Degree Tears Research Articles

Instruments for assisted vaginal birth.

Instruments for assisted vaginal birth.

Prevalence and outcome of teenage pregnancy among attendants of labour room in Bassion general hospital-Egypt (cross section study)

ABSTRACT Background: Teenage pregnancy is a global serious public health and distressing social problem, its prevalence varies among countries and among cities of the same country. Teenage mothers are exposed to maternal morbidity and mortality than women in their twenties. Objective: to assess prevalence of teenage pregnancy and their perinatal outcomes & immediate postpartum complications. Methodology: A cross -sectional study was conducted at a hospital that provides medical services to a rural area in Egypt, for six months period, started from 1st December 2019 till 1st June 2020. All women consecutively recruited were either full or preterm, singleton or multiple pregnancy. They were admitted in active labour at the delivery ward of Bassion general hospital. All demographic, prenatal and postnatal data during study period were recorded and tabulated. Results: All pregnant women who were admitted in active labour within the chosen period were 848 women, 73.6% were adults (>19 years, mean 24.06years), 26.4% were teenagers (≤ 19 years, with a mean 17.5 years). Iron deficiency anemia was the most prevalent medical complication in the teenage group 54%, followed by pregnancy induced hypertension (PIH) 21.4%, caesarean section rate was 47 % and perineal tears were recorded in 25.9 % of the teenage group. Most of them had 2nd and 3rd degree tears. 25.9% of the newborns were admitted to the neonatal intensive care unit (NICU), 4.9% due to prematurity, 4.5% due to prematurity and respiratory distress (RDs) and sepsis, 3.6% due to prematurity and RD, 1.3% due to RD ,0 4% due to meconium aspiration, 4.5% due to hyperbillirubinemia and 3.1% due to cyanosis. Conclusion: Teenage pregnancy is prevalent in this study sample in a rural area in Egypt and is associated with an increased risk of major degree perineal tear, PIH, preterm labour and iron deficiency anemia.

Identifying the factors that influence midwives’ perineal practice at the time of birth in the United Kingdom

ObjectiveThe Obstetric Anal Sphincter Injuries (OASI) Care Bundle is designed to reduce the incidence of obstetric anal sphincter injuries. However, introducing behavioural change requires an understanding of current practice. This study aims to establish midwives practise at the time of birth, and the factors that influence this. DesignQuantitative research - a national online survey. SettingNationwide - United Kingdom (UK). Participants 563 midwives from across the UK. MethodsAn online survey of midwives’ practice. Midwives were invited to participate through the Supervisor of Midwives network. Consent was sought on the landing page. Data analysis using descriptive and inferential statistics, with sub group analyses were used to explore variations in practice. Measurements Number of midwives using “hands on” the perineum and the influences on midwives’ perineal practice at the time of birth. FindingsMost midwives preferred to use “hands on” the perineum at the time of birth (61.4%). “Hands on” practise was significantly associated with where midwives worked (p<0.001), risk factors for OASI (p<0.001), and the approach that they were taught in their midwifery training (p<0.01). Midwives expressed lack of confidence in some areas with a third unsure that they could identify the third degree tear category b (38.2%) or c (34.3%). Key ConclusionsThere has been a growth in the number of midwives using “hands on” at the time of birth but midwives feel that they require additional training in regards to identifying an OASI. The study should be repeated following the roll out of the OASI care bundle, to identify its impact on midwives’ perineal practice. Implications for practiceThe study identified that there needs to be an improvement in the recognition of OASI by midwives, and in future repeating the study would identify whether the OASI care bundle has influenced midwives' practice.

Perineal Injury and Its Association with Postpartum Sexual Dysfunction among First Delivery Women

Background: Female sexual dysfunction (FSD) following childbirth imposes significant burden to the marital institution around the world. The perineal injury may potentially be one of the main risk factors contributing to postpartum female sexual dysfunction (PPFSD). The study aimed to determine the effect of perineal injury and patients’ characteristics on PPFSD.&#x0D; Methodology: This cross-sectional questionnaire study was conducted in six different health clinics in the district of Kuantan from April 2019 to October 2019. Eligible women who came to the family health clinics at 6 months postpartum were recruited as study population. The participants completed their biodata and socio-demographic form and the Malay-validated Female Sexual Function Index (MVFSFI) questionnaire given. A cut-off point of 26.55 and below on MVFSFI scoring system was used as a measure of the primary outcome of sexual dysfunction.&#x0D; Results: Out of 240 women who delivered vaginally, 34 (14%) had intact perineum, 107 (44.6%) sustained 1st degree perineal tear, 96 (40%) 2nd degree tear and three (1.25%) 3rd degree tear. Among the respondents, 60.9% of the sexually active respondents who had vaginal delivery, reported to have PPFSD. The timing of sexual resumption does not correlate with the severity of perineal tear. The severity of perineal tear is significantly associated with age (p=0.018), duration of marriage (p=0.008), body mass index (BMI) (p=0.019) and instrumental delivery (p=0.025). The level of personnel skill whom performed the repair were also found to have a significant relationship to PPFSD (p= 0.001). The relationship of participants’ mean age (p=0.271), marriage duration (p=0.903), race (p=0.928), religion (p=0.852), education level (p=0.549), employment status (p=0.102), family income (p=0.460) and BMI(p=0.159) with presence of PPFSD were all found to be statistically not significant.&#x0D; Conclusion: Occurrence of PPFSD is high among sexually active women who had vaginal delivery complicated by perineal tear, especially among those requiring instrumentation. The severity of perineal tear is associated with age, duration of marriage, BMI and mode of delivery. However, PPFSD does not significantly relate to the severity of perineal tear. None of the socio-demographic factors show a significant difference to sexual dysfunction.

The effects of perineal trauma on immediate self-reported birth experience in first-time mothers

Introduction Childbirth can sometimes be stressful or traumatic, and previous research has considered how birth complications and interventions may contribute to a negative birth experience. One of the most frequent complications during birth is trauma to the perineum. The aim of this study was to investigate whether different levels of perineal trauma were associated with differences in women’s evaluation of their birth experience. Materials and methods As part of a longitudinal cohort study, the self-reported birth experiences of 202 primiparous women were compared based on the degree of perineal trauma they had experienced. Women who had given birth for the first time, vaginally and within the last 48 h in a large tertiary maternity unit in England were invited to take part. Data were collected from their hospital records with their consent and using the Childbirth Experience Questionnaire (CEQ), Experience of Birth Scale (EBS) and a perineal pain Visual Analogue Scale (VAS). Results Women with an obstetric anal sphincter injury (OASI) or episiotomy reported a more negative overall birth experience and perceived themselves as having less ability to give birth compared to those with a 1st/2nd degree sutured tear. Those with an episiotomy also reported feeling less involved in decision making processes during their birth. Significant differences remained between the OASI and 1st/2nd degree tear groups when controlling for factors known to affect birth experience, highlighting severe perineal trauma as a potential contributor to more negative birth experience. Conclusions Perineal trauma may affect a woman’s birth experience. Experiencing an episiotomy should not be overlooked as a potential contributor, especially during instrumental birth and in the absence of involved decision making. Further research is needed to disentangle the effects of episiotomy on birth experience, to explore the care needs of women with different degrees of perineal trauma and to explore how a negative birth experience may contribute to poor psychological health in the longer term.

Predictors of Severe Perineal Tear during Delivery in Yenagoa, Southern Nigeria

Background:Perineal tear is a very common complication of vaginal delivery, and it is often mild. However, when severe, it could result in torrential life threatening hemorrhage and anal sphincter injury, with fecal incontinence.&#x0D; Objective: The objective of this study is to determine the predictors of severe perineal tear (3rd and 4th degree tear), using mild perineal tear (1st and 2nd degree) as control. It would also determine the rate of perineal tear, and the maternal and fetal demographic risk factor associated with it.&#x0D; Materials and Methods: This was an analytic observational study of 186 women who had perineal tear during vaginal delivery. Out of these, 19 women had severe (3rd and 4th degree) perineal tear, also known as obstetrics anal sphincter injury (OASI). This was compared to 167 women who had mild perineal tear (1st and 2nd degree) during the study period.&#x0D; Maternal demographic information retrieved was maternal age, parity, educational level, and occupation. Obstetrics factors were booking status, gestational age at delivery, mode of delivery, rank of the accoucheur (nurse or doctor), and degree of perineal tear. Fetal demographic data was birth weight and fetal sex.&#x0D; Categorical variables were compared with odds ratio, difference in mean was compared with student’s t-test, and the degree of association for quantitative variables was determined using Pearson’s correlation coefficient. Predictor variables were determined using simple logistic regression, and multivariate analysis. Confidence interval was set at 95%, and statistical significance was set at p value of &lt; 0.05.&#x0D; Results: The prevalence of OASI (3rd and 4th degree perineal tear) in Yenagoa was 1.1%. The significant risk factors were women of younger age, odds ratio = 1.04(0.37, 2.87) with p = 0.04, low parity, odds ratio = 0.20(0.07, 0.55) with p = 0.008, low educational background, odd ratio = 18.9(5.92, 60.81), and birth weight ≥ 4kg, odds ratio = 0.30[0.09, 1.06] with p = 0.04.&#x0D; Using simple liner regression, the most significant predictors for severe perineal tear were mode delivery (r2 = 65.5%), and educational level (r2 = 30.0%). However, on stepwise multivariate analysis, these two factors accounted for 68.5%.&#x0D; Conclusion: The rate of severe perineal tear is relatively low in Yenagoa, Nigeria, and comparable to what obtains in many countries. The most significant predictors were mode of delivery and educational level. Careful selection of the mode of delivery, especially instrumental vaginal deliveries, and women empowerment could minimize the rate in our environment.

Clinical outcomes for women who had continuity of care experiences with midwifery students

BackgroundPre-registration midwifery students in Australia are required to engage in a minimum of ten continuity of care experiences (CoCE). Students recruit and gain consent of each woman to provide CoCE under direct supervision of a registered health professional, usually a midwife. Clinical outcomes for women who had CoCE with a midwifery student placed in a continuity of midwifery care (CMC) or fragmented models are rarely reported. Aims1. analyse clinical outcomes for women experiencing CMC with CoCE by students; 2. analyse clinical outcomes for women in a fragmented care model with CoCE by students; and 3. compare clinical outcomes according to women’s primary model of care. MethodsStudents undertaking a Bachelor of Midwifery program at one Australian university recorded clinical outcomes for women experiencing CoCE during pregnancy [n=5972] and labour and birth [n=3933] in an e-portfolio. A retrospective, cohort design compared student recorded maternal data with National Core Maternity Indicators and Queensland Perinatal Data. ResultsMidwifery students providing CoCE reported better or equal clinical outcomes for women compared to population data. Women receiving CoCE had reduced likelihood of tobacco smoking after 20 weeks of pregnancy, episiotomy, and third and fourth degree tears. ConclusionsClinical outcomes for women in fragmented models of care and receiving CoCE by undergraduate, pre-registration midwifery students are equal to or better than State data across 12 variables. CoCE should be offered to all women early in their pregnancy to ensure optimal benefits. Acknowledging midwifery students’ potential to make positive impacts on women’s clinical outcomes may prompt more health services to reconceptualise and foster CoCE.

Effects of Fourth-Degree Perineal Lacerations on Women’s Physical and Mental Health

ObjectiveTo describe the physical and emotional effects of fourth-degree perineal lacerations that occur during childbirth. DesignDescriptive phenomenology. SettingInternet survey. ParticipantsEighteen women from the United States, the United Kingdom, Australia, and Canada who sustained fourth-degree perineal lacerations during childbirth. MethodsWomen were recruited from the Facebook support group Mothers With 4th Degree Tears. Participants were asked to describe the physical and emotional effects of these severe birth injuries on their daily lives. I analyzed these data using Colaizzi’s method for phenomenological analysis. ResultsThe devastating effects of these birth-related injuries permeated all aspects of the lives of participants. Participants did not receive adequate information about their perineal lacerations, and clinicians often dismissed their concerns. Some participants struggled with postpartum depression and posttraumatic stress disorder. I identified seven themes that described the effects of fourth-degree perineal lacerations: Why Wasn’t I Informed I Had This Injury?; The Unthinkable: Fecal Incontinence and So Much More; It Has Cost Me So Much; Seeking Relief: Enduring Surgery After Surgery; Why Didn’t Anyone Ask Me About My Mental Health?; To Have More Children, That Is The Question; And Are there Any Positives In All Of This? ConclusionWomen need information to prepare for recovery from their severe perineal injuries related to what to expect, how to care for themselves, and what resources are available. Clinicians have a responsibility to provide a caring environment in which women feel safe to disclose any problems they are experiencing as a result of their perineal injuries. Little, if any, attention is focused on women’s mental health by clinicians or researchers as women struggle with the aftermath of fourth-degree perineal lacerations.

Vaginal Injuries Following Consensual Sexual Intercourse and Trauma- A Case Series

Vaginal injuries following consensual intercourse are commonly encountered in clinical practice. They cause significant morbidity among sexually active women. Consensual vaginal intercourse may lead to minor hymenal or vaginal tears to rectovaginal fistula and in some cases severe haemorrhage shock can occur. It commonly results due to inadequate foreplay prior to penetration. Hereby, authors present four cases of vaginal lacerations of different age groups. The first patient bled profusely from the laceration and was haemodynamically stable; the second patient bled profusely and went into shock; the third patient presented with rectovaginal fistula who was newly married; and fourth patient was 13-year-old girl with third degree tear following trauma. The various risk factors for vaginal injury following consensual sexual intercourse are lack of foreplay, rigid perineum, vaginal atrophy and hindrance from partner. This case series highlights need of clinicians for proper and prompt diagnosis of condition and early surgical intervention in the management of the injuries and giving proper sexual education for the women.

VP68.01: Perineal clinic in the postpartum follow‐up of women who suffer third and fourth degree tears: do we need it?

VP68.01: Perineal clinic in the postpartum follow‐up of women who suffer third and fourth degree tears: do we need it?

Reducing caesarean section rate in an urban hospital serving women attending privately in India \u2013 a quality improvement initiative

BackgroundIn line with global trends, India has witnessed a sharp rise in caesarean section (CS) deliveries, especially in the private sector. Despite the urgent need for change, there are few published examples of private hospitals that have successfully lowered their CS rates. Our hospital, serving private patients too, had a CS rate of 79% in 2001. Care was provided by fee-for-service visiting consultant obstetricians without uniform clinical protocols and little clinical governance. Consultants attributed high CS rate to case-mix and maternal demand and showed little inclination for change. We attempted to reduce this rate with the objective of improving the quality of our care and demonstrating that CS could be safely lowered in the private urban Indian healthcare setting.MethodsWe hired full-time salaried consultants and began regular audit of CS cases. When this proved inadequate, we joined an improvement collaborative in 2011 and dedicated resources for quality improvement. We adopted practice guidelines, monitored outcomes by consultant, improved labour ward support, strengthened antenatal preparation, and moved to group practice among consultants.ResultsGuidelines ensured admissions in active labour and reduced CS (2011 to 2016) for foetal heart rate abnormalities (23 to 5%; p < 0.001) and delayed progress (19 to 6%; p < 0.001) in low-risk first-birth women. Antenatal preparation increased trial of labour, even among women with prior CS (28 to 79%; p < 0.001). Group practice reduced time pressure and stress, with a decline in CS (52 to 18%; p < 0.001) and low-risk first-birth CS (48 to 12%; p < 0.001). Similar CS rates were maintained in 2017 and 2018. Measures of perinatal harm including post-partum haemorrhage, 3rd-4th degree tears, shoulder dystocia, and Apgar < 7 at 5 min were within acceptable ranges (13, 3, 2% and 3 per thousand respectively in 2016–18,).ConclusionsIt is feasible to substantially reduce CS rate in private healthcare setting of a middle-income country like India. Ideas such as moving to full-time attachment of consultants, joining a collaborative, improving labour ward support, providing resources for data collection, and perseverance could be adopted by other hospitals in their own journey of moving towards a medically justifiable CS rate.

Italian survey on the residents' surgical level in gynecology and obstetrics.

Purpose:The present study aims to investigate the number of surgical procedures performed by Italian residents and their confidence to carry out different surgeries in obstetrics and gynecology.Methods:The present study is a national survey including all Italian gynecology and obstetrics senior residents. A questionnaire including 25 questions was provided. The free Google Forms site was used to create the survey. The study was conducted from April to October 2019. The survey started from the University Hospital of Parma, a tertiary hospital, and was sent to all the Italian post-graduation medical school in gynecology and obstetrics. An e-mail was sent to all representative residents in gynecology and obstetrics in Italy, then forwarded to all the senior residents.Results:Of the 555 residents enrolled, 100 joined the survey (18.2%). The analysis of the different procedures performed by residents has shown that 53%, 57%, and 77% of the residents had never performed a laparotomic, laparoscopic, and vaginal hysterectomy, respectively. The analysis of cesarean section skills has shown that 1% of residents had never performed any simple cesarean section, and 6% of residents had never performed any complex cesarean section. Fifty-two doctors in training had never performed an operative vaginal delivery. Seventy-three and ninety-three residents performed more than thirty uterine curettages and sutures of 1st or 2nd degree tears, respectively.Conclusions:In Italy, senior residents are generally confident with the low-complexity procedures and also with complex cesarean sections. The number of Italian residents confident to perform a hysterectomy is poor. (www.actabiomedica.it)

The use of metronidazole in women undergoing obstetric anal sphincter injuries: a systematic review of the literature.

Antibiotic treatment during surgical repair of obstetric anal sphincter injuries (OASIS) had been a matter of debate. We aimed to review the available literature regarding the efficacy of metronidazole administration in women undergoing perineal repair following obstetric OASIS. To identify potentially eligible studies, we searched PubMed, Scopus, Embase and the Cochrane Library from inception to January 13th, 2019.Reference lists of identified studies were searched. No language restrictions were applied. We used a combination of keywords and text words represented by "Metronidazole", "obstetrics", "obstetric anal sphincter injury", "OASIS", "third degree tear", "fourth degree tear", "third degree laceration", "fourth degree laceration", "antibiotic therapy", "perineal damage" and "perineal trauma". Two reviewers independently screened the titles and abstracts of records retrieved from the database searches. Both reviewers recommended studies for the full-text review. Thescreen of full-text articles recommended by at least one reviewer was done independently by the same two reviewers and assessedfor inclusion in the systematic review. Disagreements between reviewers were resolved by consensus. The electronic database search yielded a total of 54,356 results (Fig.1). After duplicate exclusion 28,154 references remained. Of them, 26 were relevant to the review based on title and abstract screening. None of these articles dealt with the use of metronidazole for the prevention of infections complicating anal sphincter repair in women with OASIS. A Cochrane review addressing antibiotic prophylaxis for patients following OASIS, compared prophylactic antibiotics against placebo or no antibiotics, included only one randomized controlled trial of 147 participants. This study showed that prophylactic antibiotics (not metronidazole) may be helpful to prevent perineal wound complications following OASIS. Fig. 1 Study seection process CONCLUSION: Anaerobic infections potentially complicate wound repair after OASIS. Although scientific societies recommend the use of antibiotics for the prevention of infectious morbidity after OASIS, no study has specifically assessed the role of metronidazole.

Induction of Labor and Risk of Third- and Fourth-Degree Perineal Tears [18P

INTRODUCTION: The rate of induction of labor (IOL) at term has been increasing over the years. Our objective was to evaluate the risk of third- and fourth-degree perineal tears associated with term induction of labor. METHODS: We conducted a population-based, retrospective cohort study using the United States' Nationwide Inpatient Sample to evaluate the risk of third- and fourth-degree perineal tears in women who underwent IOL at term between 2005 and 2014. We included all term livebirths and excluded, preterm births, previous cesarean deliveries, multifetal gestations, and non-cephalic presentation. Women who underwent an IOL at term were identified using ICD-9 coding. Patient characteristics were compared between those women being induced at term with those who weren't, and logistic regression analysis were carried out to estimate the adjusted effect of IOL at term with risk of 3rd and 4th perineal tears RESULTS: Among 5,982,945 eligible live births, 1,035,003 (17.3%) underwent an IOL at term, increasing from 15.7% to 18.5%. Women with an IOL were more likely to be older, Caucasian, and with comorbid illnesses. Compared with women who did not undergo an IOL, women in the IOL group had lower risk of cesarean deliveries, 0.89 (0.88–0.89), 2nd degree tears, 0.89 (0.89–0.90), 3rd degree tears, OR 0.81 (95% CI 0.79–0.82) and 4th degree tears, OR 0.84 (95% CI 0.82–0.87). CONCLUSION: Induction of labor at term results in significantly lower risk of third- and fourth-degree perineal tears among all deliveries as well as among women with vaginal deliveries.

Maternal outcomes and birth interventions among women who begin labour intending to give birth at home compared to women of low obstetrical risk who intend to give birth in hospital: A systematic review and meta-analyses

BackgroundWe previously concluded that risk of stillbirth, neonatal mortality or morbidity is not different whether birth is intended at home or hospital. Here, we compare the occurrence of birth interventions and maternal outcomes among low-risk women who begin labour intending to birth at home compared to women intending to birth in hospital. MethodsWe used our registered protocol (PROSPERO, http://www.crd.york.ac.uk, No.CRD42013004046) and searched five databases from 1990–2018. Using R, we obtained pooled estimates of effect (accounting for study design, study setting and parity). Findings16 studies provided data from ~500,000 intended home births for the meta-analyses. There were no reported maternal deaths. When controlling for parity in well-integrated settings we found women intending to give birth at home compared to hospital were less likely to experience: caesarean section OR 0.58(0.44,0.77); operative vaginal birth OR 0.42(0.23,0.76); epidural analgesia OR 0.30(0.24,0.38); episiotomy OR 0.45(0.28,0.73); 3rd or 4th degree tear OR 0.57(0.43,0.75); oxytocin augmentation OR 0.37(0.26,0.51) and maternal infection OR 0.23(0.15,0.35). Pooled results for postpartum haemorrhage showed women intending home births were either less likely or did not differ from those intending hospital birth [OR 0.66(0.54,0.80) and RR 1.30(0.79,2.13) from 2 studies that could not be pooled with the others]. Similar results were found when data were stratified by parity and by degree of integration into health systems. InterpretationAmong low-risk women, those intending to birth at home experienced fewer birth interventions and untoward maternal outcomes. These findings along with earlier work reporting neonatal outcomes inform families, health care providers and policy makers around the safety of intended home births. FundingPartial funding: Association of Ontario Midwives open peer reviewed grant.

Perineal repair of media-lateral episiotomies and 2nd degree tears by midwives: A randomised controlled trial comparing three suture techniques

BackgroundPerineal trauma pain is associated with perineal repair and its subsequent healing. New evidence is required concerning perineal repair techniques that cause less pain and favour healing. ObjectiveTo compare three perineal repair suturing techniques after episiotomy or second degree tearing during a normal birth with respect to reducing pain and improving the perineal healing process. DesignA randomised controlled trial. SettingA large public university hospital in Madrid, Spain. ParticipantsFull term pregnant women older than 18 years-of-age, who required perineal repair after episiotomy or second degree tearing and were attended for normal birth by midwives. MethodsOne hundred and eighty-three women were randomly assigned to three groups: the Continuous Suture Group (n = 58), Interrupted Cutaneous Suture Group (n = 53), or the Interrupted Subcutaneous Suture Group (n = 57). The study participants and data collectors were blinded to group allocations. Principal outcome: perineal pain 10 days after birth. Other outcomes: short (2 and 48 h) and long term (3 and 6 months) perineal pain after birth; short term healing; suture time. ResultsAt 10 days postpartum, the presence of spontaneous pain, pain when walking or moving in bed, was almost nonexistent in the 3 suture groups. The median (P25-P75) perineal pain on palpation was similar in the 3 groups, with values of 2 (1–4) in the Continuous Suture Group, 3 (2–5) in the Interrupted Cutaneous Suture Group and 2 (1–4) in the Interrupted Subcutaneous Suture Group; also were similar the perineal pain on sitting: 1 (0–3) in the Continuous Suture Group, 1 (0–2) in the Interrupted Cutaneous Suture Group and 1 (0–3) in the Interrupted Subcutaneous Suture Group. There were no statistically significant differences between the groups. Pain measurements throughout the follow-up period only showed statistically significant differences in 2 out of 22 evaluations: pain when sitting 48 h after birth and spontaneous pain at 3 months. The mean times (standard deviation) to carry out suturing were 12.86 (4.9) minutes in the Continuous Suture Group, 13.54 (5.6) in the Interrupted Cutaneous Suture Group, and 15.59 (6.9) minutes in the Interrupted Subcutaneous Suture Group (p < 0.05). ConclusionsThe three suturing methods described for perineal repair after episiotomy or second degree tearing after normal birth are comparable with respect to short, medium and long term perineal pain and the healing process. Use of the continuous suturing technique involved less time than interrupted suture methods.Tweetable abstract: proper the suturing methods for perineal repair after episiotomy or second degree tearing prevent postpartum perineal pain.

Monsel´s solution for first degree perineal bleeding tears treatment: a randomized controlled clinical trial

Introduction: During vaginal delivery, tears can occur in different areas of the lower genital tract. The policy of "restrictive episiotomy" increases anterior perineal trauma, mainly paraurethral tears. The topical application of Monsel´s solution in first degree perineal bleeding tears may benefit patients because of less use of anesthetics, sutures and procedure time. Objective: To determine if the Monsel´s solution stops active bleeding in first degree tears compared to traditional suture. Materials and methods: Randomized clinical trial, carried out at Hospital Nacional "Prof. Alejandro Posadas" from January 2011 to December 2013. 330 patients with recent postpartum vaginal delivery were admitted with a diagnosis of first degree bleeding tears. They were randomized to receive the application of Monsel´s solution, until stopping bleeding (intervention group) or traditional suture (control group). The primary outcome was the stoppage of active bleeding. Secondary outcomes were: patient discomfort with the procedure, practicality of the procedure, alterations in the scarring of the tear and wound infections. Crude and adjusted ORs and 95% CI were calculated. Analysis was done by intention to treat. The study was approved by the Bioethics Committee of the Hospital. Results: Monsel´s solution was effective for the stoppage of active bleeding in 86.7% of first degree bleeding tears. Out of 150 patients randomized to the intervention group, 130 met the primary outcome, ORc 0.04 (95% CI 0.01-0.27)/ORa 0.05 (95% CI 0.01-0.34) Monsel´s solution was safe, because it did not interfere with the scarring process It also offered a protective aspect on wound infections. The procedure was practical and simple for the intervening professionals and, despite being an irritant for the mucous; it was well tolerated by the patients. Conclusion: The Monsel´s solution appears effective, practical and safe for treatment of first degree bleeding tears.

Revisiting the risk factors associated with obstetric anal sphincter injuries

Introduction Third- and fourth-degree tears are injuries which can occur to the perineum during vaginal birth. A third degree tear extends through the anal sphincter muscle complex (1-3). A fourth degree tear extends into the rectal mucosa [1]. Together they are often known as OASIS (Obstetric Anal Sphincter InjurieS) [1]. Incidence

Postpartum Female Sexual Function: Risk Factors for Postpartum Sexual Dysfunction.

IntroductionWomen's sexual health is a vital and important part of life at any age. In particular, pregnancy and childbirth bring biological, psychological, and social changes which may influence sexual health. It has been shown that sexual function declines during pregnancy and does not return to its baseline levels during the postpartum period. Despite the complexity and significance of this subject, health providers often neglect sexual aspects during pregnancy and postpartum.AimWe believe that clarifying the risk factors will help open conversations and improvements in sexual function.MethodsIn this review, we focus on how postpartum sexual function is affected by mode of delivery, perineal trauma during delivery, episiotomy, and lactation.ConcclusionsWe conclude that the mode of delivery has no significant effect on short- and long-term postpartum sexual function. On the other hand, 3rd and 4th degree tears are strongly associated with postpartum sexual dysfunction. We found that episiotomy does not adversely affect sexual function, and lactation has a slightly negative effect. We believe that shedding light on this topic will lead to a better understanding for pregnant and postpartum women and the obstetrician. Further studies may elucidate more useful treatment approaches.Ola Gutzeit, Gali Levy, Lior Lowenstein. Postpartum Female Sexual Function: Risk Factors for Postpartum Sexual Dysfunction. Sex Med 2019;8:8–13.

Sphincter repair or Sacral Nerve Modulation: Still debatable?

Fecal incontinence (FI) is a debilitating condition with negative consequences to patients. It is recognized as a “quality of life” illness. Sphincter tears resulting often from difficult childbirth or from surgical trauma, are well-identified causes of FI. When conservative measures fail to resolve FI symptoms, a surgical treatment is recommended on the basis of a comprehensive pelvic floor work-up. A sphincter tear is frequently found on endoanal ultrasonography. The best way to surgically approach a patient with FI related/associated with a sphincter lesion is still debatable. International guidelines are inconsistent regarding the role of either sacral neuromodulation (SNM) or anal sphincteroplasty (anal sphincter repair) (AS) in patients with anal sphincter defect. Decision making for an individual patient often relies on expert opinion and personal experience due to the poor quality of the few published studies. Currently the presence of a sphincter defect is no longer considered a contraindication for sacral nerve modulation (SNM) which has several advantages. SNM is a minimally invasive procedure with very low morbidity, its results can be accurately predicted with a test phase, and are sustained with long-term placement of the implant. Nevertheless, AS has clearly a role to play, for instance in young female patients reluctant to get an implanted nerve stimulator early in life and/or in case of a cloacae-like deformity as a sequela of a post-obstetrical 4th degree tear. While waiting for prospective studies directly comparing SNM and AS for various types of FI, we propose in this paper a pragmatic treatment algorithm based on the most recently published studies and recommendations for the management of sphincter defect related/associated FI.