wall varices. Pregnant women with liver cirrhosis should ideally be managed in a tertiary centre and in a multidisciplinary setting, to include input from a gynaecologist and gastroenterologist/hepatologist.

Labour & delivery monitoring patterns in facility births across five districts of India: A cross-sectional observational study

BACKGROUND & OBJECTIVES

India has recorded a marked increase in facility births due to government's conditional cash benefit scheme initiated in 2005. However, concerns have been raised regarding the need for improvement in the quality of care at facilities. Here we report the monitoring patterns during labour and delivery documented by direct observation in reference to the government's evidence-based guidelines on skilled birth attendance in five districts of India.

METHODS

A cross-sectional study design with multistage sampling was used for observation of labour and delivery processes of low-risk women with singleton pregnancy in five districts of the country. Trained research staff recorded the findings on pre-tested case record sheets.

RESULTS

A total of 1479 women were observed during active first stage of labour and delivery in 55 facilities. The overall frequency of monitoring of temperature, pulse and blood pressure was low at all facilities. The frequency of monitoring uterine contractions and foetal heart sounds was less than the expected norm, while the frequency of vaginal examinations was high at all levels of facilities. Partograph plotting was done in only 15.8 per cent deliveries, and labour was augmented in about half of the cases.

INTERPRETATION & CONCLUSIONS

The findings of our study point towards a need for improvement in monitoring of maternal and foetal parameters during labour and delivery in facility births and to improve adherence to government guidelines for skilled birth attendance.

A multi-centre quality improvement project to reduce the incidence of obstetric anal sphincter injury (OASI): study protocol

BACKGROUND

Third and fourth degree perineal tears, or obstetric anal sphincter injuries (OASI), sustained during childbirth can result in anal incontinence and psychosocial problems which require ongoing treatment. Within the English National Health System (NHS) reported rates of OASI have gradually increased. In response, a care bundle was developed incorporating four elements: 1) antenatal information to women, 2) manual perineal protection during all vaginal births, 3) episiotomy to be performed with a 60° mediolateral angle at crowning (when clinically indicated) and 4) perineal examination (including per rectum) after childbirth. Implementation of the OASI Care Bundle is aided by a skills development module and an awareness campaign. The project is a collaboration between two national professional bodies, an NHS hospital trust and an academic institution.

METHODS

Implementation of the OASI Care Bundle will be evaluated using a stepped-wedge design. From January 2017 sixteen maternity units across England, Wales and Scotland will participate in the study over a 15-month period, with sequential roll-out of the intervention in four blocks (regions) of four units. The primary clinical outcome is OASI rate. Regression analysis will adjust for differences in organisational characteristics and obstetric risk factors in women who gave birth before and after implementation of the care bundle. Focus group discussions and in-depth interviews with clinicians will evaluate the feasibility of integrating the care bundle into routine practice. Interviews with women will explore the acceptability of the intervention.

DISCUSSION

This protocol outlines the evaluation of our quality improvement project which aims to prevent OASI using a bundle of evidence-based interventions that are each widely used in practice. The OASI project aims to 1) standardise practice to prevent OASI in a way that is acceptable to clinicians and women and 2) identify the barriers and enablers associated with upscaling interventions within maternity units. If found to be effective, feasible and acceptable, the OASI Care Bundle will be shared with a range of audiences using the communication channels available to the professional bodies.

TRIAL REGISTRATION

The OASI Project was retrospectively registered on the ISCTRN12143325 database date assigned 03/10/2017.

Comparison of the effect of breast pump stimulation and oxytocin administration on the length of the third stage of labor, postpartum hemorrhage, and anemia: a randomized controlled trial

BACKGROUND

This study aimed to compare the effect of breast pump stimulation with that of oxytocin administration regarding the duration of the third stage of labor, postpartum hemorrhage, and anemia after delivery.

METHODS

In this study, 108 women were randomly assigned to two groups of breast pump stimulation (n = 54) and oxytocin administration (n = 54). Women in the breast stimulation group received breast pump stimulation (10 min intermittently for each breast with a negative pressure of 250 mmHg), while the women in the oxytocin (control) group received an infusion of 30 IU oxytocin in 1000 mL of Ringer's serum with a maximum rate of 10 mL infusion per min after delivery. The duration of the third stage of labor, blood loss during the third stage of labor and 24 h after delivery, hemoglobin and hematocrit (before and 24 h after delivery), after-birth pain, and the number of breastfeedings during the 24 h after delivery were recorded. The data were analyzed using the chi-square test, independent t-test, and Wilcoxon test.

RESULTS

The mean duration of the third stage was 5 ± 1.97 and 5.4 ± 2.5 min in the breast stimulation and women that received intravenous oxytocin respectively (p = 0.75). Most participants had mild postpartum hemorrhage (98.1 and 96.2% in the breast stimulation and women that received intravenous oxytocin, respectively, p = 0.99). Although hemoglobin and hematocrit levels significantly decreased in both groups 24 h after delivery, there was no significant difference between both groups regarding both parameters. After-birth pain was significantly lower and the number of breastfeeding during the 24 h after delivery was significantly more in the breast stimulation group compared to the control group.

CONCLUSIONS

Our results demonstrated no differences between breast pump stimulation and oxytocin administration regarding the duration of the third stage of labor, postpartum hemorrhage, anaemia, after-birth pain, and the number of breastfeedings during the 24 h after delivery.

TRIAL REGISTRATION NUMBER

The study protocol was registered in the Iranian Randomized Controlled Trial Registry (Ref. No.: IRCT2015050722146N1 ; Registration date: 2015-11-04). The study was registered prospectively and the enrollment date was 23/8/2015.

Obstetric fistula policy in Nigeria: a critical discourse analysis

BACKGROUND

In 2012, Nigeria's Federal Ministry of Health published its National Strategic Framework for the Elimination of Obstetric Fistula (NSFEOF), 2011-2015. The framework has since lapsed and there is no tangible evidence that the goal of eliminating obstetric fistula was met. To further inform future policy directions on obstetric fistula in Nigeria, this paper explores how the NSFEOF conceptualized obstetric fistula and its related issues, including child marriage and early childbearing.

METHODS

A critical discourse analysis of the policy was performed. We examined four policies in addition to the strategic framework: the Nigerian constitution; the Marriage Act; the Matrimonial Causes Act; and the National Reproductive Health Policy. We used the three phases of critical discourse analysis: textual analysis, analysis of discourse practice, and analysis of discursive events as instances of sociocultural practice.

RESULTS

The analysis demonstrates that, despite its title, the policy document focuses on reduction rather than elimination of obstetric fistula. The overall orientation of the policy is downstream, with minimal focus on prevention. The policy language suggests victim blaming. Furthermore, the extent to which subnational stakeholders in government and civil society were engaged in decision-making process for developing this policy is ambiguous. Although the policy is ostensibly based on principles of social justice and equity, several rhetorical positions suggest that the Nigerian constitutional environment and justice systems make no real provisions to protect the reproductive rights of girls in accordance with the United Nations' "2030 Agenda for Sustainable Development."

CONCLUSION

This analysis establishes that the Nigerian constitution, justice environment and the obstetric fistula policy itself do not demonstrate clear commitment to eradicating obstetric fistula. Specifically, a clear commitment to eradicating obstetric fistula would see the constitution and Marriage Act of Nigeria specify an age of consent that is consistent with the agenda to prevent obstetric fistula. Additionally, a policy to end obstetric fistulas in Nigeria must purposefully address the factors creating barrier to women's access to quality maternal healthcare services. Future policies and programs to eliminate obstetric fistulas should include perspectives of nurses, midwives, researchers and, women's interest groups.

Enhancing recognition of obstetric anal sphincter injuries in six maternity units in Palestine: an interventional quality improvement study

OBJECTIVE

To explore the impact of a training intervention on obstetric anal sphincter injuries' (OASIS) detection rate.

DESIGN

Prospective quality improvement interventional study.

SETTING

Six secondary and tertiary maternity units in Palestine.

POPULATION

Women having singleton vaginal births ≥23 weeks' gestation or babies weighing ≥500 g (n=22 922). Caesarean births (n=5431), multiple gestations (n=443) and vaginal births of unregistered perineum status (n=800) were excluded.

INTERVENTIONS

Training programme for enhancing OASIS detection was conducted between 31 January and 31 December 2015. International experts delivered 2-day standardisation workshop teaching OASIS diagnosis and repair to each maternity unit. They also provided additional training to three research fellows employed in three of the maternity units. This was followed by 13-week period of data collection (phase 1). Research fellows then delivered training intervention over 15-week interval (phase 2), including theoretical teaching and 'onsite' training in perineal trauma assessment within the six maternity units. Finally, 13-week postintervention observation (phase 3) followed.

PRIMARY OUTCOME MEASURE

OASIS rates were used as surrogate for OASIS recognition. OASIS rates were compared between different phases and between the two maternity unit groups (research fellow and non-research fellow based) using Pearson's χ² test.

RESULTS

A total 22 922 women were included. Among primiparous women, OASIS rate was higher in phase 2 (2.8%, p<0.001) and phase 3 (3.1%, p<0.001) than phase 1 (0.5%). However, no significant differences were detected in the rates of severe OASIS (third-degree 3c and fourth-degree tears) between phase 1 and 2 (0.5% vs 0.3%), because this would have required at least 103 women with severe OASIS to be included in each phase. Among parous women, OASIS rate was significantly higher in phase 2 (0.6%, p=0.002) but not in phase 3 (0.4%, p=0.071) compared with phase 1 (0.2%). Research fellows' maternity units showed higher OASIS rates among primiparous women in phase 2 (3.6% vs 1.4%, p=0.001) and phase 3 (4.3% vs 0.8%, p<0.001) than non-research fellows' maternity units.

CONCLUSIONS

This work is basically an epidemiological study which has identified the prevalence of perineal lacerations and their severity on a large sample of women representative of an entire geographical ethnic region. The quality improvement intervention improved OASIS detection mainly in the research fellows' maternity units. Regular mandatory national programmes in obstetric perineal trauma assessment and management by local champions are essential to mitigate the risk of missing significant degrees of trauma.

[PERINEAL TEARS THAT INVOLVE THE ANAL SPHINCTER - IS IT AN UNPREVENTABLE OBSTETRIC PROBLEM AND WHAT ARE ITS REPRECUSSIONS?]

Perineal tears that involve the anal sphincter, especially those which are occult, are common in cases of vaginal delivery or instrumental deliveries. Parturients who experience such types of perineal tears may suffer from flatus or fecal incontinence and also fistula to various surrounding organs. There is no consensus in the relevant medical literature regarding the risk factors for the development of these tears, as contradictive results are presented in various relevant studies. Traditional methods for perineal protection, executed by midwives, such as perineal massage with oil, have also failed to be proven as an effective measure for that purpose. The only theme on which there appears to be a consensus is the fact that protective episiotomy is not helpful in protecting the perineum during vaginal delivery. The inability to predict which parturient will have a perineal tear that involves the anal sphincter, as well as the lack of predictive measures to avoid their occurrence, drive more and more women to demand and receive cesarean section by maternal request, which is accepted by most obstetricians nowadays.