Second-degree Lacerations Research Articles

The Impact of Delivery Methods on the Delivery Outcomes of Women with a Prolonged Second Stage and a Fetus in the Occipital Posterior Position

Background: The objective was to explore the impact of different delivery methods on maternal and infant outcomes in women with a prolonged second stage of labor and a fetus with a persistent occipital posterior position. Methods: 60 women with a fetus in the occipital posterior position who underwent obstetric low forceps-assisted delivery were selected as the study group according to the order of delivery, and 40 women who underwent cesarean section during the same period were selected as study group 1 according to the order of delivery. We compared the maternal-related indicators and neonatal outcome-related indicators of the two groups. Then, we selected women in chronological order during the same period to be included in control group 2 (60 primiparous women with a fetus in the occipital anterior position who underwent low forceps-assisted delivery during the same period) for comparison with the study group. Results: The time of fetal head delivery, postpartum hemorrhage rate, hospitalization time, average hospitalization cost, and number of cases of postpartum infection in the group with a fetus in the occipital posterior position and low forceps-assisted delivery were significantly lower than those in the cesarean section group (p < 0.05). There was no statistically significant difference in the 1-minute Apgar score, umbilical artery blood gas pH value, or number of neonatal injuries between the cesarean section group and the group with a fetus in the occipital posterior position with forceps-assisted delivery (p > 0.05). There were also no statistically significant differences in the complication-related indicators between the group with a fetus in the occipital posterior position with forceps-assisted delivery and the group with a fetus in the occipital anterior position with forceps-assisted delivery. The two groups had second-degree lacerations, cervical lacerations, vaginal wall lacerations, and vaginal wall hematomas. There was no statistically significant difference in the comparison of urinary retention (p > 0.05), and there was no statistically significant difference between the group with a fetus in the occipital posterior position and forceps-assisted delivery and the group with a fetus in the occipital anterior position and forceps-assisted delivery in the comparison of related indicators of neonatal outcomes and pelvic floor reexamination at the Aa and Ap points 42 days after delivery (p > 0.05). Conclusions: The use of low forceps for women with a prolonged second stage of labor and a fetus in a persistent occipital posterior position can effectively shorten the time of fetal head delivery, reduce postpartum bleeding, reduce the incidence of postpartum infection, shorten the hospitalization time, and reduce average hospitalization costs and does not increase adverse neonatal outcomes.

Ritgen's maneuver in childbirth care: A case-control study in a Central Italian setting.

Vaginal delivery can cause genital tract trauma and lacerations of different severity. This study aims to establish if routinary use of Ritgen's maneuver decreases the prevalence and severity of perineal lacerations compared to the traditional manual perineal protection (MPP). This prospective case-control study was conducted in the labor ward of Fondazione Policlinico A. Gemelli, Rome, Italy. One hundred sixteen women who met inclusion criteria were included. The study group (n=58) consisted of women who were assisted using the Ritgen maneuver, whereas the women who gave birth immediately afterward were selected as the control group (n=58). All information was retrieved through electronic medical records. In all, 22% women of the study group reported no perineal lacerations compared with 5% of the control group (p=0.007). Regarding the degree of lacerations, the study group exhibited more first-degree lacerations and fewer second-degree lacerations, while the control group exhibited the opposite trend. Among women who received epidural analgesia, 24% of the study group did not experience perineal lacerations, compared to 4.5% of the control (OR=0.15; 95% CI: 0.03-0.72; p=0.008). Similarly, 23.4% of cases in the study group with oxytocin-enhanced labor, experienced no perineal trauma while none in the control group had no perineal trauma in cases of oxytocin augmentation (p=0.005). Our results suggest that using Ritgen's maneuver in childbirth care may reduce the incidence and severity of perineal lacerations, even in the presence of known risk factors for perineal lacerations such as oxytocin augmentation and epidural analgesia.

Provider attitudes and current practice regarding the prescription of opioid-containing pain medication for vaginal delivery.

The epidemic of opioid misuse and abuse is rampant in the United States. A large percentage of patients who go on to misuse or abuse opioids were initially legally prescribed an opioid medication by their physician. One of the most common reasons patients of reproductive age seek medical care is for pregnancy and delivery. These patients are frequently prescribed opioids. Greater than one in 10 Medicaid-enrolled women fill an opioid prescription after vaginal delivery. To assess the opioid prescribing patterns of obstetric providers following vaginal deliveries. Obstetric physicians and certified nurse midwives (CNMs) from different practice backgrounds were administered a questionnaire regarding opioid prescribing practices for patients who undergo vaginal delivery. Providers were contacted via email and completed survey via REDCap. Ninety-nine providers completed the survey between October 2018 and January 2019. Eight percent of all providers reported prescribing opioids at discharge after vaginal deliveries. There was a statistically significant difference in the proportion of physicians who provided opioid prescriptions at discharge compared to CNMs (16.7 percent vs 1.8 percent, respectively, p < .05). Common reasons for prescribing opioids at discharge included post-partum tubal ligation (56.4 percent), third- and fourth-degree lacerations (59.6 and 73.4 percent, respectively), and operative deliveries (26.6 percent). Physicians were significantly more likely to prescribe an opioid after a second-degree laceration than CNMs (19.1 percent vs 5.3 percent, p < 0.05). Practice patterns for opioid prescription vary by provider type as well as by delivery characteristics. Further study is necessary to delineate the optimal care while minimizing unnecessary opioid prescriptions.

Does transperineal ultrasound predict the risk of perineal trauma in women with term pregnancy? A prospective observational study.

This study was conducted to evaluate the prevalence of perineal trauma during childbirth and to assess the correlations of the pelvic floor dimensions and fetal head station with obstetric trauma in a prospectively recruited cohort of women. The study included women with a gestational age of at least 37 weeks, who were carrying a single fetus in a cephalic presentation. Transperineal ultrasound (TPU) was performed prior to the onset of labor or labor induction. The purpose was to measure the anteroposterior diameter (APD) of the levator ani muscle (LAM) and the angle of progression, at both rest and maximum Valsalva maneuver. The head-perineum distance was assessed only at rest. A total of 296 women were included. Of the 253 women who delivered vaginally, 19% (48/253) experienced no perineal trauma, 18.2% (46/253) received an episiotomy during childbirth, 34.4% (87/253) sustained a first-degree laceration, 25.3% (64/253) had a second-degree laceration, and 3.2% had a third- or fourth-degree laceration (8/253). Women with episiotomy had a significantly shorter median APD under Valsalva than women without perineal trauma. Furthermore, women with LAM coactivation (identified by a negative difference between the APD at Valsalva and the APD at rest) were approximately three times more likely to undergo an operative vaginal delivery and over five times more likely to sustain a third- or fourth-degree tear during childbirth than women who exhibited normal relaxation of the LAM during the Valsalva maneuver. TPU may predict the risk of perineal trauma in women with term pregnancy during childbirth.

A Study on the Perinatal Outcomes of Natural Childbirth Led by Midwives: A Retrospective Study

Purpose: The purpose of this study was to suggest the importance of natural childbirth by investigating the results of midwife-led perinatal periods and whether they were positive experiences for both individual women and their families.Methods: This retrospective study aimed to confirm the perinatal outcomes of midwife-attended vaginal births. Among 1,127 women who gave midwife-led birth in Gyeonggi-do, Seoul between January 1, 2019 and December 31, 2021, data were collected for 829 women. Records were excluded that were missing necessary data. Data on childbirth were analyzed using frequency, percentage, mean, standard deviation, and the chi-square test.Results: Among the mothers who underwent natural childbirth, 549 (66.2%) were multiparous. In addition, all 829 patients (100%) breast-fed their infants. First-degree perineal lacerations occurred in 29.2% of patients, and second-degree lacerations occurred in 48%. Non–high-risk subjects made up 56.0% of the study sample. The average bleeding amount was 281.44±4.50, and the average 1-minute Apgar score for infants was 8.25±0.02.Conclusion: Compared to childbirth in a hospital, natural childbirth was associated with a lower risk of birth canal laceration, postpartum bleeding, and Cesarean section. In addition, the health statuses of the newborns were confirmed to be good . Based on the results of this study, there is a need for a strategy in which midwife-led natural childbirth is integrated into the local medical system, as well as a need to raise women's awareness of natural childbirth and positively influence the experience.

Obstetric Perineal Trauma and Episiotomy

Obstetric lacerations are a common complication of vaginal delivery. Lacerations can lead to chronic pain and urinary and fecal incontinence. Perineal lacerations are defined by the depth of musculature involved, with fourth-degree lacerations disrupting the anal sphincter and the underlying rectal mucosa and first-degree lacerations having no perineal muscle involvement. Late third-trimester perineal massage can reduce lacerations in primiparous women; perineal support and massage and warm compresses during the second stage of labor can reduce anal sphincter injury. Conservative care of minor hemostatic first- and second-degree lacerations without anatomic distortion reduces pain, analgesia use, and dyspareunia. Minor hemostatic lesions with anatomic disruption can be repaired with surgical glue. Second-degree lacerations are best repaired with a single continuous suture. Lacerations involving the anal sphincter complex require additional expertise, exposure, and lighting; transfer to an operating room should be considered. Limited evidence suggests similar results from overlapping and end-to-end external sphincter repairs. Postdelivery care should focus on controlling pain, preventing constipation, and monitoring for urinary retention. Acetaminophen and nonsteroidal anti-inflammatory drugs should be administered as needed. Opiates should be avoided to decrease risk of constipation; need for opiates suggests infection or problem with the repair. Osmotic laxative use leads to earlier bowel movements and less pain during the first bowel movement. Simulation models are recommended for surgical technique instruction and maintenance, especially for third- and fourth-degree repairs.

Hands-on vs hands-off technique for the prevention of perineal injury: a randomized clinical trial

Perineal trauma after vaginal delivery is common and is associated with severe morbidity, including incontinence, pelvic pain, and sexual dysfunction. Morbidity is mainly related to third- or fourthdegree lacerations. This study aimed to test the hypothesis that in nulliparous women with singleton pregnancies at term, hands-off technique during spontaneous vaginal delivery could reduce the rate of perineal laceration. This was a parallel-group, nonblinded, randomized clinical trial. Nulliparous women in spontaneous labor with singleton pregnancies and vertex presentation admitted to the labor and delivery room between 37 0/7 and 42 0/7 weeks of gestation were eligible, and were randomized in a 1:1 ratio to receive hands-off technique (intervention group) or hands-on technique during pushing in the second stage of labor. The primary outcome was perineal laceration (any degree). The effect of hands-off technique on each outcome was quantified as relative risk with 95% confidence interval. A total of 70 women were enrolled in the trial. Perineal lacerations (any degree) occurred in 15 of 35 (42.9%) women in the intervention group and 33 of 35 (94.3%) women in the control group (relative risk, 0.45; 95% confidence interval, 0.31-0.67). Hands-off technique was also associated with significantly decreased incidence of episiotomy (relative risk, 0.36; 95% confidence interval, 0.14-0.88), first-degree lacerations (relative risk, 0.41; 95% confidence interval, 0.20-0.87), and second-degree lacerations (relative risk, 0.43; 95% confidence interval, 0.19-0.99). There was no significant between-group difference in third- and fourth-degree lacerations, but the trial was not powered for these outcomes. In nulliparous women with singleton pregnancies at term, hands-off technique reduces the rate of perineal lacerations.

Effect of uterine fundal pressure applied in the second stage of labor on birth outcomes and neonatal oxygen saturation.

To examine the effect of fundal pressure applied in the second stage of labor on birth outcomes and neonatal O2 saturation. The study is of a descriptive and comparative type. Research data were collected in the obstetrics clinic of a Maternity Hospital between August 15, 2019 and February 15, 2020. The study sample consisted of 160 pregnant women who met the research criteria (80 pregnant women who received fundal pressure, 80 pregnant women who did not receive fundal pressure). The duration of the second and third stages of labor was found to be shorter in the nonfundal pressure group (t=-3.422, p=0.001; t=2.195, p=0.030). When the groups were compared, the formation of perineal trauma and second-degree laceration, episiotomy requirement, elongation of the episiotomy incision and cervical laceration rate were found to be significantly higher in the fundal pressure group χ2 =10.794 p=0.001; χ2 =8.403 p=0.004; χ2 =10.014, p=0.002; χ2 =16.579 p=0.000; χ2 =16.276 p=0.000). The 1st and 5th min Apgar scores of the newborns were lower in the fundal pressure group (t=-6.377, p=0.000; t=-3.581, p=0.001). The 1st, 5th, 10th, and 15th min oxygen saturation of the newborns were determined to be significantly lower in the fundal pressure group (t=-4.753, p=0.000; t=-2.427, p=0.016; t=-2.604, p=0.010; t=-2.492, p=0.014). According to the study results, it was determined that the uterine fundal pressure has a negative effect on birth outcomes and neonatal oxygen saturation. Adverse effects of fundal pressure application should be revealed in different aspects.

Perineal Lacerations: A Retrospective Study in a Habitual-Risk Public Maternity.

In around 85% of vaginal births, the parturients undergo perineal lacerations and/or episiotomy. The present study aimed to determine the incidence of lacerations and episiotomies among parturients in 2018 in a habitual-risk public maternity hospital in southern Brazil, and to determine the risk and protective factors for such events. A retrospective cross-sectional study. Data were obtained from medical records and analyzed using the Stata software. Univariate and multivariate logistic regressions were performed. Values of p < 0.05 were considered significant. In 2018, there were 525 vaginal births, 27.8% of which were attended by obstetricians, 70.7% by obstetric nurses, and 1.5% evolved without assistance. Overall, 55.2% of the parturients had some degree of laceration. The professional who attended the birth was a significant variable: a greater number of first- and second-degree lacerations, as well as more severe cases, occurred in births attended by nurses (odds ratio [OR]: 2,95; 95% confidence interval [95%CI]: 1,74 to 5,03). Positions at birth that did not enable perineal protection techniques (expulsive period with the "hands-off" method), when analyzed in isolation, determined the risk; however, in the final regression model, this relationship was not confirmed. Although reported in the literature, there were no associations between the occurrence of laceration and age, skin color, or birth weight. In 24% of the births, episiotomy was performed, and doctors performed 63.5% of them. Births attended by nurses resulted in an increased risk of perineal lacerations, of varying degrees. In turn, those assisted by physicians had a higher occurrence of episiotomy.

Intra-amniotic Infection

Intra-amniotic Infection

Analgesic use after vaginal delivery in women with perineal lacerations: a retrospective cohort study

Objective: To evaluate opioid consumption among parturients with varying degrees of perineal lacerations.Methods: This was a retrospective analysis of women who delivered vaginally at our institution from 1 January 2014 to 12 April 2015. We collected information regarding the degree of perineal lacerations (no lacerations, first-/second-degree, third-/fourth-degree), analgesic consumption, and postpartum pain scores. The primary outcome was opioid use from 0–48 h postpartum. Univariate and multivariable regression analyses were performed to test for the association of laceration severity with opioid use.Results: We included 5598 women in the analysis; 1948 had no lacerations, 3434 had first-/second-degree lacerations, and 216 had third-/fourth-degree lacerations. In univariate analysis, parturients with third-/fourth-degree lacerations had significantly higher use of opioids within 48 h postpartum (53.2%) compared to women with no lacerations (30.03%) or first-/second-degree lacerations (28.6%) (p < .001). In the multivariable analysis, women with third-/fourth-degree lacerations had higher odds of opioid use than those without laceration [OR (95% CI) = 2.61 (1.75–3.85), p < .001]. In pairwise comparisons, those with third-/fourth-degree lacerations had higher odds of opioid use than those without lacerations [OR (95% CI) = 3.55 (2.20–5.74)], and those with first-/second-degree lacerations [OR (95% CI) = 2.15 (1.49–3.10)] (p < .001). Oxycodone equivalent consumption was significantly different among groups with a median (IQR) of 5.00 mg (0.00–27.50), 0.00 mg (0.00–5.00) and 0.00 mg (0.00–5.00) in women with third-/fourth-degree, first-/second-degree, and no lacerations, respectively, during the 0–48 h postpartum (p < .001).Conclusion: The use of opioids and opioid doses are higher in women with third-/fourth-degree perineal lacerations compared to those with first-/second-degree or no lacerations.

The Use of Silicone Vaginal Repair Models as an Adjunct to Mannequins for Simulation Training in Sexual Assault Clinical Learning for Obstetrics and Gynecology Medical Residents.

Within urgent care scenarios in obstetrics and gynecology, there is little educational development surrounding sexual assault simulation scenarios, which reveals a need for increased rehearsal opportunities within medical education. Simulation-based medical education using mannequins, standardized patients, and anatomical silicone models have been suggested as a means to improve such parameters by providing realistic training for residents in the rehearsal of sexual assault scenarios and the application of forensic evidence kits. However, sexual assault training is often only provided to emergency medicine physicians and clinical staff and is not currently a mandatory component of obstetrics and gynecology residency programs across most national academic institutions.This technical report describes the development, implementation, and user-based evaluation of a simulation exercise within a sexual assault clinical learning scenario that uses a silicone vaginal model produced using a three-dimensional (3D) printed mold. The silicone model was covered in artificial blood and attached to an existing mannequin to simulate an examination following a violent sexual assault, which resulted in vaginal lacerations. The clinical room in which the simulation was held reflected that of an operating room in an emergency department, complete with simulation confederates acting as an attending general surgeon, nurse, and anesthesiologist. The obstetrics and gynecology residents acted as the urgent care providers being called into the operating room. The residents were briefed by the general surgeon upon arrival and scrubbed into the surgery. Next, they examined and repaired vaginal lacerations on the silicone model attached to the simulation mannequin. Finally, the residents followed up the clinical simulation with an opportunity to rehearse patient communication and empathy by consoling a standardized patient who acted as the victim of the sexual assault.The purpose of this technical report is to evaluate the efficacy of a silicone vaginal model created from a 3D printed mold, which included a second-degree laceration, to train obstetrics and gynecology residents in the repair of injuries resulting from sexual assault. An evaluation survey was completed by attending residents and the results were strongly in favor of using such anatomical silicone models to increase realism and for the improvement of procedural competency in repairing vaginal lacerations caused by sexual assault.

Selective use of episiotomy: what is the impact on perineal trauma? Results from a retrospective cohort study.

To evaluate the effects of selective use of episiotomy on perineal trauma. We performed a retrospective cohort study on consecutive vaginal deliveries from January 2010 to December 2016. From January 2010 to December 2011 episiotomy was performed liberally, based only on individual midwife/doctor's decision. Since January 2012, a shared selective use of episiotomy policy has been introduced. To evaluate the range of perineal trauma in spontaneous second-degree perineal tears, a sub-classification of second-degree lacerations has been introduced dividing them into two sub-groups: A (smaller than the average episiotomy) and B (spontaneous vaginal tear larger than the average episiotomy). The primary outcomes were the incidence and type of perineal trauma, with the proportion of type A and type B second-degree spontaneous tears under a policy of selective episiotomy. Deliveries not exposed to selective use of episiotomy were 1583 (Group 1), those exposed to selective use of episiotomy were 6409 (Group 2). In Group 2 episiotomy rate decreased, and incidence of intact perineum, first- and second-degree lacerations increased. The incidence of third- and fourth-degree lacerations did not change. Spontaneous second-degree lacerations occurred in 19.4% and 36.8% of women in group 1 and 2, respectively. With a selective episiotomy policy, 88.3% of second-degree tears was classified as type A. The selective use of episiotomy is clinically feasible and effective. This policy seems to be associated with a lower delivery-related perineal trauma as showed by the sub-classification, that could be a useful tool to monitor obstetric care.

A retrospective comparison of waterbirth outcomes in two United States hospital settings.

Water immersion during labor is an effective comfort measure; however, outcomes for waterbirth in the hospital setting have not been well documented. Our objective was to report the outcomes from two nurse-midwifery services that provide waterbirth within a tertiary care hospital setting in the United States. This study is a retrospective, observational, matched comparison design. Data were collected from two large midwifery practices in tertiary care centers using information recorded at the time of birth for quality assurance purposes. Land birth cases were excluded if events would have precluded them from waterbirth (epidural, meconium stained fluid, chorioamnionitis, estimated gestational age<37weeks, or body mass index>40). Neonatal outcomes included Apgar score and admission to the neonatal intensive care unit. Maternal outcomes included perineal lacerations and postpartum hemorrhage. A total of 397 waterbirths and 2025 land births were included in the analysis. There were no differences in outcomes between waterbirth and land birth for Apgar scores or neonatal intensive care admissions (1.8% vs 2.5%). Women in the waterbirth group were less likely to sustain a first- or second-degree laceration. Postpartum hemorrhage rates were similar for both groups. Similar results were obtained using a land birth subset matched on insurance, hospital location, and parity using propensity scores. In this study, waterbirth was not associated with increased risk to neonates, extensive perineal lacerations, or postpartum hemorrhage. Fewer women in the waterbirth group sustained first- or second-degree lacerations requiring sutures.

Opioid prescribing trends in postpartum women: a multicenter study

The postpartum period can be a particularly vulnerable time for exposure to opioid medications, and there are currently no consensus guidelines for physicians to follow regarding opioid prescribing during this period. The purpose of this study was to evaluate inter- and intrahospital variability in opioid prescribing patterns in postpartum women and better understand the role of clinical variables in prescribing. Data were extracted from electronic medical records on 4248 patients who delivered at 6 hospitals across the United States from January 2016 through March 2016. The primary outcome of the study was postpartum opioid prescription at the time of hospital discharge. Age, parity, route of delivery, and hospital were analyzed individually and with multivariate analyses to minimize confounding factors. Statistical methods included χ2 to analyze frequency of opioid prescription by hospital, parity, tobacco use, delivery method, and laceration type. An analysis of variance was used to analyze morphine equivalent dose by hospital. The percentage of women prescribed postpartum opioids varied significantly by hospital, ranging from 27.6% to 70.9% (P<0.001). Oxycodone-acetaminophen was the most commonly prescribed medication (50.3%) with each hospital having its preferred opioid type. Median number of tablets prescribed ranged from 20 to 40 (P < .0001). Primiparous women were more likely to receive opioids than multiparous women when broken down by a parity of 1, 2, 3, 4, and ≥5 (52.8%, 48.0%, 47.6%, 40.1%, and 45.8%, respectively, P= .0005). Among women who had vaginal deliveries, opioid prescription rates were higher in women who experienced either a second-degree laceration (35.5%, P= .0002) or a third-/fourth-degree laceration (59.3%, P < .001). Postpartum opioid prescription rates vary widely among hospitals, but providers within the same hospital tend to follow similar prescribing trends. The variation in prescribing found in our study illustrates the need for clear consensus guidelines for postpartum pain management.

Development of an Anatomical Silicone Model for Simulation-based Medical Training of Obstetric Anal Sphincter Injury Repair in Bangladesh.

Advancing global healthcare in developing countries has traditionally been an area of interest for many North American medical organizations, as they strive to improve patient outcomes by helping to control disease and death-related illnesses. Women’s healthcare in developing countries, in particular, presents a unique set of complexities, revealing high maternal mortality statistics surrounding pregnancy, labor, and childbirth, which is often tied to home births without medically trained attendants. In September 2018, Team Broken Earth, a Canadian-based outreach initiative, hosted a three-day women’s healthcare course in Dhaka, Bangladesh, which included simulation-based training stations, for the purpose of advancing clinical skills and education in regards to local labor and delivery. The training stations included the prevention of shoulder dystocia, helping babies breathe, the application of uterine compression sutures, and the repair of obstetric anal sphincter injuries (OASIS). The OASIS management station provided an opportunity to practice anal sphincter repair on anatomically accurate silicone models, which was a focus of the training course due to the high frequency of such injuries in rural Bangladesh. Evaluation surveys were supplied to workshop participants to capture their feedback about the use of the OASIS models and their efficacy as a training tool in Bangladesh.Overall, the models were considered superior as compared to pre-existing training methods, which traditionally involve textbook education and hands-on learning in emergency birthing scenarios by non-medically trained attendants. Two minor iterative improvements were suggested during the Team Broken Earth workshops in Dhaka, Bangladesh, with regards to improving the models for future use: (a) the ethnicity coloring of the models should be more inclusive, especially when delivering training in international countries, and (b) future silicone models should include the addition of mesh across the bottom layer to ensure participants fingers did not rupture the enclosed vaginal canal while suturing. The purpose of this technical report is to determine the efficacy of a silicone OASIS model, developed for practicing high-risk laceration repair that can occur during childbirth, which presents in higher frequency in developing countries, such as Bangladesh, due to the number of rural at-home deliveries.The original study in this series involved the investigation of silicone perineal repair models focusing on first- and second-degree lacerations, which were used at the Remote and Rural Conference in St. John’s, Newfoundland, in April 2018. The facilitators distributed the first iteration of the models to conference participants and collected participant feedback, which concluded that several improvements were required to enhance the models for medical training purposes. With the iterative revisions complete, the model is now under further validation testing to determine its efficacy within simulation-based medical education (SBME) and clinical skill maintenance. This technical report is the second in the series and includes the most recent third and fourth-degree silicone models as well as all suggested improvements from previous clinical feedback.

Racial/Ethnic Differences in Perineal Lacerations in a Diverse Urban Healthcare System.

The aim of the study was o determine whether variations exist between races/ethnicities in perineal laceration at first vaginal delivery. We assessed first vaginal deliveries greater than 35 weeks gestation, for a four-year period, in our diverse urban healthcare system. Predictor variable was race/ethnicity with outcome variable of none, first-, second-, third-, or fourth-degree perineal laceration. Race and ethnicity were self-reported and combined into one variable to facilitate analysis. We also collected data on other known risk factors for laceration to adjust our analysis accordingly. A total of 1179 charts met criteria. When comparing none, first-, or second-degree lacerations versus third or fourth degrees (obstetric anal sphincter injuries) race was not a significant factor. We also compared lacerations among the following three groups: none or first degree versus second degree versus obstetric anal sphincter injuries. In this case, Asian and white women were associated with an increasing trend of perineal lacerations as degree of severity increased (P < 0.0001), whereas black and Latina women were associated with a decreasing trend as severity increased (P < 0.0001). After adjusting for other significant variables, race was still significant (P = 0.02). With an urban diverse population, our study demonstrates an association between race/ethnicity and perineal lacerations. As degree of laceration increased, Asian and white women were noted to have more lacerations, and black and Latina women were noted to have fewer. Because perineal lacerations pose a significant risk to future pelvic floor health, the associated factors identified in this study may prove useful in counseling patients on future risk or in identifying the actual risk in underrepresented populations.

Anovaginal distance and obstetric anal sphincter injury: a prospective observational study

Introduction and HypothesisNo measurements are available for diagnosing the extent of obstetric lacerations. The primary aim of this study was to evaluate the relation between the anovaginal distance (AVD) measured with transperineal ultrasound immediately after delivery and external anal sphincter injury. A secondary aim was to assess whether the palpated perineal thickness was associated with the AVD.MethodsA prospective observational study of 150 primiparous women at the University Hospital, Linköping, Sweden. After vaginal delivery, initial inspection and palpation of the perineal thickness were performed by the midwife. The women were then divided into subgroups depending on the degree of the suspected perineal laceration. Transperineal ultrasound of the AVD was performed by a physician. Diagnostics of the perineal laceration were done according to standard care.ResultsWomen with an external sphincter injury had a shorter AVD and shorter palpatory perineal thickness compared with women without anal sphincter injury. No external sphincter injuries were diagnosed when the AVD and/or palpation height was > 20 mm. The mean AVD in the group with probable second-degree laceration (n = 85) was 18.8 mm (95% CI 17.8–19.8), in suspected third-degree laceration (n = 33) 15.7 mm (95% CI 13.7–17.7) and in probable third-degree laceration (n = 32) 11.8 mm (95% CI 9.7–13.9) (p < 0.001).ConclusionsA short AVD could be a warning sign postpartum and should increase the awareness of possible external sphincter injury before suturing. An AVD of 20 mm seems to indicate a cutoff level of the occurrence of external sphincter injury, but this needs further evaluation.

The effect of perineal massage during the second stage of birth on nulliparous women perineal: A randomization clinical trial.

BackgroundChildbirth and puerperium are of the most important periods in women’s lives and can affect different aspects of their lives.ObjectiveTo determine the effect of perineal massage in the second stage of labor on perineal lacerations, episiotomy, and perineal pain in nulliparous women.MethodsThis randomization clinical trial was conducted at Be’sat Hospital in Sanandaj, Iran, from 2013 to 2014. A total of 195 nulliparous women were included in the study. The participants were selected through convenience sampling, and randomly assigned to two groups: intervention and control groups. The intervention group received 30-minute perineal massage during second stage of labor. Subsequently, we analyzed perineal laceration, episiotomy, and perineal pain among the two groups. All of them were taught about postpartum perineal pain and its severity, and the researcher followed them up 3 days, 10 days, and 3 months after childbirth by telephone. The data were analyzed using SPSS version 18. We used descriptive statistics and analytical statistics, including t test, Chi-square test, and Fisher’s test.ResultsFrequency of episiotomy was 69.47% in the intervention group and 92.31% in the control group, and the difference was statistically significant (p<0.05). The results revealed 23.16% of first-degree perineal laceration and 2.11% of second-degree perineal laceration in the intervention group, and no vestibular laceration or third- and fourth-degree lacerations in the intervention group. However, there were 5.13% of vestibular laceration, 7.69% of first-degree laceration, 2.56% of second-degree laceration, and 1.05% of third-degree laceration (one woman) in the control group. Based on the results, the postpartum perineal pain was significantly different in both groups.ConclusionRegarding the results of this study and those of other studies, perineal massage during the second stage of labor can reduce the need to episiotomy, perineal injuries, and perineal pain.Trial registrationThe trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the Irct.ID: IRCT2013090314556N1.FundingThis study received by financial support of Kurdistan University of Medical Sciences, Sanandaj, Iran.

Does meperidine analgesia affect the incidence of obstetric lacerations at vaginal delivery?

Purpose: To study whether meperidine analgesia affects the incidence of obstetric lacerations at normal vaginal deliveries.Materials and methods: A retrospective cohort study of all women with term vertex singleton pregnancies, who underwent normal vaginal deliveries, in a single tertiary hospital, between 2011 and 2015, was performed. The incidence of various obstetric lacerations was compared between deliveries with meperidine analgesia and deliveries with no analgesia. Deliveries with epidural analgesia and instrumental deliveries were excluded. An intravenous infusion of 75 mg of meperidine was administered together with 25 mg of promethazine. A multivariate logistic regression analysis was performed to assess the association between meperidine analgesia and obstetric lacerations, after controlling for confounders.Results: Overall, 5227 (91.8%) deliveries with no analgesia and 466 (8.1%) deliveries with meperidine analgesia were included. Meperidine analgesia was associated with a decreased risk of first- and second-degree perineal lacerations (adjusted OR = 0.63, 95% CI = 0.49–0.81), and a decreased risk of any suturing (adjusted OR = 0.73, 95% CI = 0.59–0.91), after controlling for confounders. Meperidine analgesia did not affect the risk of severe perineal lacerations or episiotomies.Conclusion: Meperidine analgesia may have a protective effect against first- and second-degree perineal lacerations.