Repair Of Perineal Trauma Research Articles

Pain, healing and satisfaction of women after perineal repair with surgical glue and suture.

To compare the intensity of pain, the healing process and women's satisfaction with the repair of perineal trauma during vaginal delivery using surgical glue or suture. Cross-sectional study aligned with a clinical trial conducted at a maternity in Itapecerica da Serra, São Paulo. The sample consisted of women who were evaluated between 10 and 20 days after delivery. The outcomes were analyzed according to the distribution of women in the experimental group (EG: perineal repair with Glubran-2® surgical glue; n=55) and in the control group (CG: perineal repair with Vicryl® suture thread; n=55). 110 puerperal women were evaluated. There was no difference between EG and CG regarding sociodemographic and clinical-obstetric characteristics. The intensity of perineal pain, assessed by the visual numeric scale was lower among women in the EG compared to the CG (p<0.001). According to the REEDA scale, there was no significant difference in perineal healing (p=0.267) between EG and CG. The satisfaction of women with perineal repair, assessed using a five-point scale, was higher with the use of surgical glue (p=0.035). Surgical glue showed advantages in relation to perineal pain and greater satisfaction for women compared to the use of suture. The healing process was similar for both types of repair.

Clinical practice: Perineal suturing

This article highlights the important midwifery skill of perineal assessment and suturing. Perineal trauma resulting from vaginal birth is the most common form of obstetric injury experienced by women, and can be associated with considerable maternal morbidity ( RCOG, 2015 ). Midwives, being the lead practitioner for normal birth, should therefore be competent and skilled in the assessment and repair of perineal trauma. Providing a service which is evidence based and personalised as recommended within Better births ( National Maternity Review, 2016 ) has a massive potential for positive impact upon a women's quality of life as she enters motherhood after vaginal birth.

Never Events - the ongoing problem of the retained vaginal sponge/swab.

NHS England recently published their annual Never Events data summary (a Never Event is defined as ‘a serious incident that is wholly preventable as guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers’). Between April and March 2014/15 there were 306 Never Events. One-third of these were ‘retention of a foreign object in a patient after a surgical/invasive procedure’, a definition that includes interventions related to vaginal birth. Closer analysis of the data reveals that there were 36 cases of retained vaginal sponges/swabs. This amounts to over one-third of all retained foreign objects, and accounts for nearly 12% of all Never Events. The retained vaginal sponge/swab after vaginal birth is a universal problem. A study carried out in the USA found that vaginal sponges/swabs accounted for 22% of retained foreign bodies, and that sponge/swab counts had been omitted after all 11 vaginal births (Gawande et al. N Engl J Med 2003;348:229–35). In 2010, the UK National Patient Safety Agency published a Rapid Response Report mandating NHS organisations to implement a seven-point action plan requiring formalised swab counting procedures after all vaginal births to minimise the risk of retained vaginal sponges/swabs (Table 1). The introduction of such counts has been shown to be acceptable to healthcare professionals in the USA (Lutgendorf et al. Mil Med 2011;176:702–4; Chagolla et al. MCN Am J Matern Child Nurs 2011;36:312–17). Repair of perineal trauma after vaginal birth presents unique challenges. Repairs are often carried out in the delivery room by a single professional with limited maternal analgesia and poor lighting. Once soaked in blood, vaginal sponges/swabs are often difficult to identify. Repairs are commonly carried out by trainees who may not grasp the importance of fastidious sponge/swab counts. The presence of family members and a new baby are further distractions. A retained vaginal sponge/swab can harm the patient, healthcare professionals and the organisation. The woman may experience discharge, infection, secondary haemorrhage and/or psychological harm. The repercussions can harm the professionals as a ‘second victim’. Organisational consequences can be financial and reputational, as Never Events are considered to reflect quality and safety processes within an organisation. Although the introduction of swab counts has been shown to reduce the incidence of retained surgical sponges/swabs, the system is not infallible. Sponges/swabs can be retained even when a documented count has been performed (Gawande et al. N Engl J Med 2003;348:229–35) so total reliance on swab counts is insufficient. Technology may provide an answer. A large study from the Mayo Clinic reported that the introduction of a data-matrix bar-coded counting system totally eliminated retained surgical sponges/swabs, providing an acceptable, reliable and cost-effective solution (Cima et al. Jt Comm J Qual Patient Saf 2011;37:51–8). Addressing the challenge of the retained vaginal sponge/swab would help to achieve the NHS's aspiration of zero Never Events. Until perineal suturing is afforded the same status as other surgical procedures, the problem is likely to remain. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

PL.82 An Audit of Compliance with Current Guidelines on the Management of Third and Fourth Degree Tears in the Rotunda Hospital

3rd and 4th degree tears occur in 1% of vaginal deliveries. In the Rotunda the rate in the first six months of 2012 was increased at 3%. The aim of...

Risk, recognition and repair of perineal trauma

The risk of perineal injury during childbirth continues to affect the majority of women. Morbidity associated with perineal injury and repair is a major health problem for women. Therefore, it is vitally important that midwives are educated and trained to recognise risk factors and the extent of perineal injury. Education and training has been shown to assist midwives to gain confidence and clinical skills to suture competently and keep themselves up-to-date with the best available evidence on which to base their care. This article provides an overview of the literature relating to risk, recognition and repair of the perineum during the childbirth continuum.

Emergent Change and its Implications for Professional Autonomy and Managerial Control: A Case Study from Midwifery

Change can be seen as inevitable and constant, unpredictable and sometimes alarming and yet to stand still risks decay and stagnation. All organizations therefore need to be able to change and adapt to internal and external forces. The ability of the individual to embrace such change is in part due to the way change is managed, with this management approach often a reflection of the institution's culture whether it is in the private or public sector. Using a case study from midwifery, this article explores the tensions found between professional autonomy and managerial control during the application of a Scottish practice change initiative by NHS QIS Scotland in the repair of perineal trauma following childbirth. The study found a number of inter-related factors that drive the effectiveness of clinical change implementation namely; the emphasis placed on evidence-based practice, the role played by communities of practice within the hospital culture, the level of management commitment, and the personal and positional characteristics of the ‘change agents’. Two different stories of the change process emerged: one planned, staged and linear; the other continuous, dynamic and unpredictable.

Textbook Recommendations for Preventing and Treating Perineal Injury at Vaginal Delivery

To assess general obstetrics textbooks regarding the quality and quantity of information about perineal injury at vaginal delivery. An obstetrics and gynecology resident, a perinatologist, and a urogynecologist evaluated 7 obstetrics textbooks by using a standardized abstraction form that delineated descriptions of anatomy and physiology, episiotomy use, and perineal trauma prevention and repair. Two textbooks briefly described anal sphincter anatomy, but none provided a detailed discussion of the relative contribution of anatomic components to continence. Four textbooks discussed the evidence for and against midline or mediolateral episiotomy, and 6 advised against routine episiotomy. Six textbooks described grading lacerations, but only one described detailed repair techniques for all grades. Two textbooks discussed techniques to reduce perineal trauma at the time of delivery. Only one textbook discussed the need to reapproximate the normal anal sphincter anatomy during perineal repair. Although most textbooks accurately reflect current literature regarding routine episiotomy, there is limited discussion of advantages and disadvantages of various types of episiotomy and little offered regarding prevention and repair of perineal trauma at delivery. III.

How cost-effective is it to leave perineal skin unsutured?

This paper describes a cost-effectiveness evaluation based on a randomized controlled trial comparing two policies for surgical repair of perineal trauma. Data were collected for 1780 women who were randomly allocated to either a two-stage postpartum perineal repair policy leaving the skin unsutured (n=890) or a three-stage postpartum perineal repair policy that required suturing of the skin (n=890). The two-stage postpartum perineal repair policy was found to reduce the risk of adverse outcomes at 10days and at 3months, without leading to a significant increase in health-care costs. A widespread adoption of a two-stage postpartum perineal repair policy leaving the skin unsutured following perineal trauma is likely to represent a cost-effective use of health-care resources.

The Ipswich Childbirth Study

Objective To evaluate a policy of two stage postpartum perineal repair leaving the skin unsutured. Design A stratified randomised controlled trial using a 2 × 2 factorial design. Setting The maternity unit at Ipswich Hospital NHS Trust, a district general hospital, between 1992 and 1994. Sample 1780 women requiring surgical repair of episiotomy or first or second degree tear following a spontaneous or simple instrumental delivery. Methods A policy of two-stage perineal repair leaving skin unsutured was compared with a policy of three stage repair including skin closure with interrupted or subcuticular sutures. Both groups were assessed by a research midwife, blind to the allocation, completing questionnaires at 24 to 48 hours and 10 days postpartum, and by self-completed questionnaires at three months after birth. Main outcome measures 1. 24 to 48 hours postpartum: perineal pain; healing; 2. 10 days postpartum: perineal pain, healing and removal of sutures; 3. three months postpartum: perineal pain, removal of sutures, resuturing, dyspareunia, and failure to resume pain-free intercourse. Results Completed questionnaires were returned for 99% of women at both 24 to 48 hours and ten days and by 93% of women three months postpartum. No differences were detected in perineal pain at 24 to 48 hours (62%vs 64%; RR 0.96, 95% CI 0.90–1.03; 2P = 0.3) and 10 days (25%vs 28%; RR 0.90,95% CI 0.77–1.06; 2P = 0.2). Significantly fewer women allocated to two-stage repair reported tight stitches at ten days (14%vs 18%; RR 0.77, 95% CI 0.62–0.96, 2P = 0.02); similar numbers of repairs were judged to be breaking down (five compared with seven women). At three months postpartum fewer women allocated to the two-stage repair reported perineal pain and more had resumed pain-free intercourse. Amongst women who had resumed intercourse there was a significant difference in dyspareunia (15%vs 19%; RR 0.80, 95% CI 0.65–0.99; 2P = 0.04). Significantly fewer women in the two-stage repair group (7%vs12%; RR 0.61, 95% CI 0.45–0.83; 2P = < 0.01) reported removal of suture material. Four women in the two-stage repair group had required resuturing, compared with nine allocated to the three-stage repair. Conclusions Two-stage repair of perineal trauma leaving the skin unsutured appears to reduce pain and dyspareunia three months postpartum. There are no apparent disadvantages, in particular no evidence of an increased risk of breakdown of the repair and resuturing.

The Choice of Suture Materials and Techniques for Repair of Perineal Trauma

Summary A systematic review of the 14 relevant controlled trials was conducted because there is no agreement about the choice of material and technique for repair of perineal trauma sustained during childbirth. Derivatives of polyglycolic acid (marketed as Dexon and Vicryl) appear to be the absorbable material of choice for both deep and skin closure. Compared with catgut their use is associated with about a 40% reduction in short-term pain and need for analgesia. The main drawback is that some material often needs removal during the puerperium. Glycerol-impregnated catgut is ruled out because of its link with longterm dyspareunia. Compared with the non-absorbable materials (silk and nylon) polyglycolic acid skin sutures were associated with less shortterm perineal pain, and had no clear disadvantages. Continuous, subcuticular stitching appears preferable to interrupted, transcutaneous suturing, particularly in terms of perineal pain in the early puerperium.