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.

A women-centred exploration of postpartum perineal pain when the perineum is diagnosed as intact: A French Gadamerian research study

BACKGROUND

Postpartum perineal pain is a frequent symptom (90%) with consequences on postnatal health regardless of whether the perineum remains intact. The impact of that pain on both short and long-term health has been studied and literature suggests midwives have a role to play in addressing this issue. However, the determinants of perineal pain when no lesions are identified are under researched and there is little understanding of women's views on this topic.

AIM AND OBJECTIVES

The aim of the study was to gain an understanding of postpartum perineal pain when the perineum is considered to be intact. The objectives were •To gain an understanding of postpartum pain and its consequences on health and well-being •To explore women's views and understanding of perineal pain postpartum •To gain an understanding of the determinants of postpartum perineal pain when no anatomic lesion is diagnosed.

METHODS

A Gadamerian hermeneutic approach was used to achieve a shared understanding of the issue. Participants were recruited from two maternity hospitals in the French area of Vaucluse. All women aged 18 to 45 years old, having given birth vaginally to a single live child and diagnosed with an intact perineum, were invited to participate in face-to-face interviews. Eleven participants were interviewed once, six of whom agreed to a second interview which took place over the telephone due to Covid lockdown.

FINDINGS

The findings identified three major themes 1. Can't honestly call it pain, 2. Reassurance in normality, 3. Managing the unexpected. The use of the word pain to describe perineal sensations in postpartum was questioned by the participants, who used inner resources to deal with these sensations. Fostering self-confidence, having the possibility to explain the sensations and qualifying them as normal were some approaches women usedto manage their postpartum perineal sensations in a positive manner.

A qualitative exploration of techniques used by expert midwives to preserve the perineum intact

BACKGROUND

The perineum stretches during birth to allow passage of the baby, but 85% of women sustain some degree of perineal trauma during childbirth, which is painful post-partum. Episiotomy rates vary significantly, with some countries having rates of >60%. Recent Irish and New Zealand studies showed lower severe perineal trauma and episiotomy rates than other countries.

AIM

To explore expert Irish and New Zealand midwives' views of the skills that they employ in preserving the perineum intact during spontaneous vaginal birth.

METHODS

Following ethical approval a qualitative, descriptive study was undertaken. Semi-structured, recorded, interviews were transcribed and analysed using the constant comparative method. Expert midwives employed in New Zealand and one setting in Ireland, were invited to join the study. "Expert" was defined as achieving, in the preceding 3.5 years, an episiotomy rate for nulliparous women of <11.8%, a 'no suture' rate of 40% or greater, and a severe perineal tear rate of <3.2%. Twenty-one midwives consented to join the study.

RESULTS

Four core themes emerged: 'Calm, controlled birth', 'Position and techniques in early second stage', 'Hands on or off?' and 'Slow, blow and breathe the baby out.' Using the techniques described enabled these midwives to achieve rates, in nulliparous women, of 3.91% for episiotomy, 59.24% for 'no sutures', and 1.08% for serious lacerations.

CONCLUSIONS

This study provides further understanding of the techniques used by expert midwives at birth. These findings, combined with existing quantitative research, increases the evidence on how to preserve the perineum intact during spontaneous birth.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

Irish and New Zealand Midwives' expertise at preserving the perineum intact (the MEPPI study): Perspectives on preparations for birth

OBJECTIVES

perineal trauma during birth can result in short or long term morbidity for women. Internationally, rates of episiotomy and severe perineal tears vary considerably. In New Zealand, in 2011, and in a trial of midwife-led care in Ireland, episiotomy rates were found to be considerably lower than those in many other countries. A qualitative exploratory study was undertaken to ascertain how midwives achieve these low rates, in these countries and settings.

DESIGN AND PARTICIPANTS

a qualitative exploratory study was conducted. Midwives expert in preserving the perineum intact (PPI) from two maternity units in the Republic of Ireland and from varied birth settings in New Zealand, were eligible to participate. Twenty-one consenting midwives took part, seven from Ireland and 14 from New Zealand.

METHODS

university ethical approval was granted. Face-to-face, semi-structured interviews were used to collect the data. Interviews were recorded and transcribed verbatim. The data were analysed using Ethnograph software and were organised into prominent themes.

FINDINGS

four themes were identified; 'Sources of knowledge for PPI', 'Associated factors', 'Decision-making on episiotomy', and 'Preparations for PPI'. Participants drew heavily on multiple sources of knowledge in building their own expertise for PPI. Physical characteristics of the perineum featured prominently as factors leading to PPI. Episiotomy was, in the main, only performed when there were signs of fetal distress. Antenatal perineal massage was supported.

CONCLUSION

this study provides valuable insight into the views and skills of midwives, with expertise in PPI at birth, adding to the body of evidence on this topic.