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.

Randomized Clinical Trial of an Aquatic Physical Exercise Program During Pregnancy

OBJECTIVE

To determine the effect of an aquatic physical exercise program performed during pregnancy on rate of intact perineum after childbirth.

DESIGN

Randomized clinical trial.

SETTING

Health centers in the metropolitan health district of Granada, Spain.

PARTICIPANTS

A total of 129 pregnant women (control group [CG] = 64; aquatic exercise group [EG] = 65).

METHODS

The intervention was an aquatic physical exercise program specifically designed for pregnant women (Study of Water Exercise During Pregnancy [SWEP] method). Participants were randomly assigned to the CG or EG by simple random sampling. Participants in the EG performed three sessions per week of physical exercises, which were led by the principal investigator. All participants received routine prenatal care. We evaluated status of the perineum after birth, including laceration and episiotomy rates. We also evaluated participants' weight, body mass index (BMI) in the first and third trimesters, parity, the administration of anesthesia, and birth weight of the neonate as potential confounding variables.

RESULTS

The women in the EG had a greater rate of intact perineum than those in the CG (odds ratio [OR] = 13.54, 95% confidence interval [CI] [2.75, 66.56]). After adjusting for infant birth weight, the effect of the intervention on intact perineum was an OR of 8.57 (95% CI [1.85, 39.68]. Maternal weight gain did not influence the odds of intact perineum (OR = 1.072, 95% CI [0.896, 1.283]). Women who previously gave birth and followed the SWEP method had an OR of 10.197 (95% CI [2.190, 47.476] for an intact perineum. The administration of anesthesia and previous pregnancy also were associated with intact perineum (OR = 6.68, 95% CI [1.21, 36.84] and OR = 5.42, 95% CI [1.64, 17.89] respectively.

CONCLUSION

The women who followed the SWEP method were significantly more likely to have intact perinea after childbirth.

Enhancing postnatal perineal care

Maternal physical and psychological wellbeing during the postnatal period can be significantly impaired by perineal trauma sustained during childbirth. Current literature emphasises preventative measures, yet there is a lack of a systematic, evidence based approach to postnatal perineal care. This is concerning as the eighth 'Saving mothers' lives' report (CMACE 2011) identifies genital tract sepsis for the first time as the leading cause of maternal deaths. The aim of this article is therefore to develop a systematic approach to improve postnatal perineal care with a focus on assessment and treatment of perineal pain as well as recovery of pelvic floor function.

Getting Through Birth in One Piece

PURPOSE

To identify factors related to perineal trauma in childbirth, replicating the work of .

STUDY DESIGN AND METHOD

A retrospective descriptive analysis of pregnancy and birth data recorded into the Nurse Midwifery Clinical Data Set for women (N = 510) with a singleton pregnancy and largely uncomplicated prenatal course. Prenatal care occurred at four prenatal clinics with births at a tertiary care facility during 1996-1997, with care provided by nurse midwifery faculty. Multivariate statistics detailed clinical characteristics associated with perineal trauma.

RESULTS

Episiotomy was related to parity, marital status, infant weight, fetal bradycardia, prolonged second stage labor, and lack of perineal care measures. Factors related to laceration were age, insurance status, and marital status. For all women, laceration was more likely when in lithotomy position for birth (p = .002) or when prolonged second stage labor occurred (p = .001). Factors that were protective against perineal trauma included massage, warm compress use, manual support, and birthing in the lateral position. found that ethnicity and education were related to episiotomy and that warm compresses were protective. In this study, use of oils/lubricants increased lacerations, as did lithotomy positioning. Laceration rates were similar in both studies. Episiotomy use was lower in this study.

CLINICAL IMPLICATIONS

Side-lying position for birth and perineal support and compress use are important interventions for decreasing perineal trauma. Strategies to promote perineal integrity need to be implemented by nurses who provide prenatal education and care for the laboring woman.

Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: a randomized trial

Genital tract trauma after spontaneous vaginal childbirth is common, and evidence-based prevention measures have not been identified beyond minimizing the use of episiotomy. This study randomized 1211 healthy women in midwifery care at the University of New Mexico teaching hospital to 1 of 3 care measures late in the second stage of labor: 1) warm compresses to the perineal area, 2) massage with lubricant, or 3) no touching of the perineum until crowning of the infant's head. The purpose was to assess whether any of these measures was associated with lower levels of obstetric trauma. After each birth, the clinical midwife recorded demographic, clinical care, and outcome data, including the location and extent of any genital tract trauma. The frequency distribution of genital tract trauma was equal in all three groups. Individual women and their clinicians should decide whether to use these techniques on the basis of maternal comfort and other considerations.

Perineal trauma: reducing associated postnatal maternal morbidity

Perineal tears affect about 85% of women undergoing normal delivery in the UK. The proper understanding of perineal anatomy by midwives and trainee doctors is important for the correct recognition of the severity of tears. Measures to minimise perineal tears include teaching pelvic floor exercise during the third trimester, psychological support during labour and good perineal support during the second stage of labour. To ensure good management, systematic examination of the perineum, vagina, and rectum should be done under good light for all vaginal deliveries. Proper recognition of the degree of tears, selection of suture materials and seeking senior help whenever needed are crucial. Of those women who prefer elective caesarean section rather than vaginal delivery, 80% do so because of the fear of perineal damages. These adverse outcomes can be minimised by training midwives and trainee doctors with surgical skills workshops in the use of models, audiovisual aids, case scenarios and perineal repair simulation exercises.

Changes in postpartum perineal muscle function in women with and without episiotomies

This report presents results of a comparison perineal muscle function between antepartum and postpartum measurements in a cohort of women with different perineal conditions after childbirth. Data were obtained by using prospective electromyographic perineometry measurements to objectively determine perineal muscle function before and after delivery in 102 women. In addition, 24 nulliparous, non-pregnant women were studied to determine the effect of pregnancy on perineal muscle function. Pregnancy is associated with a decrease in perineal muscle strength and endurance compared with the postpartum state. The degree to which women improved or did not improve perineal muscle function after birth was related to perineal trauma at delivery. After controlling for parity, maternal age, birthweight, smoking status, and antepartum scores, the order of best to worst performance was cesarean birth, intact perineum, first-degree perineal injury, second- or third-degree perineal injury, and episiotomy. Pre- and post-delivery scores were compared for each woman and analyzed according to perineal outcome. Although all other perineal outcome groups increased muscle function by 6 months postpartum, women with an episiotomy had a mean net loss of perineal muscle performance after birth. These observations do not support the use of episiotomy for the purpose of preserving perineal muscle function.

Minimizing postpartum pain: a review of research pertaining to perineal care in childbearing women

This paper provides a review of literature that relates to perineal pain and care. Articles evaluated include systematic reviews and research papers from the disciplines of midwifery, physiotherapy and obstetrics. The major themes to emerge from the literature and be reviewed are the need for episiotomy, suturing methods and materials, assessment of perineal trauma, treatment of perineum in the postpartum period, and postpartum recovery. Research has highlighted that many practices relating to perineal care remain un-researched and therefore the need for evaluation is urgent. Further postpartum morbidity has been seen to affect many women, but is often unrecognized by practitioners. It is also a topic that requires further evaluation through well-designed and implemented research.

Postpartum perineal management and best practice

Sutured damage to the perineum occurs in at least 39% of women being delivered in Australia and perineal wound breakdown is associated with perineal oedema. The available literature was reviewed to ascertain what might constitute best practice for postpartum perineal wound management. Classification of levels of evidence was used to prioritise the available evidence. Little evidence that might be considered scientifically robust was found. Recommendations based on the available levels of evidence include a careful emphasis on perineal hygiene, cryotherapy, elevation of the foot of the bed in the presence of perineal oedema and regularly performed pelvic floor exercises.

Social construction of episiotomy

This article explores the meaning of episiotomy. A review of the literature examines the definition, procedure, perceptions and outcomes of episiotomy to create a better understanding for those using or experiencing its practice. The article highlights that episiotomy means more than just a cut in the perineum. Episiotomy means different things to different individuals and groups, the meaning being socially constructed depending on social context, professional background and personal experience. It is concluded that midwives need to understand what an episiotomy means to women, and that through research midwives need to develop their own body of knowledge of childbirth from the viewpoints of those who are actually experiencing it.

The role of the midwife in perineal wound care following childbirth

Midwives have an important role to play in the care of perineal wounds following childbirth. A wide variety of practices are carried out in this area. However, some current practices may not be beneficial to the promotion of wound healing. Midwives must realize the relevance of their care and potential impact, both positive and negative, of advocated treatments in wound healing. The maintenance of effective pain relief must be balanced with the need to promote wound healing. It is important that midwives recognize the need for research-based practice and that an audit is set up nationally to evaluate the efficacy of treatments and practice. Research, audit and evaluation of services are the central processes involved in providing effective and efficient care, as advocated by the Department of Health (1993).

Nurse advocacy for selective versus routine episiotomy

Although episiotomy is one of the most commonly performed surgeries, little scientific support exists for this procedure. Furthermore, the suggested advantages of routine episiotomy are challenged easily and the surgery is not without risks. Adverse effects arising from episiotomy include an increased incidence of severe lacerations, blood loss, pain, delayed healing, dyspareunia, psychologic trauma, and medical cost. Nurses can assist women in avoiding perineal trauma resulting from unnecessary episiotomy through patient education, patient advocacy, and direct care.

A discussion of some of the literature relating to history, repair and consequences of perineal trauma

OBJECTIVE

to review the key literature on perineal trauma, discussing the historical background, the materials and techniques used, the possible consequences of repair and assess midwives' current and potential contribution to perineal repair.

LITERATURE SEARCH

the literature was identified using conventional search techniques: Midwifery Information Resource Service (MIDIRS) and the Cochrane Pregnancy and Childbirth Database. Keywords used during the search were: episiotomy, perineal trauma and adverse effects. Associated keywords words were sexuality, pain and psychology.

KEY CONCLUSIONS

current practice in the UK is inconsistent with the available evidence, perineal trauma can cause long term problems, and midwives are in an ideal position to take forward evidence-based perineal repair.

IMPLICATIONS FOR PRACTICE

midwives need adequate education and training in perineal repair but are likely to be more effective in performing the repair. Systematic evaluation of the impact of extending midwives' influence in this area is essential.

A strategy to promote research-based nursing care: effects on childbirth outcomes

Studies at area hospitals revealed many gaps between research evidence and intrapartum nursing practices. A randomized controlled trial involving 20 hospitals was used to evaluate the effectiveness of a marketing strategy to promote research-based nursing care. It was hypothesized that the strategy would result in lower rates of epidural analgesia, through increasing the amount of support nurses provided to their patients. Other outcomes included rates of narcotic analgesia, episiotomy, and operative delivery. The marketing strategy was unsuccessful in improving intrapartum nursing care. Much more research is needed about the factors that facilitate improvements in nursing practice.

[A study on the personal experience and competence of student nurse midwives in the performance of episiotomy repairs]

A non-experimental, descriptive study was conducted to determine the knowledge and efficiency of student midwives in the performing of episiotomy repairs. A questionnaire was administered to 50 students from the two universities and affiliated colleges in the Western Cape. Sixty percent (N = 30) of the respondents regarded themselves as efficient. However, only one of these respondents had all the necessary knowledge concerning perineal repairs with 15 (50%) of these respondents' knowledge that could be considered as insufficient. Fifty-four percent of the respondents (N = 27) considered it necessary to repair more than 3 episiotomies in order to feel confident.

Perineal outcomes and nurse-midwifery management

This article describes the association among perineal outcomes, selected risk factors, and alternative intrapartum approaches used by nurse-midwives. This nonrandomized concurrent (cohort) study analyzed all spontaneous vaginal births (N = 1211) attended by nurse-midwives at a university hospital over a 2-year period. Univariate analysis was used to calculate relative risks for the associations between two perineal outcomes and selected variables. Study results indicated that parity, ethnicity, birth weight, and use of two techniques (hot compresses and lubrication) were associated with lacerations. The same factors that increase the risk of perineal lacerations also made the performance of an episiotomy more likely; however, for episiotomy, an inverse relationship with perineal hot compresses was noted, and perineal lubrication had no effect. Lack of perineal support was associated with a 66% rise in the risk of episiotomy. Use of birthing positions other than lithotomy significantly reduced the likelihood of episiotomy. The authors concluded that selected care measures to protect the perineum may reduce maternal morbidity and simplify intrapartum care. The risks and benefits of alternative strategies commonly used by nurse-midwives while caring for diverse populations during birth should be further evaluated in large multiethnic populations.

Episiotomy: does it have to hurt so much afterwards?

Episiotomy is one of the commonest surgical procedures in the UK. Many women suffer pain for several days sometimes weeks afterwards and dyspareunia may be a problem. Absorbable suture materials appear to be preferable to non-absorbable ones. Infiltrating the perineum with normal saline before suturing may help reduce postpartum perineal pain. Omitting sutures just below the skin surface may cause less pain. More research is needed. The skill of the operator seems to be a factor. Midwives need to evaluate their practice in repairing the perineum

Perineal care. Then and now

Since the late nineteenth century, the average postpartum woman has been subjected to a great deal of swabbing, soaking, and spraying, all in the name of perineal care. Many elaborate regimens have been devised to prevent infection, promote healing, and provide comfort to the mother, often based on little physiologic rationale or research data. All of these regimens have taken away valuable time and energy that the new mother needs for more important tasks. A review of past and current perineal care practices and major research studies relative to perineal care can form a foundation from which to evaluate and update the management of perineal care.

Psychometric properties of the REEDA

The purpose of this study was to evaluate interrater reliability and construct validity of the REEDA, an instrument designed to measure the healing process of the perineum following an episiotomy and/or laceration during childbirth. The instrument was tested in a single postpartum hospital setting. A total of 94 subjects participated in the study. Eighty-six experienced an episiotomy/laceration, while eight subjects had an intact perineum. Results indicate there are serious limitations with the REEDA tool when used for either clinical or research purposes.

Effects of heat and cold on the perineum after episiotomy/laceration

The Redness Edema Ecchymosis Discharge Approximation (REEDA) tool, devised to evaluate postpartum healing of the perineum following an episiotomy/laceration, was used to evaluate the effects of heat and cold on the perineum during the first 24 hours after delivery. Ninety patients were randomly assigned to one of three treatment groups. Treatment consisted of 30 subjects applying a warm perineal pack, 30 applying a cold perineal pack, and 30 taking a warm sitz bath. Analysis of variance indicated no difference in the REEDA score before or two hours after treatment. A Pearson r correlation indicated the REEDA score was associated with a laceration and not with infant weight. Although these findings do not support assumptions from the literature, this study provides baseline data and trends for future study.

A comparison of cold and warm sitz baths for relief of postpartum perineal pain

The effect of cold sitz baths for relieving perineal pain in the postpartum period after an episiotomy was evaluated. Forty patients took both cold and warm sitz baths with random assignment of the initial bath. Patients rated the degree of perineal pain before and after each sitz bath and at half-hour and one-hour intervals after each bath. A pain scale using 0-5, 0 representing no pain and 5 representing extreme pain, was used. Analysis of pain scale scores using a two-way analysis of variance with replications showed that cold sitz baths were significantly more effective in relieving perineal pain. The greatest amount of pain relief was experienced immediately after the cold sitz baths.