Risk Of Severe Perineal Trauma Research Articles

Perineal Massage for Prevention of Perineal Trauma and Episiotomy During Labor: A Systematic Review and Meta-Analysis.

Objective: Vaginal births are associated with a certain degree of trauma to the genital tract, with significant short-term and long-term morbidity. Awareness of morbidity following perineal trauma has led to application of different interventions during the late first stage and second stage of labour to prevent severe perineal trauma. This includes techniques such as perineal massage, warm and cold compresses, and perineal management techniques. Objective of this meta-analysis is to evaluate the effect of perineal massage during the late first stage and second stage of labour on the rate of episiotomy and risk of perineal trauma. Materials and methods: Electronic databases (PubMed, Scopus, Cochrane Library and Science Direct) were searched from inception until August 2021. We included randomized controlled trials (RCTs) which compares perineal massage during labor (i.e., intervention group) with a control group in women with singleton gestation and cephalic presentation at ≥36 weeks. The primary outcome was severe perineal trauma and the rate of episiotomy. Meta-analysis was performed using the random-effects model of DerSimonian and Laird to produce summary treatment effects in terms of relative risk (RR) with 95% confidence interval (CI). Results: Ten trials including 4,088 women were analyzed. Women with perineal massage during labor had a significantly lower incidence of severe perineal trauma (RR: 0.52, 95% CI 0.29- 0.94) compared to the control group. The incidence of episiotomy was lower in the perineal massage group (RR: 0.71, 95% CI 0.52-0.98 p < 0.01) but was statistically insignificant (P>0.05). Conclusion: The finding of meta-analysis showed that perineal massage during labor could be effective in reducing the risk of severe perineal trauma, such as third- and fourth-degree spontaneous lacerations during labor.

‘She is Not Suitable for a Water Birth’

A pseudonym has been used and details have changed to ensure anonymity. The words from a senior midwife – ‘she is not suitable for a water birth’ – are the reason for writing this article. As a student midwife, I was supporting a woman who wanted to labour and birth in water. At that time, there were no contraindications for this woman to safely have a water birth according to the hospital policy for water immersion. The midwife clarified privately to me that she wanted to be able to guard and closely watch the perineum due to the woman’s increased risk of severe perineal trauma (SPT). She clarified this was because the woman was a primiparous woman from India. I was left with unanswered questions. I was supported by my clinical midwifery educator to debrief the experience and further reflect on the evidence of the increased risk of SPT for Indian women, along with how clinicians can support normal birth in a tertiary hospital setting.

One Plus One Equals Two\u2014will that do? A trial protocol for a Swedish multicentre randomised controlled trial to evaluate a clinical practice to reduce severe perineal trauma

BackgroundSevere perineal trauma sustained during childbirth is a serious complication since it can lead to both short- and long-term consequences for women. Some of the methods used to prevent perineal injuries have been evaluated in clinical trials, but there are still gaps in the evidence. A new clinical practice has been introduced, adopted by more than half of the maternity wards in Sweden with the aim of reducing severe perineal trauma. This procedure involves two midwives assisting the woman during the second stage of labour.Methods/designIn this multicentre randomised controlled trial, 2946 women will be randomised to be assisted by one or two midwives during the second stage of labour. Women age 18–47, who plan for their first vaginal birth, with a singleton pregnancy in cephalic presentation, will be asked to participate when admitted to the maternity ward. Five maternity wards comprising 19,500 births/year in different parts of Sweden will participate in this study. The sample size is powered to demonstrate a 50% reduction (from 4.1–2.0%) in primary outcome, which is the prevalence of severe perineal trauma (3rd and 4th degree). Secondary outcomes will include maternal and neonatal outcomes, women’s experiences, midwives’ experiences of the intervention, incontinence, and pelvic floor symptoms. The primary analysis is intention to treat. Questionnaires will be sent to the women at 1 month and 1 year after the birth to assess women’s experiences, pain, incontinence, pelvic floor symptoms, sexual function, and mental health.DiscussionIt is important for care during labour and birth to be evidence based. There is a strong desire among midwives to reduce the risk of severe perineal trauma. This may lead to new strategies and practices being implemented into practice without scientific evidence. The intervention might have negative side effects or unintended consequences. On the other hand, there is a possibility of the intervention improving care for women.Trial registration {2a}ClinicalTrials.gov NCT03770962. Registered on 10 December 2018

Antenatal perineal massage benefits in reducing perineal trauma and postpartum morbidities: a systematic review and meta-analysis of randomized controlled trials.

Most vaginal births are associated with trauma to the perineum. The morbidity associated with perineal trauma can be significant, especially when it leads to third- and fourth-degree perineal tears. We hypothesized that antenatal perineal massage could decrease the incidence of perineal trauma, particularly severe perineal tears and other postpartum complications. We searched four different databases from inception until August 2019 for the available trials. We included randomized controlled trials (RCTs) which assessed the effect of antenatal perineal massage (intervention group) versus control group (no antenatal perineal massage) in perineal trauma patients. Data were extracted from eligible studies and meta-analyzed using RevMan software. Primary outcomes were the risk of episiotomies and perineal tears. Secondary outcomes were perineal pain, second stage of labor duration, wound healing, anal incontinence, and Apgar scores at 1 and 5min. Eleven RCTs with 3467 patients were analyzed. Women who received antenatal perineal massage had significantly lower incidence of episiotomies (RR = 0.79, 95% CI [0.72, 0.87], p < 0.001) and perineal tears (RR = 0.79, 95% CI [0.67, 0.94], p = 0.007), particularly the risk of third- and fourth-degree perineal tears (p = 0.03). Better wound healing and less perineal pain were evident in the antenatal perineal massage group. Antenatal perineal massage reduced the second stage of labor duration (p = 0.005) and anal incontinence (p = 0.003) with significant improvement in Apgar scores at 1 and 5min (p = 0.01 and p = 0.02). Antenatal perineal massage is associated with a lower risk of severe perineal trauma and postpartum complications.

The association between the number of vaginal examinations during labor and perineal trauma: a retrospective cohort study.

To study the association between the number of vaginal examinations (VEs) performed during labor and subsequent severe perineal trauma. This is a retrospective cohort study. We included all women admitted to the delivery ward between 2008 and 2017, in active labor. Exclusion criteria included preterm deliveries (< 37weeks), Cesarean deliveries and episiotomy during delivery. The primary outcome, severe perineal trauma, was defined as perineal tears grades 3-4. The cohort was divided into 4 groups, based on the number of VEs performed during labor: Group 1-up to two VEs (n = 4588), Group 2-three to four VEs (n = 5815), Group 3-five to six VEs (n = 4687), and Group 4-seven or more VEs (n = 7297). Overall, 22,387 women were included in the study. The rate of severe perineal trauma in groups 1, 2, 3 and 4 was 0.4%, 0.1%, 0.8%, and 0.4%, respectively (p < 0.001). Performing five or more VEs during labor was associated with a higher risk of severe perineal trauma (0.26% vs. 0.53%, p < 0.01), as compared to four VEs or less. Using a logistic regression model, we found that performing five or more VEs during labor (aOR = 1.72 CI 95% (1.21-2.47), p < 0.001) or performing an instrumental delivery (aOR = 2.65 CI 95% (1.72-4.07), p < 0.001) were directly associated with the risk for severe perineal trauma. Applying epidural anesthesia showed an inverse association with severe perineal trauma (aOR = 0.54 CI 95% (0.38-0.77), p < 0.001). Performing five or more VEs during active labor is associated with an increased risk for severe perineal trauma.

Severe perineal trauma among women undergoing vaginal birth after cesarean delivery: A population-based cohort study.

To examine risk of severe perineal trauma among nulliparous women and those undergoing vaginal birth after cesarean delivery (VBAC). This is a population-based cohort study of all births to women with their two first consecutive singleton pregnancies in Stockholm-Gotland Sweden between 2008 and 2014. Risk of severe perineal trauma was compared between nulliparous women and those undergoing VBAC with severe perineal trauma being the main outcome measure. Associations between indication and timing of primary cesarean delivery and risk of severe perineal trauma in subsequent vaginal birth were analyzed using Poisson regression analysis. The rate of severe perineal trauma among nulliparous women and those undergoing VBAC was 7.0% and 12.3%, respectively. Compared with nulliparous women, those undergoing VBAC were significantly older, had a shorter stature, and gave birth in a non-upright position to heavier infants with larger head circumferences. The rate of instrumental vaginal delivery among nulliparous women and those undergoing VBAC was 19.3% and 20.2%, respectively (P=0.331). An increased risk of severe perineal trauma remained after adjustments among those undergoing VBAC (adjusted risk ratio 1.42, 95% CI 1.23-1.63). Level of risk was not associated with indication (dystocia or signs of fetal distress) of primary cesarean delivery, nor how far the woman had progressed in labor (fully dilated versus planned cesarean delivery) before delivering by cesarean. Compared with nulliparous women, those undergoing VBAC are at increased risk of severe perineal trauma, irrespective of indication and timing of primary cesarean delivery.

Trends and risk factors for severe perineal trauma during childbirth in New South Wales between 2000 and 2008: a population-based data study

ObjectivesTo determine trends and risk factors for severe perineal trauma between 2000 and 2008.DesignThis was a population-based data study.SettingNew South Wales, Australia.Participants510 006 women giving birth to a singleton baby...

An Australian prospective cohort study of risk factors for severe perineal trauma during childbirth

Objective to determine risk factors for the occurrence of severe perineal trauma (third and fourth degree tears) during childbirth. Design a prospective cohort study was conducted using the hospital's computerised obstetric information system. Additional data were gathered on women who sustained severe perineal trauma. Descriptive statistics and logistic regression were used to assess risk factors for severe perineal trauma. Midwives were asked to comment on possible reasons for severe perineal trauma. Written responses made by midwives were analysed using content analysis. Discussion groups with midwives were held to further explore their experiences. Setting Royal Prince Alfred Hospital, Sydney, Australia. Participants all women having vaginal births ( n=6595) in a 2-year period between 1 April 1998 and 31 March 2000, in both the birth centre and the labour ward. Measurements and findings 2% of women ( n=134) experienced severe perineal trauma. One hundred and twenty-two women had third-degree tears and 12 had fourth-degree tears. Primiparity, instrumental delivery, Asian ethnicity and heavier babies were associated with an elevated risk of severe perineal trauma. Midwives identified several factors they believed contributed to severe perineal trauma. These were lack of effective communication with the woman during the birth, different birth positions, delivery technique, ethnicity and obstetric influences. Key conclusions findings support current knowledge that primiparity, instrumental birth, heavier babies and being of Asian ethnicity are associated with increased rates of severe trauma. Specific attention needs to be paid to the strong association found between being of Asian ethnicity and experiencing severe perineal trauma. Implications for practice further identification and validation of the concerns expressed by midwives to reduce severe perineal trauma is warranted so that preventative strategies can be used and researched.

Operative vaginal delivery and midline episiotomy: A bad combination for the perineum

The purpose of this study was to determine the impact of operative vaginal delivery (forceps or vacuum) and midline episiotomy on the risk of severe perineal trauma. In this retrospective cohort study, we assessed the impact of maternal and obstetric factors on the risk of development of severe perineal trauma (third- and fourth-degree perineal lacerations) for all singleton, vertex vaginal live births (n = 33,842) between 1996 and 2003. Among nulliparous women, 12.1% had operative vaginal delivery, 22.4% had midline episiotomy, and 8.1% experienced severe perineal trauma. Among multiparous women, 3.4% had operative vaginal delivery, 4.2% had midline episiotomy, and 1.2% experienced severe perineal trauma. Controlling for maternal age, ethnicity, birth weight and head circumference, evaluation of the interaction of episiotomy and delivery method revealed that forceps (nulliparous women: odds ratio [OR] 8.6, 95% CI 6.5-10.7; multiparous women: OR 26.3, 95% CI 18.1-34.5) and episiotomy (nulliparous women: OR 4.5, 95% CI 3.7-5.4; multiparous women: OR 14.6, 95% CI 10.4-20.5) were consistently associated with the increased risk of anal sphincter trauma. In fact, the magnitude of effect of the statistically significant synergistic interaction was evidenced by more than 3-fold excess of risk of using operative vaginal delivery alone. The use of operative vaginal delivery, particularly in combination with midline episiotomy, was associated with a significant increase in the risk of anal sphincter trauma in both primigravid and multigravid women. Given the reported substantial long-term adverse consequences for anal function, this combination of operative modalities should be avoided if possible.

Episiotomy in Ghana

Trauma to the genital tract commonly occurs during childbirth and causes short- and long-term morbidity in women. Episiotomy as a small and neat incision that would facilitate delivery decrease trauma and allows the perineum to be restored to its functional condition after proper suturing has been promoted extensively. Currently however there is no evidence that routine or prophylactic episiotomy reduces the risk of severe perineal trauma improves perineal healing prevents fetal trauma or reduces the risk of urinary or anal incontinence as initially purported. A selective episiotomy policy has resulted in a worldwide downward trend of episiotomy rate. In the United States between 1983 and 2000 the overall episiotomy rate fell from 69.9% of all births to 19.4% of vaginal deliveries. Recent rates in other countries include Sweden 9%; Zimbabwe 27%; Burkina Faso 46%; and Nigeria 54.9%. (excerpt)

491 Hospital variation in episiotomy use and the risk of severe perineal trauma

491 Hospital variation in episiotomy use and the risk of severe perineal trauma