Perineal Suturing Research Articles

Maternal Position at Midwife‐Attended Birth and Perineal Trauma: Is There an Association?

Most women will sustain some degree of trauma to the genital tract after vaginal birth. This study aimed to examine the association between maternal position at birth and perineal outcome in women who had a midwife-attended, spontaneous vaginal birth and an uncomplicated pregnancy at term. Data from 3,756 births in a major public tertiary teaching hospital were eligible for analysis. The need for sutures in perineal trauma was evaluated and compared for each major factor studied (maternal age, first vaginal delivery, induction of labor, not occipitoanterior, use of regional anesthesia, deflexed head and newborn birthweight >3,500 g). Birth positions were compared against each other. Subgroup analysis determined whether birth positions mattered more or less in each of the major factors studied. The chi-square test was used to compare categorical variables. Most women (65.9%) gave birth in the semi-recumbent position. Of the 1,679 women (44.5%) who required perineal suturing, semi-recumbent position was associated with the need for perineal sutures, whereas all-fours was associated with reduced need for sutures; these associations were more marked in first vaginal births and newborn birth weight over 3,500 g. When regional anesthesia was used, semi-recumbent position was associated with a need for suturing, and lateral position associated with a reduced need for suturing. The four major factors significantly related to perineal trauma included first vaginal birth, use of regional anesthesia, deflexed head, and newborn weight more than 3,500 g. Women should be given the choice to give birth in whatever position they find comfortable. Maternity practitioners have a responsibility to inform women of the likelihood of perineal trauma in the preferred birth position. Ongoing audit of all clinicians attending births is encouraged to further determine effects of maternal birth position and perineal trauma, to investigate women's perception of comfortable positioning at birth, and to measure changes to midwifery practice resulting from this study.

Techniques to reduce perineal pain during spontaneous vaginal delivery and perineal suturing: a UK survey of midwifery practice

To investigate use of pharmacological and non-pharmacological methods of perineal analgesia used by midwives during the second stage of labour and perineal repair in the UK. Postal survey. Self-complete questionnaires were sent to Heads of Midwifery in all 219 maternity units in the UK. Information was requested on the number and type of deliveries undertaken in the previous year and on the midwifery procedures used to provide pain relief immediately before delivery and for perineal repair. Details were also sought on local anaesthetics given before episiotomy or perineal repair. 207 completed questionnaires were returned providing information on 210 maternity units. Midwives reported using a variety of non-pharmacological analgesic methods to control pain at the end of the second stage of labour. Hot packs were used in 70 (33%) maternity units, cold packs in 44 (21%) and perineal massage in 109 (52%). Midwives in 131 (62%) maternity units used injectable local anaesthetics to control perineal pain. All units advocated use of local anaesthetic before episiotomy or perineal repair, but the reported doses used varied widely. The literature on levels of pain experienced immediately before spontaneous vaginal delivery and during perineal repair is sparse, but what evidence exists suggests that, for some women, these occasions are accompanied by severe pain. Findings from this survey show that there is considerable variation in what midwives provide to control pain. Formal evaluation of the perineal analgesia offered to women during the second stage of labour is urgently required.

Risk ratios and odds ratios—what are they?

A risk ratio (sometimes called relative risk, both abbreviated to RR) and an odds ratio (OR) are ways of expressing a comparison between two proportions. For example, in this paper, there are two randomised groups in the trial, women in the lateral position and women in the supported sitting position in the passive second stage of labour. The authors wanted to compare the proportions of instrumental births, episiotomies and perineal suturing in the two groups to see if there was any effect due to maternal position. A risk ratio gives the relative probability or chance of something happening in one group compared with the other, while an odds ratio gives the relative odds. Do you know what the difference is between probability and odds?

A prospective randomised trial on the effect of position in the passive second stage of labour on birth outcome in nulliparous women using epidural analgesia

Objective: to determine whether the rate of instrumental birth in nulliparous women using epidural analgesia is affected by maternal position in the passive second stage of labour. Design: a pragmatic prospective randomised trial. Setting: consultant maternity unit in the Midlands. Participants: one hundred and seven nulliparous women using epidural analgesia and reaching the second stage of labour with no contraindications to spontaneous birth. Interventions: the lateral versus the supported sitting position during the passive second stage of labour. Measurements: mode of birth, incidence of episiotomy, and perineal suturing. Findings: recruitment was lower than anticipated (107 vs. 220 planned). Lateral position was associated with lower rates of instrumental birth rate (lateral group 33%; sitting group 52%; p=0.05, RR 0.64, CI for RR: 0.40–1.01; Number-needed-to-treat (NNT)=5), of episiotomy (45% vs. 64%; p=0.05, RR 0.66, CI for RR: 0.44–1.00, NNT=5), and of perineal suturing (78% vs. 86%; p=0.243, RR 0.75, CI for RR 0.47–1.17). The odds ratio for instrumental birth in the sitting group was 2.2 (CI 1.00–4.6). Logistic regression of potential confounder variables was undertaken, due to a large variation in maternal weight between the randomised groups. Of the nine possible confounders tested, only position of the baby's head at full dilation affected the risk of instrumental birth significantly ( p=0.4, OR 2.7 where the fetal head was in the lateral or posterior position). Maternal weight did not appear to have any effect. The odds ratio for instrumental delivery for women randomised to the sitting position was slightly higher within the logistic regression model (adjusted OR 2.3). Key conclusions: women randomised to the lateral position had a better chance of a spontaneous vaginal birth than those randomised to the supported sitting position. Position of the babys’ head at full dilation had an additional effect on mode of birth. These effects are not conclusively generalisable. Recommendations for practice: the lateral position is likely to be at best beneficial, and at the worst no less harmful than the sitting position for most women and their babies who meet the criteria set for this study. Conclusive evidence for or against the technique should be established using larger trials.

Does perineal suturing make a difference? The SUNS trial

To examine differences in outcome between primiparous women who do and who do not have suturing to first or second degree perineal lacerations sustained during spontaneous vaginal births after 37 weeks of gestation. Parallel group randomised controlled trial. Bellshill Maternity Hospital, Lanarkshire, and St John's Hospital, Livingston. Primigravidae with perineal lacerations following spontaneous birth. One thousand and three hundred fourteen women were recruited to the trial antenatally from whom 74 were randomised either to be sutured or not sutured immediately after giving birth. Randomisation was stratified by degree of tear. Using standardised measures, perineal pain and healing were measured at 1 and 10 days and 6 weeks postpartum. In addition, postnatal depression was assessed at 10 days and 6 weeks postpartum. Findings indicated that there were no significant differences between the groups with regard to pain or depression but there were differences with regard to healing. At six weeks, there remained a significant difference in wound closure between the groups, with women who had not been sutured having poorer wound approximation. While acknowledging the small sample size, the results are nonetheless important, showing persistent evidence of poorer wound approximation in those women who had not been sutured. Practitioners need to review the present practices of not suturing perineal lacerations until research examining the longer term implications is undertaken.

Does perineal suturing make a difference? The SUNS trial

Objective To examine differences in outcome between primiparous women who do and who do not have suturing to first or second degree perineal lacerations sustained during spontaneous vaginal births after 37 weeks of gestation. Design Parallel group randomised controlled trial. Setting Bellshill Maternity Hospital, Lanarkshire, and St John's Hospital, Livingston. Population Primigravidae with perineal lacerations following spontaneous birth. Methods One thousand and three hundred fourteen women were recruited to the trial antenatally from whom 74 were randomised either to be sutured or not sutured immediately after giving birth. Randomisation was stratified by degree of tear. Main outcome measures Using standardised measures, perineal pain and healing were measured at 1 and 10 days and 6 weeks postpartum. In addition, postnatal depression was assessed at 10 days and 6 weeks postpartum. Results Findings indicated that there were no significant differences between the groups with regard to pain or depression but there were differences with regard to healing. At six weeks, there remained a significant difference in wound closure between the groups, with women who had not been sutured having poorer wound approximation. Conclusions While acknowledging the small sample size, the results are nonetheless important, showing persistent evidence of poorer wound approximation in those women who had not been sutured. Practitioners need to review the present practices of not suturing perineal lacerations until research examining the longer term implications is undertaken.

Postpartum urinary incontinence.

The aim of the present study was to identify prepregnancy, pregnancy and delivery correlates of urinary incontinence postpartum (PP UI) as reported by women in a cross-sectional population sample. A questionnaire-based cross-sectional survey was carried out in 1998 in a random population sample of 3900 20- to 59-year-old women. The present study includes 376 women who had their last delivery during 1993-96. UI immediately after childbirth and 6 months thereafter was reported by 23.4% and 2.7%, respectively. PP UI was strongly associated with UI both before and during the present pregnancy, explaining 37.5% and 51.7% of postpartum UI, respectively. Eight percent experienced their first UI episode ever immediately after the delivery. Among women undergoing a cesarean section 8.8% reported postpartum UI, as contrasted with 24.9% in other women. Postpartum UI was positively associated with perineal suturing but un-associated with labor augmentation, episiotomy, birth weight, and breast-feeding. In the present study, which included a comprehensive causal model, postpartum UI could be explained first of all as the decline of pregnancy UI, secondly as a manifestation of a pre-existing tendency to react by UI, and finally as a consequence of the birth process itself.

Postpartum urinary incontinence

Background. The aim of the present study was to identify prepregnancy, pregnancy and delivery correlates of urinary incontinence postpartum (PP UI) as reported by women in a cross-sectional population sample. Methods. A questionnaire-based cross-sectional survey was carried out in 1998 in a random population sample of 3900 20- to 59-year-old women. The present study includes 376 women who had their last delivery during 1993–96. Results. UI immediately after childbirth and 6 months thereafter was reported by 23.4% and 2.7%, respectively. PP UI was strongly associated with UI both before and during the present pregnancy, explaining 37.5% and 51.7% of postpartum UI, respectively. Eight percent experienced their first UI episode ever immediately after the delivery. Among women undergoing a cesarean section 8.8% reported postpartum UI, as contrasted with 24.9% in other women. Postpartum UI was positively associated with perineal suturing but un-associated with labor augmentation, episiotomy, birth weight, and breast-feeding. Conclusion. In the present study, which included a comprehensive causal model, postpartum UI could be explained first of all as the decline of pregnancy UI, secondly as a manifestation of a pre-existing tendency to react by UI, and finally as a consequence of the birth process itself.

Effectiveness of pain relief during perineal suturing.

The amount of pain women experience during perineal suturing is previously unreported, although anecdotal evidence suggests that the procedure can be associated with considerable pain. Of 68 women who participated in this descriptive study, 16.5% reported 'distressing', 'horrible' or 'excruciating' pain while receiving perineal sutures. Contrary to expectations, pain scores did not diminish as the time between suturing and pain reporting increased. Regional analgesia was associated with lower reported pain. The findings of this small study suggest that further detailed investigation of this aspect of care is urgently required.

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Effectiveness of pain relief during perineal suturing

The amount of pain women experience during perineal suturing is previously unreported, although anecdotal evidence suggests that the procedure can be associated with considerable pain. Of 68 women who participated in this descriptive study, 16.5% reported ‘distressing’, ‘horrible’ or ‘excruciating’ pain while receiving perineal sutures. Contrary to expectations, pain scores did not diminish as the time between suturing and pain reporting increased. Regional analgesia was associated with lower reported pain. The findings of this small study suggest that further detailed investigation of this aspect of care is urgently required.

Episiotomy rates in primiparous women in Latin America: hospital based descriptive study

Current scientific evidence shows that routine episiotomy is not justified: it has no benefit for mother or infant, increases the need for perineal suturing and the risk of complications to...

Accidental out-of-hospital deliveries: an obstetric and neonatal case control study.

Accidental out-of-hospital (OHD) deliveries are associated with high rates of perinatal morbidity and mortality. The ability of health care workers to identify women at risk of out-of-hospital delivery is limited. The purpose of this study was to determine the prevalence of these deliveries in our population and to quantify the neonatal morbidity and mortality associated with such births. Further we aimed to determine whether women at risk of accidental out-of-hospital delivery in our population could be identified antenatally. A retrospective case-control study was performed. Women who delivered accidentally out-of-hospital in our catchment area between January 1995 and March 1999 were identified (cases) and compared with women who delivered in hospital following spontaneous labor (controls). Outcome measures included maternal demographic characteristics, obstetric features and neonatal outcome. In the study period, 117 women delivering 121 babies were identified who delivered accidentally out-of-hospital, (0.6% of all deliveries registered at the hospital). Women who delivered before arrival at hospital were more likely to be of greater parity, unbooked, late bookers and/or poor attenders for antenatal care. Gestation at delivery, duration of labor and birthweight were less in the out-of-hospital delivery group compared with the control group. The rate of perineal suturing was lower for cases than controls. Babies who were delivered accidentally out-of-hospital were more likely to require admission to the neonatal unit and had a higher perinatal mortality rate than controls (51.7 versus 8.6/1000 deliveries, respectively). Accidental out-of-hospital deliveries account for less than 1% of deliveries in our population, but are associated with significant perinatal morbidity and mortality. Women should be educated regarding the importance of both antenatal care and a planned delivery. Since the majority of women who deliver accidentally out-of hospital are parous, there is an opportunity to do this in a previous confinement.

Combined spinal‐epidurals and epidural top‐ups 3

Shaw and Birks describe a high spinal block necessitating intubation and mechanical ventilation as ‘the most severe complication … using the CSE technique’ that they had encountered in 5 years of use (Shaw & Birks. Anaesthesia 2001; 56: 346–9). We would suggest that the event they report could equally have occurred had an epidural been used. Difficulty in interpreting an epidural test-dose after a subarachnoid block is frequently cited as a disadvantage of the needle-through-needle CSE technique. In this case, however, the spinal block had worn off by the time the epidural ‘test-dose’ was given. We would question both the use of a high-concentration, low-volume test-dose (2 ml of bupivacaine 0.5%) to detect intrathecal catheter placement, and the need for such a large dose of bupivacaine (50 mg) for perineal repair. The low-dose bupivacaine–fentanyl mixture used for routine top-ups in the authors' institution can be used as a test dose (10–15 ml): 12.5 mg bupivacaine in a dilute mixture has been given both intrathecally [1] and intravenously [2] to simulate positive test-doses which were specific and sensitive. There were no blocks above T10 with this dose, but the dense motor block produced (modified Bromage score 2–3) would distinguish it from that of a standard initial intrathecal analgesic dose used in the CSE technique for labour [3]. An audit in our institution revealed that amongst women with indwelling CSEs, 65% were ‘topped up’ for instrumental delivery, including perineal suturing, with 20 ml or less of bupivacaine 0.1%. Fewer than 10% required any more concentrated local anaesthetic and bupivacaine 0.5% was not used at all. Finally, we require the anaesthetist to be present for all instrumental deliveries. We believe that regardless of the dose used, only an anaesthetist should convert regional analgesia to anaesthesia, both for reasons of safety and also to ensure that anaesthesia is adequate for the procedure undertaken.

A feminist analysis of women's experiences of perineal trauma in the immediate post-delivery period

Objective: to provide an account of women's experiences of perineal trauma in the immediate post-delivery period.Design: qualitative, using unstructured interviews with broad questions about experiences of childbirth and perineal trauma.Setting: the South Wales.Participants: a snowball technique was employed to recruit six participants, all of whom were between 25 and 40 years of age, white, British and had had access to further education.Findings: the women identified several factors which informed their experience. Of significance to midwives are the following: the doctor – ‘patient’ relationship, particularly in relation to gender, not feeling heard, the expression of feelings; and a lack of available information and advice.Key conclusions and implications for practice: the study identified some of the reasons why women sufferers find it difficult to get these issues on the health-care agendae and the need for more research. Improvements in care are necessary in the areas of interpersonal skills and perineal suturing. Listening to women is the key to responsive care.

Prevalent urinary incontinence as a correlate of pregnancy, vaginal childbirth, and obstetric techniques.

This study examined the association between pregnancy, vaginal childbirth and obstetric techniques, and the prevalence of urinary incontinence among adult women aged 20 to 59 years. A cross-sectional survey enrolled a random sample of 6240 women aged 20 to 59 years who were mailed a self-administered questionnaire focusing on urinary incontinence and other health variables. More than 75% of the women responded. The present analysis includes 4345 women who were not pregnant and did not experience a vaginal childbirth during 1994. Multivariate prevalence odds ratios showed increases in relation to urinary incontinence during pregnancy, urinary incontinence immediately after a vaginal childbirth, and age of 30 years or more at the second vaginal childbirth. No multivariate associations were found for forceps delivery or vacuum extraction delivery, episiotomy, or perineal suturing. Not only the process of childbirth itself but also processes during pregnancy seem to be strongly associated with prevalent urinary incontinence. Perineal suturing may be associated with prevalent urinary incontinence, whereas other obstetric techniques inspected do not seem to be so.

To Suture or not to Suture

Mary Steen (Br J Midwifery 6(9): 572-9) has suggested that research is required urgently into the merits of perineal suturing following normal births. We are pleased to report that such a study has just commenced in central Scotland. The two year study, funded by the Chief Scientist Office, The Scottish Office, is a randomized controlled trial of suturing versus non-suturing of first and second degree postpartum perineal tears in primiparous women. As suggested by Mary Steen, we found little research evidence which measured the benefits of suturing or non-suturing of the perineum. Our study, being carried out in a standardized manner, will examine differences in outcome between primiparous women who do and do not have suturing to first or second degree perineal lacerations sustained during spontaneous vaginal births between 37 and 42 weeks gestation.

Randomised trial of educational visits to enhance use of systematic reviews in 25 obstetric units

Objective To evaluate the effectiveness of an educational visit to help obstetricians and midwives select and use evidence from a Cochrane database containing 600 systematic reviews.Design Randomised single blind controlled...

Suturing of perineal trauma: how well are we doing — an audit

The traditional role of the midwife is fast changing as has been recognized by the Department of Health (Changing Childbirth — 1993). Historically, perineal suturing was considered an obstetrician's role, but it is now an integral part of the role of the midwife and incorporated in basic midwifery education programs (UKCC, 1992). The comfort of the client can be difficult to assess and did not form part of this study. This is being critically appraised by most hospital trusts and the time between delivery and suturing appears to be an important factor. In this respect the Heatherwood and Wexham Park Trust (1994) recommended that the majority of perineal repairs should be performed within 30minutes of delivery.

Cost-effectiveness of different approaches to perineal suturing

Perineal pain is an important postnatal problem for many hundreds of thousands of women each year. This article describes a cost-effectiveness analysis of alternative types of suture material and technique for repair of the perineal skin and for minimising postpartum pain.