Management Of Perineal Trauma Research Articles

Emerging trends in research on perineal trauma management: A bibliometric analysis of articles published since 1985

BackgroundThe purpose of this bibliometric analysis is to explore global trends in scientific research involving spontaneous perineal tears sustained during childbirth. This research is critical as a significant number of women have vaginal lacerations after birth resulting in complications such as pain and pelvic floor dysfunction. MethodsThe articles used in this bibliometric analysis were collected from PubMed, Web of Science, Cochrane library and Scopus. Analysis was carried out in Python and R programming languages with some visualizations created using VOS software. Apart from traditional methods, this analysis also involved time series forecasting and assessment of rolling correlations. ResultsResults indicate authors and institutions from the United Kingdom as the most productive in the research on this subject research. National level analyses for six countries showed that productivity was positively correlated with GDP/capita, average health expenditure and negatively associated with proportion of C-sections. Recent and emerging themes include those involving pharmacological interventions for pain management. ConclusionThere is a growing global interest in the research on postnatal perineal trauma with authors from the UK playing a leading role so far. Countries with high vaginal birth rates, need to promote research in this field to minimise trauma-associated comorbidities.

Postpartum management of perineal injury - A critical narrative review of level 1 evidence

BackgroundInjury to the perineum is a common sequalae of vaginal birth. Lack of appropriateperineal wound care in the postnatal period is associated with increased pain and morbidity in theshort, medium, and long term. Women and maternity healthcare providers require high-levelevidence-based information to inform postnatal perineal wound care. ObjectivesTo review the high-level evidence informing postpartum management of perineal trauma. DesignA systematic search of the literature regarding the postnatal management of perineal injury to produce a critical narrative review of the available level I evidence regarding the postnatal management of perineal trauma up to six months postpartum was undertaken. Systematic reviews were identified from searching the following databases: CINAHL, Cochrane Library, MEDLINE, PUBMED, and SCOPUS. Papers were selected if they met the following criteria: systematic reviews/level I evidence related to postnatal management of any form of perineal injury up to six months post birth, written in English, and published from January 2010 to 30th May 2021. A synthesis of the results was developed. FindingsNineteen systematic reviews met criteria for inclusion. The systematic reviews fell into one of the following categories of perineal trauma management: use of medication for pain relief, the decision to suture, suture techniques/materials, cryotherapy, use of antibiotics, ultrasound, physiotherapy treatment and complementary therapies. Conclusion: There is an overall lack of focused high-quality research to inform management of perineal injuries beyond the acute postnatal period. Clinical trials that include women’s satisfaction and wellbeing as outcome measures are limited. Implications for practiceIt is vital that women are provided with evidence-based postnatal care strategies to enhance perineal healing and resumption of normal activities. Future clinical trials for the management of perineal trauma should incorporate women’s satisfaction as an outcome measure.Further research examining the follow-up care for the medium-long term for women experiencing ongoing sequalae of symptoms in the community setting is required to support clinical practice recommendations.

The Management of Perineal Trauma in Children.

Aims:This study aimed to evaluate the outcome of perineal trauma in children and to a define protocol for their management.Methods:It is a retrospective study of children who presented with perineal injury between August 2012 and December 2020. The patients were classified into three groups: Group-1 included children with perineal and genitourinary injuries; Group-2 included patients with perineal and anorectal injuries; and Group-3 included patients with perineal, genitourinary, and anorectal injuries. All patients underwent primary repair. Those with full-thickness anorectal injury underwent an additional covering colostomy, while urethral disruption was initially managed by a diverting suprapubic cystostomy (SPC).Results:A total of 41 patients were studied. Impalement injury (n = 11; 27%) and sexual abuse (n = 11; 27%) were the most common mechanisms of injury. Twenty (49%) patients had anorectal injuries with 10 (24%) each of partial-thickness and full-thickness injury. There were 24 (59%) genital injuries and five (12%) urethral injuries. One patient each developed anal and vaginal stenosis, both were managed with dilatation. One patient developed a rectovaginal fistula repaired surgically at a later date.Conclusion:Perineal injuries with resultant anorectal or genital damage require a careful primary survey. Following stabilization, an examination under anesthesia as a set protocol will help determine the treatment strategy. A colostomy is essential in the acute management of severe anorectal injuries to reduce local complications and preserve continence. Urethral injuries may warrant an initial diverting SPC in selected cases.

Perineal trauma management and follow-up: Are we meeting the standard of care?

Birth-related third- and fourth-degree perineal trauma is common and associated with short- and long-term complications. To conduct a review of clinical audits investigating management of women with perineal trauma. We identified all audits undertaken in eight New Zealand public hospitals between 2005 and 2014 that investigated whether women with birth-related third- and fourth-degree perineal trauma were receiving care according to clinical guidelines. We aggregated audit results and calculated the proportion of women receiving the recommended standard of care. During the review period, 25 audits investigated intra-operative (n=11), post-operative (n=14) and outpatient care (n=18). Baseline audits showed variation in care by site; intra-operative care (range 39-96% for repair conducted under anaesthesia, 60-96% for repair by or under supervision of a senior clinician, and 33-54% for completion of Accident Compensation Corporation forms); post-operative care (range 40-93% for prescribed antibiotics and 33-96% for stool softeners) and outpatient care (45-84% for referral to outpatient clinic and 54-78% for physiotherapy follow-up). Sustained high quality of care and improvements in adherence with recommendations were seen for most of the follow-up audits (eg 90% adherence for prescribed stool softeners over three audits; over 50% increase in prescribed antibiotics over seven years). These clinical audits exemplify the need to measure patient care against standards, learn from the findings, implement changes to improve patient experience and reduce life-long sequelae from perineal trauma. This review showed some progress in some care services and highlighted where further changes are needed to close evidence-practice gaps.

National survey of perineal trauma and its subsequent management in the United Kingdom.

Perineal trauma affects approximately 350,000 women per annum in the United Kingdom (UK) and is associated with considerable morbidity. Symptoms are most severe following obstetric anal sphincter injuries (OASIS) compared with other grades of perineal trauma. The Royal College of Obstetricians and Gynaecologists (RCOG) guidelines indicate that the rate of OASIS is 1 % of vaginal deliveries. In 2011, the RCOG implemented the "Maternity Dashboard" so that units could benchmark their performance against national standards of which OASIS is a component. Our primary objective was to establish the national rate of OASIS and audit variations in incidence and management of obstetric perineal trauma. We carried out a questionnaire-based survey auditing national practice. Every UK maternity unit was contacted regarding perineal outcomes after all deliveries between January 2009 and January 2010. 215 of the 265 units in the UK responded (81 %). 692,259 of the 790,197 deliveries in the UK for the same period were sampled (88 %). 75 % delivered vaginally. The median national OASIS rate was 2.85 % (0-8 %). 20.2 % of women delivering vaginally had episiotomies; none were midline. 12.4 % of second-degree tears were not repaired in low-risk units compared with 5.9 % in high-risk units. 57.1 % of units used the perineal trauma classification of the RCOG. This study provides comprehensive data regarding the incidence and management of perineal trauma across the UK. Clinicians and policy-makers, both local and at the RCOG, can devise up-to-date realistic guidelines on the anticipated rate of OASIS and help to assess the compliancy of units with guidelines on the appropriate management of perineal trauma.

Secondary suturing compared to non-suturing for broken down perineal wounds following childbirth

Each year approximately 350,000 women in the United Kingdom and millions more worldwide, experience perineal suturing following childbirth. The postpartum management of perineal trauma is a core component of routine maternity care. However, for those women whose perineal wound dehisces (breaks down), the management varies depending on individual practitioners preferences as there is limited scientific evidence and no clear guidelines to inform best practice. For most women the wound will be managed expectantly whereas, others may be offered secondary suturing. To evaluate the therapeutic effectiveness of secondary suturing of dehisced perineal wounds compared to non-suturing (healing by secondary intention, expectancy). We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 July 2013) and reference lists of retrieved studies. Randomised controlled trials of secondary suturing of dehisced perineal wounds (second-, third- or fourth-degree tear or episiotomy), following wound debridement and the removal of any remaining suture material within the first six weeks following childbirth compared with non-suturing. Three review authors independently assessed trials for inclusion. Two review authors independently assessed trial quality and extracted data. Data were checked for accuracy. Two small studies of poor methodological quality including 52 women with a dehisced and/or infected episiotomy wound at point of entry have been included.Only one small study presented data in relation to wound healing at less than four weeks, (the primary outcome measure for this review), although no reference was made to demonstrate how healing was measured. There was a trend to favour this outcome in the resuturing group, however, this difference was not statistically significant (risk ratio (RR) 1.69, 95% confidence interval (CI) 0.73 to 3.88, one study, 17 women).Similarly, only one trial reported on rates of dyspareunia (a secondary outcome measure for this review) at two months and six months with no statistically significant difference between both groups; two months, (RR 0.44, 95% CI 0.18 to 1.11, one study, 26 women) and six months, (RR 0.39, 95% CI 0.04 to 3.87, one study 32 women). This trial also included data on the numbers of women who resumed sexual intercourse by two months and six months. Significantly more women in the secondary suturing group had resumed intercourse by two months (RR 1.78, 95% CI 1.10 to 2.89, one study, 35 women), although by six months there was no significant difference between the two groups (RR 1.08, 95% CI, 0.91 to 1.28).Neither of the trials included data in relation to the following prespecified secondary outcome measures: pain at any time interval; the woman's satisfaction with the aesthetic results of the perineal wound; exclusive breastfeeding; maternal anxiety or depression. Based on this review, there is currently insufficient evidence available to either support or refute secondary suturing for the management of broken down perineal wounds following childbirth. There is an urgent need for a robust randomised controlled trial to evaluate fully the comparative effects of both treatment options.

Perineal Assessment and Repair Longitudinal Study (PEARLS): a matched-pair cluster randomized trial.

BackgroundPerineal trauma during childbirth affects millions of women worldwide every year. The aim of the Perineal Assessment and Repair Longitudinal Study (PEARLS) was to improve maternal clinical outcomes following childbirth through an enhanced cascaded multiprofessional training program to support implementation of evidence-based perineal management.MethodsThis was a pragmatic matched-pair cluster randomized controlled trial (RCT) that enrolled women (n = 3681) sustaining a second-degree perineal tear in one of 22 UK maternity units (clusters), organized in 11 matched pairs. Units in each matched pair were randomized to receive the training intervention either early (group A) or late (group B). Outcomes within each cluster were assessed prior to any training intervention (phase 1), and then after the training intervention was given to group A (phase 2) and group B (phase 3). Focusing on phase 2, the primary outcome was the percentage of women who had pain on sitting or walking at 10 to 12 days post-natal. Secondary outcomes included use of pain relief at 10 to 12 days post-natal, need for suture removal, uptake and duration of exclusive breastfeeding, and perineal wound infection. Practice-based measures included implementation of evidence into practice to promote effective clinical management of perineal trauma. Cluster-level paired t-tests were used to compare groups A and B.ResultsThere was no significant difference between the clusters in phase 2 of the study in the average percentage of women reporting perineal pain on sitting and walking at 10 to 12 days (mean difference 0.7%; 95% CI −10.1% to 11.4%; P = 0.89). The intervention significantly improved overall use of evidence-based practice in the clinical management of perineal trauma. Following the training intervention, group A clusters had a significant reduction in mean percentages of women reporting perineal wound infections and of women needing sutures removed.ConclusionPEARLS is the first RCT to assess the effects of a ‘training package on implementation of evidence-based perineal trauma management. The intervention did not significantly improve the primary outcome but did significantly improve evidence-based practice and some of the relevant secondary clinical outcomes for women.Trial registrationsISRCTN28960026NIHR UKCRN portfolio no: 4785.

PL.20 Perineal Assessment and Repair E-Learning System (ePEARLS): An E-Learning Training Package to Improve Clinical Management of Perineal Trauma Following Childbirth

Background Birth related perineal trauma can have a major impact on women’s health. The correct assessment and repair of perineal injuries are procedures that require knowledge and skill. Currently, there...

3.3 A Cluster Randomised Trial to Enhance Assessment and Repair of Birth Associated Perineal Trauma: The PEARLS Study

Background Birth associated perineal trauma affects millions of women worldwide. The aim of the Perineal Assessment and Repair Longitudinal Study (PEARLS) was to evaluate if an enhanced, cascaded training programme...

The development and validation of an internet-based training package for the management of perineal trauma following childbirth: MaternityPEARLS

BackgroundBirth-related perineal trauma has a major impact on women's health. Appropriate management of perineal injuries requires clinical knowledge and skill. At present, there is no agreement as to what constitutes...

How good are we at implementing evidence to support the management of birth related perineal trauma? A UK wide survey of midwifery practice.

BackgroundThe accurate assessment and appropriate repair of birth related perineal trauma require high levels of skill and competency, with evidence based guideline recommendations available to inform UK midwifery practice. Implementation of guideline recommendations could reduce maternal morbidity associated with perineal trauma, which is commonly reported and persistent, with potential to deter women from a future vaginal birth. Despite evidence, limited attention is paid to this important aspect of midwifery practice. We wished to identify how midwives in the UK assessed and repaired perineal trauma and the extent to which practice reflected evidence based guidance. Findings would be used to inform the content of a large intervention study.MethodsA descriptive cross sectional study was completed. One thousand randomly selected midwives were accessed via the Royal College of Midwives (RCM) and sent a questionnaire. Study inclusion criteria included that the midwives were in clinical practice and undertook perineal assessment and management within their current role. Quantitative and qualitative data were collated. Associations between midwife characteristics and implementation of evidence based recommendations for perineal assessment and management were examined using chi-square tests of association.Results405 midwives (40.5%) returned a questionnaire, 338 (83.5%) of whom met inclusion criteria. The majority worked in a consultant led unit (235, 69.5%) and over a third had been qualified for 20 years or longer (129, 38.2%). Compliance with evidence was poor. Few (6%) midwives used evidence based suturing methods to repair all layers of perineal trauma and only 58 (17.3%) performed rectal examination as part of routine perineal trauma assessment. Over half (192, 58.0%) did not suture all second degree tears. Feeling confident to assess perineal trauma all of the time was only reported by 116 (34.3%) midwives, with even fewer (73, 21.6%) feeling confident to perform perineal repair all of the time. Two thirds of midwives (63.5%) felt confident to perform an episiotomy. Midwives qualified for 20 years or longer and those on more senior clinical grades were most likely to implement evidence based recommendations and feel confident about perineal management.ConclusionsThere are considerable gaps with implementation of evidence to support management of perineal trauma.

Perineal trauma in children

Background/purpose The management of perineal trauma in children is very challenging in the absence of a well-defined institutional management protocol. The purpose of this study was to evaluate the result of implementing a standardized therapeutic approach to perineal trauma in children in our institution. Patients and methods This is a prospective study on the management of perineal trauma in children, according to a predefined protocol. Thirty-four patients with perineal trauma were treated at the Tanta University Hospital and affiliated hospitals during the period May 2003–July 2010. Two patients died of associated head trauma and other concomitant injuries. After initial assessment, resuscitation, and treatment of any existing life threatening condition, the patients were treated either by primary repair of all perineal soft tissue injuries without colostomy (group 1, n=16), primary perineal repair with covering colostomy (group 2, n=11), or fecal diversion and wound drainage with delayed sphincter repair if needed (group 3, n=5). Each patient was assigned to a particular management depending on the presence or absence of full-thickness anorectal injuries, anorectal lacerations, degree of wound contamination, and/or significant skin loss. All patients were evaluated with regard to the type of trauma, physical findings, management, postoperative wound infection or disruption, postoperative functional outcome, and cosmetic results. Results The ages ranged from 2 to 14 years. Significant wound infection occurred in three patients (one in each group), moderate-to-mild wound infection occurred in another four patients, partial wound disruption occurred in two patients in group 1. Urethral stricture occurred in two patients, who were treated by repeated dilatation. Vaginal stenosis developed in one patient. Anorectal continence was noted in 25 (80.6%) of 31 patients who were older than 3 years during the last follow-up visit. Conclusion (i) The proposed simple algorithm for the management of perineal trauma in children has facilitated decision making in the emergency room. (ii) Primary repair of the anorectal sphincter and other injured soft tissue with or without covering colostomy is recommended. (iii) Fecal diversion without sphincter repair should be reserved to cases with significant anorectal lacerations associated with gross contamination. Keywords : children, colostomy, perineal trauma, primary repair

PErineal Assessment and Repair Longitudinal Study (PEARLS): protocol for a matched pair cluster trial

BackgroundThe Perineal Assessment and Repair Longitudinal Study (PEARLS) is a national clinical quality improvement initiative designed to improve the assessment and management of perineal trauma. Perineal trauma affects around 85% of women who have a vaginal birth in the UK each year and millions more world-wide. Continuous suturing techniques compared with traditional interrupted methods are more effective in reducing pain and postnatal morbidity, however they are not widely used by clinicians despite recommendations of evidence based national clinical guidelines. Perineal suturing skills and postnatal management of trauma remain highly variable within and between maternity units in the UK as well as worldwide. Implementation of a standardised training package to support effective perineal management practices could reduce perineal pain and other related postnatal morbidity for a substantial number of women.Methods/DesignPEARLS is a matched pair cluster trial, which is being conducted in maternity units across the UK. Units within a matched pair will be randomised to implement the study intervention either early or late in the study period. The intervention will include the cascading of a multi-professional training package to enhance midwifery and obstetric skills in the assessment, repair and postnatal management of perineal trauma. Women who have had an episiotomy or second degree perineal tear will be eligible for recruitment. Prior to developing the intervention and deciding on study outcomes, a Delphi survey and a consensus conference were held to identify what women, who previously suffered perineal trauma during childbirth, considered to be important outcomes for them. Findings from this preliminary work (which will be reported elsewhere) and other outcomes including women's experiences of perineal pain and pain on activity, breastfeeding uptake and duration and psychological well-being as assessed using the Edinburgh Postnatal Depression Scale (EPDS) will be assessed at 10 days and three months post-birth.DiscussionImplementation of evidence-based perineal assessment and management practices, could lead to significantly improved physical and psychological health outcomes for women in the UK and world-wide.Trial registrationPEARLS is registered with the Current Controlled Trials Registry (no: ISRCTN28960026). NIHR UKCRN portfolio no: 4785.

Pitfalls in the management of perineal trauma

Mismanagement of perineal trauma may have major adverse impact on a woman's health. Unrecognized trauma to the external anal sphincter or anatomically incorrect approximation of wounds can lead to dyspareunia, discontentment with the cosmetic appearance of the perineum, urinary and anal incontinence, and related psychological and social problems. This article explores the pitfalls in the management of obstetric-related perineal trauma and describes the principles of good management.