[Routine episiotomy in modern obstetrics. Is it necessary?].

PubMed

Korczyński, Jerzy

2002-01-01

The study presents a literature review on the benefits and risk of the routine episiotomy during the second stage of labour. Perineal trauma complications as well as perinatal outcomes are discussed. The risk of stress incontinence and sexual dysfunction are described. New techniques for improve of perinatal outcomes and prevention of post partum incontinence are described. Routine episiotomy gives poor effects in many cases. Perineal massage during pregnancy, waterbirth, are most interesting methods to avoid routine episiotomy and improve the quality of life in post partum women.

[Evolution of episiotomy. Following 2 types of care].

PubMed

Martín Jiménez, E; Menesas Escribano, M J; Castejón Martin, D; Gil Martínez, C; Pérez Doblado, P; Rodríguez, B P

2001-11-01

Unified care when treating an episiotomy is essential to avoid complications which develop during puerperium. An analysis was carried out by means of a comparative clinical study of two groups of primiparous women, the evolution of their episiotomy in terms of the application of 0.4% providone-iodine" in eight qualitative variables analyzed independently. Due to its greater influence on the evolution of an episiotomy, this study evaluated in more depth one of these variables which defines its quality: dehiscence.

Variations in rates of severe perineal tears and episiotomies in 20 European countries: a study based on routine national data in Euro-Peristat Project.

PubMed

Blondel, Béatrice; Alexander, Sophie; Bjarnadóttir, Ragnheiður I; Gissler, Mika; Langhoff-Roos, Jens; Novak-Antolič, Živa; Prunet, Caroline; Zhang, Wei-Hong; Hindori-Mohangoo, Ashna D; Zeitlin, Jennifer

2016-07-01

Rates of severe perineal tears and episiotomies are indicators of obstetrical quality of care, but their use for international comparisons is complicated by difficulties with accurate ascertainment of tears and uncertainties regarding the optimal rate of episiotomies. We compared rates of severe perineal tears and episiotomies in European countries and analysed the association between these two indicators. We used aggregate data from national routine statistics available in the Euro-Peristat project. We compared rates of severe (third- and fourth-degree) tears and episiotomies in 2010 by mode of vaginal delivery (n = 20 countries), and investigated time trends between 2004 and 2010 (n = 9 countries). Statistical associations were assessed with Spearman's ranked correlations (rho). In 2010 in all vaginal deliveries, rates of severe tears ranged from 0.1% in Romania to 4.9% in Iceland, and rates of episiotomies from 3.7% in Denmark to 75.0% in Cyprus. A negative correlation between the rates of episiotomies and severe tears was observed in all deliveries (rho = -0.66; p = 0.001), instrumental deliveries (rho = -0.67; p = 0.002) and non-instrumental deliveries (rho = -0.72; p < 0.001). However there was no relation between time trends of these two indicators (rho = 0.43; p = 0.28). The large variations in severe tears and episiotomies and the negative association between these indicators in 2010 show the importance of improving the assessment and reporting of tears in each country, and evaluating the impact of low episiotomy rates on the perineum. © 2016 Nordic Federation of Societies of Obstetrics and Gynecology.

Statistical trends of episiotomy around the world: Comparative systematic review of changing practices.

PubMed

Clesse, Christophe; Lighezzolo-Alnot, Joëlle; De Lavergne, Sylvie; Hamlin, Sandrine; Scheffler, Michèle

2018-06-01

The authors' purpose for this article is to identify, review and interpret all publications about the episiotomy rates worldwide. Based on the criteria from the PRISMA guidelines, twenty databases were scrutinized. All studies which include national statistics related to episiotomy were selected, as well as studies presenting estimated data. Sixty-one papers were selected with publication dates between 1995 and 2016. A static and dynamic analysis of all the results was carried out. The assumption for the decline in the number of episiotomies is discussed and confirmed, recalling that nowadays high rates of episiotomy remain in less industrialized countries and East Asia. Finally, our analysis aims to investigate the potential determinants which influence apparent statistical disparities.

Site and incidence of birth canal lacerations from instrumental delivery with mediolateral episiotomy.

PubMed

Chikazawa, Kenro; Ushijima, Junko; Takagi, Kenjiro; Nakamura, Eishin; Samejima, Koki; Kadowaki, Kanako; Horiuchi, Isao

2016-12-01

Instrument-assisted vaginal delivery is a significant risk factor for birth canal lacerations. Although many obstetricians recently are recommending restrictive rather than a routine episiotomy, reports have shown restrictive episiotomy to be associated with more extensive anterior birth canal trauma compared with routine episiotomy. We retrospectively reviewed 110 cases of forceps and vacuum deliveries and investigated the site of birth canal lacerations. Birth canal lacerations were divided into four sites according to direction-anterior, ipsilateral, contralateral, and posterior. The frequency of lacerations were, from most to least, posterior (34%), lateral (21.7%), and anterior (1.9%). Moreover, among the lateral lacerations, they were more frequent in the contralateral side of episiotomy than the ipsilateral side (18.9% vs. 4.7%, p < 0.01). Our results indicate that caution is also needed concerning not only the anterior site, but also the contralateral site of an episiotomy to prevent laceration in an instrument-assisted vaginal delivery. Copyright © 2016. Published by Elsevier B.V.

Comparison of the Effects of Lidocaine Prilocaine Cream (EMLA) and Lidocaine Injection on Reduction of Perineal Pain During Perineum Repair in Normal Vaginal Delivery

PubMed Central

Kargar, Roxana; Aghazadeh-Nainie, Afsaneh; Khoddami-Vishteh, Hamid Reza

2016-01-01

Objective: To compare the efficacy of EMLA cream and lidocaine injection to reduce pain during episiotomy repair. Materials and methods: A total of 46 primiparous women with normal pregnancy who referred for normal vaginal delivery and needed episiotomy repair were selected and randomly divided into two groups. For EMLA group, one hour before the estimated time of delivery, 5g of EMLA cream was applied to perinealmediolateral incision, and after the delivery of the fetus and placenta, again 5g of EMLA cream was applied to healthy skin around the episiotomy for repair. In the other group, lidocaine 2% was used before episiotomy and for its repair, too. Results: Only 8 people (19%) were in need of further analgesia. The mean ± SD of pain during repair of episiotomy on the VAS scale in all cases was 4.2 ± 2.3 cm. Most people (97%) were satisfied with their episiotomy repair. Comparing the two groups of EMLA and lidocaine, there was no difference between the two groups in terms of the duration of episiotomy repair, need for further analgesia, pain on the VAS scale, and satisfaction with the repair method. Conclusion: The findings of this study showed that the use of EMLA cream in the site of episiotomy incision in primiparous women can induce a level of analgesia equal to that of lidocaine, and cause a similar level of satisfaction. PMID:27385970

The Impact of Aloe vera and Calendula on Perineal Healing after Episiotomy in Primiparous Women: A Randomized Clinical Trial

PubMed Central

Eghdampour, Farideh; Jahdie, Fereshteh; Kheyrkhah, Masomeh; Taghizadeh, Mohsen; Naghizadeh, Somayeh; Hagani, Hamid

2013-01-01

Introduction: Episiotomy is used for enlarging the perineum. Aloe vera and Calendula have been used for treating different diseases from ancient times, limited researches have been done regarding the healing of these plants. Since the effect of their ointment on episiotomy healing has not been studied, this study is being done for determining the impact of Aloe vera and Calendula on episiotomy healing in primiparous women. Methods: This clinical trial involves 111 qualified primiparous women admitted in Lolagar hospital. They were randomly categorized into three groups of control (n=1) and experimental (n=2) groups. The women in experimental group used Aloe vera and Calendula Ointment every 8 hours and the control group used hospital routine on episiotomy for 5 days. The data were collected by demographic questionnaire and redness, edema, ecchymosis, discharge and approximation scale (REEDA) which investigated the episiotomy healing before and five days after intervention in two groups. ANOVA, Tukey test, Kruskal-wallis, Chi-square were used for data analysis. Results: The three groups do not have statistically significant different regarding demographic and other intervening variables. Comparing the mean of REEDA in five days after delivery showed statistically significant difference between control and experimental groups. Conclusion: According to the results, using Aloe vera and Calendula ointment considerably increases the speed of episiotomy wound healing so it can be used for quickening the episiotomy healing. PMID:25276736

The role of episiotomy in prevention and management of shoulder dystocia: a systematic review.

PubMed

Sagi-Dain, Lena; Sagi, Shlomi

2015-05-01

Shoulder dystocia is an obstetric emergency with potential catastrophic outcomes. To perform a systematic literature review examining the effectiveness of episiotomy in the prevention and management of shoulder dystocia during vaginal birth. Search was conducted by a research librarian in MEDLINE, Web of Science, Cochrane Library, and SCOPUS databases using the terms "episiotomy" and "shoulder dystocia," with no language or time restrictions. Two investigators independently selected original researches examining the effects of episiotomy on shoulder dystocia and its neonatal andmaternal outcomes. Relevant articles were accessed in full text, including manual search of the references. We contacted authors of studies with insufficient or unclear data. Because of clinical and methodological diversity of the studies, meta-analysis was not performed. Fourteen articles met the inclusion criteria, encompassing a total of 9769 shoulder dystocia cases. Only 1 study effectively evaluated the role of episiotomy in shoulder dystocia prevention, yielding a nonsignificant result. Three articles assessed neonatal consequences of shoulder dystocia, one of them linking episiotomy to higher risk of neonatal injury. Two of the 3 studies evaluating maternal outcomes showed that episiotomy is related to increased risk of advanced perineal tears. Overall quality of evidence was rated as very low. Our systematic review found no evidence supporting the use of episiotomy in the prevention and management of shoulder dystocia. This observation carries major clinical and legal implications for the obstetricians. Higher-quality studies are needed to evaluate this important issue.

[A policy of selective episiotomy in a ward: an example of medical professional assessment].

PubMed

Azuar, A S; Vendittelli, F; Tergny, E; Savary, D; Accoceberry, M; Jacquetin, B; Gallot, D; Lémery, D

2013-01-01

To reduce the episiotomy rates, according to the Clinical Practice Guidelines, of 2005, from the French College of Obstetricians and Gynaecologists. A cross sectional study was conducted, in the university hospital maternities (Maternity 1 and 2) with a retrospective record from medical files. Patients who had delivered in those maternities, by vaginal route, after 22 weeks amenorrhea were eligible. The global rate of episiotomy was analysed from 2006 to 2008. A descriptive clinical study was performed with a retrospective analysis (from July to December 2005 on 100 medical files and from July to December 2007 on 85 files). Besides, a study of episiotomy rate was conducted from 2006 to 2008. Improvement actions were developed between the two phases of assessment of the audit: sharing and comparing the results to standardized episiotomy rates, and elaborating an informatized regional perinatality file with episiotomy related items and national recommendations. Episiotomy rate decreased during the study, from 22.35% in 2005 to 19.34% in 2008, in the Ward 1 (p<0.0001) and from 33.62% in 2005 to 17.93% en 2008 (p<0.0001) in the Ward 2. An improvement was observed between the two periods of audits, for each item of the chart but without statistical signification. Theses procedures have led to a positive impact on practices thanks to the work group and because of the politics of the perinatal network in favour of an episiotomy reduction. We hope these results could be improved in the future. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Episiotomy and its relationship to various clinical variables that influence its performance

PubMed Central

Ballesteros-Meseguer, Carmen; Carrillo-García, César; Meseguer-de-Pedro, Mariano; Canteras-Jordana, Manuel; Martínez-Roche, Mª Emilia

2016-01-01

Objective: to understand the episiotomy rate and its relationship with various clinical variables. Method: a descriptive, cross-sectional, analytic study of 12,093 births in a tertiary hospital. Variables: Parity, gestational age, start of labor, use of epidural analgesia, oxytocin usage, position during fetal explusion, weight of neonate, and completion of birth. The analysis was performed with SPSS 19.0. Results: the global percentage of episiotomies was 50%. The clinical variables that presented a significant association were primiparity (RR=2.98), gestational age >41 weeks (RR=1.2), augmented or induced labor (RR=1.33), epidural analgesia use (RR=1,95), oxytocin use (RR=1.58), lithotomy position during fetal expulsion (RR=6.4), and instrumentation (RR=1.84). Furthermore, maternal age ≥35 years (RR=0.85) and neonatal weight <2500 g (RR=0.8) were associated with a lower incidence of episiotomy. Conclusions: episiotomy is dependent on obstetric interventions performed during labor. If we wish to reduce the episiotomy rate, it will be necessary to bear in mind these risk factors when establishing policies for reducing this procedure. PMID:27224064

Selective versus routine use of episiotomy for vaginal birth

PubMed Central

Jiang, Hong; Qian, Xu; Carroli, Guillermo; Garner, Paul

2017-01-01

Background Some clinicians believe that routine episiotomy, a surgical cut of the vagina and perineum, will prevent serious tears during childbirth. On the other hand, an episiotomy guarantees perineal trauma and sutures. Objectives To assess the effects on mother and baby of a policy of selective episiotomy ('only if needed') compared with a policy of routine episiotomy ('part of routine management') for vaginal births. Search methods We searched Cochrane Pregnancy and Childbirth's Trials Register (14 September 2016) and reference lists of retrieved studies. Selection criteria Randomised controlled trials (RCTs) comparing selective versus routine use of episiotomy, irrespective of parity, setting or surgical type of episiotomy. We included trials where either unassisted or assisted vaginal births were intended. Quasi-RCTs, trials using a cross-over design or those published in abstract form only were not eligible for inclusion in this review. Data collection and analysis Two authors independently screened studies, extracted data, and assessed risk of bias. A third author mediated where there was no clear consensus. We observed good practice for data analysis and interpretation where trialists were review authors. We used fixed-effect models unless heterogeneity precluded this, expressed results as risk ratios (RR) and 95% confidence intervals (CI), and assessed the certainty of the evidence using GRADE. Main results This updated review includes 12 studies (6177 women), 11 in women in labour for whom a vaginal birth was intended, and one in women where an assisted birth was anticipated. Two were trials each with more than 1000 women (Argentina and the UK), and the rest were smaller (from Canada, Germany, Spain, Ireland, Malaysia, Pakistan, Columbia and Saudi Arabia). Eight trials included primiparous women only, and four trials were in both primiparous and multiparous women. For risk of bias, allocation was adequately concealed and reported in nine trials; sequence generation random and adequately reported in three trials; blinding of outcomes adequate and reported in one trial, blinding of participants and personnel reported in one trial. For women where an unassisted vaginal birth was anticipated, a policy of selective episiotomy may result in 30% fewer women experiencing severe perineal/vaginal trauma (RR 0.70, 95% CI 0.52 to 0.94; 5375 women; eight RCTs; low-certainty evidence). We do not know if there is a difference for blood loss at delivery (an average of 27 mL less with selective episiotomy, 95% CI from 75 mL less to 20 mL more; two trials, 336 women, very low-certainty evidence). Both selective and routine episiotomy have little or no effect on infants with Apgar score less than seven at five minutes (four trials, no events; 3908 women, moderate-certainty evidence); and there may be little or no difference in perineal infection (RR 0.90, 95% CI 0.45 to 1.82, three trials, 1467 participants, low-certainty evidence). For pain, we do not know if selective episiotomy compared with routine results in fewer women with moderate or severe perineal pain (measured on a visual analogue scale) at three days postpartum (RR 0.71, 95% CI 0.48 to 1.05, one trial, 165 participants, very low-certainty evidence). There is probably little or no difference for long-term (six months or more) dyspareunia (RR1.14, 95% CI 0.84 to 1.53, three trials, 1107 participants, moderate-certainty evidence); and there may be little or no difference for long-term (six months or more) urinary incontinence (average RR 0.98, 95% CI 0.67 to 1.44, three trials, 1107 participants, low-certainty evidence). One trial reported genital prolapse at three years postpartum. There was no clear difference between the two groups (RR 0.30, 95% CI 0.06 to 1.41; 365 women; one trial, low certainty evidence). Other outcomes relating to long-term effects were not reported (urinary fistula, rectal fistula, and faecal incontinence). Subgroup analyses by parity (primiparae versus multiparae) and by surgical method (midline versus mediolateral episiotomy) did not identify any modifying effects. Pain was not well assessed, and women's preferences were not reported. One trial examined selective episiotomy compared with routine episiotomy in women where an operative vaginal delivery was intended in 175 women, and did not show clear difference on severe perineal trauma between the restrictive and routine use of episiotomy, but the analysis was underpowered. Authors' conclusions In women where no instrumental delivery is intended, selective episiotomy policies result in fewer women with severe perineal/vaginal trauma. Other findings, both in the short or long term, provide no clear evidence that selective episiotomy policies results in harm to mother or baby. The review thus demonstrates that believing that routine episiotomy reduces perineal/vaginal trauma is not justified by current evidence. Further research in women where instrumental delivery is intended may help clarify if routine episiotomy is useful in this particular group. These trials should use better, standardised outcome assessment methods. Selective versus routine use of episiotomy for vaginal birth What is the issue? Normal birth can cause tears to the vagina and the surrounding tissue, usually as the baby's head is born, and sometimes these tears extend to the rectum. These are repaired surgically, but take time to heal. To avoid these severe tears, doctors have recommended making a surgical cut to the perineum with scissors or scalpel to prevent severe tearing and facilitate the birth. This intervention, known as an episiotomy, is used as a routine care policy during births in some countries. Both a tear and an episiotomy need sutures, and can result in severe pain, bleeding, infection, pain with sex, and can contribute to long term urinary incontinence. Why is this important? An episiotomy requires suturing and benefits and harms as part of routine management of normal births remains unclear. In particular, we need to know if it does indeed prevent large tears, because women otherwise may be subjected to an unnecessary operation, pain and in some cases long-term problems. The question of whether to apply a policy of routine episiotomy is important for clinical practice and for the health and well-being of women and babies. What evidence did we find? We prepared this edition of this review by updating the methods and searching for evidence from the medical literature on 14 September 2016. The review now includes 11 randomised controlled trials (with 5977 women) that compared episiotomy as needed (selective episiotomy) with routine episiotomy in terms of benefits and harms for mother and baby in women at low risk of instrumental delivery. The trials were from ten different countries. In women where health staff were only conducting selective episiotomy, there may be 30% fewer with severe perineal trauma at birth compared with women where a policy of routine episiotomy was applied (eight trials, 5375 women, low-certainty evidence). We do not know if there is a difference in average blood loss between the groups (two trials, very low-certainty evidence). There is probably no difference in Apgar less than seven at five minutes, with no events in either groups (moderate-certainty evidence). We do not know if there is a difference in the number of women with moderate or severe perineal pain three days after giving birth (one trial, 165 women, very low-certainty evidence) but careful assessment of women's pain was not well carried out in the included trials. There may be little or no difference in the number of women developing perineal infection (two trials, low-certainty evidence); and there is probably little or no difference in women reporting painful sexual intercourse six months or more after delivery (three trials, 1107 women, moderate-certainty evidence); for urinary incontinence six months or more after delivery, there may be little or no difference between the groups. One study reported genital prolapse three years after the birth and there was no clear difference between groups (low-certainty evidence). Other important outcomes relating to long-term effects were not reported in these trials (urinary fistula, rectal fistula, and faecal incontinence). One trial examined selective episiotomy compared with routine episiotomy in women for whom an operative vaginal birth was intended. The results showed no clear difference in severe perineal trauma between the restrictive and routine use of episiotomy. Women's views on the different policies were not reported. What does this mean? Overall, the findings show that selective use of episiotomy in women (where a normal delivery without forceps is anticipated) means that fewer women have severe perineal trauma. Thus the rationale for conducting routine episiotomies to prevent severe perineal trauma is not justified by current evidence, and we could not identify any benefits of routine episiotomy for the baby or the mother. More research is needed in order to inform policy in women where an instrumental birth is planned and episiotomy is often advocated. Outcomes could be better standardised and measured. PMID:28176333

Impact of mediolateral episiotomy on incidence of obstetrical anal sphincter injury diagnosed by endoanal ultrasound.

PubMed

Drusany Staric, Kristina; Lukanovic, Adolf; Petrocnik, Petra; Zacesta, Vita; Cescon, Corrado; Lucovnik, Miha

2017-08-01

to examine potential association between mediolateral episiotomy and reduced incidence of obstetrical anal sphincter injuries (OASIS) diagnosed by endoanal ultrasound. prospective cohort study. tertiary referral university hospital. sixty nulliparous women at 28-33 weeks of gestation with singleton pregnancies were included between 2010 and 2012. participants were examined with endoanal ultrasound at 28-33 weeks gestation and at 6-7 weeks post-partum. At both visits, symptoms of anal incontinence were assessed using Cleveland Clinic (Wexner) faecal incontinence scoring system. Mann Whitney U-test and χ 2 test was used to compare groups with vs. without episiotomy and groups with vs. without OASIS diagnosed by ultrasound. χ 2 test was used to assess correlation between OASIS and anal incontinence symptoms (p≤0.05 considered significant). None of the women included had sphincter injury or anal incontinence before childbirth. All delivered vaginally. Mediolateral episiotomy was performed in 33 (55%) cases. Six (10%) had OASIS on endoanal ultrasound (two were also diagnosed clinically), and 11 had symptoms of anal incontinence post-partum. No significant differences were seen in clinical characteristics between groups with vs. without episiotomy. No significant differences were seen in episiotomy rate (p=0.14), angle (p=0.42) and length (p=0.14) between groups with vs. without OASIS on ultrasound. Correlation between anal incontinence symptoms and sonographically diagnosed OASIS was statistically significant (p=0.04). mediolateral episiotomy does not seem to be protective against clinically or sonographically diagnosed OASIS even when episiotomy technique is considered. Endoanal ultrasound allows a significantly better detection of symptomatic OASIS compared to clinical examination alone. mediolateral episiotomy should be considered only when shortening the second stage of labour is indicated due to foetal distress, and not as a means of OASIS prevention. Copyright © 2017 Elsevier Ltd. All rights reserved.

Episiotomy: the final cut?

PubMed

Steiner, Naama; Weintraub, Adi Y; Wiznitzer, Arnon; Sergienko, Ruslan; Sheiner, Eyal

2012-12-01

To investigate whether episiotomy prevents 3rd or 4th degree perineal tears in critical conditions such as shoulder dystocia, instrumental deliveries (vacuum or forceps), persistent occiput-posterior position, fetal macrosomia (>4,000 g), and non-reassuring fetal heart rate (NRFHR) patterns. A retrospective study comparing 3rd and 4th degree perineal tears during vaginal deliveries with or without episiotomy, in selected critical conditions was performed. Multiple gestations, preterm deliveries (<37 weeks' gestation) and cesarean deliveries were excluded from the analysis. Stratified analysis (using the Mantel-Haenszel technique) was used to obtain the weighted odds ratio (OR), while controlling for these variables. During the study period, there were 168,077 singleton vaginal deliveries. Of those, 188 (0.1%) had 3rd or 4th degree perineal tears. Vaginal deliveries with episiotomy had statistically significant higher rates of 3rd or 4th degree perineal tears than those without episiotomy (0.2 vs. 0.1%; P<0.001). The association between episiotomy and severe perineal tears remained significant even in the critical conditions. Stratified analysis revealed that the adjusted ORs for 3rd or 4th degree perineal tears in these critical conditions (Macrosomia OR=2.3; instrumental deliveries OR=1.8; NRFHR patterns OR=2.1; occipito-posterior position OR=2.3; and shoulder dystocia OR=2.3) were similar to the crude OR (OR=2.3). Mediolateral episiotomy is an independent risk factor for 3rd or 4th degree perineal tears, even in critical conditions such as shoulder dystocia, instrumental deliveries, occiput-posterior position, fetal macrosomia, and NRFHR. Prophylactic use of episiotomy in these conditions does not seem beneficial if performed to prevent 3rd or 4th degree perineal tears.

The use of perineal massage in the second stage of labor and follow-up of postpartum perineal outcomes.

PubMed

Karaçam, Zekiye; Ekmen, Hatice; Calişir, Hüsniye

2012-01-01

Because perineal trauma causes both short- and long-term problems after labor, the high rate of episiotomies and spontaneous lacerations is an important women's health problem in Turkey. Our aim in this study was to investigate whether perineal massage during labor decreased perineal trauma and trauma-related problems. The study included 396 pregnant women who were giving birth for the first time, between March 2007 and February 2009, in Turkey. It can be concluded that perineal massage decreases the amount of suture material required for episiotomy and thereby the size of the episiotomy and the rate of episiotomies and lacerations.

The Effect of Chamomile Cream on Episiotomy Pain in Primiparous Women: A Randomized Clinical Trial

PubMed Central

Aradmehr, Maryam; Azhari, Sedigheh; Ahmadi, Sedigheh; Azmoude, Elham

2017-01-01

Introduction: Episiotomy is a surgical incision made in the perineum to enlarge it. Perineal pain is the most common complaint of mothers after episiotomy. Chamomile extract has been proposed as a sedative in traditional medicine. This study was conducted to assess the effect of chamomile cream on the pain after episiotomy. Methods: This triple blind clinical trial was performed on 114 eligible women at Ommolbanin Hospital in Mashhad, Iran in 2014.They were randomly assigned to two groups using random blocks. After delivery, mothers in the intervention group used 0.5 g of prescribed chamomile while the control group used placebo cream on the stitch twice a day lasting ten days. Episiotomy pain was evaluated before intervention and 12 hours after episiotomy repair and also on the first, seventh, tenth and fourteenth day after delivery by McGill pain questionnaire. Data was analyzed by SPSS ver.13. Results: There was no significant difference between the two groups before the intervention, 12 hours and the first day after delivery. However, a significant difference was found on the seventh, tenth and fourteenth day after delivery. McGill mean (SD) score on the seventh, tenth and fourteenth in experimental group was 11.36 (5.04), 4.44 (3.43) and 7.16 (4.10) respectively. It was reported 14.88 (7.34), 7.41(4.92) and 9.96 (4.81) in placebo group, respectively. Conclusion: Chamomile cream can be used to reduce episiotomy pain in Primiparous us women. PMID:28299294

The Effect of Chamomile Cream on Episiotomy Pain in Primiparous Women: A Randomized Clinical Trial.

PubMed

Aradmehr, Maryam; Azhari, Sedigheh; Ahmadi, Sedigheh; Azmoude, Elham

2017-03-01

Introduction: Episiotomy is a surgical incision made in the perineum to enlarge it. Perineal pain is the most common complaint of mothers after episiotomy. Chamomile extract has been proposed as a sedative in traditional medicine. This study was conducted to assess the effect of chamomile cream on the pain after episiotomy. Methods: This triple blind clinical trial was performed on 114 eligible women at Ommolbanin Hospital in Mashhad, Iran in 2014.They were randomly assigned to two groups using random blocks. After delivery, mothers in the intervention group used 0.5 g of prescribed chamomile while the control group used placebo cream on the stitch twice a day lasting ten days. Episiotomy pain was evaluated before intervention and 12 hours after episiotomy repair and also on the first, seventh, tenth and fourteenth day after delivery by McGill pain questionnaire. Data was analyzed by SPSS ver.13. Results: There was no significant difference between the two groups before the intervention, 12 hours and the first day after delivery. However, a significant difference was found on the seventh, tenth and fourteenth day after delivery. McGill mean (SD) score on the seventh, tenth and fourteenth in experimental group was 11.36 (5.04), 4.44 (3.43) and 7.16 (4.10) respectively. It was reported 14.88 (7.34), 7.41(4.92) and 9.96 (4.81) in placebo group, respectively. Conclusion: Chamomile cream can be used to reduce episiotomy pain in Primiparous us women.

Association between median episiotomy and severe perineal lacerations in primiparous women

PubMed Central

Labrecque, M; Baillargeon, L; Dallaire, M; Tremblay, A; Pinault, J J; Gingras, S

1997-01-01

OBJECTIVE: To evaluate the association between median episiotomy and severe (third- and fourth-degree) perineal lacerations in primiparous women. DESIGN: Retrospective cohort study. SETTING: University-affiliated hospital providing secondary obstetric care in Quebec City. PATIENTS: A total of 6522 primiparous women who gave birth vaginally to a single live baby in cephalic position between 1985 and 1993. OUTCOME MEASURE: Incidence of third- and fourth-degree perineal lacerations. RESULTS: Median episiotomy was performed in 4390 women (67.3%). A total of 1002 women (15.4%) had a third- or fourth-degree laceration. The frequency of severe perineal lacerations was 20.6% with episiotomy and 4.5% without episiotomy (relative risk [RR] 4.58, 95% confidence interval [CI] 3.74-5.62). This association persisted after adjustment by stratified analysis for type of delivery and birth weight (RR 3.03, 95% CI 2.52-3.63) and by logistic regression for type of delivery, birth weight, epidural analgesia, shoulder dystocia, baby's head circumference, experience of the physician and year of delivery (odds ratio 3.58, 95% CI 2.84-4.50). CONCLUSION: Median episiotomy is strongly associated with third- and fourth-degree perineal lacerations in primiparous women. Reducing the use of this procedure could decrease the occurrence of severe perineal tears. PMID:9084384

The role of episiotomy in prevention of genital lacerations during vaginal deliveries--results from two European centers.

PubMed

Laganà, Antonio Simone; Terzic, Milan; Dotlic, Jelena; Sturlese, Emanuele; Palmara, Vittorio; Retto, Giovanni; Kocijancic, Dusica

2015-03-01

There is an ongoing debate regarding the routine versus restrictive use of episiotomy The study aim was to investigate if episiotomy during vaginal deliveries can reduce both, the number and severity of genital lacerations. The study included all women who gave vaginal birth at AOU. "G. Martino" Messina (n=382) and the Clinic for Ob/Gyn Clinical Center of Serbia, Belgrade (n=4227) during 2011. Lacerations during birth were recorded and divided according to location and severity Women with lacerations were subdivided into two groups: with or without mediolateral episiotomy We assessed potential risk factors for laceration: maternal age, parity use of labor stimulants and epidural analgesia, participation in antenatal classes, fetal presentation, neonatal birth weight, and duration of the second stage of labor. Older women had higher grade perineum or combined lacerations. Children with higher birth weight in occipito-posterior presentation caused higher grade lacerations. Performance of episiotomy was connected with fewer perineum and labial lacerations. There were no differences in laceration grade between patients with and without episiotomy Assessed parameters proved to be good discriminating factors between lacerations sites. According to logistic regression, laceration site was the most important risk factor for laceration grade. Combined lacerations had the highest grade. Episiotomy can significantly reduce the number of genital lacerations, but it does not influence laceration grade. Advanced maternal age, higher parity occipitoposterior presentation and fetal macrosomia can cause lacerations during vaginal birth. Therefore, we suggest analysis of maternal and fetal factors to prevent widespread genital lacerations.

The Effect of Warm Compress Bistage Intervention on the Rate of Episiotomy, Perineal Trauma, and Postpartum Pain Intensity in Primiparous Women with Delayed Valsalva Maneuver Referring to the Selected Hospitals of Shiraz University of Medical Sciences in 2012-2013.

PubMed

Akbarzadeh, Marzieh; Vaziri, Faride; Farahmand, Mahnaz; Masoudi, Zahra; Amooee, Sedigheh; Zare, Najaf

2016-02-01

Genital trauma during vaginal delivery may result from episiotomy, spontaneous perineal tears (perineum, vagina), or both. In 2012, this study aimed to investigate the effect of warm compress bistage intervention on the rate of episiotomy, perineal trauma, and postpartum pain intensity in the primiparous woman with delayed Valsalva maneuver. In this randomized clinical trial, which was performed in hospitals in Shiraz, Iran, in 2012-2013, 150 women were randomly divided into 2 groups: 1 intervention and 1 control. The intervention group received warm compress bistage intervention at 7-cm and 10-cm dilatation and zero position during the first and second stages of labor for 15 to 20 minutes, whereas the control group received the hospitals' routine care. After delivery, the prevalence of episiotomy; intact perineum; location, degree, and length of rupture; and postpartum pain intensity were assessed in the 2 groups. Following that, the data were analyzed with SPSS statistical software (version 16) using χ test, t test, and odds ratio. The results revealed a significant difference between the intervention and control groups regarding the frequency of intact perinea (27% vs 6.7%) and the frequency of episiotomy (45% vs 90.70%). In addition, the frequency of the location of rupture (P = .019), mean length of episiotomy incision (P = .02), and mean intensity of pain the day after delivery (P < .001) were significantly lower in the intervention group compared with the control group. However, the rate of ruptures was higher in the intervention group. Warm compress bistage intervention was effective in reducing episiotomies and the mean length of episiotomy incision, reducing pain after delivery, and increasing the rate of intact perinea. However, the rate of ruptures slightly increased in the intervention group compared with the control group.

[Can we reduce the episotomy rate?].

PubMed

Faruel-Fosse, H; Vendittelli, F

2006-02-01

Determine whether scientific evidence supports an "appropriate" episiotomy rate - and whether this rate can be reduced via medical intervention and or preventive actions during pregnancy or at the time of delivery. A survey of the literature available on Medline and the Cochrane Library between 1980 and 2005 and dealing with the objectives of the present study was undertaken. In France, the national episiotomy rate should not reach 30%. A program aiming at continuous improvement in quality-of-care after episiotomy and including various actions - training courses, audits, presence of a staff leader, episiotomy rate feedback per midwife or obstetrician - could help reduce the use of episiotomies (grade B). There is insufficient scientific data available to recommend perineal massaging or pre-birth perineal physiotherapy (grade B), and the benefits of a pre-birth training course on the perineum are still to be assessed (grade C). A pregnancy-long support provided to a woman by the same professional could reduce the use of episiotomies but not resorting to perineum repair (grade B). The effects of various types of pre-birth training courses on the perineum are unknown (grade C). We lack scientific data to promote perineal massaging during labor (grade B). Some studies show that an upright position during the second stage of labor is less harmful to the perineum than the classical dorsal reclining position, however it can increase the possibility of post-partum hemorrhage (grade B). Scientific proof is not sufficient to advise favoring a particular type of pushing or a specific manner to release the baby's head (grade B). More randomized studies are necessary to assess the relevance of all these preventive measures as regards the use of episiotomies.

Awareness Regarding Perineal Protection, Obstetric Anal Sphincter Injury, and Episiotomy Among Obstetrics and Gynecology Residents; Effects of an Educational Workshop.

PubMed

Stecher, Anna M; Yeung, Jennifer; Crisp, Catrina C; Pauls, Rachel N

Appropriate perineal protection may reduce rates of obstetric anal sphincter injuries (OASIS). We sought to investigate the knowledge and attitudes of obstetrics and gynecology residents concerning perineal protection, OASIS, and episiotomy before and after an educational workshop. This was an institutional review board-approved cross-sectional survey study of obstetrics and gynecology residents. Two experts in perineal protection, whose methods have been shown to reduce OASIS by 50%, provided 1 week of education. Residents were taught in hands-on workshops and labor and delivery wards. Residents were surveyed regarding experiences, knowledge, and opinions of perineal protection, OASIS, and episiotomy. Surveys were administered immediately before and after the workshop and at 3 months following. All 31 residents participated. Almost all (97%) felt it was possible to reduce the incidence of OASIS prior to the workshop. Statistically significant increases were noted following training in the number that felt it was "very effective" to use the 2-handed technique taught in the workshop (P = 0.002), as well as those that reported most commonly performing a mediolateral episiotomy (protective against OASIS, if used selectively) when episiotomy was indicated (P = 0.001). The percent that reported feeling "comfortable" or "very comfortable" performing episiotomies increased from 45% to 77% immediately after the workshop (P = 0.002); this declined to 55% at 3 months. A large majority (77%) reported that the workshop was beneficial; 65% described an impact to patient care. A workshop targeting perineal protection improved awareness and changed clinical practice in this group of residents. Ongoing education regarding perineal protection and episiotomy may reinforce behavior modifications.

Relationship between the degree of perineal trauma at vaginal birth and change in haemoglobin concentration.

PubMed

Rubio-Álvarez, Ana; Molina-Alarcón, Milagros; Hernández-Martínez, Antonio

2017-10-01

Postpartum anaemia is a problem with high prevalence that significantly affects maternal recovery. Among the causal factors is perineal trauma. However, it is still not known what degree of perineal trauma produces a greater reduction of haemoglobin. To assess the relationship between the degree of perineal trauma and change in haemoglobin concentration at vaginal birth. An observational, analytical retrospective cohort study was performed at the Mancha-Centro Hospital (Spain) during the period 2010-2014. Data were collected regarding 3479 women who gave birth vaginally. The main outcome variable was the change in haemoglobin concentration. Multivariate analysis by means of multiple linear regression was performed to control possible confounding factors and to determine the net effect of each degree of perineal trauma on haemoglobin reduction. Of the total sample, 20.1% of women (699) had an intact perineum, 41.6% (1446) experienced some form of perineal trauma, but not episiotomy, and the remaining 38.3% of women (1334) underwent an episiotomy. The average reduction of haemoglobin was 1.46g/dL (Standard Deviation (SD)=1.09g/dL) for women without episiotomy with a second degree tear and 2.07g/dL (SD=1.24g/dL) for women who had an episiotomy and no perineal tear. The greatest reduction occurred among women with episiotomy and a third or fourth degree tear with a decrease of 3.10g/dL (SD=1.32g/dL). Episiotomy is related to greater reduction of haemoglobin concentration in comparison with all degrees of spontaneous perineal trauma. The use of episiotomy should be strictly limited. Copyright © 2017 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Reducing high-order perineal laceration during operative vaginal delivery.

PubMed

Hirsch, Emmet; Haney, Elaine I; Gordon, Trent E J; Silver, Richard K

2008-06-01

This study was undertaken to assess the impact of a focused intervention on reducing high-order (third and fourth degree) perineal lacerations during operative vaginal delivery. The following recommendations for clinical management were promulgated by departmental lectures, distribution of pertinent articles and manuals, training of physicians, and prominent display of an instructional poster: (1) increased utilization of vacuum extraction over forceps delivery; (2) conversion of occiput posterior to anterior positions before delivery; (3) performance of mediolateral episiotomy if episiotomy was deemed necessary; (4) flexion of the fetal head and maintenance of axis traction; (5) early disarticulation of forceps; and (6) reduced maternal effort at expulsion. Peer comparison was encouraged by provision of individual and departmental statistics. Clinical data were extracted from the labor and delivery database and the medical record. One hundred fifteen operative vaginal deliveries occurred in the 3 quarters preceding the intervention, compared with 100 afterward (P = .36). High-order laceration with operative vaginal delivery declined from 41% to 26% (P = .02), coincident with increased use of vacuum (16% vs 29% of operative vaginal deliveries, P = .02); fewer high-order lacerations after episiotomy (63% vs 22%, P = .003); a nonsignificant reduction in performance of episiotomy (30% vs 23%, P = .22); and a nonsignificant increase in mediolateral episiotomy (14% vs 30% of episiotomies, P = .19). Introduction of formal practice recommendations and performance review was associated with diminished high-order perineal injury with operative vaginal delivery.

[Initial experiences with primiparous women using a new kind of Epi-no labor trainer].

PubMed

Hillebrenner, J; Wagenpfeil, S; Schuchardt, R; Schelling, M; Schneider, K T

2001-01-01

The effectiveness of a vaginal dilatator (Epi-no) in avoiding episiotomies and improving the fetal outcome was examined. Fifty pregnant women were included in our prospective study and took part in the prepartal birth training program with Epi-no. Matched-pairs were compared for the rate of episiotomy and perineal tears, neonatal APGAR score, average time of training, duration of labour and analgesia during delivery. We found a significant reduction in the rate of episiotomies in the group of women who participated in the birth training program with Epi-no (EG: 49%) compared to women who did not take part in our training program (NEG: 82%). Also the rate of perineal tears was twice as high in the latter (4% vs. 2%). Moreover, children of women of the EG showed better one-minute-APGAR-scores. In addition to this we found a significant reduction in the average duration of the second stage of labour in the EG (29 min) if compared with the NEG (54 min). Women in the EG had a lower rate of PDA (16% vs. 36%) and needed less analgesics than those in the NEG. Women of the EG who delivered without episiotomy had trained on average two days longer than women who had had an episiotomy. Birth training with Epi-no decreases the rate of episiotomies in primiparous significantly.

Episiotomy

MedlinePlus

... that widens the opening of the vagina during childbirth. It is a cut to the perineum -- the ... I Need an Episiotomy? Many women get through childbirth without tearing on their own, and without needing ...

Episiotomy increases perineal laceration length in primiparous women.

PubMed

Nager, C W; Helliwell, J P

2001-08-01

The aim of this study was to determine the clinical factors that contribute to posterior perineal laceration length. A prospective observational study was performed in 80 consenting, mostly primiparous women with term pregnancies. Posterior perineal lacerations were measured immediately after delivery. Numerous maternal, fetal, and operator variables were evaluated against laceration length and degree of tear. Univariate and multivariate regression analyses were performed to evaluate laceration length and parametric clinical variables. Nonparametric clinical variables were evaluated against laceration length by the Mann-Whitney U test. A multivariate stepwise linear regression equation revealed that episiotomy adds nearly 3 cm to perineal lacerations. Tear length was highly associated with the degree of tear (R = 0.86, R(2) = 0.73) and the risk of recognized anal sphincter disruption. None of 35 patients without an episiotomy had a recognized anal sphincter disruption, but 6 of 27 patients with an episiotomy did (P <.001). Body mass index was the only maternal or fetal variable that showed even a slight correlation with laceration length (R = 0.30, P =.04). Episiotomy is the overriding determinant of perineal laceration length and recognized anal sphincter disruption.

Perineal Massage in Pregnancy

MedlinePlus

... stretches a lot during childbirth, and sometimes it tears. If your health care provider cuts an episiotomy ... your baby is born if you have a tear or have an episiotomy. I’m Concerned About ...

High-frequency TENS in post-episiotomy pain relief in primiparous puerpere: a randomized, controlled trial.

PubMed

Pitangui, Ana Carolina Rodarti; de Sousa, Ligia; Gomes, Flávia Azevedo; Ferreira, Cristine Homsi Jorge; Nakano, Ana Márcia Spanó

2012-07-01

We evaluated the effectiveness of high-frequency transcutaneous electrical nerve stimulation (TENS) as a pain relief resource for primiparous puerpere who had experienced natural childbirth with an episiotomy. A controlled, randomized clinical study was conducted in a Brazilian maternity ward. Forty puerpere were randomly divided into two groups: TENS high frequency and a no treatment control group. Post-episiotomy pain was assessed in the resting and sitting positions and during ambulation. An 11-point numeric rating scale was performed in three separate evaluations (at the beginning of the study, after 60 min and after 120 min). The McGill pain questionnaire was employed at the beginning and 60 min later. TENS with 100 Hz frequency and 75 µs pulse for 60 min was employed without causing any pain. Four electrodes ware placed in parallel near the episiotomy site, in the area of the pudendal and genitofemoral nerves. An 11-point numeric rating scale and McGill pain questionnaire showed a significant statistical difference in pain reduction in the TENS group, while the control group showed no alteration in the level of discomfort. Hence, high-frequency TENS treatment significantly reduced pain intensity immediately after its use and 60 min later. TENS is a safe and viable non-pharmacological analgesic resource to be employed for pain relief post-episiotomy. The routine use of TENS post-episiotomy is recommended. © 2012 The Authors. Journal of Obstetrics and Gynaecology Research © 2012 Japan Society of Obstetrics and Gynecology.

Severe perineal lacerations in nulliparous women and episiotomy type.

PubMed

Aytan, Hakan; Tapisiz, Omer L; Tuncay, Gorkem; Avsar, Filiz A

2005-07-01

To determine the patient-related factors associated with severe perineal lacerations in nulliparous women and to evaluate the effect of episiotomy type on the risk of severe perineal tears. In all, 400 nulliparous women admitted in labor between June and December 2001 were prospectively enrolled. Maternal height, perineal length, fetal birth weight, fetal head circumference, and severe perineal lacerations (third and fourth degrees) were recorded. The rate of severe perineal lacerations was 2% (8/400); 3% with midline, 1% with mediolateral groups. In patients with severe lacerations, perineal length was significantly (p < 0.001) shorter and the head circumference of their babies in the midline significantly (p < 0.05) greater than normal, and birth weights were also significantly (p < 0.05) greater in the mediolateral group. A cut-off value for perineal length of 3.05 cm was found for severe lacerations in the midline group. If episiotomy is to be performed, it must be borne in mind that patients with a perineal length of < or = 3 cm have an elevated risk of severe perineal lacerations, and if clinical or ultrasound examination suggests that the fetal head is large, mediolateral episiotomy may be preferred. Otherwise, midline episiotomy must be considered.

Episiotomy and severe perineal trauma among Eastern African immigrant women giving birth in public maternity care: A population based study in Victoria, Australia.

PubMed

Belihu, Fetene B; Small, Rhonda; Davey, Mary-Ann

2017-08-01

Eastern African immigrants from countries affected by female genital mutilation have resettled in many developed countries, including Australia. Although possibly at risk of perineal trauma and episiotomy, research investigating their perineal status post-migration is sparse. To investigate variations in episiotomy use and incidence of severe perineal tear for women born in Eritrea, Ethiopia, Somalia and Sudan compared with Australian-born women. A population-based study of 203,206 Australian-born and 3502 Eastern African immigrant women admitted as public patients, with singleton vaginal births between 1999 and 2007, was conducted using the Victorian Perinatal Data Collection. Descriptive and multivariable logistic regression analysis adjusting for confounders selected a priori, were performed to compute incidence and adjusted odds ratios. Overall, 30.5% Eastern African immigrants had episiotomy compared to 17.2% Australian-born women. Severe perineal trauma occurred in 2.1% of Eastern African immigrants and 1.6% of Australian-born women. While the odds of severe perineal trauma was significantly elevated only during non-instrumental vaginal births for Eastern African immigrants {OR adj 1.56 95%CI(1.17, 2.12)}; that of episiotomy was increased during both non-instrumental {OR adj 4.47 95%CI(4.10, 4.88)} and instrumental {OR adj 2.51 95%CI(1.91, 3.29)} vaginal births. Overall, Eastern African immigrant women experienced elevated odds of episiotomy and severe perineal tear. Health care providers need to be mindful of the increased risk of severe perineal tear in these women and enhance efforts in identification and treatment of severe perineal trauma to minimise associated short and long term morbidity. Strategies to reduce unneeded episiotomy and ways of enhancing perineal safety are also needed. Crown Copyright © 2016. Published by Elsevier Ltd. All rights reserved.

Risk and protective factors for obstetric anal sphincter injuries: A retrospective nationwide study.

PubMed

Marschalek, Marie-Louise; Worda, Christof; Kuessel, Lorenz; Koelbl, Heinz; Oberaigner, Willi; Leitner, Hermann; Marschalek, Julian; Husslein, Heinrich

2018-03-14

In view of the reported increase in obstetric anal sphincter injuries, the objective of this study was to evaluate the incidence of such injuries over time and the associated risk and protective factors. This was a retrospective cohort study from a national database of 168 137 primiparous women with term, singleton, cephalic, vaginal delivery between 2008 and 2014. The main outcome measure was obstetric anal sphincter injury. A multivariate regression model was used to identify risk and protective factors. Age >19 years, birthweight >4000 g, and operative vaginal delivery were independent risk factors for obstetric anal sphincter injuries. Mediolateral episiotomy increased the risk for obstetric anal sphincter injuries in spontaneous vaginal birth (number needed to harm 333), whereas it was protective in vacuum delivery (number needed to treat 50). From 2008 to 2014, there was an increase in the rate of obstetric anal sphincter injuries (2.1% vs 3.1%, P < .01), vacuum deliveries (12.1% vs 12.8%, P < .01), and cesarean delivery after labor (17.1% vs 19.4%, P < .01), while forceps deliveries (0.4% vs 0.1%, P < .01) and episiotomy rate decreased (35.9% vs 26.4%, P < .01). Episiotomy may be a risk or protective factor depending on the type of episiotomy and the clinical setting in which it is used. Our study supports a restrictive use of mediolateral episiotomy in spontaneous vaginal deliveries. In vacuum deliveries mediolateral episiotomy may help prevent obstetric anal sphincter injuries. © 2018 the Authors. Birth published by Wiley Periodicals, Inc.

To cut or not to cut, that is the question: A review of the anatomy, the technique, risks, and benefits of an episiotomy.

PubMed

Muhleman, Mitchel Alan; Aly, Islam; Walters, Andrew; Topale, Nitsa; Tubbs, R Shane; Loukas, Marios

2017-04-01

Childbirth can be a traumatic experience on the female body. Some techniques may be implemented to make the process smoother and decrease the potential lacerations that can occur. Episiotomies have been used by obstetricians and midwives to help make the fetal decent down the vaginal canal less turbulent. A physician must use his best judgment on when it is necessary to make this incision and what form of incision to make. Before making an incision one must understand the female external and internal anatomy and thoroughly comprehend the stages of birth to understand how and what complications can occur. Even though an episiotomy is a minor incision, it is still a surgical incision nonetheless and as with any form of surgery there are both risks and benefits that are to be considered. Nevertheless, episiotomies have proven to help ease births that are complicated by shoulder dystocia, prevent severe lacerations, and decrease the second stage of labor. The following comprehensive review provides a description of the female anatomy, as well as an extensive description of why, when, and how an episiotomy is done. Clin. Anat. 30:362-372, 2017. © 2017 Wiley Periodicals, Inc. © 2017 Wiley Periodicals, Inc.

Effect of perineal massage on the rate of episiotomy and perineal tearing.

PubMed

Demirel, Gulbahtiyar; Golbasi, Zehra

2015-11-01

To examine the effects of perineal massage during active labor on the frequency of episiotomy and perineal tearing. A randomized controlled study was conducted at a center in Sivas, Turkey, between January 1, 2010, and May 31, 2011. Healthy pregnant women presenting for their first or second delivery at 37-42 weeks of pregnancy were enrolled during the first stage of labor. Participants were randomly assigned (1:1) to the massage group (10-minute perineal massage with glycerol four times during the first stage and once during the second stage of labor) or control group (routine care). The frequency of episiotomy and perineal tearing were compared between the groups. Participants and investigators were not masked to group assignment. Both groups contained 142 participants. Episiotomy was performed among 44 (31.0%) women in the massage group and 99 (69.7%) in the control group (P = 0.001). Lacerations were recorded among 13 (4.2%) women in the massage group and 6 (4.2%) in the control group (P = 0.096). Application of perineal massage during active labor decreased the frequency of episiotomy procedures. ClinicalTrials.gov:NCT02201615. Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Risk of episiotomy and perineal lacerations recurring after first delivery.

PubMed

Manzanares, Sebastian; Cobo, Davinia; Moreno-Martínez, Maria Dolores; Sánchez-Gila, Mar; Pineda, Alicia

2013-12-01

To assess whether the presence of an episiotomy or spontaneous perineal trauma at the first delivery increases the risk of perineal trauma at the following one. We studied 2,695 women who gave birth twice at Virgen de las Nieves University Hospital of Granada, Spain. All second deliveries were from 2004 to 2011 and prenatal database records were used to obtain information about the first deliveries. All births, first and second, were single, vaginal, unassisted, and in a cephalic presentation. Two groups were made as follows: Intact perineum (no perineal trauma or first-degree spontaneous tear at the first delivery) and perineal trauma (episiotomy or second-degree or higher spontaneous tear at the first delivery). Both groups were compared according to the degree of perineal trauma at the second delivery. Women included in the perineal trauma group were significantly older and a higher proportion was attended by a midwife with an obstetrician present in the delivery room. No differences were observed according to gestational age, epidural analgesia or fetal birth weight. Adjusting for these possible compounding factors and the year of birth, the risk of undergoing a second-degree or higher spontaneous tear at their next delivery was fivefold (adjusted OR 5.15, 95% CI 3.11-8.54), and the risk of undergoing an episiotomy in the second delivery was threefold (adjusted OR 3.20, 95% CI 2.19-4.69) for the perineal trauma group. The risk of undergoing a spontaneous perineal tear or an episiotomy in the second delivery is increased by the practice of episiotomy in the first one. © 2013, Copyright the Authors Journal compilation © 2013, Wiley Periodicals, Inc.

A surgical skills laboratory improves residents' knowledge and performance of episiotomy repair.

PubMed

Banks, Erika; Pardanani, Setul; King, Mary; Chudnoff, Scott; Damus, Karla; Freda, Margaret Comerford

2006-11-01

This study was undertaken to assess whether a surgical skills laboratory improves residents' knowledge and performance of episiotomy repair. Twenty-four first- and second-year residents were randomly assigned to either a surgical skills laboratory on episiotomy repair or traditional teaching alone. Pre- and posttests assessed basic knowledge. Blinded attending physicians assessed performance, evaluating residents on second-degree laceration/episiotomy repairs in the clinical setting with 3 validated tools: a task-specific checklist, global rating scale, and a pass-fail grade. Postgraduate year 1 (PGY-1) residents participating in the laboratory scored significantly better on all 3 surgical assessment tools: the checklist, the global score, and the pass/fail analysis. All the residents who had the teaching laboratory demonstrated significant improvements on knowledge and the skills checklist. PGY-2 residents did not benefit as much as PGY-1 residents. A surgical skills laboratory improved residents' knowledge and performance in the clinical setting. Improvement was greatest for PGY-1 residents.

[Impact of a major decrease in the use of episiotomy on perineal tears in a level III maternity ward].

PubMed

Chehab, M; Courjon, M; Eckman-Lacroix, A; Ramanah, R; Maillet, R; Riethmuller, D

2014-06-01

To evaluate the perineal outcome after a major decrease in episiotomy rate in a high-risk (level III) maternity ward. This was a retrospective cohort study in a teaching high-risk maternity comparing perineal tears between 2003 and 2010. We included for analysis: pregnancies at 25 weeks or more, fetal birthweights of 500 g or more, vaginal deliveries in our maternity, singletons or multiple pregnancies, cephalic or breech presentations. The two populations were comparable. In 2003, we performed 18.8% of episiotomies and 1.3% in 2010. Between these years, our intact perineum rate increased from 28.8 to 37.5% (P<0.0001). We also report an increase in first and second degree perineum lesions (20.5% in 2003 and 40.2% in 2010, P<0.0001) and anterior perineal lesions (17.8% in 2003 and 30.3% in 2010, P<0.0001). We also report a significant decrease in perineal lesions with sphincter injuries (1% in 2003 and 0.3% in 2010 P<0.0001). Comparing 2003 to 2010, the majority of cases with no episiotomy (over 2/3) resulted in first degree perineum lesions which are today recognized as benign lesions without any systematic need for suturing. A restrictive use of episiotomy increases the rate of intact perineum and of "non-severe" perineal lesions. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Antibiotic prophylaxis for episiotomy repair following vaginal birth.

PubMed

Bonet, Mercedes; Ota, Erika; Chibueze, Chioma E; Oladapo, Olufemi T

2017-11-02

Bacterial infections occurring during labour, childbirth, and the puerperium may be associated with considerable maternal and perinatal morbidity and mortality. Antibiotic prophylaxis might reduce wound infection incidence after an episiotomy, particularly in situations associated with a higher risk of postpartum perineal infection, such as midline episiotomy, extension of the incision, or in settings where the baseline risk of infection after vaginal birth is high. However, available evidence is unclear concerning the role of prophylactic antibiotics in preventing infections after an episiotomy. To assess whether routine antibiotic prophylaxis before or immediately after incision or repair of episiotomy for women with an uncomplicated vaginal birth, compared with either placebo or no antibiotic prophylaxis, prevents maternal infectious morbidities and improves outcomes. We searched the Cochrane Pregnancy and Childbirth's Trials Register, LILACS, ClinicalTrials.gov, and the WHO International Clinical Trials Registry Platform (ICTRP) on 24 July 2017, and screened reference lists of retrieved studies. We considered randomised controlled trials, quasi-randomised trials, and cluster-randomised trials that compared the use of routine antibiotic prophylaxis for incision or repair of an episiotomy for women with otherwise normal vaginal births, compared with either placebo or no antibiotic prophylaxis. Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked them for accuracy. We only found one quasi-randomised trial that met the inclusion criteria and was included in the analysis, therefore, we did not perform a meta-analysis. We included one quasi-RCT (with data from 73 women) in the review. The trial, which was conducted in a public hospital in Brazil, compared oral chloramphenicol 500 mg four times daily for 72 hours after episiotomy repair (N = 34) and no treatment (N = 39). We assessed most of the domains at high risk of bias because women were randomised according to even and odd numbers, allocation concealment was based on protocol number, there was no treatment or placebo administered in the control group, we were unclear about the blinding of outcome assessments, and outcomes were incompletely reported. We considered the other domains to be at low risk of bias. We downgraded the quality of the evidence for very serious design limitations (related to lack of random sequence generation, allocation concealment, and blinding) and imprecision of effect estimates (small sample sizes and wide confidence intervals (CI) of effect estimates).We found very low-quality evidence, from one trial of 73 women, that there was no clear indication that prophylactic antibiotics reduced the incidence of episiotomy wound dehiscence with infection (risk ratio (RR) 0.13, 95% CI 0.01 to 2.28), or without infection (RR 0.82, 95% CI 0.29 to 2.34). No cases of other puerperal infections (e.g. endometritis) were reported in either the antibiotic or control group.The trial did not report on any of the secondary outcomes of interest for this review, including severe maternal infectious morbidity, discomfort or pain at the episiotomy wound site, sexual function postpartum, adverse effects of antibiotics, costs of care, women's satisfaction with care, and individual antimicrobial resistance. There was insufficient evidence to assess the clinical benefits or harms of routine antibiotic prophylaxis for episiotomy repair after normal birth. The only trial included in this review had several methodological limitations, with very serious limitations in design, and imprecision of effect estimates. In addition, the trial tested an antibiotic with limited application in current clinical practice. There is a need for a careful and rigorous assessment of the comparative benefits and harms of prophylactic antibiotics on infection morbidity after episiotomy, in well-designed randomised controlled trials, using common antibiotics and regimens in current obstetric practice.

Virtual reality and anxiety in primiparous women during episiotomy repair.

PubMed

Shourab, Nahid Jahani; Zagami, Samira Ebrahimzadeh; Golmakhani, Nahid; Mazlom, Seyed Reza; Nahvi, Ali; Pabarja, Ferial; Talebi, Mahdi; Rizi, Sohaiela Mohamadi

2016-01-01

In recent studies, using virtual reality (VR) has been proposed as a nonpharmacological method for anxiety reduction, but until this time, its effects have not been assessed on anxiety during episiotomy repair. This study aimed to determine the effect of audiovisual distraction (VR) on anxiety in primiparous women during episiotomy repair. This clinical trial was conducted on 30 primigravida from May to July 2012 in the maternity unit of the Omolbanin Hospital, Mashhad city, Iran. The samples were divided randomly into two groups with the toss of a coin. Anxiety were evaluated by the numeric 0-10 anxiety self-report, in the first and during labor. However, after delivery, anxiety was measured with the Spilberger scale. Mann-Whitney, Chi-square, Fisher tests, and repeated-measures analysis of variance were used to analyze data. Anxiety scores were not significantly different between the two groups (wearing video-glass and receiving routine care), but anxiety scores were lower in the intervention group during and after repair ( P = 0.000). VR are safe, appropriate, and nonpharmacologic to decrease and manage the anxiety-associated episiotomy.

Virtual reality and anxiety in primiparous women during episiotomy repair

PubMed Central

Shourab, Nahid Jahani; Zagami, Samira Ebrahimzadeh; Golmakhani, Nahid; Mazlom, Seyed Reza; Nahvi, Ali; Pabarja, Ferial; Talebi, Mahdi; Rizi, Sohaiela Mohamadi

2016-01-01

Background: In recent studies, using virtual reality (VR) has been proposed as a nonpharmacological method for anxiety reduction, but until this time, its effects have not been assessed on anxiety during episiotomy repair. This study aimed to determine the effect of audiovisual distraction (VR) on anxiety in primiparous women during episiotomy repair. Materials and Methods: This clinical trial was conducted on 30 primigravida from May to July 2012 in the maternity unit of the Omolbanin Hospital, Mashhad city, Iran. The samples were divided randomly into two groups with the toss of a coin. Anxiety were evaluated by the numeric 0–10 anxiety self-report, in the first and during labor. However, after delivery, anxiety was measured with the Spilberger scale. Mann-Whitney, Chi-square, Fisher tests, and repeated-measures analysis of variance were used to analyze data. Results: Anxiety scores were not significantly different between the two groups (wearing video-glass and receiving routine care), but anxiety scores were lower in the intervention group during and after repair (P = 0.000). Conclusions: VR are safe, appropriate, and nonpharmacologic to decrease and manage the anxiety-associated episiotomy. PMID:27904638

Low-level laser therapy for pain relief after episiotomy: a double-blind randomised clinical trial.

PubMed

Santos, Jaqueline de O; de Oliveira, Sonia M J V; da Silva, Flora M B; Nobre, Moacyr R C; Osava, Ruth H; Riesco, Maria L G

2012-12-01

To evaluate the effectiveness of a low-level laser therapy for pain relief in the perineum following episiotomy during childbirth. Laser irradiation is a painless and non-invasive therapy for perineal pain treatment and its effects have been investigated in several studies, with no clear conclusion on its effectiveness. A double-blind randomised controlled clinical trial. One hundred and fourteen women who underwent right mediolateral episiotomies during vaginal birth in an in-hospital birthing centre in São Paulo, Brazil and reported pain ≥ 3 on a numeric scale (0-10) were randomised into three groups of 38 women each: two experimental groups (treated with red and infrared laser) and a control group. The experimental groups were treated with laser applied at three points directly on the episiotomy after suturing in a single session between 6-56 hours postpartum. We used a diode laser with wavelengths of 660 nm (red laser) and 780 nm (infrared laser). The control group participants underwent all laser procedures, excluding the emission of irradiation. The participants and the pain scores evaluator were blinded to the type of intervention. The perineal pain scores were assessed at three time points: before, immediately after and 30 minutes after low-level laser therapy. The comparison of perineal pain between the three groups showed no significant differences in the three evaluations (p = 0.445), indicating that the results obtained in the groups treated with low-level laser therapy were equivalent to the control group. Low-level laser therapy did not decrease the intensity of perineal pain reported by women who underwent right mediolateral episiotomy. The effect of laser in perineal pain relief was not demonstrated in this study. The dosage may not have been sufficient to provide relief from perineal pain after episiotomy during a vaginal birth. © 2012 Blackwell Publishing Ltd.

Hysteroscopy and episiotomy in a rescued, cold-stressed Florida manatee (Trichechus manatus latirostris) for diagnosis and treatment of a retained fetal skeleton.

PubMed

Hall, Natalie H; Walsh, Mike; DeLuca, Catherine; Bukoski, Alex

2012-09-01

A rescued female manatee was observed expelling a fetal bone from the vulva. The manatee was anesthetized and diagnosed with uterine retention of a fetal skeleton by ultrasound and hysteroscopy. Episiotomy was performed to gain manual access to the vagina and uterus for removal of the skeleton. Second intention healing of the episiotomy site produced excellent results. Rescued female manatees should receive a thorough reproductive tract evaluation since presence of retained fetal tissues might not be evident in blood or hormone analyses. Retention of a whole or partial dead fetus can be life-threatening to manatees, and retained tissues should be removed as early as possible.

Evaluation of recovery and quality of sexual activity in women during postpartum in relation to the different mode of delivery: a retrospective analysis.

PubMed

Laganà, A S; Burgio, M A; Ciancimino, L; Sicilia, A; Pizzo, A; Magno, C; Butticè, S; Triolo, O

2015-08-01

Aim of the study was to assess the recovery and quality of sexual activity of women during postpartum, in relation to delivery. We recruited 200 women at 8 weeks after delivery. For each patient we recorded mode of delivery, age, body mass index (BMI), parity and test Female Sexual Function Index (FSFI) score. Sixty-four women (32%) had spontaneous deliveries without episiotomy, 48 (24%) had it with episiotomy, 88 (44%) had caesarean sections. The analysis of variance (ANOVA) test showed no significant differences among the 3 groups for age, BMI, parity. The test FSFI evidenced 68 cases (34%) of Regular Female Sexual Function (RFSF) and 132 (66%) of Female Sexual Dysfunction (FSD). The ANOVA test showed significant differences among the 3 groups in RFSF (F [2, 14]=8.075, P=0.005), but not in FSD (F [2, 30]=2.646, P=0.087). In RFSF, FSFI score was higher in women who had vaginal delivery with episiotomy compared with the other two groups. Conversely, in FSD (both with or without resumed sexual activity at 8 weeks postpartum) we evidenced that patients who had vaginal delivery with episiotomy showed lower FSFI score than the other two groups, with a decrease in lubrication, orgasm and satisfaction scores. Furthermore, we observed that most of the RFSF patients had a job and breastfed. Our results did not evidence a direct and significant correlation between mode of delivery and onset of female postpartum sexual dysfunction, even if FSD patients who underwent episiotomy during delivery markedly showed low FSFI scores.

Evaluation of training programme uptake in an attempt to reduce obstetric anal sphincter injuries: the SUPPORT programme.

PubMed

Rahman, Nadia; Vinayakarao, Latha; Pathak, Sangeeta; Minden, Dawn; Melson, Louise; Vitue, Ella; Pradhan, A

2017-03-01

The objective was to assess the feedback from a quality improvement training programme to reduce obstetric anal sphincter injuries (OASIS). Training sessions were organised that included evidence-based information on OASIS risk factors and training on models to measure perineal body length (PBL), perform episiotomies with standard and 60° fixed angle scissors (EPISCISSORS-60®), and measure post-delivery episiotomy suture angles with protractor transparencies. Feedback forms using a Likert scale (1-4) were completed and analysed. The setting was an evidence-based quality improvement programme (Strategy for Using Practical aids for Prevention of OASIS, Recording episiotomies and clinician Training [SUPPORT]) at two National Health Service (NHS) Hospitals in the UK. The participants were midwives and doctors attending the SUPPORT training programme RESULTS: All of the participants (100 %) would recommend the training programme to a friend or colleague. 92 % felt that the training session improved their knowledge of the impact of PBL and perineal distension and their knowledge of the relationship between episiotomy angle and OASIS "a lot" or "somewhat". Based on this feedback, we recommend the addition of the knowledge content of the SUPPORT programme to other centres providing perineal assessment and repair courses.

Perineal outcomes in a home birth setting.

PubMed

Aikins Murphy, P; Feinland, J B

1998-12-01

Perineal lacerations are a source of significant discomfort to many women. This descriptive study examined perineal outcomes in a home birth population, and provides a preliminary description of factors associated with perineal laceration and episiotomy. Data were drawn from a prospective cohort study of 1404 intended home births in nurse-midwifery practices. Analyses focused on a subgroup of 1068 women in 28 midwifery practices who delivered at home with a midwife in attendance. Perineal trauma included both episiotomy and lacerations. Minor abrasions and superficial lacerations that did not require suturing were included with the intact perineum group. Associations between perineal trauma and study variables were examined in the pooled dataset and for multiparous and nulliparous women separately. In this sample 69.6 percent of the women had an intact perineum, 15 (1.4%) had an episiotomy, 28.9 percent had first- or second-degree lacerations, and 7 women (0.7%) had third- or fourth-degree lacerations. Logistic regression analyses showed that in multiparas, low socioeconomic status and higher parity were associated with intact perineum, whereas older age (>/= 40 yr), previous episiotomy, weight gain of over 40 pounds, prolonged second stage, and the use of oils or lubricants were associated with perineal trauma. Among nulliparas, low socioeconomic status, kneeling or hands-and-knees position at delivery, and manual support of the perineum at delivery were associated with intact perineum, whereas perineal massage during delivery was associated with perineal trauma. The results of this study suggest that it is possible for midwives to achieve a high rate of intact perineums and a low rate of episiotomy in a select setting and with a select population.

Lavender-thymol as a new topical aromatherapy preparation for episiotomy: A randomised clinical trial.

PubMed

Marzouk, T; Barakat, R; Ragab, A; Badria, F; Badawy, A

2015-01-01

The objective of this study was to evaluate the effectiveness of topical lavender-thymol in promoting episiotomy healing. This placebo-controlled, single-blinded, randomised clinical trial involved 60 primiparous women. REEDA score was used to evaluate the outcome of the trial. On the 7th post-partum day, women in Placebo-treated group had worse Redness, Edema, Ecchymosis, Discharge and Approximation (REEDA) score of 3.93 ± 3.65 compared with those in Lavender-thymol-treated group (2.03 ± 1.7) with significant difference (P = 0.013). Visual analogue Scale (VAS) score for pain at episiotomy in Lavender-thymol-treated group was 3.5 ± 1.9, whereas in Placebo-treated group it was 2.1 ± 2.2 (p = 0.011) for dyschezia, 3.8 ± 1.7 and 2.8 ± 1.6 in Placebo- and Lavender-thymol-treated women, respectively (p = 0.023). At 7th post-partum week, dyspareunia was more severe in Placebo-treated group compared with that in Lavender-thymol-treated group (5.3 ± 2.7 vs 2.7 ± 1.5 and p < 0.001). Topical aromatherapy using lavender-thymol was highly effective, suitable and safe for episiotomy wound care with little or no expected side effects compared with that using placebo.

Prospective randomised multicentre trial with the birth trainer EPI-NO for the prevention of perineal trauma.

PubMed

Ruckhäberle, Eugen; Jundt, Katharina; Bäuerle, Martin; Brisch, Karl-Heinz; Ulm, Kurt; Dannecker, Christian; Schneider, Karl Theo Mario

2009-10-01

In several non-randomised trials training with EPI-NO increased the rate of intact perineum and decreased episiotomy rates, shortened the second stage of labour and lowered use of pain killers. To verify the preliminary results with EPI-NO in a prospective randomised trial. Randomised, single-blind multicentre trial in four university hospitals in Germany including 276 primigravidae. After training with EPI-NO we observed a significant increase in the incidence of intact perineum (37.4% vs 25.7%; P = 0.05) and a tendency towards lower episiotomy rates (41.9% vs 50.5%; P = 0.11). We found no significant differences between the two groups regarding incidence of perineal tears, duration of second stage of labour, use of pain relief and rate of vaginal infection. Training with EPI-NO increases significantly the likelihood of having an intact perineum and reduces the episiotomy rate.

DEFENSE HEALTH CARE: Access to Care for Beneficiaries Who Have Not Enrolled in TRICARE’s Managed Care Option

DTIC Science & Technology

2006-12-01

Higher than Medicare Reimbursement Rates CPT codea Procedure or service performed Ratio of TRICARE to Medicare reimbursement 20250 Biopsy ...59350 Hysterorrhaphy of ruptured uterus 1.205 59409 Vaginal delivery only (with or without episiotomy and/or forceps ) 1.184 59410 Vaginal delivery only...with or without episiotomy and/or forceps ); including postpartum car 1.156 59412 External cephalic version, with or without tocolysis 1.139 59414

Effect of cryotherapy on relief of perineal pain after vaginal childbirth with episiotomy: a randomized and controlled clinical trial.

PubMed

Beleza, Ana Carolina Sartorato; Ferreira, Cristine Homsi Jorge; Driusso, Patricia; Dos Santos, Claudia Benedita; Nakano, Ana Márcia Spanó

2017-12-01

Verify the effectiveness of cryotherapy in relieving perineal pain in women after vaginal delivery with episiotomy. Randomized controlled clinical trial. Reference Center of Women's Health of Ribeirão Preto (MATER), in the state of São Paulo. The study included 50 women who reported pain in the postpartum period following vaginal delivery with episiotomy. The women in the experimental group applied a bag of crushed ice to the perineal region for 20minutes. Both groups were assessed before, immediately after removal of the ice bag, and one hour after cryotherapy treatment. Complaint of pain was evaluated using a numerical pain assessment scale (0 to 10). Perineal temperature was also measured using an infrared thermometer, and the satisfaction of women undergoing the treatment was assessed using a questionnaire. Pain relief was verified for the experimental group compared to the control group in the second (immediately after use of cryotherapy) and third evaluations (one hour after cryotherapy). The temperature of the perineal region was found to be related to the intensity of pain, e.g. the lower the temperature provided by cryotherapy, the lower the woman's complaint of pain. 88% of women reported being satisfied with the treatment. After 20minutes of application, cryotherapy was effective in relieving perineal pain in women in the immediate postpartum period after vaginal birth with episiotomy. ACTRN12613000052730. Copyright © 2016. Published by Elsevier Ltd.

Reducing perineal trauma through perineal massage with vaseline in second stage of labor.

PubMed

Geranmayeh, Mehrnaz; Rezaei Habibabadi, Zahra; Fallahkish, Bijan; Farahani, Mahdi Azizabadi; Khakbazan, Zohreh; Mehran, Abbas

2012-01-01

Maintaining an intact perineum is a highly regarded aim in delivery procedures today. Since perineal massage is a common practice during delivery, the present study aims to investigate the effect of perineal massage with Vaseline on perineal trauma (rate of episiotomy procedures and perineal tears). Ninety primiparous women (aged between 18 and 30 years with gestational age of 38-42 weeks) were selected sequentially in Tehran in 2009. Once participants' characteristics were registered, they were randomly assigned to the intervention (perineal massage with Vaseline) or control groups. In the massage group, perineal massage was performed in the second stage of delivery once the genitalia were treated with sterilized Vaseline. The perineum was examined after the delivery in terms of episiotomy or tear and its severity degree. The two groups were homogeneous in terms of demographic data, weight gain during pregnancy, gestational age, abortion history and fetal weight. The second stage of delivery was significantly shorter in the massage group than the control group and the massage group had significantly more intact perineum (P = 0.004). In addition, lower episiotomy and higher first- and second-degree perineal tears were seen in the massage group in comparison with the control one (P < 0.001). Neither of the groups suffered from third- and fourth-degree tears. The findings showed that the perineal massage with Vaseline in the second stage of labor increases perineal integrity and decreases perineal traumas (episiotomy and tears). So, it seems that the perineal massage could be an effective way to preserve an intact perineum in labor.

Irish and New Zealand Midwives' expertise at preserving the perineum intact (the MEPPI study): Perspectives on preparations for birth.

PubMed

Smith, Valerie; Guilliland, Karen; Dixon, Lesley; Reilly, Mary; Keegan, Caroline; McCann, Colette; Begley, Cecily

2017-12-01

perineal trauma during birth can result in short or long term morbidity for women. Internationally, rates of episiotomy and severe perineal tears vary considerably. In New Zealand, in 2011, and in a trial of midwife-led care in Ireland, episiotomy rates were found to be considerably lower than those in many other countries. A qualitative exploratory study was undertaken to ascertain how midwives achieve these low rates, in these countries and settings. a qualitative exploratory study was conducted. Midwives expert in preserving the perineum intact (PPI) from two maternity units in the Republic of Ireland and from varied birth settings in New Zealand, were eligible to participate. Twenty-one consenting midwives took part, seven from Ireland and 14 from New Zealand. university ethical approval was granted. Face-to-face, semi-structured interviews were used to collect the data. Interviews were recorded and transcribed verbatim. The data were analysed using Ethnograph software and were organised into prominent themes. four themes were identified; 'Sources of knowledge for PPI', 'Associated factors', 'Decision-making on episiotomy', and 'Preparations for PPI'. Participants drew heavily on multiple sources of knowledge in building their own expertise for PPI. Physical characteristics of the perineum featured prominently as factors leading to PPI. Episiotomy was, in the main, only performed when there were signs of fetal distress. Antenatal perineal massage was supported. this study provides valuable insight into the views and skills of midwives, with expertise in PPI at birth, adding to the body of evidence on this topic. Copyright © 2017 Elsevier Ltd. All rights reserved.

Low and high-frequency TENS in post-episiotomy pain relief: a randomized, double-blind clinical trial.

PubMed

Pitangui, Ana C R; Araújo, Rodrigo C; Bezerra, Michelle J S; Ribeiro, Camila O; Nakano, Ana M S

2014-01-01

To evaluate the effectiveness of low-frequency TENS (LFT) and high-frequency TENS (HFT) in post-episiotomy pain relief. A randomized, controlled, double-blind clinical trial with placebo composed of 33 puerperae with post-episiotomy pain. TENS was applied for 30 minutes to groups: HFT(100 Hz; 100 µs), LFT (5 Hz; 100 µs), and placebo (PT). Four electrodes were placed in parallel near the episiotomy and four pain evaluations were performed with the numeric rating scale. The first and the second evaluation took place before TENS application and immediately after its removal and were done in the resting position and in the activities of sitting and ambulating. The third and fourth evaluation took place 30 and 60 minutes after TENS removal, only in the resting position. Intragroup differences were verified using the Friedman and Wilcoxon tests, and the intergroup analysis employed the Kruskal-Wallis test. In the intragroup analysis, there was no significant difference in the PT during rest, sitting, and ambulation (P>0.05). In the HFT and LFT, a significant difference was observed in all activities (P<0.001). In the intergroup analysis, there was a significant difference in the resting position in the HFT and LFT (P<0.001). In the sitting activity, a significant difference was verified in the second evaluation in the HFT and LFT (P<0.008). No significant difference was verified among the groups in ambulation (P<0.20). LFT and HFT are an effective resource that may be included in the routine of maternity wards.

A randomized study of two methods of teaching perineal massage: effects on practice rates, episiotomy rates, and lacerations.

PubMed

Mynaugh, P A

1991-09-01

This study examined the effects of two methods of teaching perineal massage on the rates of practice of perineal massage, of episiotomy, and of lacerations in primiparas at birth. Couples in 20 randomly selected sections of four prenatal class series received routine printed and verbal instruction and a 12-minute video demonstration of perineal massage, or only the routine printed and verbal instruction. Women reported their practice rates in daily diary records, which were mailed to the researcher weekly. Hospital records provided delivery data. Of the 83 women, 23 (28%) practiced perineal massage: 16 (35.6%) in the experimental group, 7 (18.4%) controls. Even though the rate of practice almost doubled among experimental group women, the videotape instruction method was statistically nonsignificant. Episiotomy and laceration rates were not affected by teaching method. More severe lacerations occurred among the experimental group; however, the control group had almost four times as many severe (21%) as minor (5.3%) lacerations. The experimental group had twice as many severe (28.9%) as minor (13.3%) lacerations. These results were also nonsignificant.

Long-term impacts of vaginal birth with mediolateral episiotomy on sexual and pelvic dysfunction and perineal pain.

PubMed

Doğan, Bülent; Gün, İsmet; Özdamar, Özkan; Yılmaz, Ali; Muhçu, Murat

2017-02-01

To investigate whether spontaneous vaginal birth with mediolateral episiotomy has any long-term impact on urinary and/or fecal incontinence, sexual dysfunction and perineal pain in primiparous women. This matched case-control study included 150 women between 25 and 35 years old who had a singleton childbirth at least five years previously. Patients were grouped as; women who had a spontaneous vaginal delivery with mediolateral episiotomy (Group 1), an elective cesarean delivery (Group 2), and who had no delivery (Group 3). Controls were matched for age and delivery time. Urinary/fecal incontinence were questioned and Female Sexual Function Index (FSFI) questionnaire was completed. Total FSFI and domain scores were compared. Statistical evaluation was performed using One-way ANOVA test or χ 2 test. Statistical significance was defined as p < 0.05. No women had urinary/fecal incontinence nor sexual dysfunction. Mean total FSFI points in Group 1 were significantly lower than in Groups 2 and 3 (p = 0.001). There were significant differences in sexual desire between groups 1 and 3 (p = 0.005), in arousal and in orgasm between both groups 1 and 2 (p = 0.001 and p = 0.038, respectively) and groups 1 and 3 (p = 0.001 and p = 0.001, respectively). There was no significant difference between groups 2 and 3 in any parameters or total points. Vaginal delivery with mediolateral episiotomy is not associated with urinary and/or fecal incontinence and sexual dysfunction but associated with a decreased sexual functioning as well as sexual desire, arousal and orgasm within postpartum five years.

Efficacy of early skin-to-skin contact on the rate of exclusive breastfeeding in term neonates: a randomized controlled trial.

PubMed

Sharma, Amit

2016-09-01

Despite multiple benefits of breast milk, the rates of exclusive breastfeeding in developing countries are low. To evaluate the efficacy of early skin -to -skin contact (SSC) on the rate of exclusive breastfeeding (EBF) at 6 weeks of age among term neonates born by vaginal delivery. Term neonates born by vaginal delivery and did not require any resuscitation were randomized at birth to SSC (n=100) and control (n=100) group. Immediately after clamping the umbilical cord, SSC group neonates were placed on the bare bosom of mother and control group neonates were placed under a radiant warmer for a period of 45 minutes each while mothers underwent management of the third stage of labor and episiotomy repair. Pain experienced by mother during episiotomy repair was recorded using a numerical pain scale The primary outcome evaluated was the rate of exclusive breastfeeding at 6 weeks of postnatal age. A significantly higher proportion of neonates were exclusively breastfeed at 6 weeks of age in the SSC group than in the control group (72% vs. 57.6%, p=0.04, relative risk: 1.3, 95% confidence interval: 1.0 -1.6). The pain score during episiotomy repair in mothers of the SSC group was significantly lower than the control group (4.74±0.85 versus 5.34±0.81; P <0.01). Early SSC significantly improved the rate of exclusively breastfeeding at 6 weeks of age among healthy term neonates. An important additional effect was a decrease in the amount of pain that mothers in the SSC group experienced during episiotomy repair.

Pelvic Floor Disorders After Childbirth: Effect of Episiotomy, Perineal Laceration, and Operative Birth

PubMed Central

Handa, Victoria L.; Blomquist, Joan L.; McDermott, Kelly C.; Friedman, Sarah; Muñoz, Alvaro

2011-01-01

Objective To investigate whether episiotomy, perineal laceration, and operative delivery are associated with pelvic floor disorders after vaginal childbirth. Methods This is a planned analysis of data for a cohort study of pelvic floor disorders. Participants who had experienced at least one vaginal birth were recruited 5–10 years after delivery of their first child. Obstetric exposures were classified by review of hospital records. At enrollment, pelvic floor outcomes, including stress incontinence, overactive bladder, anal incontinence, and prolapse symptoms were assessed with a validated questionnaire. Pelvic organ support was assessed using the Pelvic Organ Prolapse Quantification system. Logistic regression analysis was used to estimate the relative odds of each pelvic floor disorder by obstetric history, adjusting for relevant confounders. Results Of 449 participants, 71 (16%) had stress incontinence, 45 (10%) had overactive bladder, 56 (12%) had anal incontinence, 19 (4%) had prolapse symptoms and 64 (14%) had prolapse to or beyond the hymen on examination. Forceps delivery increased the odds of each pelvic floor disorder considered, especially overactive bladder (odds ratio 2.92, 95% confidence interval 1.44, 5.93) and prolapse (odds ratio 1.95, 95% confidence interval 1.03, 3.70). Episiotomy was not associated with any of these pelvic floor disorders. In contrast, women with a history of more than one spontaneous perineal laceration were significantly more likely to have prolapse to or beyond the hymen (odds ratio 2.34, 95% confidence interval 1.13, 4.86). Our multivariable results suggest that one additional woman would develop prolapse for every 8 women who experienced at least one forceps birth (versus delivering all her children by spontaneous vaginal birth). Conclusion Forceps deliveries and perineal lacerations, but not episiotomies, were associated with pelvic floor disorders 5–10 years after a first delivery. PMID:22227639

Effect of low-level laser therapy on pain and perineal healing after episiotomy: A triple-blind randomized controlled trial.

PubMed

Alvarenga, Marina B; de Oliveira, Sonia Maria Junqueira Vasconcellos; Francisco, Adriana A; da Silva, Flora Maria B; Sousa, Marcelo; Nobre, Moacyr Roberto

2017-02-01

Episiotomy is associated with perineal pain and healing complications. The low-level laser therapy (LLLT) reduces pain and inflammation and stimulates the healing process. This study aimed to assess the effect of LLLT on pain and perineal healing after an episiotomy. A randomized, triple-blind, parallel clinical trial with 54 postpartum women who had a spontaneous birth with a right mediolateral episiotomy. The women were randomized into two groups: the experimental group (applications of LLLT n = 29) or the placebo group (simulated LLLT applications n = 25). Three sessions of real or sham irradiation were performed at 6-10 hours after normal birth, and the 2nd and 3rd applications were performed at 20-24 hours and 40-48 hours after the first session, respectively. Perineal pain was recorded using a Numeric Scale ranging from 0 to 10 (0 = absence and 10 = worst pain). Perineal healing was assessed using the redness, oedema, ecchymosis, discharge, and approximation (REEDA) scale. Both groups were assessed four times: in each of the three LLLT sessions and at 7-10 days after normal birth. The groups were compared using the Student's t, Mann-Whitney, and Chi-square tests. There was no significant difference between the groups regarding perineal healing after LLLT. The perineal pain scores were statistically higher in the experimental group in the first assessment and after the third LLLT. There was no significant difference between the groups related to the perineal pain scores 7-10 days after normal birth. The use of LLLT does not provide any benefit for treating postpartum perineal trauma using these specific protocol and parameters. Lasers Surg. Med. 49:181-188, 2017. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

How can second-stage management prevent perineal trauma? Critical review.

PubMed Central

Flynn, P.; Franiek, J.; Janssen, P.; Hannah, W. J.; Klein, M. C.

1997-01-01

OBJECTIVE: To learn which factors influencing perineal integrity were modifiable by physicians and pregnant women. DATA SOURCES: Medical, nursing, and midwifery literature was searched mainly for randomized controlled trials. STUDY SELECTION: We chose articles on perineal trauma pattern, sexual dysfunction or satisfaction, urinary incontinence, and pelvic floor function. We identified 80 papers and studied 16 in detail. SYNTHESIS: Five factors affected perineal integrity: episiotomy, third-trimester perineal massage, mother's position in second-stage labour, method of pushing, and administration of epidural analgesia. Episiotomy does not improve perineal outcomes when used routinely. Third-trimester perineal massage was discussed only in inadequate studies. Studies comparing position in birth chairs and recumbent versus upright positions were inadequate for making firm recommendations. Studies of methods of pushing and use of epidural analgesia were limited and uncontrolled; no recommendations were possible. CONCLUSION: Only limiting episiotomy can be strongly recommended. In the absence of strong data to the contrary, women should be encouraged to engage in perineal massage if they wish and to adopt the birth positions of their choice. Caretakers should be aware of the possibility of interfering with placental function when women hold their breath for a long time when pushing. PMID:9626426

How can second-stage management prevent perineal trauma? Critical review.

PubMed

Flynn, P; Franiek, J; Janssen, P; Hannah, W J; Klein, M C

1997-01-01

To learn which factors influencing perineal integrity were modifiable by physicians and pregnant women. Medical, nursing, and midwifery literature was searched mainly for randomized controlled trials. We chose articles on perineal trauma pattern, sexual dysfunction or satisfaction, urinary incontinence, and pelvic floor function. We identified 80 papers and studied 16 in detail. Five factors affected perineal integrity: episiotomy, third-trimester perineal massage, mother's position in second-stage labour, method of pushing, and administration of epidural analgesia. Episiotomy does not improve perineal outcomes when used routinely. Third-trimester perineal massage was discussed only in inadequate studies. Studies comparing position in birth chairs and recumbent versus upright positions were inadequate for making firm recommendations. Studies of methods of pushing and use of epidural analgesia were limited and uncontrolled; no recommendations were possible. Only limiting episiotomy can be strongly recommended. In the absence of strong data to the contrary, women should be encouraged to engage in perineal massage if they wish and to adopt the birth positions of their choice. Caretakers should be aware of the possibility of interfering with placental function when women hold their breath for a long time when pushing.

Postpartum anal sphincter lacerations in a population with minimal exposure to episiotomy and operative vaginal delivery.

PubMed

Lewis, Cindi; Williams, Alana M; Rogers, Rebecca G

2008-01-01

This case-control study was designed to identify risk factors for anal sphincter lacerations (ASL) in a multicultural population where episiotomies and operative vaginal deliveries are rarely performed. Cases were subjects with ASL delivered between July 1997 and June 2003. Two controls were selected for each case matched for gestational age. Independent variables collected included age, race/ethnicity, parity, tobacco use, medical conditions, episiotomy, operative vaginal delivery, epidural use, and infant weight. One thousand and sixty-six subjects met the inclusion criteria. The risk of ASL increased with increasing maternal age (Odds ratio [OR] 1.09 per year, 95% confidence interval [CI] 1.06, 1.12) and increasing infant weight (OR 1.09 per 100 g, 95% CI 1.06, 1.13). Multiparity was protective (P1 vs P2 OR 0.19, 95% CI 0.13, 0.28, and > or =P3 vs P1 OR 0.04, 95% CI 0.02, 0.11). Hispanic and Native American women were at increased risk for ASL (OR 2.08, 95% CI 1.41, 3.09 and OR 1.92, 95% CI 1.07, 3.45, respectively).

Influence of a pelvic floor training programme to prevent perineal trauma: A quasi-randomised controlled trial.

PubMed

Leon-Larios, Fatima; Corrales-Gutierrez, Isabel; Casado-Mejía, Rosa; Suarez-Serrano, Carmen

2017-07-01

perineal injury is common after birth and may be caused by tears or episiotomy or both. Perineal massage has been shown to prevent episiotomies in primiparous women. On the other hand, pelvic floor exercises might have an influence by shortening the first and second stages of labour in the primigravida. the aim of this study was to investigate the effects of a pelvic floor training following a birth programme on perineal trauma. a single-blind quasi-randomized controlled trial with two groups: standard care and intervention. a tertiary, metropolitan hospital in Seville, Spain. women (n=466) who were 32 weeks pregnant, having a singleton pregnancy and anticipating a normal birth were randomised. Women in the experimental groups were asked to perform a pelvic floor training programme that included: daily perineal massage and pelvic floor exercises from 32 weeks of pregnancy until birth. They were allocated to an intervention group by clusters (antenatal education groups) randomized 1:1. The control group had standard care that did not involve a perineal/pelvic floor intervention. These women were collected in a labour ward at admission 1:3 by midwives. outcomes were analysed by intention-to-treat. Women assigned to the perineal/pelvic floor intervention showed a 31.63% reduction in episiotomy (50.56% versus 82.19%, p<0.001) and a higher likelihood of having an intact perineum (17.61% versus 6.85%, p<0.003). There were also fewer third (5.18% versus 13.12%, p<0.001) and fourth degree-tears (0.52% versus 2.5%, p<0.001). Women allocated to the intervention group also had less postpartum perineal pain (24.57% versus 36.30%, p<0.001) and required less analgesia in the postnatal period (21.14% versus 30.82%, p<0.001). a training programme composed of pelvic floor exercises and perineal massage may prevent episiotomies and tears in primiparous women. This programme can be recommended to primiparous women in order to prevent perineal trauma. the pelvic floor programme was associated with significantly lower rates of episiotomies and severe perineal trauma; and higher intact perineum when compared with women who received standard care only. the programme is an effective intervention that we recommend to all women at 32nd week of pregnancy to prevent perineal trauma. Copyright © 2017 Elsevier Ltd. All rights reserved.

The effect of water immersion delivery on the strength of pelvic floor muscle and pelvic floor disorders during postpartum period: An experimental study.

PubMed

Zhao, Yun; Xiao, Mei; Tang, Fei; Tang, Wan; Yin, Heng; Sun, Guo-Qiang; Lin, Yin; Zhou, Yong; Luo, Yan; Li, Lu-Man; Tan, Zhi-Hua

2017-10-01

Water immersion delivery is a non-pharmacological approach to ease labor pain. This paper aims to investigate the effect of water immersion delivery on increasing strength of pelvic floor muscle (PFM) and relieving pelvic floor disorders (PFDs) during postpartum period. A total of 2749 vaginal-delivery primiparas in postpartum 6-8 weeks were selected as research objects. Based on the modes of delivery, 600 patients were assigned into water immersion delivery group, 2149 were assigned into conventional delivery group. The scales of PFM strength and pelvic organ prolapsed (POP) were determined by specially trained personnel using digital palpation, and the symptoms of stress urinary incontinence (SUI) were investigated by questionnaire survey. The weak PFM strength was improved by doing Kegel exercise at home for 6-8 weeks. We found that ①The rate of episiotomy in water immersion delivery group was 77.50% (465/600), which was lower than that in conventional delivery group (84.69%, 1820/2149) (P < .01); The primiparas without having an episiotomy have higher PFM strength than those having an episiotomy for both groups (P < .01). ②There was a negative correlation between the scale of PFM strength and SUI or POP, wherein the r-values were -0.135 and -0.435, respectively (P < .01). ③The rate of SUI was 6.50% (39/600) in water immersion delivery group and 6.89% (148/2149) in the conventional delivery group, wherein the intergroup difference was not significant (P > .05); ④The rates of vaginal wall prolapsed and uterus prolapsed were 29.83% (179/600) and 2.83% (17/600) in water immersion delivery group and 30.95% (665/2149) and 4.37% (94/2149) in the conventional delivery group, wherein the intergroup difference was not significant (P > .05). ⑤After Kegel exercise, the strength of PFM was promoted (P < .01). Water immersion delivery has been proved to a beneficial alternative method for conventional delivery method. This delivery mode is associated with fewer episiotomy rate, and avoiding episiotomy is beneficial for maintaining PFM strength of women in postpartum 6-8 weeks. The strength of PFM during postpartum period can be improved by doing Kegel exercise at home.

The effect of water immersion delivery on the strength of pelvic floor muscle and pelvic floor disorders during postpartum period

PubMed Central

Zhao, Yun; Xiao, Mei; Tang, Fei; Tang, Wan; Yin, Heng; Sun, Guo-Qiang; Lin, Yin; Zhou, Yong; Luo, Yan; Li, Lu-Man; Tan, Zhi-Hua

2017-01-01

Abstract Background: Water immersion delivery is a non-pharmacological approach to ease labor pain. This paper aims to investigate the effect of water immersion delivery on increasing strength of pelvic floor muscle (PFM) and relieving pelvic floor disorders (PFDs) during postpartum period. Methods: A total of 2749 vaginal-delivery primiparas in postpartum 6-8 weeks were selected as research objects. Based on the modes of delivery, 600 patients were assigned into water immersion delivery group, 2149 were assigned into conventional delivery group. The scales of PFM strength and pelvic organ prolapsed (POP) were determined by specially trained personnel using digital palpation, and the symptoms of stress urinary incontinence (SUI) were investigated by questionnaire survey. The weak PFM strength was improved by doing Kegel exercise at home for 6-8 weeks. Results: We found that ①The rate of episiotomy in water immersion delivery group was 77.50% (465/600), which was lower than that in conventional delivery group (84.69%, 1820/2149) (P < .01); The primiparas without having an episiotomy have higher PFM strength than those having an episiotomy for both groups (P < .01). ②There was a negative correlation between the scale of PFM strength and SUI or POP, wherein the r-values were −0.135 and −0.435, respectively (P < .01). ③The rate of SUI was 6.50% (39/600) in water immersion delivery group and 6.89% (148/2149) in the conventional delivery group, wherein the intergroup difference was not significant (P > .05); ④The rates of vaginal wall prolapsed and uterus prolapsed were 29.83% (179/600) and 2.83% (17/600) in water immersion delivery group and 30.95% (665/2149) and 4.37% (94/2149) in the conventional delivery group, wherein the intergroup difference was not significant (P > .05). ⑤After Kegel exercise, the strength of PFM was promoted (P < .01). Conclusion: Water immersion delivery has been proved to a beneficial alternative method for conventional delivery method. This delivery mode is associated with fewer episiotomy rate, and avoiding episiotomy is beneficial for maintaining PFM strength of women in postpartum 6-8 weeks. The strength of PFM during postpartum period can be improved by doing Kegel exercise at home. PMID:29019880

[The possibility of antepartal prevention of episiotomy and perineal tears during delivery].

PubMed

Bohatá, P; Dostálek, L

To determine the effect of antepartal methods on the prevention of birth injuries in primiparous women. Retrospective study. Nemocnice Český Krumlov, a.s. Between February 2014 and November 2015 were 315 primiparous women questioned after a vaginal delivery on the use of methods of birth injury prevention (vaginal dilatators EPI-NO and Aniball, perineal massage, natural methods - raspberry-leaf tea or linseed). Consecutively, the rates of intact perineum, perineal tears and episiotomies among respective methods were compared with the control group using no preventive method. The effects of the methods were tested on the occurrence of spontaneous or vaginal operative delivery. There was a significantly higher number of women with intact perineum after the use of vaginal dilatators (43.1% vs.14.1% in control group (p < 0.001). We also found a significant reduction of episiotomies in this group (29.3% vs. 57.7%, p < 0.001). There was no significant effect of perineal massage, raspberry-leaf tea or linseed on perineum injury prevention. A lower occurrence of vaginal operative delivery was also confirmed in the group of women using vaginal dilatators (p = 0.02). Significant benefit of the use of the antepartal vaginal dilatators in the reduction of birth injuries was shown as well as of the occurrence of vaginal operative delivery.

Trends in major modifiable risk factors for severe perineal trauma, 1996-2006.

PubMed

Kudish, Bela; Sokol, Robert J; Kruger, Michael

2008-08-01

To examine what effect the major modifiable risk factors for severe perineal trauma have had on the rates of this trauma over time. A retrospective observational cohort study of singleton vaginal deliveries taken from a perinatal database for the period 1996 through 2006. A total of 46,239 singleton vertex vaginal deliveries met the inclusion criteria. Major risk factors for severe perineal trauma were increased maternal age (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.1-1.5), non-African American ethnicity (OR 1.5, 95% CI 1.3-1.7), nulliparity (OR 4.8, 95% CI 4.11-5.6), fetal birth weight (OR 2.2, 95% CI 1.9-2.4), forceps (OR 8.3, 95% CI 5.4-10.8), vacuum (OR 2.9, 95% CI 1.9-4.4), and midline episiotomy (OR 5.7, 95% CI 5.0-6.4). Evaluation of the changes in rates of these factors over the study period revealed that the decline in the rates of episiotomy and the use of forceps accounted for a reduction in severe lacerations of more than 50%. Reduction of severe perineal trauma by restricted use of the 2 modifiable clinical variables, episiotomy and forceps, is evident over time.

Trends in major modifiable risk factors for severe perineal trauma, 1996–2006

PubMed Central

Kudish, Bela; Sokol, Robert J.; Kruger, Michael

2009-01-01

Objective To examine what effect the major modifiable risk factors for severe perineal trauma have had on the rates of this trauma over time. Methods A retrospective observational cohort study of singleton vaginal deliveries taken from a perinatal database for the period 1996 through 2006. Results A total of 46 239 singleton vertex vaginal deliveries met the inclusion criteria. Major risk factors for severe perineal trauma were increased maternal age (odds ratio [OR] 1.28, 95% confidence interval [CI] 1.1–1.5), non–African American ethnicity (OR 1.5, 95% CI 1.3–1.7), nulliparity (OR 4.8, 95% CI 4.11–5.6), fetal birth weight (OR 2.2, 95% CI 1.9–2.4), forceps (OR 8.3, 95% CI 5.4–10.8), vacuum (OR 2.9, 95% CI 1.9–4.4), and midline episiotomy (OR 5.7, 95% CI 5.0–6.4). Evaluation of the changes in rates of these factors over the study period revealed that decline in the rates of episiotomy and use of forceps accounted for a reduction in severe lacerations of more than 50%. Conclusion Reduction of severe perineal trauma by restricted use of the 2 modifiable clinical variables, episiotomy and forceps, is evident over time. PMID:18420204

Evaluation of risk factors in women with puerperal genital hematomas.

PubMed

İskender, Cantekin; Topçu, Hasan Onur; Timur, Hakan; Oskovi, Aslı; Göksu, Gonca; Sucak, Ayhan; Danışman, Nuri

2016-01-01

Our aim was to assess the incidence and risk factors of the puerperal genital hematomas (PGH). We retrospectively reviewed recorded cases of PGH at Zekai Tahir Burak Research and Training Hospital, Ankara, Turkey, between January 2010 and 2014. Next three patients were chosen as control group. There were 47 cases of PGH with an incidence of 1 in 762 deliveries. Patients with PGH were younger, more likely to be nulliparous and had a greater weight gain during pregnancy than the control group. Patients with PGH had a longer first and second stage of labor than the control group. Mediolateral episiotomy and operative delivery were more frequently performed in patients with PGH than the control group. Neonates born to mothers with PGH were heavier than the control group (3525 ± 428 versus 3325 ± 579; p = 0.031). In the logistic regression model, nulliparity (OR: 8.68, 95% CI = 2.96-25.3), instrumental delivery (OR: 7.96, 95% CI = 1.37-49.0) and mediolateral episiotomy (OR: 6.67, 95% CI = 2.61-17.1) were factors which had an independent impact on risk of PGH. Nulliparity, instrumental delivery and mediolateral episiotomy are the main risk factors for hematomas.

Risk factors for the breakdown of perineal laceration repair after vaginal delivery.

PubMed

Williams, Meredith K; Chames, Mark C

2006-09-01

The purpose of this study was to identify risk factors that are associated with the breakdown of perineal laceration repair in the postpartum period. We conducted a retrospective, case-control study to review perineal laceration repair breakdown in patients who were delivered between September 1995 and February 2005 at the University of Michigan. Bivariate analysis with chi-square test and t-test and stepwise logistic regression analysis were performed. Fifty-nine cases and 118 control deliveries were identified from a total of 14,124 vaginal deliveries. Risk factors were longer second stage of labor (142 vs 87 minutes; P = .001), operative vaginal delivery (odds ratio, 3.6; 95% CI, 1.8-7.3), mediolateral episiotomy (odds ratio, 6.9; 95% CI, 2.6-18.7), third- or fourth-degree laceration (odds ratio, 3.1; 95% CI, 1.5-6.4), and meconium-stained amniotic fluid (odds ratio, 3.0; 95% CI, 1.1-7.9). Previous vaginal delivery was protective (odds ratio, 0.38; 95% CI, 0.18-0.84). Logistic regression showed the most significant factor to be an interaction between operative vaginal delivery and mediolateral episiotomy (odd ratio, 6.36; 95% CI, 2.18-18.57). The most significant events were mediolateral episiotomy, especially in conjunction with operative vaginal delivery, third- and fourth-degree lacerations, and meconium.

Sonographic assessment of the anal sphincter after obstetric anal sphincter injury (OASI) using transperineal ultrasound (TPUS).

PubMed

Eisenberg, Vered H; Valsky, Dan V; Yagel, Simcha

2018-03-24

Obstetric anal sphincter injury (OASI) is the most common cause of anal incontinence and ano-rectal symptoms in women 1 . Reported rates of anal incontinence following primary repair of OASI range between 15-61%, with a mean of 39% 2, 3 . Other possible complications of OASI include perineal pain, dyspareunia, and less commonly, abscess formation, wound breakdown, and rectovaginal fistulae. Symptom onset may occur immediately, several years postpartum, or only late in life when aging of tissues adds to the delivery insult. Having sustained an OASI may impact significantly on women's physical and emotional health. Missed OASI, inadequate repair or lack of follow up are potential sources of litigation 4 . The reported incidence of OASI may be as high as 4-6.6% 4 , averaging 2.9% in the UK 3 . The incidence is higher in primiparae (6.1%) than in multiparae (1.7%) 3 . Recent years are seeing an increased awareness and structured training programs, which appear to have resulted in an increase in the detection rate of OASI 3 . The following risk factors have been identified with varying risk rates reported 3 : Asian ethnicity (OR 2.27, 95% CI 2.14-2.41), nulliparity (relative risk [RR] 6.97, 95% CI 5.40-8.99), birth weight greater than 4 kg (OR 2.27, 95% CI 2.18-2.36), shoulder dystocia (OR 1.90, 95% CI 1.72-2.08), occipito-posterior position (RR 2.44, 95% CI 2.07-2.89), prolonged second stage of labor (up to RR 2.02, 95% CI 1.62-2.51 after four hours duration). Instrumental deliveries and episiotomy use have been extensively studied resulting in the following evidence: Vacuum delivery without episiotomy (OR 1.89, 95% CI 1.74-2.05); vacuum delivery with episiotomy is protective (OR 0.57, 95% CI 0.51-0.63); forceps delivery without episiotomy carries the highest potential risk (OR 6.53, 95% CI 5.57-7.64); and forceps delivery with episiotomy (OR 1.34, 95% CI 1.21-1.49). Other potential risk factors have been suggested with varying evidence such as advanced maternal age at first birth, Asian race, a vaginal birth after cesarean, and type of obstetrical care provider 4 . Possible protective factors include obesity, perineal massage (RR 0.91, 95% CI 0.86-0.96) 5 , perineal protection at crowning 3 , warm compression during the second stage of labor (RR 0.48, 95% CI 0.28-0.84) 3 , mediolateral episiotomy in instrumental deliveries 6 , a wide angle of the mediolateral episiotomy (at least 60 degrees away from the midline when the perineum is distended) 7 , and pre-labor cesarean section 4 . However, clinicians and patients alike should be aware that risk factors do not allow the accurate prediction of OASI 3 . OASI is usually diagnosed in the immediate postpartum period. The classification is based on the extent of lacerations to the external and internal anal sphincter (EAS and IAS, respectively) and epithelium as devised by Sultan 2,3,8 (Figure 1) and adopted by the World Health Organization (WHO). The degree of damage impacts on the development of symptoms, with 3C and 4 th degree tears carrying a graver prognosis than 3A and 3B tears 9 . It is not unusual for a tear to be missed in the labor ward: the reported rates of missed OASI range from 26-87% 10 . Since all women having a vaginal delivery are at risk of sustaining OASI, they should be examined systematically, including a digital rectal examination, to assess the severity of damage, prior to suturing 3 . This article is protected by copyright. All rights reserved.

THIRD DEGREE LACERATION AT DELIVERY—Etiological Considerations, and a Technique for Repair

PubMed Central

McNulty, James V.

1952-01-01

In a series of 14,080 cases in which either median or mediolateral episiotomy was used to facilitate delivery, third degree extension occurred in 75 cases (0.5 per cent). In related data extension of laceration was observed to occur in an inordinately high proportion of cases in association with use of forceps, greater than normal anterior pelvic depth, delivery of a large baby, primiparity, abnormal position and presentation, use of median incision (although extension also occurred in some cases in which mediolateral episiotomy was done), and hyperflexion and extreme abduction of the thighs. The method of immediate postpartum repair employed was associated with a minimal amount of postpartum discomfort, and late complications were almost nil. PMID:13009483

Episiotomy - slideshow

MedlinePlus

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[Antepartum perineal massage: review of randomized trials].

PubMed

Vendittelli, F; Tabaste, J L; Janky, E

2001-10-01

To assess the effectiveness of ante partum perineal massage to reduce the number of perineal injuries and episiotomies through a survey of the existing literature. [corrected] A search both in English and French on randomized clinical trials using the Medline and Cochrane Library databases. The key words: "Perineum", "massage", "perineum injuries", "randomized controlled trial" were selected from the years 1966 to November 2000. Four randomized controlled trials were found. The definition of the selected issues, as well as the included and excluded criteria varied according to the authors. Perineal massages seemed to reduce the occurrence of perineal injuries and episiotomies, mostly among primipara: Labrecque et al. in 1999, noted an OR of 0.56; 95% CI: 0.61-1.31 and at the opposite an increased rate of intact perineum in the massage group (OR = 1.79; 95% CI 1.27-2.52]; and Shipman et al. in 1997 stressed among women of > or = 30 years old an augmentation of intact perineum in the intervention group (OR = 1.93; 95% CI 1.08-3.48), and in the logistic regression taking into account age and birth weight they found a reduction of episiotomies and important perineal injuries (p = 0.02). Ante partum perineal massages would seem valid but further studies would be necessary to evaluate the utility of this intervention in the avoidance of serious perineal injuries and the women's satisfaction.

Getting through birth in one piece: protecting the perineum.

PubMed

Hastings-Tolsma, Marie; Vincent, Deborah; Emeis, Cathy; Francisco, Teresa

2007-01-01

To identify factors related to perineal trauma in childbirth, replicating the work of . A retrospective descriptive analysis of pregnancy and birth data recorded into the Nurse Midwifery Clinical Data Set for women (N = 510) with a singleton pregnancy and largely uncomplicated prenatal course. Prenatal care occurred at four prenatal clinics with births at a tertiary care facility during 1996-1997, with care provided by nurse midwifery faculty. Multivariate statistics detailed clinical characteristics associated with perineal trauma. Episiotomy was related to parity, marital status, infant weight, fetal bradycardia, prolonged second stage labor, and lack of perineal care measures. Factors related to laceration were age, insurance status, and marital status. For all women, laceration was more likely when in lithotomy position for birth (p = .002) or when prolonged second stage labor occurred (p = .001). Factors that were protective against perineal trauma included massage, warm compress use, manual support, and birthing in the lateral position. found that ethnicity and education were related to episiotomy and that warm compresses were protective. In this study, use of oils/lubricants increased lacerations, as did lithotomy positioning. Laceration rates were similar in both studies. Episiotomy use was lower in this study. Side-lying position for birth and perineal support and compress use are important interventions for decreasing perineal trauma. Strategies to promote perineal integrity need to be implemented by nurses who provide prenatal education and care for the laboring woman.

Risk factors for vertical transmission of hepatitis C virus: a single center experience with 710 HCV-infected mothers.

PubMed

Garcia-Tejedor, Amparo; Maiques-Montesinos, Vicente; Diago-Almela, Vicente José; Pereda-Perez, Antonio; Alberola-Cuñat, Vicente; López-Hontangas, José Luís; Perales-Puchalt, Alfredo; Perales, Alfredo

2015-11-01

The aim of this study was to analyze the risk factors on the perinatal transmission of hepatitis C virus (HCV). A retrospective cohort study with 711 infants born to 710 HCV-infected mothers was conducted at the Hospital La Fe, in Valencia, Spain, from 1986 to 2011. As potential risk factors for transmission we analyzed: maternal age, mode of acquisition of HCV infection, HIV co-infection, antiretroviral treatment against HIV, CD4 cell count, HIV and HCV viral load, liver enzyme levels during pregnancy, smoking habit, gestational age, intrapartum invasive procedures, length of rupture of membranes, length of labor, mode of delivery, episiotomy, birth weight, newborn gender and type of feeding. Overall perinatal HCV transmission rate was 2.4%. The significant risk factors related with HCV transmission were maternal virus load >615copies/mL (OR 9.3 [95% CI 1.11-78.72]), intrapartum invasive procedures (OR 10.1 [95% CI 2.6-39.02]) and episiotomy (OR 4.2 [95% CI 1.2-14.16]). HIV co-infection and newborn female were near significance (p=0.081 and 0.075, respectively). Invasive procedures as fetal scalp blood sampling or internal electrode and episiotomy increase vertical transmission of HCV, especially in patients with positive HCV RNA virus load at delivery. Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

Episiotomy - aftercare

MedlinePlus

... ed. Philadelphia, PA: Elsevier Mosby; 2011:chap 166. Review Date 5/16/2016 Updated by: Irina Burd, ... Johns Hopkins University School of Medicine, Baltimore, MD. Review provided by VeriMed Healthcare Network. Also reviewed by ...

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

PubMed

Shahoei, Roonak; Zaheri, Farzaneh; Nasab, Lila Hashemi; Ranaei, Fariba

2017-10-01

Childbirth and puerperium are of the most important periods in women's lives and can affect different aspects of their lives. To determine the effect of perineal massage in the second stage of labor on perineal lacerations, episiotomy, and perineal pain in nulliparous women. This 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. Frequency 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. Regarding 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. The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the Irct.ID: IRCT2013090314556N1. This study received by financial support of Kurdistan University of Medical Sciences, Sanandaj, Iran.

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

PubMed Central

Shahoei, Roonak; Zaheri, Farzaneh; Nasab, Lila Hashemi; Ranaei, Fariba

2017-01-01

Background Childbirth and puerperium are of the most important periods in women’s lives and can affect different aspects of their lives. Objective To determine the effect of perineal massage in the second stage of labor on perineal lacerations, episiotomy, and perineal pain in nulliparous women. Methods This 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. Results Frequency 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. Conclusion Regarding 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 registration The trial was registered at the Iranian Registry of Clinical Trials (http://www.irct.ir) with the Irct.ID: IRCT2013090314556N1. Funding This study received by financial support of Kurdistan University of Medical Sciences, Sanandaj, Iran. PMID:29238501

Role of age, bowel function and parity on anorectocele pathogenesis according to cinedefecography and anal manometry evaluation.

PubMed

Soares, F A; Regadas, F S P; Murad-Regadas, S M; Rodrigues, L V; Silva, F R S; Escalante, R D; Bezerra, R F

2009-11-01

The study aimed to verify the role of parity, age and bowel function in the pathogenesis of anorectocele. A cross-sectional study was conducted regarding age, obstetrical history, Cleveland Clinic Constipation Score (CCCS), cinedefecography and anal manometry findings. Forty-five adult women complaining of obstructed defecation were evaluated; the median age was 46 years and median CCCS, 13. Fifteen patients were nulliparous and 23 multiparous (median parity 2). Eighteen had a history of episiotomy, fourteen delivered large babies and two had forceps-assisted delivery. Statistical analysis was performed using Spearman's correlation test and Fisher's exact test. Anal hypertonia was found in 14 (31.1%) patients, anal hypotonia in eight (17.8%), anismus in 13 (28.9%) and anorectoceles in 34 (75.6%) [median size 2.8 cm (0-6.4)]. There were no correlations between anorectocele and anal hypertonia (P = 0.7171), anismus (P = 0.4666), parity comparing nulliparous and multiparous patients (P = 1.000), episiotomy (P = 1.0000), forceps assistance (P = 1.0000), delivery of a large baby (P = 1.0000) anal resting pressure (P = 0.0883), anal voluntary pressure (P = 0.7327), parity (P = 0.4987) and age (P = 0.8603). There were correlations between anorectocele and the CCCS (P = 0.0082) and anal hypotonia (P = 0.0141). Anorectocele is not correlated with parity, age, episiotomy, delivery of a large baby and anismus. It was more frequent in patients with severe constipation and less common in patients with anal hypotonia.

Patient Safety Center Organization

DTIC Science & Technology

2007-06-01

placement Medicine, Surgery Lumbar puncture* Medicine Thoracentesis* Medicine Shoulder dystocia Obstetrics & Gynecology Mock code-depressed newborn...Airway 2) Team Training (using SimMan), 3) Endoscopy, 4) Shoulder Dystocia , 5) Episiotomy, and 6) Central Line Placement. The second group is

Antenatal use of a novel vaginal birth training device by term primiparous women in Singapore.

PubMed

Kok, J; Tan, K H; Koh, S; Cheng, P S; Lim, W Y; Yew, M L; Yeo, G S H

2004-07-01

To study the use, safety and effectiveness of a novel antenatal vaginal birth training device (EPI-NO) in primiparous women. Antenatal use of the EPI-NO vaginal birth trainer was prospectively studied in 31 primiparous booked patients who were delivered by obstetricians from July to December 2002 at the KK Women's and Children's Hospital. This was studied in relation to episiotomy rate, perineal trauma and analgesic requirements during the postpartum period. A patient questionnaire form was used to assess their perception of pain and how well they coped with its use. For comparison, perineal trauma was also studied retrospectively in 60 consecutive obstetrician-booked primiparous term patients who had normal vaginal delivery (NVD) and who did not use EPI-NO during the same study period. The mean length of usage was for 2.1 weeks (standard deviation [sd] 1.2 weeks). The mean frequency of use was 5.3 episodes per week (sd 2.1, range 1 to 7). There was no laceration and vaginal infection arising from its usage. There was a case of minimal bleeding post-usage. There were 20 (64.5 percent) NVDs, four (12.9 percent) forceps deliveries, five vacuum deliveries (16.1 percent) and two (6.5 percent) Caesarean sections. Of the 29 vaginal delivery cases, 19 (65.5 percent) had episiotomy, eight (27.6 percent) had lacerations, and two (6.9 percent) did not sustain laceration. The reasons for episiotomy in the 19 cases were nine cases of pending tearing of vagina/perineum, nine cases of instrumental vaginal deliveries, and one to shorten second stage. There was no third degree tear. 21 (67.7 percent) out of 30 required a painkiller. The majority of patients (17; 54.8 percent) appeared to be comfortable with the use of EPI-NO. All coped well with vaginal examination after using EPI-NO perineal training. Comparing among term primiparous NVD cases with (n value equals 20) and without (n value equals 60) EPI-NO, the perineal trauma rate (90.0 percent vs 96.6 percent, p value equals 0.24) was slightly but not significantly lower in the EPI-NO group. The episiotomy rate was significantly lower (50.0 percent vs 93.3 percent, p value is less than 0.0001) and the extent of perineal trauma in the patient appeared to be less severe in cases using EPI-NO. EPI-NO appeared to be safe and acceptable to the majority of users. Although birth training with EPI-NO significantly decreases the rate of episiotomies in term primiparous patients, and the degree of perineal tissue injury appeared to be less in the EPI-NO group especially among those with lacerations, the overall perineal trauma rate was slightly but not significantly lower, in view of the higher spontaneous laceration rate in the EPI-NO group.

Prevention of childbirth injuries to the pelvic floor.

PubMed

Heit, M; Mudd, K; Culligan, P

2001-08-01

The majority of childbirth injuries to the pelvic floor occur after the first vaginal delivery. Cesarean sections performed after the onset of labor may not protect the pelvic floor. Elective cesarean section is the only true primary prevention strategy for childbirth injuries to the pelvic floor. Alternative primary prevention strategies include elective cesarean section for women with nonmodifiable risks for childbirth injuries to the pelvic floor, antepartum pelvic floor exercises, or intrapartum pudendal nerve monitoring. Secondary prevention strategies must focus on modifying obstetric practices that predispose women to pelvic floor injury. These factors are best delineated for anal incontinence and include restrictive use of episiotomy, mediolateral episiotomy when necessary, spontaneous over forceps-assisted vaginal delivery, vacuum extraction over forceps delivery, and antepartum perineal massage. Finally, tertiary prevention strategies should address the mode of delivery made for women with childbirth injuries to the pelvic floor who desire future fertility.

Influence of training in the use and generation of evidence on episiotomy practice and perineal trauma

PubMed Central

Ho, Jacqueline J.; Pattanittum, Porjai; Japaraj, Robert P.; Turner, Tari; Swadpanich, Ussanee; Crowther, Caroline A.

2010-01-01

Objective To examine episiotomy practices before and after a multi-component intervention designed to support the use and generation of research evidence in maternal and neonatal health care. Methods Set in 9 centers across 4 Southeast Asian countries, a retrospective survey was performed for 12 recommended pregnancy/childbirth practices and 13 outcomes of women in each center before and after intervention. Qualitative interviews were conducted to assess staff awareness and experience in evidence-based practice. Results There were significant decreases in the rate of episiotomy, from 64.1% to 60.1% (risk difference [RD] –4.0; 95% confidence interval [CI], –5.8 to –2.2) for all women and from 92.2% to 80.7% (RD –11.5; 95% CI, –13.4 to –9.6) for nulliparous women. Severe trauma decreased from 3.9% to 1.9% (RD –2.0; 95% CI, –2.7 to –1.4) for all women and from 6.7% to 3.0% (RD –3.7; 95% CI, –4.9 to –2.5) for nulliparous women. The frequency of intact perineum increased from 12.4% to 15.6% (RD 3.2; 95% CI, 1.9–4.6) for all women and from 1.7% to 8.0% (RD 6.3; 95% CI, 5.0–7.5) for nulliparous women. Conclusion An intervention based on understanding and using the best available evidence can result in significant improvements in care and health outcomes. PMID:20598690

Relieving perineal pain after perineorrhaphy by diclofenac rectal suppositories: a randomized double-blinded placebo controlled trial.

PubMed

Achariyapota, Vuthinun; Titapant, Vitaya

2008-06-01

Perineal pain after episiotomy is a common problem following vaginal birth. The pain affects either physical or mental function negatively. There are many methods in perineal pain relief such as local ice pack and a bath, ultrasound, oral anesthesia, and intravenous anesthesia. Analgesic rectal suppository is one of various methods in pain relief especially in drowsy patients, or when oral preparation causes gastric discomfort, nausea or vomiting. To assess the effectiveness of diclofenac rectal suppositories for relief perineal pain after perineorrhaphy. A randomized double-blinded placebo controlled trial. Seventy-two term, singleton, pregnant women who gave vaginal birth with second to third degree episiotomy tears were randomized with envelop concealment to either diclofenac or placebo rectal suppositories group. Each group received two tablets of 50 mg diclofenac or two tablets of look-alike placebo rectal suppositories. Visual analogue scale was used for scaling pain score before administration of the medications, and at 30 minutes, 1, 2, 12, and 24 hours after administration. No differences were found in the median pain scores before administration of medications and at 30 min, 1 hour and 2 hour after administration (p > 0.05), while the median pain scores were significantly reduced in the diclofenac group at 12 and 24 hours after administration compared to the control group (4.5 vs. 0.0; p < 0.001 and 2.0 vs. 0.0; p = 0.02 for 12 hours and 24 hours, consecutively). The present study suggested that diclofenac suppository was effective on reducing perineal pain after episiotomy, especially at 12 and 24 hours after administration.

[Immediate fetal-maternal morbidity of first instrumental vaginal delivery using Thierry's spatulas. A prospective continuous study of 195 fetal extractions].

PubMed

Parant, O; Simon-Toulza, C; Capdet, J; Fuzier, V; Arnaud, C; Rème, J-M

2009-10-01

To investigate the immediate fetal-maternal morbidity related to Thierry's spatula for first instrumental vaginal delivery. We conducted a prospective observational study in Toulouse university hospital, including primiparas who vaginally delivered a live singleton cephalic infant>36 WG, between December 2005 and June 2006. Instrumental deliveries were performed using short spatulas in all cases. Outcome measures were: perineal complications (episiotomy, laceration and associated lesions, urinary retention, pain at H48), neonatal morbidity (cutaneous injuries, neonatal transfer, cord pH, Apgar score). Instrumental deliveries were compared with spontaneous vaginal deliveries (SVD). Six hundred and eight primiparas were included, distributed in 195 extractions (32%) and 413 SVD (68%). Spatulas allowed fetal extraction in all cases. Main differences between the two groups were: length of labour, occiput posterior position (12.8% for spatulas vs 1.7% for SVD; p<0.0001), episiotomy rate (97.9% vs 51.3%; p<0.0001), severe perineal lacerations (3.6% vs 0.2%; p=0.0007), post-partum morbidity (pain, hematoma, and urinary retention). No case of early severe neonatal complication was related to the use of the spatulas. Perineal complications (severe lacerations) associated with spatulas are increased with regard to SVD, but comparable to that reported with forceps. The main disadvantage is the high frequency of episiotomy, which should not be systematic. Neonatal morbidity is reduced. Comparative studies (spatulas vs. other procedures) are needed to confirm these data, but spatulas remain a multipurpose instrument which should continue to be taught.

Ascertaining severe perineal trauma and associated risk factors by comparing birth data with multiple sources.

PubMed

Ampt, Amanda J; Ford, Jane B

2015-09-30

Population data are often used to monitor severe perineal trauma trends and investigate risk factors. Within New South Wales (NSW), two different datasets can be used, the Perinatal Data Collection ('birth' data) or a linked dataset combining birth data with the Admitted Patient Data Collection ('hospital' data). Severe perineal trauma can be ascertained by birth data alone, or by hospital International Classification of Diseases Australian Modification (ICD-10-AM) diagnosis and procedure coding in the linked dataset. The aim of this study was to compare rates and risk factors for severe perineal trauma using birth data alone versus using linked data. The study population consisted of all vaginal births in NSW between 2001 and 2011. Perineal injury coding in birth data was revised in 2006, so data were analysed separately for 2001-06 and 2006-11. Rates of severe perineal injury over time were compared in birth data alone versus linked data. Kappa and agreement statistics were calculated. Risk factor distributions (maternal age, primiparity, instrumental birth, birthweight ≥4 kg, Asian country of birth and episiotomy) were compared between women with severe perineal trauma identified by birth data alone, and those identified by linked data. Multivariable logistic regression was used to calculate the adjusted odds ratios (aORs) of severe perineal trauma. Among 697 202 women with vaginal births, 2.1% were identified with severe perineal trauma by birth data alone, and 2.6% by linked data. The rate discrepancy was higher among earlier data (1.7% for birth data, 2.4% for linked data). Kappa for earlier data was 0.78 (95% CI 0.78, 0.79), and 0.89 (95% CI 0.89, 0.89) for more recent data. With the exception of episiotomy, differences in risk factor distributions were small, with similar aORs. The aOR of severe perineal trauma for episiotomy was higher using linked data (1.33, 95% CI 1.27, 1.40) compared with birth data (1.02, 95% CI 0.97, 1.08). Although discrepancies in ascertainment of severe perineal trauma improved after revision of birth data coding in 2006, higher ascertainment by linked data was still evident for recent data. There were also higher risk estimates of severe perineal trauma with episiotomy by linked data than by birth data.

A Comparative Study on the Efficacy of Ibuprofen and Celecoxib on the Intensity of Perineal Pain Following Episiotomy: A Randomized Clinical Trial

PubMed Central

Suhrabi, Zainab; Taghinejad, Hamid

2013-01-01

Background: Pain is a worldwide problem that often originates from disease process, and diagnostic and treatment procedures such as surgical operations. Objectives: This trial was performed to compare the effectiveness of two analgesics for the management of perineal pain caused by episiotomy. Materials and Methods: A total of 170 nulliparous women who gave birth vaginally with episiotomy between March 2009 and November 2010 were randomly assigned to receive either ibuprofen or celecoxib which were given orally every 6 or 12 hours, respectively. Pain levels were measured before the intervention, and at 1, 2, 4, 8 and 12 hours after providing the first dose on a 10-cm visual analogue scale. Results: The results showed that the two groups had no significant differences regarding demographic characteristics, maternal, neonatal, and post-delivery factors, and mean premedication pain severity. Means of pain severity were different between the two groups as patients in the celecoxib group had lower means than the other group at 1,2,4,8 and 12 hours (4.01 ± 1.8 vs. 4.46 ± 1.9, 3.17 ± 1.9 vs. 3.79 ± 1.7, 2.89 ± 1.3 vs. 2.96 ± 1.5, 2.19 ± 1.8 vs. 2.55 ± 1.4, and 1.98 ± 1.1 vs. 2.45 ± 1.2, respectively) after administration of analgesics. Conclusions: Patients who received celecoxib had lower VAS in comparison with others. Although these differences were not significant, as celecoxib has longer half-life, fewer upper GI symptoms, and is better tolerated based on the previous studies, and this study is in favor of using it. PMID:24693414

Anal sphincter lacerations and upright delivery postures--a risk analysis from a randomized controlled trial.

PubMed

Altman, Daniel; Ragnar, Inga; Ekström, Asa; Tydén, Tanja; Olsson, Sven-Eric

2007-02-01

To evaluate obstetric sphincter lacerations after a kneeling or sitting position at second stage of labor in a multivariate risk analysis model. Two hundred and seventy-one primiparous women with normal pregnancies and spontaneous labor were randomized, 138 to a kneeling position and 133 to a sitting position. Medical data were retrieved from delivery charts and partograms. Risk factors were tested in a multivariate logistic regression model in a stepwise manner. The trial was completed by 106 subjects in the kneeling group and 112 subjects in the sitting group. There were no significant differences with regard to duration of second stage of labor or pre-trial maternal characteristics between the two groups. Obstetrical sphincter tears did not differ significantly between the two groups but an intact perineum was more common in the kneeling group (p<0.03) and episiotomy (mediolateral) was more common in the sitting group (p<0.05). Three grade IV sphincter lacerations occurred in the sitting group compared to none in the kneeling group (NS). Multivariate risk analysis indicated that prolonged duration of second stage of labor and episiotomy were associated with an increased risk of third- or fourth-degree sphincter tears (p<0.01 and p<0.05, respectively). Delivery posture, maternal age, fetal weight, use of oxytocin, and use of epidural analgesia did not increase the risk of obstetrical anal sphincter lacerations in the two upright postures. Obstetrical anal sphincter lacerations did not differ significantly between a kneeling or sitting upright delivery posture. Episiotomy was more common after a sitting delivery posture, which may be associated with an increased risk of anal sphincter lacerations. Upright delivery postures may be encouraged in healthy women with normal, full-term pregnancy.

Oxytocin and dystocia as risk factors for adverse birth outcomes: a cohort of low-risk nulliparous women.

PubMed

Bernitz, Stine; Øian, Pål; Rolland, Rune; Sandvik, Leiv; Blix, Ellen

2014-03-01

augmented and not augmented women without dystocia were compared to investigate associations between oxytocin and adverse birth outcomes. Augmented women with and without dystocia were compared, to investigate associations between dystocia and adverse birth outcomes. a cohort of low-risk nulliparous women originally included in a randomised controlled trial. the Department of Obstetrics and Gynaecology, Østfold Hospital Trust, Norway. the study population consists of 747 well defined low-risk women. incidence of oxytocin augmentation, and associations between dystocia and augmentation, and mode of delivery, transfer of newborns to the intensive care unit, episiotomy and postpartum haemorrhage. of all participants 327 (43.8%) were augmented with oxytocin of which 139 (42.5%) did not fulfil the criteria for dystocia. Analyses adjusted for possible confounders found that women without dystocia had an increased risk of instrumental vaginal birth (OR 3.73, CI 1.93-7.21) and episiotomy (OR 2.47, CI 1.38-4.39) if augmented with oxytocin. Augmented women had longer active phase if vaginally delivered and longer labours if delivered by caesarean section if having dystocia. Among women without dystocia, those augmented had higher body mass index, gave birth to heavier babies, had longer labours if vaginally delivered and had epidural analgesia more often compared to women not augmented. in low-risk nulliparous without dystocia, we found an association between the use of oxytocin and an increased risk of instrumental vaginal birth and episiotomy. careful attention should be paid to criteria for labour progression and guidelines for oxytocin augmentation to avoid unnecessary use. Copyright © 2013 Elsevier Ltd. All rights reserved.

Is severe perineal damage increased in women with prior anal sphincter injury?

PubMed

Edwards, Heather; Grotegut, Chad; Harmanli, Ozgur H; Rapkin, David; Dandolu, Vani

2006-11-01

There is conflicting data in the literature regarding the risk of obstetric anal sphincter laceration in patients with a prior laceration. This retrospective chart review seeks to examine the risk of recurrence of obstetric anal sphincter lacerations. Patients who sustained anal sphincter laceration at delivery during a 13-year time period from January 1991 to December 2003 were identified from the medical records database at Temple University Hospital. All subsequent deliveries in this group of patients were extracted from the database. Chart review was performed on all subsequent deliveries with specific attention to demographic factors such as age, race, parity, etc., maternal weight, fetal weight, presence of maternal diabetes, and labor characteristics such as induction or augmentation of labor, instrumentation at delivery (vacuum or forceps), use of episiotomy, and degree of perineal laceration. There were 23 451 vaginal deliveries at Temple University Hospital between January 1, 1991 and December 31, 2003. Anal sphincter laceration was noted in 778 subjects. Subsequent deliveries among the group of patients with prior sphincter tears numbered 271. Six (2.4%) patients had recurrence of anal sphincter lacerations, and five of them were third degree lacerations. The rate of recurrent lacerations was not significantly different from the rate of initial lacerations (2.4% vs. 3.3%; odds ratio 0.72, 95% confidence interval 0.33-1.59; p = 0.4). Women who sustained recurrent lacerations were older, more obese (mean weight 92 kg vs. 82 kg), had larger babies (3506 g vs. 3227 g), and were more likely to have episiotomies (66.7% vs. 7%) or instrumental deliveries (33.3 vs. 6.5%). Prior anal sphincter laceration does not result in an increased rate of recurrence. Operative vaginal delivery particularly with episiotomy is a risk factor for both initial and recurrent laceration.

Antepartum use of Epi-No birth trainer for preventing perineal trauma: systematic review.

PubMed

Brito, Luiz Gustavo Oliveira; Ferreira, Cristine Homsi Jorge; Duarte, Geraldo; Nogueira, Antonio Alberto; Marcolin, Alessandra Cristina

2015-10-01

In this systematic review we aimed to assess if the Epi-No birth trainer used during antepartum could prevent perineal trauma in nulliparous women. We searched CENTRAL, MEDLINE, EMBASE, Scielo, and Conference abstracts, looking for randomized controlled studies (RCT). High heterogeneity (i(2) > 50 %) was corrected with random models. All studies were analyzed according to their quality and risk of bias. Nulliparous women or women whose previous pregnancy ended before 21 weeks' gestation were included and the main outcome measures were: episiotomy rates, perineal tears, severe (3rd/4th) perineal tears, and intact perineum. Five studies were included (1,369 participants) for systematic review and two of them (932 participants) were eligible for meta-analysis. Epi-No did not reduce episiotomy rates (RR 0.92 [95%CI 0.75-1.13], n = 710, p =0.44; two studies; fixed model) and second stage of labor (MD -12.50 [95%CI -29.62, -4.62], n = 162, p = 0.54; one study; fixed model), and did not increase intact perineum (RR 1.15 [95 % CI 0.81-1.64], n = 705, p = 0.43; two studies; random model). No influence of Epi-No on reducing all perineal tears (RR 0.99 [95%CI 0.84-1.17], n = 705, p = 0.93, two studies; fixed model) or severe (3rd/4th) perineal tears (RR 1.31 [95%CI 0.72-2.37], n = 705, p = 0.38, two studies; fixed model). Mean birthweight of the Epi-No group was higher than that of the control group in both studies, with no statistical significance. Epi-No birth trainer is a device that did not reduce episiotomy rates and had no influence on reducing perineal tears.

Caesarean section greatly increases risk of scar endometriosis.

PubMed

Nominato, Nilo Sérgio; Prates, Luis Felipe Victor Spyer; Lauar, Isabela; Morais, Jaqueline; Maia, Laura; Geber, Selmo

2010-09-01

To estimate the incidence of scar endometriosis after different surgical procedures. A retrospective study of 72 patients diagnosed with scar endometriosis between 1978 and 2003 was performed. Patient age, site of endometriosis, previous operations, time-gap between last surgery and onset of symptoms, nodule characteristics, and recurrence were evaluated. Age ranged from 16 to 48 years. Location varied according to the previous surgery: 46 caesarean section, one hysterectomy, one in abdominal surgery, 19 episiotomy, one was a relapse and two pelvic floor procedures, two women with no previous surgery. The incidence of scar endometriosis after caesarean section was significantly higher than after episiotomy (0.2 and 0.06%, respectively: p<0.00001) with a relative risk of 3.3. Pain was the most frequent symptom. The mean time between surgery and onset of symptoms was 3.7 years. Our findings confirm that scar endometriosis is a rare condition and indicate, probably for the first time, that caesarean section greatly increases the risk of developing scar endometriosis. Copyright 2010 Elsevier Ireland Ltd. All rights reserved.

The effect of green tea ointment on episiotomy pain and wound healing in primiparous women: A randomized, double-blind, placebo-controlled clinical trial.

PubMed

Shahrahmani, Hadis; Kariman, Nourossadat; Jannesari, Sharareh; Rafieian-Kopaei, Mahmoud; Mirzaei, Moghadameh; Ghalandari, Sahar; Shahrahmani, Nasim; Mardani, Gashtasb

2018-03-01

The delayed healing of episiotomy wound and its associated pain is a major problem in obstetrics. Because green tea has analgesic and wound-healing properties, the present study was conducted to determine the effect of green tea ointment on episiotomy pain and wound-healing. The green tea extract was also standardized by measuring its Phenolic and flavonoid compounds, antioxidant activity, and one of its active components, that is, Epigallocatechin gallate. The present clinical trial was conducted on 99 primiparous women visiting Afzalipour Hospital in Kerman in 2015. The subjects were randomly divided into 3 groups, including a green tea ointment group, a placebo ointment group, and a routine care group. The 2 ointment groups smeared 2 cm of the green tea or placebo ointments onto their sutured area twice daily for a total of 10 days. The severity of pain was assessed in the subjects using the visual pain scale and wound-healing using the Redness, Edema, Ecchymosis, Discharge, Approximation (REEDA) scale before the intervention and on the 5th and 10th days after delivery. To standardize the extract, Epigallocatechin gallate was measured by high-performance liquid chromatography (HPLC). Phenolic and flavonoid compounds, as well as antioxidant activity of the extract were also determined by spectrometry methods. Before the intervention, no significant differences were observed between the 3 groups in terms of their personal and obstetric details (p > .05), the severity of pain (p = .118), and the REEDA score (p = .212). On the 5th and 10th days after delivery, the severity of pain was significantly lower in the green tea group than in the other 2 groups (p < .0001). The mean REEDA score on the 5th and 10th days showed a better and faster healing in the green tea group compared to the other 2 groups (p < .0001). Total content of phenolic and flavonoids contents of green tea were 74.2 mg/g Gallic acid equivalent and 16.3 mg/g Rutin equivalent, respectively, and its antioxidant capacity was 46% of b-carotene. Green tea ointment appears to be effective in relieving episiotomy pain and improving wound-healing in this study. Further studies are recommended to be conducted on the effectiveness and safety of the different doses of green tea ointment. Copyright © 2017 John Wiley & Sons, Ltd.

Advanced age is a risk factor for higher grade perineal lacerations during delivery in nulliparous women.

PubMed

Hornemann, Amadeus; Kamischke, Axel; Luedders, Doerte W; Beyer, Daniel A; Diedrich, Klaus; Bohlmann, Michael K

2010-01-01

To identify risk factors for the development of severe perineal lacerations and to give recommendations for their prevention in nulliparous women. A retrospective case-control analysis of deliveries at our University Hospital was performed. Multiparae, Caesarean sections, twin pregnancies, fetal breech position and preterm deliveries were excluded. Univariate and multivariate step forward regression analyses were performed; correlations between contributors were further analyzed by Spearman Rank Correlation. Differences between the degree of lacerations and maternal age were further analyzed with Friedman ANOVA followed by Dunn's Multiple Comparison Test. A total of 2,967 deliveries fitted our inclusion criteria, 50 (1.7%) mothers had higher-grade lacerations. Mediolateral and median episiotomy, advanced maternal age, vaginal operative delivery, higher fetal birth weight and abnormal cephalic presentation were associated with severe lacerations. Advanced maternal age plays an important role in the development of anal sphincter tears in nulliparous women. Episiotomy and operative vaginal deliveries should be restrictively performed when possible. To identify further preventive approaches in patients with accumulated risk factors prospective randomized studies are needed.

The impact of Advanced Life Support in Obstetrics (ALSO) training in low-resource countries.

PubMed

Dresang, Lee T; González, María Mercedes Ancheta; Beasley, John; Bustillo, Maura Carolina; Damos, Jim; Deutchman, Mark; Evensen, Ann; de Ancheta, Norma González; Rojas-Suarez, José A; Schwartz, Jonathan; Sorensen, Bjarke L; Winslow, Diana; Leeman, Lawrence

2015-11-01

To examine the effects of the Advanced Life Support in Obstetrics (ALSO) program on maternal outcomes in four low-income countries. Data were obtained from single-center, longitudinal cohort studies in Colombia, Guatemala, and Honduras, and from an uncontrolled prospective trial in Tanzania. In Colombia, maternal morbidity and the number of near misses increased after ALSO training, but maternal mortality decreased. In Guatemala, sustained reductions in overall maternal mortality and mortality from postpartum hemorrhage (PPH) were recorded after ALSO implementation. In Honduras, there was a significant decrease in episiotomy rates, and increases in active management of the third stage of labor (AMTSL), vacuum-assisted delivery, and reported comfort managing obstetric emergencies. In Tanzania, the frequency of PPH and severe PPH decreased after training, while management improved. In low-income countries, ALSO training was associated with decreased in-hospital maternal mortality, episiotomy use, and PPH. AMTSL and vacuum-assisted vaginal delivery increased in frequency after ALSO training. Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial.

PubMed

Shipman, M K; Boniface, D R; Tefft, M E; McCloghry, F

1997-07-01

To study the effects of antenatal perineal massage on subsequent perineal outcomes at delivery. A randomised, single-blind prospective study. Department of Obstetrics and Gynaecology, Watford General Hospital. Eight hundred and sixty-one nulliparous women with singleton pregnancy and fulfilling criteria for entry to the trial between June 1994 and October 1995. Comparison of the group assigned to massage with the group assigned to no massage showed a reduction of 6.1% in second or third degree tears or episiotomies. This corresponded to tear rates of 75.1% in the no-massage group and 69.0% in the massage group (P = 0.073). There was a corresponding reduction in instrumental deliveries from 40.9% to 34.6% (P = 0.094). After adjustment for mother's age and infant's birthweight these reductions achieved statistical significance (P = 0.024 and P = 0.034, respectively). Analysis by mother's age showed a much larger benefit due to massage in those aged 30 and over and a smaller benefit in those under 30. Antenatal perineal massage appears to have some benefit in reducing second or third degree tears or episiotomies and instrumental deliveries. This effect was stronger in the age group 30 years and above.

Step 6: Does Not Routinely Employ Practices, Procedures Unsupported by Scientific Evidence

PubMed Central

Goer, Henci; Sagady Leslie, Mayri; Romano, Amy

2007-01-01

Step 6 of the Ten Steps of Mother-Friendly Care addresses two issues: 1) the routine use of interventions (shaving, enemas, intravenous drips, withholding food and fluids, early rupture of membranes, and continuous electronic fetal monitoring; and 2) the optimal rates of induction, episiotomy, cesareans, and vaginal births after cesarean. Rationales for compliance and systematic reviews are presented. PMID:18523680

Care of the perineum in the second stage of labour: a study of views and practices of Australian midwives.

PubMed

Stamp, G E

1997-06-01

to seek the views of midwives on the practices related to the perineum in the second stage of labour; to identify predictors of their practices and to identify their actual practices in the second stage of labour, prior to a randomised trial of second stage perineal massage. independent midwives in South Australia and 194 midwives working in the delivery suites and birth centres of seven public hospitals in four states of Australia. midwives were surveyed using a questionnaire which sought their views on, and practices relating to, second stage perineal massage, delivery of the head and reasons for cutting an episiotomy. one third of the respondents 'never' practised perineal massage in the second stage of labour, 43% were 'undecided' as to its value and 19% disagreed with the practice. Over half agreed that its use should be decided by the woman and her partner. When invited to select the five statements they most agreed with, and the five they most disagreed with, out of a possible 24, equal numbers (26%) were for and against the statement referring to such massage as helping to stretch the perineum and prevent tearing. More than half (55%) disagreed with the statement which predicted they would find the practice distasteful, while only 1.6% agreed with this statement. During delivery of the head, 71% of respondents attempted some form of flexion. There was 100% agreement that fetal distress almost always or frequently was an indication for cutting an episiotomy. there is little evidence from randomised trials to support many of the second stage practices, and further research will clarify those which are most effective. This sample of midwives demonstrated considerable variation in their views on, and practices in, the second stage of labour. Although one-fifth disagreed with the practice of second stage perineal massage, and 40% agreed that the midwife should decide, more than half (57%) believed it was a matter of choice for the woman and her partner. All were supportive of episiotomy use for fetal distress.

Effect of an Exercise Protocol on Pelvic Muscle Resting Pressure in Healthy Adult Women.

DTIC Science & Technology

1992-01-01

function as it related to the postpartum period, parity, type of delivery, episiotomy, age, breastfeeding, physical activity, body mass, stress urinary...incontinence, and orgasm in 98 healthy postpartal and nonpostpartal women. Pelvic muscle pressure measurements were made with the intravaginal balloon...subjects may be performing contractions while the pelvic muscles are still in a partially contracted state from the previous stimulation . The longer resting

The efficacy of cold-gel packing for relieving episiotomy pain - a quasi-randomised control trial.

PubMed

Lu, Yu-Ying; Su, Mei-Ling; Gau, Meei-Ling; Lin, Kuan-Chia; Au, Heng-Kien

2015-01-01

This study evaluated the effectiveness of cold-gel packing on episiotomy pain among postpartum women who had normal spontaneous deliveries. A quasi-randomised control trial was conducted in a maternity ward of a regional teaching hospital in northern Taiwan. Seventy postpartum women were recruited, choosing to be in either the experimental or control group (35 women per group). Subjects in the experimental group received at least six interventions of cold-gel packing applied to the perineal wound and were provided oral analgesics routinely. The subjects in the control group received oral analgesics routinely. Pain intensity, pain interference on daily activities and satisfaction levels with pain management were assessed using Brief Pain Inventory (BPI) and pain management questionnaire, respectively. The results showed that women in the experimental group reported significantly lower mean pain intensity score, pain interference on daily activities scores at 48 hours post-delivery, and higher level of satisfaction with pain management at 24 and 48 hours post-delivery than the control group after adjusting for demographic and obstetric data. Cold-gel packing on the perineum is a cost-effective, convenient, easy-to-deploy and non-pharmacologic approach to pain reduction, with an overall positive impact on postpartum recovery for parturients.

The EpiNo® Device: Efficacy, Tolerability, and Impact on Pelvic Floor—Implications for Future Research

PubMed Central

Kavvadias, Tilemachos; Hoesli, Irene

2016-01-01

Aims. The aim of this review is to provide a comprehensive overview of the available literature on preventing perineal trauma with the EpiNo. Methods. We perfomed a literature research in the MedLine and EMBASE databases for studies referring to EpiNo published between 1990 and 2014, without restrictions for language and study type. Results. Five published studies were identified, regarding the effect of EpiNo on the rate of episiotomy and perineal tears, pelvic floor muscle function, and fetal outcome. The device seems to reduce episiotomy and perineal tears' rate, as well as the risk for levator ani microtrauma and avulsion, though not always statistically significant. It does not seem to have an effect on duration of second stage of labour and fetal outcome. The device is well tolerated and the adverse events are rare and mild. However, design and reporting bias in the reviewed articles do not allow evidence based conclusions. Conclusions. The EpiNo device seems to be promising, with potential positive effects on natural birth, while being uncomplicated to use and without major complications. Well designed, randomized trials are needed in order to understand the effects of EpiNo on pelvic floor and make evidence based recommendations on its use. PMID:26981126

Midwives' and doctors' perceptions of their preparation for and practice in managing the perineum in the second stage of labour: a cross-sectional survey.

PubMed

East, Christine E; Lau, Rosalind; Biro, Mary Anne

2015-01-01

to identify the perceptions of midwives and doctors at Monash Women's regarding their educational preparation and practices used for perineal management during the second stage of labour. anonymous cross-sectional semi-structured questionnaire ('The survey'). the three maternity hospitals that form Monash Women's Maternity Services, Monash Health, Victoria, Australia. midwives and doctors attending births at one or more of the three Monash Women's maternity hospitals. a semi-structured questionnaire was developed, drawing on key concepts from experts and peer-reviewed literature. surveys were returned by 17 doctors and 69 midwives (37% response rate, from the 230 surveys sent). Midwives and doctors described a number of techniques they would use to reduce the risk of perineal trauma, for example, hands on the fetal head/perineum (11.8% of doctors, 61% of midwives), the use of warm compresses (45% of midwives) and maternal education and guidance with pushing (49.3% of midwives). When presented with a series of specific obstetric situations, respondents indicated that they would variably practice hands on the perineum during second stage labour, hands off and episiotomy. The majority of respondents indicated that they agreed or strongly agreed that an episiotomy should sometimes be performed (midwives 97%, doctors 100%). All the doctors had training in diagnosing severe perineal trauma involving anal sphincter injury (ASI), with 77% noting that they felt very confident with this. By contrast, 71% of the midwives reported that they had received training in diagnosing ASI and only 16% of these reported that they were very confident in this diagnosis. All doctors were trained in perineal repair, compared with 65% of midwives. Doctors were more likely to indicate that they were very confident in perineal repair (88%) than the midwives (44%). Most respondents were not familiar with the rates of perineal trauma either within their workplace or across Australia. Midwives and doctors indicated that they would use the hands on or hands off approach or episiotomy depending on the specific clinical scenario and described a range of techniques that they would use in their overall approach to minimising perineal trauma during birth. Midwives were more likely than doctors to indicate their lack of training and/or confidence in conducting perineal repair and diagnosing ASI. many midwives indicated that they had not received training in diagnosing ASI, perineal repair and midwives' and doctors' knowledge of the prevalence of perineal outcomes was poor. Given the importance of these skills to women cared for by midwives and doctors, the findings may be used to inform the development of quality improvement activities, including training programs and opportunities for gaining experience and expertise with perineal management. The use of episiotomy and hands on/hands off the perineum in the survey scenarios provides reassurance that doctors and midwives take a number of factors into account in their clinical practice, rather than a preference for one or more interventions over others. Copyright © 2014 Elsevier Ltd. All rights reserved.

Preventing perineal trauma during childbirth: a systematic review.

PubMed

Eason, E; Labrecque, M; Wells, G; Feldman, P

2000-03-01

To review systematically techniques proposed to prevent perineal trauma during childbirth and meta-analyze the evidence of their efficacy from randomized controlled trials. MEDLINE (1966-1999), the Cochrane Library (1999 Issue 1), and the Cochrane Collaboration: Pregnancy and Childbirth Database (1995); and reference lists from articles identified. Search terms included childbirth or pregnancy or delivery, and perineum, episiotomy, perineal massage, obstetric forceps, vacuum extraction, labor stage-second. No language or study-type constraints were imposed. Randomized controlled trials (RCTs) of interventions affecting perineal trauma were reviewed. If no RCTs were available, nonrandomized research designs such as cohort studies were included. Studies were selected by examination of titles and abstracts of more than 1,500 articles, followed by analysis of the methods sections of studies that appeared to be RCTs. INTEGRATION AND RESULTS: Eligible studies used random or quasirandom allocation of an intervention of interest and reported perineal outcomes. Further exclusions were based on failure to report results by intention to treat, or incomplete or internally inconsistent reporting of perineal outcomes. Final selection of studies and data extraction was by consensus of the first two authors. Data from trials that evaluated similar interventions were combined using a random effects model to determine weighted estimate of risk difference and number needed to treat. Effects of sensitivity analysis and quality scoring were examined. Results indicated good evidence that avoiding episiotomy decreased perineal trauma (absolute risk difference -0.23, 95% confidence interval [CI] -0.35, -0.11). In nulliparas, perineal massage during the weeks before giving birth also protected against perineal trauma (risk difference -0.08, CI -0.12, -0.04). Vacuum extraction (risk difference -0.06, CI -0.10, -0.02) and spontaneous birth (-0.11, 95% CI -0.18, -0.04) caused less anal sphincter trauma than forceps delivery. The mother's position during the second stage has little influence on perineal trauma (supported upright versus recumbent: risk difference 0.02, 95% CI -0.05, 0.09). Factors shown to increase perineal integrity include avoiding episiotomy, spontaneous or vacuum-assisted rather than forceps birth, and in nulliparas, perineal massage during the weeks before childbirth. Second-stage position has little effect. Further information on techniques to protect the perineum during spontaneous delivery is sorely needed.

[Water birthing: retrospective review of 2625 water births. Contamination of birth pool water and risk of microbial cross-infection].

PubMed

Thöni, A; Mussner, K; Ploner, F

2010-06-01

The aim of this study was to document the practice of 2625 water births at Vipiteno over the period 1997-2009 and compare outcome and safety with normal vaginal delivery. The microbial load of the birth pool water was analyzed, and neonatal infection rates after water birth and after land delivery were compared. Methods. The variables analyzed in the 1152 primiparae were: length of labor; incidence of episiotomies and tears; arterial cord blood pH and base excess values; percentage of pH<7.10 and base excess values >/=12 mmol/L. In all 2625 water births, the variables were: analgesic requirements; shoulder dystocia/ neonatal complications; and deliveries after a previous caesarean section. Bacterial cultures of water samples obtained from the bath after filling (sample A) and after delivery (sample B) were analyzed in 300 cases. The pediatricians recorded signs of suspected neonatal infection after water birth and after conventional vaginal delivery. There was a marked reduction in labor duration in the primiparae who birthed in water; the episiotomy rate was 0.46%. Owing to the pain relieving effect of the warm birth pool water, pain relievers (opiates) were required in only 12.9% of water births. Arterial cord blood pH and base excess values were comparable in both groups. Shoulder dystocia/neonatal complications were managed in 4 water births; 105 women with a previous caesarean section had a water birth. In sample A, the isolated micro-organisms were Legionella spp. and Pseudomonas aeruginosa; in sample B, there was elevated colonization of birth pool water by total coliform bacilli and Escherichia coli. Despite microbial contamination of birth pool water during delivery, antibiotic prophylaxis, as indicated by clinical and laboratory suspicion of infection, was administered to only 0.98% of babies after water birth versus 1.64% of those after land delivery. Results suggest clear medical advantages of water birthing: significantly shorter labor duration among the primiparae; a net reduction in episiotomy rates; and a marked drop in requests for pain relievers. During expulsion of the fetus at delivery, fecal matter is released into the birth pool water, contaminating it with micro-organisms. Despite this, water birthing was found to be safe for the neonate and did not carry a higher risk of neonatal infection when compared with conventional vaginal delivery.

Perineal massage during pregnancy: a prospective controlled trial.

PubMed

Mei-dan, Elad; Walfisch, Asnat; Raz, Iris; Levy, Amalia; Hallak, Mordechai

2008-07-01

Women frequently suffer perineal trauma while giving birth. Interventions to increase the possibility for an intact perineum are needed. To evaluate the effectiveness of antenatal perineal massage in increasing the likelihood of delivering with an intact perineum. This single blinded prospective controlled trial included 234 nulliparous women with a singleton fetus. Women allocated to the study group were instructed to practice a 10 minute perineal massage daily from the 34th week of gestation until delivery. Primary outcome measures included the episiotomy rate; first, second, third and fourth-degree perineal tear rates; and intact perineum. Secondary outcomes were related to specific tear locations and the amount of suture material required for repair. Episiotomy rates, overall spontaneous tears and intact perineum rates were similar in the study and control groups. Women in the massage group had slightly lower rates of first-degree tears (73.3% vs. 78.9%, P = 0.39) and slightly higher rates of second-degree tears (26.7% vs. 19.3%, P= 0.39), although both of these outcomes did not reach statistical significance. The rates of anterior perineal tears were significantly higher in the massage group (9.5% vs. 3%, P = 0.05), whereas internal lateral tears rates were slightly lower but without statistical significance (11.5% vs.13.1%, P=0.44). The practice of antenatal perineal massage showed neither a protective nor a detrimental significant effect on the occurrence of perineal trauma.

Factors associated with spontaneous perineal lacerations in deliveries without episiotomy in a university maternity hospital in the city of Recife, Brazil: a cohort study.

PubMed

Lins, Vanessa Maria Laranjeiras; Katz, Leila; Vasconcelos, Fernanda Barros Lima; Coutinho, Isabela; Amorim, Melania Maria

2018-04-18

The objective of this study is to determine factors associated with spontaneous perineal laceration in low-risk pregnant women who delivered vaginally without episiotomy in a university maternity hospital in Recife, Pernambuco, Brazil. A prospective cohort study was conducted with 222 low-risk, full-term pregnant women admitted in labor with a single fetus in cephalic presentation. Women with malformed fetuses were excluded from the study. The variables analyzed were: the frequency and severity of lacerations, the women's biological, sociodemographic, clinical and obstetrical characteristics, neonatal characteristics, and data on their deliveries and procedures. For the data analysis, risk ratios and their 95% confidence intervals were calculated. A significance level of 5% was adopted and multiple regression analysis was performed. Spontaneous first-degree perineal tears were registered in 47% of the women, second-degree tears in 31%, and third degree tears in only 1.8%. There were no cases of fourth-degree tears. Having experienced normal childbirth previously constituted a protective factor against vaginal tearing (OR =  0.46; 95%CI: 0.23-0.91; p = .027). The principal protective factor against spontaneous lacerations was having experienced normal childbirth previously. Intrapartum strategies aimed at protecting the perineum and pelvic floor muscle training during prenatal care should be encouraged in these women.

Care in a birth room versus a conventional setting: a controlled trial.

PubMed Central

Klein, M; Papageorgiou, A; Westreich, R; Spector-Dunsky, L; Elkins, V; Kramer, M S; Gelfand, M M

1984-01-01

A controlled clinical trial was carried out to assess whether a birth room setting would influence the care of mothers and newborns. Of the 163 low-risk women enrolled, 49 (30%) manifested some prenatal risk and were excluded. The remaining 114 were allocated by strict alternation to a birth room or a conventional setting. Of the 56 women allocated to the birth room, 63% of the primiparas and 19% of the multiparas were later transferred. The numbers in the two settings who had oxytocin stimulation, epidural anesthesia, forceps delivery or cesarean section did not show statistically significant differences. The episiotomy rates were slightly lower in the birth room than in the conventional setting, and the rates of an intact perineum were higher in the birth room. Neither the Apgar scores nor the morbidity rates of the infants showed statistically significant differences related to the setting to which the mother had been allocated, although more infants from the conventional setting were admitted to a special care unit. Both "experimental" groups of women less often received routine perineal shaving, enemas or intravenous infusions than did an obstetrically similar nonexperimental comparison group. Despite the apparent inability in this setting for the birth room to influence the rate of major obstetric procedures (except for episiotomy) and outcomes, the authors believe that a birth room is desirable in tertiary care centres as well as in community hospitals. PMID:6388776

The outcome of midwife-led labor in low-risk women within an obstetric referral unit.

PubMed

Ferrazzi, Enrico; Visconti, Elena; Paganelli, Andrea M; Campi, Carmen M; Lazzeri, Cristina; Cirillo, Federico; Livio, Stefania; Piola, Cinzia

2015-09-01

To analyze maternal and neonatal outcomes of midwife-led labor in low-risk women at term. Prospective observational cohort of 1788 singleton low-risk pregnancies in spontaneous term labor, managed according to a specific midwife-led labor protocol. Primary outcomes were mode of delivery, episiotomy, 3rd-4th degree lacerations, post-partum hemorrhage (PPH), need for blood transfusions, pH and Apgar score and NICU admissions. A total 1754 low-risk women (50.3% of all deliveries) were included in the analysis. Epidural analgesia was performed in 29.8% of cases. The rate of cesarean section was 3.7%. Episiotomy was performed in 17.6% of women. PPH > 1000 ml occurred in 1.7% of cases. 3.2% and 0.3% of the cases had an Apgar score <7 and pH < 7.10, respectively, while 0.3% of the newborns were admitted to NICU. Consultant-led labor was required for emerging risk factors during 1st and 2nd stage of labor in 16.1 and 8.6% of cases, respectively. Although maternal outcome were worse in women with emerging risk factors in labor, while neonatal outcomes were not affected by the presence these complications. In hospital settings, midwife-led labor in low-risk women might unfold its major advantages without additional risks of medicalization for the mother and the neonate.

Effectiveness of a physical activity programme based on the Pilates method in pregnancy and labour.

PubMed

Rodríguez-Díaz, Luciano; Ruiz-Frutos, Carlos; Vázquez-Lara, Juana María; Ramírez-Rodrigo, Jesús; Villaverde-Gutiérrez, Carmen; Torres-Luque, Gema

To assess the effectiveness and safety of a physical activity programme based on use of the Pilates method, over eight weeks in pregnant women, on functional parameters, such as weight, blood pressure, strength, flexibility and spinal curvature, and on labour parameters, such as, type of delivery, episiotomy, analgesia and newborn weight. A randomized clinical trial was carried out on pregnant women, applying a programme of physical activity using the Pilates method, designed specifically for this population. A sample consisting of a total of 105 pregnant women was divided into two groups: intervention group (n=50) (32.87±4.46 years old) and control group (n=55) (31.52±4.95 years old). The intervention group followed a physical activity programme based on the Pilates method, for 2 weekly sessions, whereas the control group did not follow the program. Significant improvements (p<0.05) in blood pressure, hand grip strength, hamstring flexibility and spinal curvature, in addition to improvements during labour, decreasing the number of Caesareans and obstructed labour, episiotomies, analgesia and the weight of the newborns were found at the end of the intervention. A physical activity programme of 8 weeks based on the Pilates method improves functional parameters in pregnant women and benefits delivery. Copyright © 2017 Elsevier España, S.L.U. All rights reserved.

Comparison of childbirth care models in public hospitals, Brazil.

PubMed

Vogt, Sibylle Emilie; Silva, Kátia Silveira da; Dias, Marcos Augusto Bastos

2014-04-01

To compare collaborative and traditional childbirth care models. Cross-sectional study with 655 primiparous women in four public health system hospitals in Belo Horizonte, MG, Southeastern Brazil, in 2011 (333 women for the collaborative model and 322 for the traditional model, including those with induced or premature labor). Data were collected using interviews and medical records. The Chi-square test was used to compare the outcomes and multivariate logistic regression to determine the association between the model and the interventions used. Paid work and schooling showed significant differences in distribution between the models. Oxytocin (50.2% collaborative model and 65.5% traditional model; p < 0.001), amniotomy (54.3% collaborative model and 65.9% traditional model; p = 0.012) and episiotomy (collaborative model 16.1% and traditional model 85.2%; p < 0.001) were less used in the collaborative model with increased application of non-pharmacological pain relief (85.0% collaborative model and 78.9% traditional model; p = 0.042). The association between the collaborative model and the reduction in the use of oxytocin, artificial rupture of membranes and episiotomy remained after adjustment for confounding. The care model was not associated with complications in newborns or mothers neither with the use of spinal or epidural analgesia. The results suggest that collaborative model may reduce interventions performed in labor care with similar perinatal outcomes.

Burn Center Management of Necrotizing Fasciitis

DTIC Science & Technology

2003-06-01

caesarian sec- tion, vaginal delivery with episiotomy, percutaneous endoscopic gastrostomy, laparoscopy, dental extrac- tion, or liposuction .1,6–11...fasciitis was related to a trivial or unknown injury in six cases and to a small (2% TBSA) contact burn in one case. Two cases re- sulting from liposuction ...31 F Liposuction surgery None 22 8 41 49 Survived 5 48 F Liposuction surgery None 9 6 13 19 Expired 6 72 F Unknown Age, HTN 8 4 51 55 Survived 7 33 M

Practices that minimize trauma to the genital tract in childbirth: a systematic review of the literature.

PubMed

Renfrew, M J; Hannah, W; Albers, L; Floyd, E

1998-09-01

Trauma to the genital tract commonly occurs at birth, and can cause short- and long-term morbidity. Clinical measures to reduce its occurrence have not been fully identified. A systematic review of the English language literature was conducted to describe the current state of knowledge on reduction of genital tract trauma before planning a large randomized controlled trial of ways to prevent such trauma. Randomized trials and other published reports were identified from relevant databases and hand searches. Studies were reviewed and assessed using a structured format. A total of 77 papers and chapters were identified and placed into 5 categories after critical review: 25 randomized trials, 4 meta-analyses, 4 prospective studies, 36 retrospective studies, and 8 descriptions of practice from textbooks. The available evidence is conclusive in favor of restricted use of episiotomy. The contribution of maternal characteristics and attitudes to intact perineum has not been investigated. Several other topics warrant further study, including maternal position, style of pushing, and antenatal perineal massage. Strong opinions and sparse data exist regarding the role of hand maneuvers by the birth attendant for perineal management and birth of the baby. This became the topic of the planned randomized controlled trial, which was completed; results will be published soon. The case for restricting the use of episiotomy is conclusive. Several other clinical factors warrant investigation, including the role of hand maneuvers by the birth attendant in preventing birth trauma. A large randomized controlled trial will report on this topic.

Perineal massage in labour and prevention of perineal trauma: randomised controlled trial.

PubMed

Stamp, G; Kruzins, G; Crowther, C

2001-05-26

To determine the effects of perineal massage in the second stage of labour on perineal outcomes. Randomised controlled trial. At 36 weeks' gestation, women expecting normal birth of a singleton were asked to join the study. Women became eligible to be randomised in labour if they progressed to full dilatation of the cervix or 8 cm or more if nulliparous or 5 cm or more if multiparous. 1340 were randomised into the trial. Massage and stretching of the perineum during the second stage of labour with a water soluble lubricant. rates of intact perineum, episiotomies, and first, second, third, and fourth degree tears. pain at three and 10 days postpartum and pain, dyspareunia, resumption of sexual intercourse, and urinary and faecal incontinence and urgency three months postpartum. Rates of intact perineums, first and second degree tears, and episiotomies were similar in the massage and the control groups. There were fewer third degree tears in the massage group (12 (1.7%) v 23 (3.6%); absolute risk 2.11, relative risk 0.45; 95% confidence interval 0.23 to 0.93, P<0.04), though the trial was underpowered to measure this rarer outcome. Groups did not differ in any of the secondary outcomes at the three assessment points. The practice of perineal massage in labour does not increase the likelihood of an intact perineum or reduce the risk of pain, dyspareunia, or urinary and faecal problems.

The effect of antenatal pelvic floor muscle training on labor and delivery outcomes: a systematic review with meta-analysis.

PubMed

Du, Yihui; Xu, Li; Ding, Lilu; Wang, Yiping; Wang, Zhiping

2015-10-01

Pelvic floor muscle training (PFMT) has been widely used to prevent and treat urinary incontinence; however, the possible effect of antenatal PFMT on labor and delivery is still not clear. The purpose of the study was to investigate the possible effect of antenatal PFMT on labor and delivery. A systematic review of the scientific literature was conducted in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement. Randomized or quasi-randomized controlled studies of an obstetric population who had done antenatal PFMT met the inclusion criteria. Data about labor and delivery outcomes included the first stage of labor, the second stage of labor, episiotomy, instrumental delivery, and perineal laceration. The nine English and four Chinese databases were searched from their inception through November 6, 2014. Fixed or random effects models were selected based on study heterogeneity. The weighted mean differences (WMDs) and odds ratios (ORs) with the corresponding 95 % confidence intervals (CIs) were calculated to assess the association between PFMT and the labor and delivery outcomes. Twelve studies were identified, involving a total of 2,243 women, in which 1,108 were PFMT and 1,135 controls. They indicated that PFMT during pregnancy significantly shortened the first and second stage of labor in the primigravida (WMD = -28.33, 95 % CI: -42.43 to -14.23, I(2) = 0.0 % , and WMD = -10.41, 95 % CI: -18.38 to -2.44, I(2) = 64.0 % respectively). In the subgroup analysis on the second stage of labor, heterogeneity decreased for subgroups of China and European countries (I(2) = 0.0 %, P = 0.768 and I(2) = 0.0 %, P = 0.750 respectively), but statistically significant association only existed in the subgroup of China (WMD = -17.42, 95 % CI: -23.41 to -11.43). When evaluating the effect on the rates of episiotomy, instrumental delivery and perineal laceration, the meta-analysis showed that the results were not significant (OR = 0.75, 95 % CI: 0.54 to 1.02; OR = 0.84, 95 % CI: 0.61 to 1.17 and OR = 0.96, 95 % CI: 0.66 to 1.40 respectively). Antenatal PFMT might be effective at shortening the first and second stage of labor in the primigravida. The moderate heterogeneity for the second stage of labor data need further study. Antenatal PFMT may not increase the risk of episiotomy, instrumental delivery, and perineal laceration in the primigravida.

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

PubMed

Sanders, Julia; Peters, Tim J; Campbell, Rona

2005-06-01

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.

The impact of an intervention programme employing a hands-on technique to reduce the incidence of anal sphincter tears: interrupted time-series reanalysis.

PubMed

Fretheim, Atle; Odgaard-Jensen, Jan; Røttingen, John-Arne; Reinar, Liv Merete; Vangen, Siri; Tanbo, Tom

2013-10-22

To re-evaluate previously published findings from an uncontrolled before-after evaluation of an intervention programme to reduce the incidence of anal sphincter tears. A key component of the programme was the use of a hands-on technique where the birth attendant presses the neonate's head during the final stage of delivery while simultaneously supporting the woman's perineum with the other hand. Interrupted time-series analysis using segmented regression modelling. Obstetric departments of five Norwegian hospitals. All women giving births vaginally in the study hospitals, 2002-2008. The main data source was the Medical Birth Registry of Norway. We estimated the change in incidence of anal sphincter tears before and after implementation of the intervention in the five intervention hospitals, taking into account the trends in incidence before and after implementation. Incidence of anal sphincter tears and episiotomies. There were 75 543 registered births at the five included hospitals. We found a 2% absolute reduction in incidence of anal sphincter tears associated with the hospital intervention programme, representing almost a halving in the number of women experiencing serious anal sphincter tears. This is a substantially smaller estimate than previously reported. However, it does represent a highly significant decrease in anal sphincter injuries. The programme was also associated with a significant increase in episiotomies. The intervention programme was associated with a significant reduction in the incidence of obstetric anal sphincter tears. Still, the findings should be interpreted with caution as they seem to contradict the findings from randomised controlled studies of similar interventions.

[Anaemia in pregnancy and in the immediate postpartum period. Prevalence and risk factors in pregnancy and childbirth].

PubMed

Urquizu I Brichs, Xavier; Rodriguez Carballeira, Mónica; García Fernández, Antonio; Perez Picañol, Emilio

2016-05-20

The objective of the study was to assess the prevalence of anaemia in the immediate postpartum period (48-72hours), determine the risk factors and the value of haemoglobin before birth to reduce postpartum anaemia. A prospective, observational and longitudinal study that included 1,426 women who delivered consecutively and agreed to participate in the study. Different variables, analytical, epidemiological, foetal and maternal symptoms were studied. The prevalence of anaemia in the postpartum period was 49.7%. The most important risk factors were antepartum anaemia and type of delivery. The types of delivery most influencing postpartum anaemia were, forceps (82.3%), the ventouse 67%, cesarean section (58,2%) and vaginal delivery (37.2%). In the multivariate study was found as the most important independent risk factors, the haemoglobin in the delivery day (OR 6.16, CI: 3.73 to 10.15) and instrumental delivery (OR: 4.61, CI: 3.44 to 6, 19). Other independent risk factors were haemoglobin in the third trimester, episiotomy and perineal tears, ethnicity, birth weight, parity and intra/postpartum complications. Anaemia in the immediate postpartum is a prevalent problem. The factors most associated postpartum anaemia were antepartum anaemia and instrumental delivery. If patients arrive at the day of delivery with haemoglobins≥12,6g/dl and were restricted to necessary instrumented deliveries and cesarean sections, episiotomies and we could avoid perineal tears we can decrease anaemia in the immediate postpartum period very significantly. Copyright © 2016 Elsevier España, S.L.U. All rights reserved.

Dystocia following prolonged retention of a dead fetus in an Asian elephant (Elephas maximus).

PubMed

Thitaram, Chatchote; Pongsopawijit, Pornsawan; Thongtip, Nikorn; Angkavanich, Taweepoke; Chansittivej, Sarun; Wongkalasin, Waroot; Somgird, Chalermchart; Suwankong, Niyada; Prachsilpchai, Worapat; Suchit, Kittiphat; Clausen, Bjarne; Boonthong, Pinich; Nimtrakul, Kannika; Niponkit, Charawee; Siritepsongklod, Somchai; Roongsri, Ronnachit; Mahasavankul, Sittidet

2006-09-15

A 32-year-old nulliparous female Asian elephant (Elephas maximus) showed signs of parturition 8 months later than predicted from the breeding records. However, while serosanguineous fluid, necrotic tissue and pieces of amnion were expelled, second-stage labor did not progress. Since the fetus was not found during an endoscopic examination of the vestibule, it was assumed that the elephant had calved unseen and she was returned to the forest to recuperate. Twelve months later, the elephant showed clear signs of second-stage labor accompanied by a bulge in the perineum and passage of keratinized nail through the vulva. A 35 cm episiotomy incision was made in the perineum just below the anus, via which chains were attached to the forelimbs of the fetus. Traction on the forelimbs alone proved insufficient to achieve delivery because the fetal head kept rotating and impacting in the pelvis. However, traction applied via a hook inserted behind the mandibular symphysis allowed the head to be elevated and extended, and the fetus to be delivered. The episiotomy wound was sutured in two layers and although the skin did not heal during primary closure it subsequently healed uneventfully by second intention. Retrospective evaluation of the elephant's serum progestagens profile demonstrated a fall to baseline at the suspected onset of parturition, supporting the supposition that the fetus was retained in the uterus for 12 months after parturition began. It is suggested that serum progestagens concentrations should be monitored regularly in mated elephant cows to verify the establishment of pregnancy and to better estimate the expected timing, and the onset of calving.

Trends in hospital-based childbirth care: the role of health insurance.

PubMed

Kozhimannil, Katy B; Shippee, Tetyana P; Adegoke, Olusola; Vemig, Beth A

2013-04-01

Childbirth is the leading reason for hospitalization in the United States, and maternity related expenditures are substantial for many health insurance programs, including Medicaid. We studied the relationship between primary payer and trends in hospital-based childbirth care. Retrospective analysis of hospital discharge data from the Nationwide Inpatient Sample (NIS) of the Healthcare Cost and Utilization Project, a 20% stratified sample of US hospitals. Data on 6,717,486 hospital-based births for the years 2002 through 2009 came from the NIS. We used generalized estimating equations to measure associations over time between primary payer (Medicaid, private insurance, or self) and cesarean delivery, vaginal birth after cesarean (VBAC), labor induction, and episiotomy. Controlling for clinical, demographic, and hospital factors, births covered by Medicaid had lower odds of cesarean delivery (adjusted odds ratio [AOR], 0.91), labor induction (AOR, 0.73), and episiotomy (AOR, 0.62) and higher odds of VBAC (AOR, 1.20; P <.001 for all AORs) compared with privately insured births. Cesarean rates increased 6% annually among births paid by private insurance (AOR, 1.06; P <.001) and less rapidly (5% annually) among those covered by Medicaid. US hospital-based births covered by private insurance were associated with higher rates of obstetric intervention than births paid for by Medicaid. After controlling for clinical, demographic, and hospital factors, cesarean delivery rates increased more rapidly among births covered by private insurance, compared with Medicaid. Changes in insurance coverage associated with healthcare reform may impact costs and quality of care for women giving birth in US hospitals.

Double incontinence in a cohort of nulliparous pregnant women.

PubMed

Espuña-Pons, Montserrat; Solans-Domènech, Maite; Sánchez, Emília

2012-11-01

To estimate the frequency of double incontinence, and to identify associated risk factors during pregnancy and postpartum in previously continent nulliparous women. A cohort study in healthy, nulliparous, continent pregnant women, attending the public healthcare system of Catalonia (Spain) was designed. The field work was conducted during the control visits of pregnancy, at the time of delivery, and in the postpartum. Double incontinence was defined as a situation in which participants reported simultaneously urinary incontinence (UI) and anal incontinence with the help of a self-administered questionnaire. Prevalence rates, and their corresponding confidence intervals (95% CI), were calculated, as well as the impact on daily life. Multivariable logistic regressions in pregnancy and postpartum were estimated to assess the association of potential risk factors. The prevalence rate of double incontinence during pregnancy was 8.6% (95% CI: 7.0-10.3). Age over 35 years, and family history of UI were associated to a higher risk of double incontinence. After delivery, the prevalence rate decreased to 3.5% (95% CI: 2.4-4.6); only 6.7% of women with double incontinence in pregnancy had a persistency of their symptoms in early postpartum. Instrumental vaginal deliveries carried 2.2 times more risk of double incontinence than spontaneous ones. Episiotomy implied a higher risk for double incontinence. Symptoms of double incontinence are prevalent during first pregnancy; age and other intrinsic factors may favor the occurrence of double incontinence throughout gestation, while instrumental delivery and episiotomy increase the risk of double incontinence in the postpartum period. Copyright © 2012 Wiley Periodicals, Inc.

Anal incontinence after two vaginal deliveries without obstetric anal sphincter rupture.

PubMed

Persson, Lisa K G; Sakse, Abelone; Langhoff-Roos, Jens; Jangö, Hanna

2017-06-01

To evaluate prevalence and risk factors for long-term anal incontinence in women with two prior vaginal deliveries without obstetric anal sphincter injury (OASIS) and to assess the impact of anal incontinence-related symptoms on quality of life. This is a nation-wide cross-sectional survey study. One thousand women who had a first vaginal delivery and a subsequent delivery, both without OASIS, between 1997 and 2008 in Denmark were identified in the Danish Medical Birth Registry. Women with more than two deliveries in total till 2012 were excluded at this stage. Of the 1000 women randomly identified, 763 were eligible and received a questionnaire. Maternal and obstetric data were retrieved from the national registry. The response rate was 58.3%. In total, 394 women were included for analysis after reviewing responses according to previously defined exclusion criteria. Median follow-up time was 9.8 years after the first delivery and 6.4 years after the second. The prevalence of flatal incontinence, fecal incontinence and fecal urgency were 11.7, 4.1, and 12.3%, respectively. Overall, 20.1% had any degree of anal incontinence and/or fecal urgency. In 6.3% these symptoms affected their quality of life. No maternal or obstetric factors including episiotomy and vacuum extraction were consistently associated with altered risk of anal incontinence in the multivariable analyses. Anal incontinence and fecal urgency is reported by one fifth of women with two vaginal deliveries without OASIS at long-term follow-up. Episiotomy or vacuum extraction did not alter the risk of long-term anal incontinence.

The effect of perineal control with hands-on and hand-poised methods on perineal trauma and delivery outcome

PubMed Central

Foroughipour, Azam; Firuzeh, Farah; Ghahiri, Ataolah; Norbakhsh, Vajihe; Heidari, Tayebeh

2011-01-01

BACKGROUND: The objective of the present study was to evaluate the effect of the two methods of delivery, “hands-on” vs. “hands poised”, on perineal trauma and delivery outcome in primiparous women referred to Shariati Hospital of Isfahan during 2007-2008. METHODS: In a clinical trial study, 100 low risk primiparous pregnant women were randomly assigned to two hands-on and hand-poised (hands-off) groups. In the hands-on group, this method was used to control fetal head in the second stage of labor. It means that the fingers of one hand supported fetal occiput and the other hand applied slight pressure on the head to control the delivery of the head during the crowning process. In the hands-poised group, midwife observed the parturient woman and do not touch perineum during the second labor stage while fetal head was delivering. Then, the two groups were compared in terms of perineal trauma, as well as neonatal and delivery outcome. RESULTS: Demographic characteristics of all studied women were similar in two groups. The rate of episiotomy was higher in hands-on group (84% vs. 40%, p = 0.001). The rate of postpartum hemorrhage (4th stage) was higher in hands-on group (12% vs. 4%, p = 0.04). The rate of mild and moderate postpartum pain in hands-on group was higher than hands-off group (70% vs. 58% and 29% vs. 10%, p < 0.001) but sever pain was not different in two groups. CONCLUSIONS: It seems that hands-poised method is associated with less perineal trauma, particularly regarding the lower need for episiotomy and postpartum hemorrhage. PMID:22279480

Effectiveness of antenatal perineal massage in reducing perineal trauma and post-partum morbidities: A randomized controlled trial.

PubMed

Ugwu, Emmanuel Onyebuchi; Iferikigwe, Eric Sunday; Obi, Samuel Nnamdi; Eleje, George Uchenna; Ozumba, Benjamin Chukwuma

2018-04-02

The study aimed to evaluate the effectiveness of antenatal perineal massage (APM) in reducing perineal trauma and post-partum morbidities. A randomized controlled trial of 108 primigravidae at the University of Nigeria Teaching Hospital, Enugu, Nigeria, was conducted from January 2013 to May 2014. The intervention group received APM, while the control group did not receive APM. Women who received APM were significantly more likely to have an intact perineum after childbirth [27/53 (50.9%) vs 16/55 (29.1%); RR: 1.75; 95% CI: 1.07-2.86; P = 0.02]. The incidence of episiotomy was lower in the intervention group [20/53 (37.7%) vs 32/55 (58.2%); RR: 0.65; 95% CI: 0.43-0.98; P = 0.03; NNT = 5]. Women who received APM were significantly less likely to develop flatus incontinence [4/53 (8.3%) vs 13/55 (26.0%); RR: 0.32; 95% CI: 0.11-0.91; P = 0.03]. However, the incidences of premature rupture of membranes, preterm labor and birth asphyxia were similar between the two groups (P > 0.05). APM reduces the incidence of episiotomy and increases the incidence of women with an intact perineum after vaginal delivery. It also reduces the risk of flatus incontinence after childbirth without increased maternal or neonatal complications. Women should therefore be counseled on the likely benefits of APM and the information provided during antenatal care. Obstetricians should consider the technique as routine prenatal care for nulliparous women so as to reduce the incidence of perineal trauma during vaginal birth. © 2018 Japan Society of Obstetrics and Gynecology.

Characteristics Associated With Severe Perineal and Cervical Lacerations During Vaginal Delivery

PubMed Central

Landy, Helain J.; Laughon, S. Katherine; Bailit, Jennifer; Kominiarek, Michelle A.; Gonzalez-Quintero, Victor Hugo; Ramirez, Mildred; Haberman, Shoshana; Hibbard, Judith; Wilkins, Isabelle; Branch, D. Ware; Burkman, Ronald T.; Gregory, Kimberly; Hoffman, Matthew K.; Learman, Lee A.; Hatjis, Christos; VanVeldhuisen, Paul C.; Reddy, Uma M.; Troendle, James; Sun, Liping; Zhang, Jun

2011-01-01

Objective To characterize potentially modifiable risk factors for third- or fourth-degree perineal lacerations and cervical lacerations in a contemporary U.S. obstetric practice. Methods The Consortium on Safe Labor collected electronic medical records from 19 hospitals within 12 institutions (228,668 deliveries from 2002 to 2008). Information on patient characteristics, prenatal complications, labor and delivery data, and maternal and neonatal outcomes were collected. Only women with successful vaginal deliveries of cephalic singletons at 34 weeks of gestation or later were included; we excluded data from sites lacking information about lacerations at delivery and deliveries complicated by shoulder dystocia; 87,267 and 71,170 women were analyzed for third- or fourth-degree and cervical lacerations, respectively. Multivariable logistic regressions were used to adjust for other factors. Results Third- or fourth-degree lacerations occurred in 2,516 women (2,223 nulliparous [5.8%], 293 [0.6%] multiparous) and cervical lacerations occurred in 536 women (324 nulliparous [1.1%], 212 multiparous [0.5%]). Risks for third or fourth-degree lacerations included nulliparity (7.2-fold risk), being Asian or Pacific Islander, increasing birth weight, operative vaginal delivery, episiotomy, and longer second stage of labor. Increasing body mass index was associated with fewer lacerations. Risk factors for cervical lacerations included young maternal age, vacuum vaginal delivery, and oxytocin use among multiparous women, and cerclage regardless of parity. Conclusion Our large cohort of women with severe obstetric lacerations reflects contemporary obstetric practices. Nulliparity and episiotomy use are important risk factors for third- or fourth-degree lacerations. Cerclage increases the risk for cervical lacerations. Many identified risk factors may not be modifiable. PMID:21343766

A proposed mother-friendly childbirth model for Taiwanese women, the implementation and satisfaction survey.

PubMed

Li, Yi-Ping; Yeh, Chih-Hsin; Lin, Shin-Yu; Chen, Tai-Chang; Yang, Ya-Ling; Lee, Chien-Nan; Kuo, Su-Chen

2015-12-01

Pleasant and humane childbirth is every mother's wish. We established one practicable and tailored Taiwanese mother-friendly childbirth model, and the objective of this study was to investigate the implementation, pregnancy outcomes, and women's satisfaction. We used the Taiwanese mother-friendly childbirth model. Women from eight hospitals were divided into an experimental group and control group. The experimental group received prenatal care modified by the Taiwanese mother-friendly childbirth model and the control group received routine prenatal care according to their hospital. We performed a quasi-experimental study of women's satisfaction toward this mother-friendly childbirth model by questionnaires and surveyed the practicality and effectiveness of this model. Seven hundred and fifty-one women from eight hospitals, including three medical centers and five regional hospitals were included. There was significantly different practices between the two groups, such as: (1) intermittent fetal monitoring for low-risk pregnancy; (2) no routine enema; (3) no perineal shaving; (4) less routine parenteral fluid support; (5) using an upright position; and (6) restrictive episiotomy. The mean maternal height, body weight gain, gestational age, birth weight, and episiotomy wound infection rate were indifferent. The epidural anesthesia rate and induction medication use were significantly lower in the experimental group. The self-reported pain score was higher in the experimental group and the self-reported satisfactory score was also higher in the experimental group, without statistical significance. Women receiving standardized prenatal care modified by the woman-friendly childbirth model of prenatal care had less epidural anesthesia, less induction medication, higher self-reported satisfaction score, and indifferent pregnancy outcomes such as gestational age, birth weight, and wound infection rate. Copyright © 2015. Published by Elsevier B.V.

Pelvic floor dysfunction, and effects of pregnancy and mode of delivery on pelvic floor.

PubMed

Bozkurt, Murat; Yumru, Ayşe Ender; Şahin, Levent

2014-12-01

Pelvic floor dysfunction (PFD), although seems to be simple, is a complex process that develops secondary to multifactorial factors. The incidence of PFD is increasing with increasing life expectancy. PFD is a term that refers to a broad range of clinical scenarios, including lower urinary tract excretory and defecation disorders, such as urinary and anal incontinence, overactive bladder, and pelvic organ prolapse, as well as sexual disorders. It is a financial burden on the health care system and disrupts women's quality of life. Strategies applied to decrease PFD are focused on the course of pregnancy, mode and management of delivery, and pelvic exercise methods. Many studies in the literature define traumatic birth, usage of forceps, length of the second stage of delivery, and sphincter damage as modifiable risk factors for PFD. Maternal age, fetal position, and fetal head circumference are nonmodifiable risk factors. Although numerous studies show that vaginal delivery affects pelvic floor structures and their functions in a negative way, there is not enough scientific evidence to recommend elective cesarean delivery in order to prevent development of PFD. PFD is a heterogeneous pathological condition, and the effects of pregnancy, vaginal delivery, cesarean delivery, and possible risk factors of PFD may be different from each other. Observational studies have identified certain obstetrical exposures as risk factors for pelvic floor disorders. These factors often coexist; therefore, the isolated effects of these variables on the pelvic floor are difficult to study. The routine use of episiotomy for many years in order to prevent PFD is not recommended anymore; episiotomy should be used in selected cases, and the mediolateral procedures should be used if needed. Copyright © 2014. Published by Elsevier B.V.

Position in the second stage of labour and de novo onset of post-partum urinary incontinence.

PubMed

Serati, Maurizio; Di Dedda, Maria Carmela; Bogani, Giorgio; Sorice, Paola; Cromi, Antonella; Uccella, Stefano; Lapenna, Martina; Soligo, Marco; Ghezzi, Fabio

2016-02-01

The aim of this study was to evaluate the role of the maternal position at the time of delivery on the onset of de novo symptoms of urinary incontinence (UI) in the post-partum period. This prospective study evaluated the data of consecutive women undergoing labour and delivery, between January 2014 and July 2014. We included only women with a singleton pregnancy undergoing vaginal delivery. During the study period, patients chose to deliver in the position that they considered the most comfortable. The onset of UI was evaluated according to the International Consultation on Incontinence Questionnaire-Short Form (ICIQ-sf). Overall, 716 primiparous women were included in the study. Sixty women refused the 12-week post-partum interview (8.4%). Women were divided in two groups: 296 women (45.1%) who chose an upright position during delivery (group 1) and 360 women (54.9%) who chose a supine position (group 2). Group 1 had a significantly lower episiotomy rate, but a higher rate of greater than second degree perineal tears. In group 1 we found a significantly lower rate of de novo UI (40.5% vs 48.9%, p = 0.03) and in particular of stress urinary incontinence. Via multivariate analysis, birth position was the only factor correlating with the occurrence of urinary incontinence in the post-partum period (OR: 1.52; 95%CI: 1.06, 2.18; p = 0.02). Upright positions at delivery are related to a lower episiotomy rate and a higher rate of greater than second degree perineal tears. Supine positions are an independent risk factor for the onset of de novo UI.

Sexual violence and mode of delivery: a population-based cohort study.

PubMed

Henriksen, L; Schei, B; Vangen, S; Lukasse, M

2014-09-01

This study aimed to explore the association between sexual violence and mode of delivery. National cohort study. Women presenting for routine ultrasound examinations were recruited to the Norwegian Mother and Child Cohort Study between 1999 and 2008. A total of 74,059 pregnant women. Sexual violence was self-reported during pregnancy using postal questionnaires. Mode of delivery, other maternal birth outcomes and covariates were retrieved from the Medical Birth Registry of Norway. Risk estimations were performed using multivariable logistic regression analysis. Mode of delivery and selected maternal birth outcomes. Of 74,059 women, 18.4% reported a history of sexual violence. A total of 10% had an operative vaginal birth, 4.9% had elective caesarean section and 8.6% had an emergency caesarean section. Severe sexual violence (rape) was associated with elective caesarean section, adjusted odds ratio (AOR) 1.56 (95% CI 1.18-2.05) for nulliparous women and 1.37 (1.06-1.76) for multiparous women. Those exposed to moderate sexual violence had a higher risk of emergency caesarean section, AOR 1.31 (1.07-1.60) and 1.41 (1.08-1.84) for nulliparous and multiparous women, respectively. No association was found between sexual violence and operative vaginal birth, except for a lower risk among multiparous women reporting mild sexual violence, AOR 0.73 (0.60-0.89). Analysis of other maternal outcomes showed a reduced risk of episiotomy for women reporting rape and a higher frequency of induced labour. Women with a history of rape had higher odds of elective caesarean section and induction and significantly fewer episiotomies. © 2014 Royal College of Obstetricians and Gynaecologists.

Audit and feedback: effects on professional obstetrical practice and healthcare outcomes in a university hospital.

PubMed

Costa, Maria L; Cecatti, Jose G; Milanez, Helaine M; Souza, Joao P; Gülmezoglu, Metin

2009-01-01

To assess the effects of audit and feedback on the practice of professionals in obstetrics. Before-after intervention study. Obstetric unit of a university hospital in Brazil. Before the intervention the prevalence rates of six evidence-based interventions were assessed. Seminars and workshops were administered, with the baseline results and also the main contents from systematic reviews on the topics studied, followed by detailed discussion of each topic, based on the Reproductive Health Library. After four months, the same practices were measured again and compared with the pre-intervention period. Selective episiotomy; continuous electronic fetal monitoring (EFM) during labor of low-risk pregnant women; antibiotic prophylaxis in cesarean section; active management of third stage of labor; routine induction of labor at 41 weeks for uncomplicated pregnancies; and continuous support for women during childbirth. Both periods showed a similar number and mode of deliveries. There was a significant reduction in episiotomies (RR = 0.84; 0.73-0.97) and an increase in continuous support for women during childbirth by a companion (RR = 1.42; 1.24-1.63). Although there was not a significant change in the use of oxytocin during the third stage of labor, there was a shift to the internationally recommended dosage of 10 IU (p<0.0001). There was no significant change in the use of antibiotic prophylaxis for cesarean section, continuous EFM, or routine induction of labor at 41 weeks for uncomplicated pregnancies. Audit and feedback can be used as a tool to improve obstetrical practice, at least for some interventions and when the medical staff is open and receptive to change.

[Analysis of maternal morbidity and mortality in Slovak Republic in the years 2007-2012].

PubMed

Korbeľ, M; Krištúfková, A; Dugátová, M; Daniš, J; Némethová, B; Kaščák, P; Nižňanská, Z

Analysis of maternal morbidity and mortality in Slovak Republic (SR) in the years 2007-2012. Epidemiological perinatological nation-wide. 1st Department of Gynaecology and Obstetrics School of Medicine, Comenius University and University Hospital, Bratislava, Slovak Republic. The analysis of selected maternal morbidity and mortality data prospective collected in the years 2007-2012 from all obstetrics hospitals in the Slovak Republic. Caesarean section rate progressively increased from 24.1% in the year 2007 up to 30.3% in the year 2012. In the year 2012 the frequency of vacuum-extraction was 1.4%, forceps 0.6%, perineal tears 3th and 4th degree 0.49% and episiotomy 65%. Incidence of total severe acute maternal morbidity was 6.34 per 1,000 births. Incidence (per 1,000 births) of transport to anaesthesiology department/intensive care unit was 2.32, postpartum hysterectomy 0.72, HELLP syndrome 0.63, eclampsia 0.29, abnormal placental invasion 0.37, uterine rupture 0.27, severe sepsis in pregnancy and puerperium 0.21. In the years 2007-2012 frequency of fatal amniotic fluid embolism was 2.46/100,000 maternities or 2.43/100,000 live-births. Maternal mortality ratio in this period was 14 per 100,000 live births and pregnancy-related deaths ratio was 11.9 per 100,000 live births. In the year 2012 Slovakia reached the highest caesarean section rate in her own history - 30.3%. Incidence of severe acute maternal morbidity was 6.34 per 1,000 births. Maternal mortality ratio in Slovakia was one of the highest in European Union. Decreasing of caesarean section rate and episiotomy, incidence of severe acute maternal morbidity and maternal mortality still need to be improved in Slovak Republic.

[The risk of infection to the mother prior, during and after delivery. A registration of nosocomial infections].

PubMed

Hirsch, H A; Niehues, U

1982-09-01

During 5 1/2 years all infections arising in the hospital (nosocomial infections) were registered prospectively by an infection control nurse. The incidence of all nosocomial infections in 3192 maternity patients was 2.1%. In 10,569 women following vaginal deliveries 2.6% and in 1,353 women following Caesarean section 21.1%. The commonest infections were urinary tract infections, endometritis, infections of the abdominal wound or the episiotomy, and a phlebitis of the intravenous infusion site. Measures to prevent infection resulted in a steadily decreasing incidence of infections during the 6 years of registration of nosocomial infections.

The case for reassessment of health care technology. Once is not enough.

PubMed

Banta, H D; Thacker, S B

1990-07-11

Assessment of health care technologies should be an iterative process, not a single event. In the United States there are an increasing number of organized attempts at reassessment of technologies by the health industry, professional societies, and national government agencies, such as the Medical Necessity Project of Blue Cross/Blue Shield, the Clinical Efficacy Assessment Project of the American College of Physicians, and the work of the US Preventive Services Task Force. We examine four clinical practices--electronic fetal monitoring, episiotomy, electroencephalography, and hysterectomy--to illustrate the need to continuously reassess existing technologies and to challenge our current inertia in this critical arena of health practice.

Giant primary vaginal calculus secondary to vesicovaginal fistula with partial vaginal outlet obstruction in a 12-year-old girl.

PubMed

Chen, Shushang; Ge, Rong; Zhu, Lingfeng; Yang, Shunliang; Wu, Weizhen; Yang, Yin; Tan, Jianming

2011-10-01

A vesicovaginal fistula with vagina obstruction associated with vaginal calculi is an extremely rare medical condition. We report a giant primary vaginal calculus resulting from vesicovaginal fistula with partial vaginal outlet obstruction secondary to perineum trauma and surgery in a 12-year-old girl. Episiotomy was performed and the adhesive labia minora was split. After the removal of a giant calculus in the vagina, approximately 8 cm in diameter, the fistula tract was completely excised, followed by the repair of the vesicovagina fistula and the vagina. The patient was symptom-free at 6-month follow-up examination. Copyright © 2011 Elsevier Inc. All rights reserved.

[Group G streptococcal bacteremia in the post-partum period. A case report].

PubMed

Verdonk, C; Botto, J-N; Worcel, I

2014-03-01

Bacteremia with streptococcus group G is a rare infection, particularly in the post-partum, but of which the incidence has been increasing since the end of the 20th century. The objective of our work is to report the clinical and the bacteriologic aspects, as well as the therapeutic modalities of an exceptional case of bacteremia with streptococcus group G, after a normal vaginal delivery, in a 26-year-old woman. Streptococcus group G being a part of the normal flora of the female genital tract, the endogenous contamination probably took place by passage in the blood circulation during the episiotomy. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

Perineal techniques during the second stage of labour for reducing perineal trauma.

PubMed

Aasheim, Vigdis; Nilsen, Anne Britt Vika; Reinar, Liv Merete; Lukasse, Mirjam

2017-06-13

Most vaginal births are associated with trauma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including perineal massage, warm or cold compresses, and perineal management techniques have been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011. To assess the effect of perineal techniques during the second stage of labour on the incidence and morbidity associated with perineal trauma. We searched Cochrane Pregnancy and Childbirth's Trials Register (26 September 2016) and reference lists of retrieved studies. Published and unpublished randomised and quasi-randomised controlled trials evaluating perineal techniques during the second stage of labour. Cross-over trials were not eligible for inclusion. Three review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. We checked data for accuracy. Twenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Overall, trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques.Most studies did not report data on our secondary outcomes. We downgraded evidence for risk of bias, inconsistency, and imprecision for all comparisons. Hands off (or poised) compared to hands onHands on or hands off the perineum made no clear difference in incidence of intact perineum (average risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.12, two studies, Tau² 0.00, I² 37%, 6547 women; moderate-quality evidence), first-degree perineal tears (average RR 1.32, 95% CI 0.99 to 1.77, two studies, 700 women; low-quality evidence), second-degree tears (average RR 0.77, 95% CI 0.47 to 1.28, two studies, 700 women; low-quality evidence), or third- or fourth-degree tears (average RR 0.68, 95% CI 0.21 to 2.26, five studies, Tau² 0.92, I² 72%, 7317 women; very low-quality evidence). Substantial heterogeneity for third- or fourth-degree tears means these data should be interpreted with caution. Episiotomy was more frequent in the hands-on group (average RR 0.58, 95% CI 0.43 to 0.79, Tau² 0.07, I² 74%, four studies, 7247 women; low-quality evidence), but there was considerable heterogeneity between the four included studies.There were no data for perineal trauma requiring suturing. Warm compresses versus control (hands off or no warm compress)A warm compress did not have any clear effect on the incidence of intact perineum (average RR 1.02, 95% CI 0.85 to 1.21; 1799 women; four studies; moderate-quality evidence), perineal trauma requiring suturing (average RR 1.14, 95% CI 0.79 to 1.66; 76 women; one study; very low-quality evidence), second-degree tears (average RR 0.95, 95% CI 0.58 to 1.56; 274 women; two studies; very low-quality evidence), or episiotomy (average RR 0.86, 95% CI 0.60 to 1.23; 1799 women; four studies; low-quality evidence). It is uncertain whether warm compress increases or reduces the incidence of first-degree tears (average RR 1.19, 95% CI 0.38 to 3.79; 274 women; two studies; I² 88%; very low-quality evidence).Fewer third- or fourth-degree perineal tears were reported in the warm-compress group (average RR 0.46, 95% CI 0.27 to 0.79; 1799 women; four studies; moderate-quality evidence). Massage versus control (hands off or routine care)The incidence of intact perineum was increased in the perineal-massage group (average RR 1.74, 95% CI 1.11 to 2.73, six studies, 2618 women; I² 83% low-quality evidence) but there was substantial heterogeneity between studies). This group experienced fewer third- or fourth-degree tears (average RR 0.49, 95% CI 0.25 to 0.94, five studies, 2477 women; moderate-quality evidence).There were no clear differences between groups for perineal trauma requiring suturing (average RR 1.10, 95% CI 0.75 to 1.61, one study, 76 women; very low-quality evidence), first-degree tears (average RR 1.55, 95% CI 0.79 to 3.05, five studies, Tau² 0.47, I² 85%, 537 women; very low-quality evidence), or second-degree tears (average RR 1.08, 95% CI 0.55 to 2.12, five studies, Tau² 0.32, I² 62%, 537 women; very low-quality evidence). Perineal massage may reduce episiotomy although there was considerable uncertainty around the effect estimate (average RR 0.55, 95% CI 0.29 to 1.03, seven studies, Tau² 0.43, I² 92%, 2684 women; very low-quality evidence). Heterogeneity was high for first-degree tear, second-degree tear and for episiotomy - these data should be interpreted with caution. Ritgen's manoeuvre versus standard careOne study (66 women) found that women receiving Ritgen's manoeuvre were less likely to have a first-degree tear (RR 0.32, 95% CI 0.14 to 0.69; very low-quality evidence), more likely to have a second-degree tear (RR 3.25, 95% CI 1.73 to 6.09; very low-quality evidence), and neither more nor less likely to have an intact perineum (RR 0.17, 95% CI 0.02 to 1.31; very low-quality evidence). One larger study reported that Ritgen's manoeuvre did not have an effect on incidence of third- or fourth-degree tears (RR 1.24, 95% CI 0.78 to 1.96,1423 women; low-quality evidence). Episiotomy was not clearly different between groups (RR 0.81, 95% CI 0.63 to 1.03, two studies, 1489 women; low-quality evidence). Other comparisonsThe delivery of posterior versus anterior shoulder first, use of a perineal protection device, different oils/wax, and cold compresses did not show any effects on perineal outcomes. Only one study contributed to each of these comparisons, so data were insufficient to draw conclusions. Moderate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent. Poor-quality evidence suggests hands-off techniques may reduce episiotomy, but this technique had no clear impact on other outcomes. There were insufficient data to show whether other perineal techniques result in improved outcomes.Further research could be performed evaluating perineal techniques, warm compresses and massage, and how different types of oil used during massage affect women and their babies. It is important for any future research to collect information on women's views.

Anal incontinence after childbirth

PubMed Central

Eason, Erica; Labrecque, Michel; Marcoux, Sylvie; Mondor, Myrto

2002-01-01

Background Incontinence of stool and flatus are frequent complications of childbirth. We examined the prevalence and possible causes of these adverse outcomes in a large cohort of women. Methods We studied 949 pregnant women who gave birth in 5 hospitals in 1995/96 in the province of Quebec. These women, participants in a randomized controlled trial of prenatal perineal massage, completed a self-administered questionnaire 3 months after giving birth. Results Three months after delivery 29 women (3.1%) reported incontinence of stool, and 242 (25.5%) had involuntary escape of flatus. Incontinence of stool was more frequent among women who delivered vaginally and had third- or fourth-degree perineal tears than among those who delivered vaginally and had no anal sphincter tears (7.8% v. 2.9%). Forceps delivery (adjusted risk ratio [RR] 1.45, 95% confidence interval [CI] 1.01–2.08) and anal sphincter tears (adjusted RR 2.09, 95% CI 1.40–3.13) were independent risk factors for incontinence of flatus or stool or both. Anal sphincter injury was strongly and independently associated with first vaginal birth (RR 39.2, 95% CI 5.4–282.5), median episiotomy (adjusted RR 9.6, 95% CI 3.2–28.5), forceps delivery (adjusted RR 12.3, 95% CI 3.0–50.4) and vacuum-assisted delivery (adjusted RR 7.4, 95% CI 1.9–28.5) but not with birth weight (adjusted RR for birth weight 4000 g or more: 1.4, 95% CI 0.6–3.0) or length of the second stage of labour (adjusted RR for second stage 1.5 hours or longer compared with less than 0.5 hours: 1.2, 95% CI 0.5–2.7). Interpretation Anal incontinence is associated with forceps delivery and anal sphincter laceration. Anal sphincter laceration is strongly predicted by first vaginal birth, median episiotomy, and forceps or vacuum delivery but not by birth weight or length of the second stage of labour. PMID:11868640

Anal incontinence after childbirth.

PubMed

Eason, Erica; Labrecque, Michel; Marcoux, Sylvie; Mondor, Myrto

2002-02-05

Incontinence of stool and flatus are frequent complications of childbirth. We examined the prevalence and possible causes of these adverse outcomes in a large cohort of women. We studied 949 pregnant women who gave birth in 5 hospitals in 1995/96 in the province of Quebec. These women, participants in a randomized controlled trial of prenatal perineal massage, completed a self-administered questionnaire 3 months after giving birth. Three months after delivery 29 women (3.1%) reported incontinence of stool, and 242 (25.5%) had involuntary escape of flatus. Incontinence of stool was more frequent among women who delivered vaginally and had third- or fourth-degree perineal tears than among those who delivered vaginally and had no anal sphincter tears (7.8% v. 2.9%). Forceps delivery (adjusted risk ratio [RR] 1.45, 95% confidence interval [CI] 1.01-2.08) and anal sphincter tears (adjusted RR 2.09, 95% CI 1.40-3.13) were independent risk factors for incontinence of flatus or stool or both. Anal sphincter injury was strongly and independently associated with first vaginal birth (RR 39.2, 95% CI 5.4-282.5), median episiotomy (adjusted RR 9.6, 95% CI 3.2-28.5), forceps delivery (adjusted RR 12.3, 95% CI 3.0-50.4) and vacuum-assisted delivery (adjusted RR 7.4, 95% CI 1.9-28.5) but not with birth weight (adjusted RR for nirth weight 4000 g or more: 1.4, 95% CI 0.6-3.0) or length of the second stage of labour (adjusted RR for second stage 1.5 hours or longer compared with less than 0.5 hours: 1.2, 95% CI 0.5-2.7). Anal incontinence is associated with forceps delivery and anal sphincter laceration. Anal sphincter laceration is strongly predicted by first vaginal birth, median episiotomy, and forceps or vacuum delivery but not by birth weight or length of the second stage of labour.

Bacterial Profile, Antibacterial Resistance Pattern, and Associated Factors from Women Attending Postnatal Health Service at University of Gondar Teaching Hospital, Northwest Ethiopia.

PubMed

Bitew Kifilie, Abebaw; Dagnew, Mulat; Tegenie, Birhanemeskel; Yeshitela, Biruk; Howe, Rawleigh; Abate, Ebba

2018-01-01

Surgical site infection is a vital cause of maternal mortality and morbidity, especially in resource-limited countries. The rise of antibiotic resistance bacterial infection poses a big threat to this vulnerable population. However, there is lack of studies around the study area. The purpose of this study was to identify bacterial profile, antibacterial resistance pattern, and associated factors among mothers attending postnatal care health service. Institutional based cross-sectional study was conducted on 107 study participants at University of Gondar Teaching Hospital from 1 January 2016 to 30 May 2016. Wound swab, aspirate, and biopsy were collected and performed for culture and drug resistance testing. Data were entered and analyzed by using SPSS version 20. Bivariate and multivariate logistic regression models were fitted to determine the associated factors for bacterial infection. Odds ratio (95% CI) was calculated to determine the strength of statistically significant associated factors. Bacterial growth was confirmed in 90 (84.1%) of 107 study participants suspected to have surgical site infection. The predominant bacterial isolates were S. aureus (41.6%), E. coli (19.8%), K. pneumoniae (13.9%), coagulase negative Staphylococcus (12.9%), and Enterobacter spp. (4%). The majority of isolates were resistant to ampicillin, amoxicillin, and tetracycline but susceptible to ceftriaxone and amikacin. Multidrug-resistant bacteria species were isolated. Using a procedure such as cesarean section and episiotomy for delivery and premature rapture of membrane had strong association with bacterial infection. The high prevalence of bacterial profile and isolation of multidrug-resistant bacteria pose a big threat to postnatal mothers and their children. Factors such as cesarean section, episiotomy for delivery, and premature rapture of membrane were predictors for bacterial infection. Therefore, there should be done a continuous surveillance as well as rational use of antibiotics and a longitudinal study using phenotypic and genotypic methods will be done.

Mode of birth and medical interventions among women at low risk of complications: A cross-national comparison of birth settings in England and the Netherlands.

PubMed

de Jonge, Ank; Peters, Lilian; Geerts, Caroline C; van Roosmalen, Jos J M; Twisk, Jos W R; Brocklehurst, Peter; Hollowell, Jennifer

2017-01-01

To compare mode of birth and medical interventions between broadly equivalent birth settings in England and the Netherlands. Data were combined from the Birthplace study in England (from April 2008 to April 2010) and the National Perinatal Register in the Netherlands (2009). Low risk women in England planning birth at home (16,470) or in freestanding midwifery units (11,133) were compared with Dutch women with planned home births (40,468). Low risk English women with births planned in alongside midwifery units (16,418) or obstetric units (19,096) were compared with Dutch women with planned midwife-led hospital births (37,887). CS rates varied across planned births settings from 6.5% to 15.5% among nulliparous and 0.6% to 5.1% among multiparous women. CS rates were higher among low risk nulliparous and multiparous English women planning obstetric unit births compared to Dutch women planning midwife-led hospital births (adjusted (adj) OR 1.89 (95% CI 1.64 to 2.18) and 3.66 (2.90 to 4.63) respectively). Instrumental vaginal birth rates varied from 10.7% to 22.5% for nulliparous and from 0.9% to 5.7% for multiparous women. Rates were lower in the English comparison groups apart from planned births in obstetric units. Transfer, augmentation and episiotomy rates were much lower in England compared to the Netherlands for all midwife-led groups. In most comparisons, epidural rates were higher among English groups. When considering maternal outcomes, findings confirm advantages of giving birth in midwife-led settings for low risk women. Further research is needed into strategies to decrease rates of medical intervention in obstetric units in England and to reduce rates of avoidable transfer, episiotomy and augmentation of labour in the Netherlands.

Does the Finnish intervention prevent obstetric anal sphincter injuries? A systematic review of the literature

PubMed Central

Poulsen, Mette Østergaard; Madsen, Mia Lund; Skriver-Møller, Anne-Cathrine; Overgaard, Charlotte

2015-01-01

Objectives A rise in obstetric anal sphincter injuries (OASIS) has been observed and a preventive approach, originating in Finland, has been introduced in several European hospitals. The aim of this paper was to systematically evaluate the evidence behind the ‘Finnish intervention’. Design A systematic review of the literature conducted according to the Preferred Reporting for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Outcome measures The primary outcome was OASIS. Secondary outcomes were (perinatal): Apgar scores, pH and standard base excess in the umbilical cord, and (maternal): episiotomy, intact perineum, first and second-degree perineal lacerations, duration of second stage, birth position and women's perceptions/birth experiences. Methods Multiple databases (Cochrane, Embase, Pubmed and SveMed) were systematically searched for studies published up to December 2014. Both randomised controlled trials and observational studies were eligible for inclusion. Studies were excluded if a full-text article was not available. Studies were evaluated by use of international reporting guidelines (eg, STROBE). Results Overall, 1042 articles were screened and 65 retrieved for full-text evaluation. Seven studies, all observational and with a level of evidence at 2c or lower, were included and consistently reported a significant reduction in OASIS. All evaluated episiotomy and found a significant increase. Three studies evaluated perinatal outcomes and reported conflicting results. No study reported on other perineal outcomes, duration of the second stage, birth positions or women's perceptions. Conclusions A reduction in OASIS has been contributed to the Finnish intervention in seven observational studies, all with a low level of evidence. Knowledge about the potential perinatal and maternal side effects and women's perceptions of the intervention is extremely limited and the biological mechanisms underlying the Finnish intervention are not well documented. Studies with a high level of evidence are needed to assess the effects of the intervention before implementation in clinical settings can be recommended. PMID:26369797

Anal sphincter injury in vaginal deliveries complicated by shoulder dystocia.

PubMed

Hehir, Mark P; Rubeo, Zachary; Flood, Karen; Mardy, Anne H; O'Herlihy, Colm; Boylan, Peter C; D'Alton, Mary E

2018-03-01

Shoulder dystocia is an obstetric emergency that occurs in 0.2-3% of all cephalic vaginal deliveries. We hypothesized that because of the difficult nature of deliveries complicated by shoulder dystocia, the condition may be associated with anal sphincter injury. We sought to identify risk factors for obstetric anal sphincter injury in women with shoulder dystocia. This retrospective analysis included all cases of shoulder dystocia from 2007 to 2011 at two large tertiary referral centers, in the USA and Ireland. Details of maternal demographics, intrapartum characteristics, and delivery outcomes in cases of shoulder dystocia were analyzed. Univariate and multivariate analyses were used to describe the association between shoulder dystocia and anal sphincter injury. There were 685 cases of shoulder dystocia, and the rate of shoulder dystocia was similar at both institutions. The incidence of anal sphincter injury was 8.8% (60 out of 685). The rate was 14% (45 out of 324) in nulliparas and 4.2% (15 out of 361) in multiparas. Women with sphincter injury were more likely to be nulliparous (75% [45 out of 60] vs 45% [279 out of 625]; p < 0.0001), have had an operative vaginal delivery (50% [30 out of 60] vs 36% [226 out of 625]; p = 0.03) and require internal maneuvers (50% [30 out of 60] vs 32% [198 out of 625], p = 0.004) than those with an intact sphincter. On multivariate regression analysis, these predictors of sphincter injury remained significant when adjusted for other risk factors. Episiotomy was negatively associated with sphincter injury on multivariate regression analysis. In a retrospective cohort of 685 women with shoulder dystocia, the risk of anal sphincter injury is 9%. Risk factors include nulliparity, operative vaginal delivery, and use of internal maneuvers, whereas episiotomy was found to have a protective effect against anal sphincter injury during cases of shoulder dystocia.

Effect of a population-level performance dashboard intervention on maternal-newborn outcomes: an interrupted time series study.

PubMed

Weiss, Deborah; Dunn, Sandra I; Sprague, Ann E; Fell, Deshayne B; Grimshaw, Jeremy M; Darling, Elizabeth; Graham, Ian D; Harrold, JoAnn; Smith, Graeme N; Peterson, Wendy E; Reszel, Jessica; Lanes, Andrea; Walker, Mark C; Taljaard, Monica

2018-06-01

To assess the effect of the Maternal Newborn Dashboard on six key clinical performance indicators in the province of Ontario, Canada. Interrupted time series using population-based data from the provincial birth registry covering a 3-year period before implementation of the Dashboard and 2.5 years after implementation (November 2009 through March 2015). All hospitals in the province of Ontario providing maternal-newborn care (n=94). A hospital-based online audit and feedback programme. Rates of the six performance indicators included in the Dashboard. 2.5 years after implementation, the audit and feedback programme was associated with statistically significant absolute decreases in the rates of episiotomy (decrease of 1.5 per 100 women, 95% CI 0.64 to 2.39), induction for postdates in women who were less than 41 weeks at delivery (decrease of 11.7 per 100 women, 95% CI 7.4 to 16.0), repeat caesarean delivery in low-risk women performed before 39 weeks (decrease of 10.4 per 100 women, 95% CI 9.3 to 11.5) and an absolute increase in the rate of appropriately timed group B streptococcus screening (increase of 2.8 per 100, 95% CI 2.2 to 3.5). The audit and feedback programme did not significantly affect the rates of unsatisfactory newborn screening blood samples or formula supplementation at discharge. No statistically significant effects were observed for the two internal control outcomes or the four external control indicators-in fact, two external control indicators (episiotomy and postdates induction) worsened relative to before implementation. An electronic audit and feedback programme implemented in maternal-newborn hospitals was associated with clinically relevant practice improvements at the provincial level in the majority of targeted indicators. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Are recent graduates enough prepared to perform obstetric skills in their rural and compulsory year? A study from Ecuador.

PubMed

Sánchez Del Hierro, Galo; Remmen, Roy; Verhoeven, Veronique; Van Royen, Paul; Hendrickx, Kristin

2014-07-31

The aim of this study was to assess the possible mismatch of obstetrical skills between the training offered in Ecuadorian medical schools and the tasks required for compulsory rural service. Primary care, rural health centres in Southern Ecuador. A total of 92 recent graduated medical doctors during their compulsory rural year. A web-based survey was developed with 21 obstetrical skills. The questionnaire was sent to all rural doctors who work in Loja province, Southern Ecuador, at the Ministry of Health (n=92). 'importance of skills in rural practice' with a five-point Likert-type scale (1= strongly disagree; 5= strongly agree); and 'clerkship experience' using a nominal scale divided in five levels: level 1 (not seen, not performed) to level 5 (performed 10 times or more). Spearman's rank correlation coefficient (r) was used to observe associations. A negative correlation was found in the skills: 'episiotomy and repair', 'umbilical vein catheterisation', 'speculum examination', 'evaluation of cervical dilation during active labour', 'neonatal resuscitation' and 'vacuum-assisted vaginal delivery'. For instance 'Episiotomy and repair' is important (strongly agree and agree) to 100% of respondents, but in practice, only 38.9% of rural doctors performed the task three times and 8.3% only once during the internship, similar pattern is seen in the others. In this study we have noted the gap between the medical needs of populations in rural areas and training provided during the clerkship experiences of physicians during their rural service year. It is imperative to ensure that rural doctors are appropriately trained and skilled in the performance of routine obstetrical duties. This will help to decrease perinatal morbidity and mortality in rural Ecuador. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Are recent graduates enough prepared to perform obstetric skills in their rural and compulsory year? A study from Ecuador

PubMed Central

Sánchez del Hierro, Galo; Remmen, Roy; Verhoeven, Veronique; Van Royen, Paul; Hendrickx, Kristin

2014-01-01

Objectives The aim of this study was to assess the possible mismatch of obstetrical skills between the training offered in Ecuadorian medical schools and the tasks required for compulsory rural service. Setting Primary care, rural health centres in Southern Ecuador. Participants A total of 92 recent graduated medical doctors during their compulsory rural year. Primary and secondary outcomes measures A web-based survey was developed with 21 obstetrical skills. The questionnaire was sent to all rural doctors who work in Loja province, Southern Ecuador, at the Ministry of Health (n=92). We measured two categories ‘importance of skills in rural practice’ with a five-point Likert-type scale (1= strongly disagree; 5= strongly agree); and ‘clerkship experience’ using a nominal scale divided in five levels: level 1 (not seen, not performed) to level 5 (performed 10 times or more). Spearman's rank correlation coefficient (r) was used to observe associations. Results A negative correlation was found in the skills: ‘episiotomy and repair’, ‘umbilical vein catheterisation’, ‘speculum examination’, ‘evaluation of cervical dilation during active labour’, ‘neonatal resuscitation’ and ‘vacuum-assisted vaginal delivery’. For instance ‘Episiotomy and repair’ is important (strongly agree and agree) to 100% of respondents, but in practice, only 38.9% of rural doctors performed the task three times and 8.3% only once during the internship, similar pattern is seen in the others. Conclusions In this study we have noted the gap between the medical needs of populations in rural areas and training provided during the clerkship experiences of physicians during their rural service year. It is imperative to ensure that rural doctors are appropriately trained and skilled in the performance of routine obstetrical duties. This will help to decrease perinatal morbidity and mortality in rural Ecuador. PMID:25082424

Mode of birth and medical interventions among women at low risk of complications: A cross-national comparison of birth settings in England and the Netherlands

PubMed Central

Peters, Lilian; Geerts, Caroline C.; van Roosmalen, Jos J. M.; Twisk, Jos W. R.; Brocklehurst, Peter; Hollowell, Jennifer

2017-01-01

Objectives To compare mode of birth and medical interventions between broadly equivalent birth settings in England and the Netherlands. Methods Data were combined from the Birthplace study in England (from April 2008 to April 2010) and the National Perinatal Register in the Netherlands (2009). Low risk women in England planning birth at home (16,470) or in freestanding midwifery units (11,133) were compared with Dutch women with planned home births (40,468). Low risk English women with births planned in alongside midwifery units (16,418) or obstetric units (19,096) were compared with Dutch women with planned midwife-led hospital births (37,887). Results CS rates varied across planned births settings from 6.5% to 15.5% among nulliparous and 0.6% to 5.1% among multiparous women. CS rates were higher among low risk nulliparous and multiparous English women planning obstetric unit births compared to Dutch women planning midwife-led hospital births (adjusted (adj) OR 1.89 (95% CI 1.64 to 2.18) and 3.66 (2.90 to 4.63) respectively). Instrumental vaginal birth rates varied from 10.7% to 22.5% for nulliparous and from 0.9% to 5.7% for multiparous women. Rates were lower in the English comparison groups apart from planned births in obstetric units. Transfer, augmentation and episiotomy rates were much lower in England compared to the Netherlands for all midwife-led groups. In most comparisons, epidural rates were higher among English groups. Conclusions When considering maternal outcomes, findings confirm advantages of giving birth in midwife-led settings for low risk women. Further research is needed into strategies to decrease rates of medical intervention in obstetric units in England and to reduce rates of avoidable transfer, episiotomy and augmentation of labour in the Netherlands. PMID:28749944

Ibuprofen versus acetaminophen with codeine for the relief of perineal pain after childbirth: a randomized controlled trial

PubMed Central

Peter, Elizabeth A.; Janssen, Patricia A.; Grange, Caroline S.; Douglas, M. Joanne

2001-01-01

Background Pain from episiotomy or tearing of perineal tissues during childbirth is often poorly treated and may be severe. This randomized double-blind controlled trial was performed to compare the effectiveness, side effects and cost of, and patient preference for, 2 analgesics for the management of postpartum perineal pain. Methods A total of 237 women who gave birth vaginally with episiotomy or a third- or fourth-degree tear between August 1995 and November 1996 at a tertiary-level teaching and referral centre for obstetric care in Vancouver were randomly assigned to receive either ibuprofen (400 mg) (n = 127) or acetaminophen (600 mg) with codeine (60 mg) and caffeine (15 mg) (Tylenol No. 3) (n = 110), both given orally every 4 hours as necessary. Pain ratings were recorded before the first dose and at 1, 2, 3, 4, 12 and 24 hours after the first dose on a 10-cm visual analogue scale. Side effects and overall opinion were assessed at 24 hours. Results Ibuprofen and acetaminophen with codeine had similar analgesic properties in the first 24 hours post partum (mean pain rating 3.4 and 3.3, mean number of doses in 24 hours 3.4 and 3.3, and proportion of treatment failures 13.8% [16/116] and 16.0% [16/100] respectively). Significantly fewer subjects in the ibuprofen group than in the acetaminophen with codeine group experienced side effects (52.4% v. 71.7%) (p = 0.006). There were no significant differences in overall patient satisfaction between the 2 groups. The major determinant of pain intensity was forceps-assisted delivery. Overall, 78% of the treatment failures were in women with forceps-assisted deliveries. Interpretation Since the 2 analgesics were rated similarly, ibuprofen may be the preferred choice because it is less expensive and requires less nursing time to dispense. Further studies need to address improved analgesia for women with forceps-assisted deliveries. PMID:11706909

A Case of Toxic Breast-feeding?

PubMed

Schultz, Megan L; Kostic, Mark; Kharasch, Sigmund

2017-01-06

Opiates are frequently prescribed postpartum for pain relief after cesarean delivery, episiotomies, and headaches. It is estimated that greater than 30% of breast-feeding mothers in the United States are prescribed opiates for pain relief associated with childbirth. Many opiates are readily transferred to human milk, although life-threatening events are rare. We report a 6-day-old breast-feeding infant whose mother was taking hydromorphone for pain relief from a cesarean delivery and whose clinical course was suggestive of opiate toxicity. This case emphasizes the importance of thorough medication history taking in postpartum breast-feeding mothers whose infants may present with symptoms of opiate toxicity. Semisynthetic opiates are frequently not detected on emergency department urine toxicology screens. The pertinent literature is reviewed.

[Childbirth in multiparae].

PubMed

Pilić, Z; Sulović, V; Dukić, M; Trajković, L

1978-01-01

The authors present problems of multiparity in women with four or more deliveries, by analysing the course of delivery in these women. To this end they made a retrospective study of 299 such deliveries, by comparing them with 100 randomly selected primiparae from the same period. The results have shown as follows: The incidence of multiparae is about 1.04%; multiparae are significantly older than primapare; multiparae have a larger of spontaneous deliveries, whereas directed and induced labour proved more frequent in primiparae; in primiparae there are significantly more interventions in the course of labour (episiotomy and manual revision of the uterine cavity); labour in multiparae lasts less and their offspring has less wight and less vitality (more at risk); stillborns are four times as frequent in multiparae (3.68%) as is the general rate of mortality (0.94%).

The impact of occiput posterior fetal head position on the risk of anal sphincter injury in forceps-assisted vaginal deliveries.

PubMed

Benavides, Lorena; Wu, Jennifer M; Hundley, Andrew F; Ivester, Thomas S; Visco, Anthony G

2005-05-01

A forceps-assisted vaginal delivery is a well-recognized risk factor for anal sphincter injury. Some studies have shown that occiput posterior (OP) fetal head position is also associated with an increased risk for third- or fourth-degree lacerations. The objective of this study was to assess whether OP position confers an incrementally increased risk for anal sphincter injury above that present with forceps deliveries. This was a retrospective cohort study of 588 singleton, cephalic, forceps-assisted vaginal deliveries performed at our institution between January 1996 and October 2003. Maternal demographics, labor and delivery characteristics, and neonatal factors were examined. Statistical analysis consisted of univariate statistics, Student t test, chi2, and logistic regression. The prevalence of occiput anterior (OA) and OP positions was 88.4% and 11.6%, respectively. The groups were similar in age, marital status, body mass index, use of epidural, frequency of inductions, episiotomies, and shoulder dystocias. The OA group had a higher frequency of rotational forceps (16.2% vs 5.9%, P = .03), greater birth weights (3304 +/- 526 g vs 3092 +/- 777 g, P = .004), and a larger percentage of white women (48.8% vs 34.3%, P = .04). Overall, 35% of forceps deliveries resulted in a third- or fourth-degree laceration. Anal sphincter injury occurred significantly more often in the OP group compared with the OA group (51.5% vs 32.9%, P = .003), giving an odds ratio of 2.2 (CI: 1.3-3.6). In a logistic regression model that controlled for occiput posterior position, maternal body mass index, race, length of second stage, episiotomy, birth weight, and rotational forceps, OP head position was 3.1 (CI: 1.6-6.2) times more likely to be associated with anal sphincter injury than OA head position. Forceps-assisted vaginal deliveries have been associated with a greater risk for anal sphincter injury. Within this population of forceps deliveries, an OP position further increases the risk of third- or fourth-degree lacerations when compared with an OA position.

PROMOTE Study: Safety of Osteopathic Manipulative Treatment During the Third Trimester by Labor and Delivery Outcomes.

PubMed

Hensel, Kendi L; Roane, Brandy M; Chaphekar, Anita Vikas; Smith-Barbaro, Peggy

2016-11-01

Few quality data exist on the safety of osteopathic manipulative treatment (OMT) during pregnancy. The Pregnancy Research on Osteopathic Manipulation Optimizing Treatment Effects (PROMOTE) study was a randomized controlled clinical trial that studied the application of an OMT protocol to manage pain and dysfunction in pregnant patients during their third trimester. To evaluate the safety of an OMT protocol applied during the third trimester of pregnancy by analyzing incidence of high-risk status and labor and delivery outcomes. In the PROMOTE study, 400 pregnant patients were randomly assigned to 1 of 3 study groups: usual care plus OMT (OMT), usual care plus placebo ultrasound treatment (PUT), or usual care only (UCO). The incidence of high-risk status of participants and outcomes of labor and delivery, including length of labor, fever in mother during labor, operative vaginal delivery, conversion to cesarean delivery, need for forceps or vacuum device, need for episiotomy, incidence of perineal laceration, meconium-stained amniotic fluid, and infants' Apgar scores, were analyzed. Data from 380 participants were studied. High-risk status was less likely to develop in participants who received OMT (95% CI, 0.16-0.91; P=.03). The OMT protocol also did not increase risk of precipitous labor, operative vaginal delivery, conversion to cesarean delivery, need for forceps or vacuum device, need for episiotomy, incidence of perineal laceration, or meconium-stained amniotic fluid when compared with participants in the other 2 groups (P>.05). Of all other maternal outcomes examined, no difference was reported among the 3 treatment groups with the exception of incidence of prolonged labor in the OMT group. Participants receiving OMT had longer durations of labor than participants in the other groups (P=.002). These results suggest that the OMT protocol given during the third trimester of pregnancy as applied in the PROMOTE study is safe with regard to labor and delivery outcomes. The increased duration in labor in the OMT group needs further study. (ClinicalTrials.gov number NCT00426244).

The effect of rehabilitation exercises combined with direct vagina low voltage low frequency electric stimulation on pelvic nerve electrophysiology and tissue function in primiparous women: A randomised controlled trial.

PubMed

Yang, Sumian; Sang, Wenshu; Feng, Jing; Zhao, Haifeng; Li, Xian; Li, Ping; Fan, Hongfang; Tang, Zengjun; Gao, Lina

2017-12-01

To evaluate the effect of rehabilitation exercises combined with Direct Vagina Low Voltage Low Frequency Electric Stimulation (DES) on pelvic nerve electrophysiology and tissue function after delivery. Whether and how DES effects pelvic floor dysfunction (PFD) are not known clearly. This was a randomised, controlled clinical trial. The 189 primiparous women 20-35 years old and with an episiotomy or second degree episiotomy tear were divided into three groups: the control group (n = 60) received routine postpartum guidance 2 hr postpartum, the training group (n = 63) performed rehabilitation exercises (Kegel exercises and pelvic movements) from 2 days postpartum until 3 months postpartum, and the combination group (n = 66) received DES 15 times (3 times a week for 30 min at a time) beginning at the sixth week postpartum in addition to performing rehabilitation exercises. Adopt international standard scale and score method to inspect maternal life treatment, such as pelvic organ prolapse situation (POP-Q division), the degree of incontinence score and pelvic floor muscle intensity of muscular contraction. Data were collected during the third month after delivery. Three months postpartum, there were differences among the three groups in the POP-Q grade, the degree of incontinence score, the Oxford grade for pelvic floor muscle strength and the pelvic floor muscle electrophysiology condition. Additionally, there were significant differences regarding the pubic symphysis clearance. Rehabilitation exercises can promote healing of the maternal pubic symphysis and recovery of the pelvis. The total electrical value, type I muscle fibre strength and type II muscle fibre strength were significantly increased in the combination group after treatment than before treatment. Rehabilitation exercises combined with DES were beneficial to the recovery of postpartum pelvic nerve tissue function, and a synergistic effect was observed when the two methods were combined. These conclusions justify that rehabilitation exercise combined with DES can better relieve uncomfortable symptoms postpartum and improve the women's quality of life. © 2017 John Wiley & Sons Ltd.

Postpartum Perineal Pain in a Low Episiotomy Setting: Association with Severity of Genital Trauma, Labor Care and Birth Variables

PubMed Central

Leeman, Lawrence; Fullilove, Anne M.; Borders, Noelle; Manocchio, Regina; Albers, Leah L.; Rogers, Rebecca G.

2013-01-01

Background Perineal pain is common after childbirth. We studied the effect of genital tract trauma, labor care, and birth variables on the incidence of pain in a population of healthy women exposed to low rates of episiotomy and operative delivery. Methods A prospective study of genital trauma at birth and assessment of postpartum perineal pain and analgesic use was conducted in 565 midwifery patients. Perineal pain was assessed using the Present Pain Intensity (PPI) and Visual Analog Scale (VAS) components of the validated short form McGill pain scale. Multivariate logistic regression examined which patient characteristics or labor care measures were significant determinants of perineal pain and use of analgesic medicines. Results At hospital discharge, women with major trauma reported higher VAS pain scores (2.16 +/− 1.61 vs 1.48 +/− 1.40; P< 0.001) and were more likely to use analgesic medicines (76.3 vs 23.7%, P= 0.002) than women with mild or no trauma. By 3 months average VAS scores were low in each group and not significantly different. Perineal pain at the time of discharge was associated in univariate analysis with higher education level, ethnicity (non-Hispanic white), nulliparity, and longer length of active maternal pushing efforts. In a multivariate model only trauma group and length of active pushing predicted pain at hospital discharge. In women with minor or no trauma, only length of the active part of second stage labor had a positive relationship with pain. In women with major trauma, the length of active second stage labor had no independent effect on level of pain at discharge beyond its effect on the incidence of major trauma. Conclusions Women with spontaneous perineal trauma reported very low rates of postpartum perineal pain. Women with major trauma reported increased perineal pain compared with women who had no or minor trauma; however, by 3 months postpartum this difference was no longer present. In women with minor or no perineal trauma, a longer period of active pushing was associated with increased perineal pain. PMID:20002420

Aspirin (single dose) for perineal pain in the early postpartum period.

PubMed

Molakatalla, Sujana; Shepherd, Emily; Grivell, Rosalie M

2017-02-09

Perineal trauma (due to spontaneous tears, surgical incision (episiotomy) or in association with operative vaginal birth) is common after vaginal birth, and is often associated with postpartum perineal pain. Birth over an intact perineum may also lead to perineal pain. There are adverse health consequences associated with perineal pain for the women and their babies in the short- and long-term, and the pain may interfere with newborn care and the establishment of breastfeeding. Aspirin has been used in the management of postpartum perineal pain and its effectiveness and safety should be assessed. To determine the efficacy of a single dose of aspirin (acetylsalicylic acid), including at different doses, in the relief of acute postpartum perineal pain. We searched Cochrane Pregnancy and Childbirth's Trials Register (30 August 2016), ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (31 May 2016) and reference lists of retrieved studies. Randomised controlled trials (RCTs) assessing single dose aspirin compared with placebo, no treatment, a different dose of aspirin, or single dose paracetamol/acetaminophen for women with perineal pain in the early postpartum period. We planned to include cluster-RCTs but none were identified. Quasi-RCTs and cross-over studies were not eligible for inclusion in this review. Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of the included RCTs. Data were checked for accuracy. The quality of the evidence for the main comparison (aspirin versus placebo) was assessed using the GRADE approach. We included 17 RCTs, with 16 involving 1132 women randomised to aspirin or placebo (one RCT did not report numbers of women). Two RCTs (of 16) did not contribute data to review meta-analyses. All women had perineal pain post-episiotomy, and were not breastfeeding. Studies were published between 1967 and 1997, and the risk of bias was often unclear due to poor reporting.We included four comparisons: aspirin versus placebo (data from 15 RCTs); 300 mg versus 600 mg aspirin (1 RCT); 600 mg versus 1200 mg aspirin (2 RCTs); and 300 mg versus 1200 mg aspirin (1 RCT). Primary outcomes Aspirin versus placeboMore women who received aspirin experienced adequate pain relief compared with women who received placebo over four to eight hours after administration (risk ratio (RR) 2.03, 95% confidence intervals (CI) 1.69 to 2.42; 13 RCTs, 1001 women; low-quality evidence). Women who received aspirin were less likely to need additional pain relief over four to eight hours after administration (RR 0.25, 95% CI 0.17 to 0.37; 10 RCTs, 744 women; very low-quality evidence). There was no difference in maternal adverse effects over four to eight hours post-administration (RR 1.08, 95% CI 0.57 to 2.06; 14 RCTs, 1067 women; very low-quality evidence). Subgroup analyses based on dose did not reveal any clear subgroup differences.There was no clear difference over four hours after administration between 300 mg and 600 mg aspirin for adequate pain relief (RR 0.82, 95% CI 0.36 to 1.86; 1 RCT, 81 women) or need for additional pain relief (RR 0.68, 95% CI 0.12 to 3.88; 1 RCT, 81 women). There were no maternal adverse effects in either aspirin group.There was no clear difference over four to eight hours after administration between 600 mg and 1200 mg aspirin for adequate pain relief (RR 0.85, 95% CI 0.52 to 1.39; 2 RCTs, 121 women), need for additional pain relief (RR 1.32, 95% CI 0.30 to 5.68; 2 RCTs, 121 women), or maternal adverse effects (RR 3.00, 95% CI 0.13 to 69.52; 2 RCTs, 121 women).There was no clear difference over four hours after administration between 300 mg and 1200 mg aspirin for adequate pain relief (RR 0.62, 95% CI 0.29 to 1.32; 1 RCT, 80 women) or need for additional pain relief (RR 2.00, 95% CI 0.19 to 21.18; 1 RCT, 80 women). There were no maternal adverse effects in either aspirin group.None of the included RCTs reported on neonatal adverse effects. Secondary outcomesNo studies reported on secondary review outcomes: prolonged hospitalisation due to perineal pain; re-hospitalisation due to perineal pain; fully breastfeeding at discharge; mixed feeding at discharge; fully breastfeeding at six weeks; mixed feeding at six weeks; perineal pain at six weeks; maternal views; maternal postpartum depression. We found low-quality evidence to suggest that single dose aspirin compared with placebo can increase pain relief in women with perineal pain post-episiotomy. Very low-quality evidence also suggested that aspirin can reduce the need for additional analgesia, without increasing maternal adverse effects. Evidence was downgraded based on study limitations (risk of bias), imprecision, and publication bias or both. RCTs excluded breastfeeding women so there is no evidence to assess the effects of aspirin on neonatal adverse effects or breastfeeding.With international guidance recommending mothers initiate breastfeeding within one hour of birth, and exclusively breastfeed for the first six months, the evidence from this review is not applicable to current recommended best practice. Aspirin may be considered for use in non-breastfeeding women with post-episiotomy perineal pain. Although formal assessment was beyond the remit of this review, current guidance suggests that other analgesic drugs (including paracetamol) should be considered first for postpartum perineal pain. Such agents are the focus of other reviews in this series on drugs for perineal pain in the early postpartum period. It is considered most likely that if RCTs are conducted in the future they could compare aspirin with other pain relievers. Future RCTs should be designed to ensure high methodological quality, and address gaps in the evidence, such as the secondary outcomes established for this review. Current research has focused on women with post-episiotomy pain, future RCTs could be extended to women with perineal pain associated with spontaneous tears or operative birth.

Minimizing genital tract trauma and related pain following spontaneous vaginal birth.

PubMed

Albers, Leah L; Borders, Noelle

2007-01-01

Genital tract trauma is common following vaginal childbirth, and perineal pain is a frequent symptom reported by new mothers. The following techniques and care measures are associated with lower rates of obstetric lacerations and related pain following spontaneous vaginal birth: antenatal perineal massage for nulliparous women, upright or lateral positions for birth, avoidance of Valsalva pushing, delayed pushing with epidural analgesia, avoidance of episiotomy, controlled delivery of the baby's head, use of Dexon (U.S. Surgical; Norwalk, CT) or Vicryl (Ethicon, Inc., Somerville, NJ) suture material, the "Fleming method" for suturing lacerations, and oral or rectal ibuprofen for perineal pain relief after delivery. Further research is warranted to determine the role of prenatal pelvic floor (Kegel) exercises, general exercise, and body mass index in reducing obstetric trauma, and also the role of pelvic floor and general exercise in pelvic floor recovery after childbirth.

Sudden Bilateral Sensorineural Hearing Loss Following Postpartum Hemorrhage: A Case Report

PubMed Central

Mirzaeian, Sara; Ayati, Sedigheh; Maleki, Asieh

2017-01-01

The prevalence of bilateral sudden sensorineural hearing loss (SSNHL) is less than 5% and the etiology of most cases is unknown. Due to many structural and functional similarities between the kidney and inner ear, many conditions, diseases, and drugs have both renal and cochlear effects and toxicities. There are several reports of SSNHL in patients with CRF, uraemic patient, hemodialysis treatment, and ARF. Here, we report a rare manifestation of SSNHL following severe postpartum hemorrhage that has simultaneous renal failure and cochlear impairment. The patient was a 22-year-old primigravida woman with term pregnancy who after delivery and episiotomy hematoma and postpartum hemorrhage subsequently suffered from kidney failure, oliguria, and SSNHL that occurred after 3 days of delivery. In conditions such as severe postpartum bleeding leading to acute renal involvement, the possibility of simultaneous involvement of cochlea due to hypoxia or received drugs should be considered. PMID:28761208

Severe perineal laceration during operative vaginal delivery: the impact of occiput posterior position.

PubMed

Hirsch, E; Elue, R; Wagner, A; Nelson, K; Silver, R K; Zhou, Y; Adams, M G

2014-12-01

To identify risk factors for severe (third/fourth degree) perineal laceration with operative vaginal delivery (OVD, forceps or vacuum). Case-control study comparing singleton OVDs with or without severe laceration (n=138). In multivariable analyses, severe perineal laceration was associated with occiput posterior (OP) position at delivery, vaginal nulliparity, use of forceps, longer period pushing in the second stage and lower gestational age, but not birth weight, labor induction or episiotomy. Among 29 OP patients at full dilation, 9/13 (69%) attempted rotations to occiput anterior (OA) were successful, and 14/16 (88%) patients in whom rotation was not attempted remained OP at delivery. Successful rotation from OP to OA was associated with fewer severe lacerations than no attempt or unsuccessful rotation (22 vs 75%, P=0.01). Severe perineal laceration during OVD is associated with OP position at delivery and is reduced threefold in patients successfully rotated from OP to OA.

Risk factors for obstetric anal sphincter injuries and postpartum anal and urinary incontinence: a case-control trial.

PubMed

Burrell, Madeline; Dilgir, Sapna; Patton, Vicki; Parkin, Katrina; Karantanis, Emmanuel

2015-03-01

Obstetric anal sphincter injuries (OASIS) cause serious maternal morbidity for mothers. A clearer understanding of aetiological factors is needed. We aimed to determine the risk factors for OASIS . Birth details of 222 primiparous women sustaining OASIS were compared with 174 women who did not sustain OASIS (controls) to determine the relevant risk factors. The data underwent univariate analysis and logistic regression analysis. Asian or Indian ethnicity, operative vaginal birth (p = 0.00), persistent occipito-posterior position (p = 0.038) and rapid uncontrolled delivery of the head were identified as risk factors for OASIS. Pushing time, use of epidural, episiotomy and head circumference were not predictors of OASIS. Women with Asian or Indian ethnicity, operative vaginal birth, persistent occipito-posterior position and rapid uncontrolled delivery of the fetal head were likely to sustain OASIS. Awareness of these factors may help to minimise the incidence of OASIS.

Perineal massage in labour and prevention of perineal trauma: randomised controlled trial

PubMed Central

Stamp, Georgina; Kruzins, Gillian; Crowther, Caroline

2001-01-01

Objective To determine the effects of perineal massage in the second stage of labour on perineal outcomes. Design Randomised controlled trial. Participants At 36 weeks' gestation, women expecting normal birth of a singleton were asked to join the study. Women became eligible to be randomised in labour if they progressed to full dilatation of the cervix or 8 cm or more if nulliparous or 5 cm or more if multiparous. 1340 were randomised into the trial. Intervention Massage and stretching of the perineum during the second stage of labour with a water soluble lubricant. Main outcome measures Primary outcomes: rates of intact perineum, episiotomies, and first, second, third, and fourth degree tears. Secondary outcomes: pain at three and 10 days postpartum and pain, dyspareunia, resumption of sexual intercourse, and urinary and faecal incontinence and urgency three months postpartum. Results Rates of intact perineums, first and second degree tears, and episiotomies were similar in the massage and the control groups. There were fewer third degree tears in the massage group (12 (1.7%) v 23 (3.6%); absolute risk 2.11, relative risk 0.45; 95% confidence interval 0.23 to 0.93, P<0.04), though the trial was underpowered to measure this rarer outcome. Groups did not differ in any of the secondary outcomes at the three assessment points. Conclusions The practice of perineal massage in labour does not increase the likelihood of an intact perineum or reduce the risk of pain, dyspareunia, or urinary and faecal problems. What is already known on this topicPerineal trauma during vaginal birth and its sequelae, including urinary and faecal incontinence, dyspareunia, and persistent pain, have a negative impact on the sexuality, self esteem, and quality of life of countless women each yearPerineal massage conducted antenatally has some benefit in reducing the risk of perineal traumaPerineal massage in the second stage of labour has been promoted and practised without sound evidence of its effectivenessWhat this study addsPerineal massage in the second stage of labour did not have any effect on the likelihood of an intact perineum, perineal trauma, pain, or subsequent sexual, urinary or faecal outcomes but was not harmfulThe results support midwives in following their usual practice while taking account of the preferences of individual women PMID:11375230

Effect of planned place of birth on obstetric interventions and maternal outcomes among low-risk women: a cohort study in the Netherlands.

PubMed

Bolten, N; de Jonge, A; Zwagerman, E; Zwagerman, P; Klomp, T; Zwart, J J; Geerts, C C

2016-10-28

The use of interventions in childbirth has increased the past decades. There is concern that some women might receive more interventions than they really need. For low-risk women, midwife-led birth settings may be of importance as a counterbalance towards the increasing rate of interventions. The effect of planned place of birth on interventions in the Netherlands is not yet clear. This study aims to give insight into differences in obstetric interventions and maternal outcomes for planned home versus planned hospital birth among women in midwife-led care. Women from twenty practices across the Netherlands were included in 2009 and 2010. Of these, 3495 were low-risk and in midwife-led care at the onset of labour. Information about planned place of birth and outcomes, including instrumental birth (caesarean section, vacuum or forceps birth), labour augmentation, episiotomy, oxytocin in third stage, postpartum haemorrhage >1000 ml and perineal damage, came from the national midwife-led care perinatal database, and a postpartum questionnaire. Women who planned home birth more often had spontaneous birth (nulliparous women aOR 1.38, 95 % CI 1.08-1.76, parous women aOR 2.29, 95 % CI 1.21-4.36) and less often episiotomy (nulliparous women aOR 0.73, 0.58-0.91, parous women aOR 0.47, 0.33-0.68) and use of oxytocin in the third stage (nulliparous women aOR 0.58, 0.42-0.80, parous women aOR 0.47, 0.37-0.60) compared to women who planned hospital birth. Nulliparous women more often had anal sphincter damage (aOR 1.75, 1.01-3.03), but the difference was not statistically significant if women who had caesarean sections were excluded. Parous women less often had labour augmentation (aOR 0.55, 0.36-0.82) and more often an intact perineum (aOR 1.65, 1.34-2.03). There were no differences in rates of vacuum/forceps birth, unplanned caesarean section and postpartum haemorrhage >1000 ml. Women who planned home birth were more likely to give birth spontaneously and had fewer medical interventions.

Antenatal perineal massage for reducing perineal trauma.

PubMed

Beckmann, Michael M; Stock, Owen M

2013-04-30

Perineal trauma following vaginal birth can be associated with significant short-term and long-term morbidity. Antenatal perineal massage has been proposed as one method of decreasing the incidence of perineal trauma. To assess the effect of antenatal digital perineal massage on the incidence of perineal trauma at birth and subsequent morbidity. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (22 October 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2012, Issue 10), PubMed (1966 to October 2012), EMBASE (1980 to October 2012) and reference lists of relevant articles. Randomised and quasi-randomised controlled trials evaluating any described method of antenatal digital perineal massage undertaken for at least the last four weeks of pregnancy. Both review authors independently applied the selection criteria, extracted data from the included studies and assessed study quality. We contacted study authors for additional information. We included four trials (2497 women) comparing digital perineal massage with control. All were of good quality. Antenatal digital perineal massage was associated with an overall reduction in the incidence of trauma requiring suturing (four trials, 2480 women, risk ratio (RR) 0.91 (95% confidence interval (CI) 0.86 to 0.96), number needed to treat to benefit (NNTB) 15 (10 to 36)) and women practicing perineal massage were less likely to have an episiotomy (four trials, 2480 women, RR 0.84 (95% CI 0.74 to 0.95), NNTB 21 (12 to 75)). These findings were significant for women without previous vaginal birth only. No differences were seen in the incidence of first- or second-degree perineal tears or third-/fourth-degree perineal trauma. Only women who have previously birthed vaginally reported a statistically significant reduction in the incidence of pain at three months postpartum (one trial, 376 women, RR 0.45 (95% CI 0.24 to 0.87) NNTB 13 (7 to 60)). No significant differences were observed in the incidence of instrumental deliveries, sexual satisfaction, or incontinence of urine, faeces or flatus for any women who practised perineal massage compared with those who did not massage. Antenatal digital perineal massage reduces the likelihood of perineal trauma (mainly episiotomies) and the reporting of ongoing perineal pain, and is generally well accepted by women. As such, women should be made aware of the likely benefit of perineal massage and provided with information on how to massage.

Midwifery care measures in the second stage of labor and reduction of genital tract trauma at birth: a randomized trial.

PubMed

Albers, Leah L; Sedler, Kay D; Bedrick, Edward J; Teaf, Dusty; Peralta, Patricia

2005-01-01

Genital tract trauma after spontaneous vaginal childbirth is common, and evidence-based prevention measures have not been identified beyond minimizing the use of episiotomy. This study randomized 1211 healthy women in midwifery care at the University of New Mexico teaching hospital to 1 of 3 care measures late in the second stage of labor: 1) warm compresses to the perineal area, 2) massage with lubricant, or 3) no touching of the perineum until crowning of the infant's head. The purpose was to assess whether any of these measures was associated with lower levels of obstetric trauma. After each birth, the clinical midwife recorded demographic, clinical care, and outcome data, including the location and extent of any genital tract trauma. The frequency distribution of genital tract trauma was equal in all three groups. Individual women and their clinicians should decide whether to use these techniques on the basis of maternal comfort and other considerations.

Midwifery Care Measures in the Second Stage of Labor and Reduction of Genital Tract Trauma at Birth: A Randomized Trial

PubMed Central

Albers, Leah L.; Sedler, Kay D.; Bedrick, Edward J.; Teaf, Dusty; Peralta, Patricia

2005-01-01

Genital tract trauma following spontaneous vaginal childbirth is common, and evidence-based prevention measures have not been identified, beyond minimizing the use of episiotomy. This study randomized 1211 healthy women in midwifery care at the University of New Mexico teaching hospital to one of three care measures late in the second stage of labor:1) warm compresses to the perineal area, 2) massage with lubricant, or 3) no touching of the perineum until crowning of the infant’s head. The purpose was to assess whether any of these measures was associated with lower levels of obstetric trauma. After each birth, the clinical midwife recorded demographic, clinical care, and outcome data, including the location and extent of any genital tract trauma. The frequency distribution of genital tract trauma was equal in all three groups. Individual women and their clinicians should decide whether to use these techniques based on maternal comfort and other considerations. PMID:16154062

Clostridium sordellii Toxic Shock Syndrome: A Case Report and Review of the Literature

PubMed Central

Savage, Beverley A.; Vaccarello, Luis

1996-01-01

Background: Since the 1980s, there have been isolated reports of a toxic shock syndrome associated with Clostridium sordellii necrotizing subcutaneous infections during the puerperium. Relatively localized fascial and muscle necrosis is noted at the surgical incision sites. However, circulating toxins produce marked edema, resulting in shock and cardiovascular collapse. Despite aggressive surgical and supportive therapy, all postpartum cases thus far have been fatal. Case: A 24-year-old primipara developed an episiotomy infection which progressed to involve the underlying fascia and muscle. Despite early and adequate debridement of the devitalized tissue, she developed anasarca, marked leukocytosis, refractory hypotension, hypothermia, and a persistent coagulopathy, and expired on postpartum day 5. The cultures from the excised tissue grew C. sordellii All blood cultures were negative. Conclusion: Treatment modalities aimed solely at the eradication of the microbe and removal of necrotic tissue, although essential components of therapy, have proved inadequate. Future efforts should be directed toward neutralization or elimination of the circulating exotoxins responsible for the systemic shock. PMID:18476062

[Accidental exposure to blood by midwives in French maternity units: results of the national surveillance 2003].

PubMed

Vincent, A; Cohen, M; Bernet, C; Parneix, P; L'Hériteau, F; Branger, B; Talon, D; Hommel, C; Abiteboul, D; Coignard, B

2006-05-01

Midwives appear to be the health care workers exposed to the highest rates of bloodborne injury. In this paper - based on a national survey - we describe the bloodborne injuries occurring in this profession. During the year 2003, 241 hospitals took part in a national survey of bloodborne injuries. Employees registered anonymous standardized reports of bloodborne events with the Occupational Medicine Unit. The data were processed by the coordination center for the fight against nosocomial infections (C. CLIN) which is in charge of the national analysis of all the events reported in this database. 169 of the 6973 bloodborne events reported during 2003 (2.4%), were signed by midwives or midwife students. The first three most frequent accidents reported were: ocular projections during childbirth, pricks when repairing episiotomy, pricks or cuts when handling soiled instruments. Improving knowledge of risk as well as promotion of protection/prevention measures well adapted to this profession should be helpful in optimizing future attitudes.

Occiput posterior fetal head position increases the risk of anal sphincter injury in vacuum-assisted deliveries.

PubMed

Wu, Jennifer M; Williams, Kathryn S; Hundley, Andrew F; Connolly, AnnaMarie; Visco, Anthony G

2005-08-01

The purpose of this study was to determine whether an occiput posterior (OP) fetal head position increases the risk for anal sphincter injury when compared with an occiput anterior (OA) position in vacuum-assisted deliveries. We conducted a retrospective cohort study of 393 vacuum-assisted singleton vaginal deliveries. Maternal demographics and obstetric and neonatal data were collected from an obstetric database and chart review. Within the OP group, 41.7% developed a third- or fourth-degree laceration compared with 22.0% in the OA group (OR 2.5, 95% CI 1.4-4.7). In a logistic regression model that controlled for BMI, race, nulliparity, length of second stage, episiotomy, birth weight, head circumference, and fetal head position, OP position was 4.0 times (95% CI 1.7-9.6) more likely to be associated with an anal sphincter injury than OA position. Among vacuum deliveries, an OP head position confers an incrementally increased risk for anal sphincter injury over an OA position.

[Analysis of the use of the Salinas forceps at the Gynecologic-Obstetric Hospital of Garza García, N.L. (Nuevo León)].

PubMed

de la Garza Quintanilla, C; González Salinas, M V; Celaya Juárez, J A

1995-09-01

Six hundred and thirteen cases of Salinas forceps application at Hospital de Ginecoobstetricia de Garza García, N.L. from November 1992 to April, 1993, were reviewed. The largest patients group, 20 to 29 years of age with 54.5%; primiparae were predominant with 55.9%, the largest amount of applications in term products, 80.8%; elective forceps with 72.5%; low application with 83.0%; medium 2.5%; episiotomy, medium, right lateral in all the cases; epidural block anesthesia in all the patients, and only one complication 0.1%; most frequent position variety OIA with 50%; and the smaller OIP with 2.6%; 96.3% of products weighted more than 2,500 g; and 87.1% with Apgar 8-9 at one minute. Maternal morbidity, 30.1%; fetal morbidity, 6.1%, with one case with facial paralysis (0.1%) by medium forceps. There were no maternal deaths; 3 antepartum fetal deaths; none postpartum.

Spontaneous vaginal delivery in the birth-chair versus in the conventional dorsal position: a matched controlled comparison.

PubMed

Scholz, H S; Benedicic, C; Arikan, M G; Haas, J; Petru, E

2001-09-17

The aim of the study was to assess the effect of a birth-chair on obstetric outcome. We reviewed the hospital records of 220 consecutive pregnant women who gave birth on a birth-chair at our institution. The control group consisted of 440 pregnant women who preceded and followed the index cases and who had spontaneous vaginal deliveries in the conventional dorsal supine position. The controls were matched for parity and for the attending mid-wife. Patients who delivered in the birth-chair had significantly lower rates of episiotomy and manual separation of the placenta. The umbilical blood cord pH was significantly higher in neonates of the birth-chair group. The duration of labour, rate of perineal and vaginal injury, Apgar scores and rate of admission to a neonatal intermediate care unit were not influenced by the mode of delivery. Our data support previous studies that a birth-chair delivery may be a safe alternative to conventional delivery in the supine position.

The impact of female genital cutting on health of newly married women.

PubMed

Elnashar, A; Abdelhady, R

2007-06-01

To detect the rate of female genital cutting among a sample of newly married women in Benha city, and make a comparison between circumcised and non-circumcised women regarding long-term health problems. Randomly selected (264) newly married women were the subjects of this work. Circumcised group constitutes 75.8% of the sample. All non-circumcised women were living in an urban area. Dysmenorrhea was more common among circumcised rather than non-circumcised, with statistically significant difference (P<0.01). Marital problems (dyspareunia, loss of libido, failure of orgasm and husband's dissatisfaction) had statistically different levels of significance among circumcised women. Obstetric problems such as tears, episiotomy and consequently distressed babies were more events among circumcised mothers with statistical significance. Circumcised females had significant mental problems such as somatization, anxiety and phobia (P<0.001). Female genital cutting remains a widely practiced custom in our society. Grave complications of circumcision may last throughout women's life particularly the time of consummation of marriage and the time of childbirth.

Successful vaginal delivery at term after vaginal reconstruction with labium minus flaps in a patient with vaginal atresia: A rare case report.

PubMed

Liu, Yu; Wang, Yi-Feng

2017-07-01

We report a case of successful vaginal delivery after vaginal reconstruction with labium minus flaps in a 23-year-old patient with congenital vaginal atresia. The patient primarily presented with amenorrhea and cyclic abdominal pain; transabdominal ultrasonography revealed an enlarged uterus due to hematometra and absence of the lower segment of the vagina. Eight years ago, she had undergone an unsuccessful attempt at canalization at a local hospital. Upon referral to our hospital, she underwent vaginal reconstruction with labium minus flaps. Four months after this procedure, she became pregnant and, subsequently, successfully and safely vaginally delivered a healthy female baby weighing 3250 g at 38 +1 weeks' gestation. The delivery did not involve perineal laceration by lateral episiotomy. To the best of our knowledge, this is the first reported case of successful vaginal delivery at term after vaginal reconstruction with labium minus flaps in a patient with vaginal atresia. © 2017 Japan Society of Obstetrics and Gynecology.

Prenatal perineal massage: preventing lacerations during delivery.

PubMed

Davidson, K; Jacoby, S; Brown, M S

2000-01-01

To investigate the associations between perineal lacerations and 13 variables associated with the incidence of perineal lacerations. Of particular interest was the variable of prenatal preparation of the perineum. This retrospective descriptive study used a convenience sample of 368 women whose delivery was attended by at least one of two midwives practicing in the Northwest between 1979 and 1995. All births in the study occurred in a home-based midwifery practice in the Northwest. The sample was primarily white and included 307 multiparous and 61 primiparous women. The initial chi squares indicated that five of the 13 factors investigated were significantly associated with the degree of laceration: parity, maternal age, maternal position at delivery, length of second stage of labor, and prenatal perineal massage. However, further analyses showed that when parity was controlled, the only factors independently associated with the seriousness of lacerations were parity and prenatal perineal massage. This study supports the conclusion that teaching perineal massage to primiparous women and multiparae who had episiotomies with their previous births is a useful intervention. It suggests that further study may help clarify the optimum frequency, timing, and technique of massage.

[Pelvic floor and pregnancy].

PubMed

Fritel, X

2010-05-01

Congenital factor, obesity, aging, pregnancy and childbirth are the main risk factors for female pelvic floor disorders (urinary incontinence, anal incontinence, pelvic organ prolapse, dyspareunia). Vaginal delivery may cause injury to the pudendal nerve, the anal sphincter, or the anal sphincter. However the link between these injuries and pelvic floor symptoms is not always determined and we still ignore what might be the ways of prevention. Of the many obstetrical methods proposed to prevent postpartum symptoms, episiotomy, delivery in vertical position, delayed pushing, perineal massage, warm pack, pelvic floor rehabilitation, results are disappointing or limited. Caesarean section is followed by less postnatal urinary incontinence than vaginal childbirth. However this difference tends to disappear with time and following childbirth. Limit the number of instrumental extractions and prefer the vacuum to forceps could reduce pelvic floor disorders after childbirth. Ultrasound examination of the anal sphincter after a second-degree perineal tear is useful to detect and repair infra-clinic anal sphincter lesions. Scientific data is insufficient to justify an elective cesarean section in order to avoid pelvic floor symptoms in a woman without previous disorders. Copyright 2010 Elsevier Masson SAS. All rights reserved.

Maternal Malaria and Perinatal HIV Transmission, Western Kenya1,2

PubMed Central

Ayisi, John G.; van Eijk, Anna M.; ter Kuile, Feiko O.; Shi, Ya Ping; Yang, Chunfu; Kolczak, Margarette S.; Otieno, Juliana A.; Misore, Ambrose O.; Kager, Piet A.; Lal, Renu B.; Steketee, Richard W.; Nahlen, Bernard L.

2004-01-01

To determine whether maternal placental malaria is associated with an increased risk for perinatal mother-to-child HIV transmission (MTCT), we studied HIV-positive women in western Kenya. We enrolled 512 mother-infant pairs; 128 (25.0%) women had malaria, and 102 (19.9%) infants acquired HIV perinatally. Log10 HIV viral load and episiotomy or perineal tear were associated with increased perinatal HIV transmission, whereas low-density malaria (<10,000 parasites/μL) was associated with reduced risk (adjusted relative risk [ARR] 0.4). Among women dually infected with malaria and HIV, high-density malaria (>10,000 parasites/μL) was associated with increased risk for perinatal MTCT (ARR 2.0), compared to low-density malaria. The interaction between placental malaria and MTCT appears to be variable and complex: placental malaria that is controlled at low density may cause an increase in broad-based immune responses that protect against MTCT; uncontrolled, high-density malaria may simultaneously disrupt placental architecture and generate substantial antigen stimulus to HIV replication and increase risk for MTCT. PMID:15200854

Do maternal pushing techniques during labour affect obstetric or neonatal outcomes?

PubMed

Barasinski, C; Lemery, D; Vendittelli, F

2016-10-01

To assess, through a literature review, the maternal and neonatal morbidity associated with the type of pushing used during the second stage of labour. We searched the Cochrane Library and the Medline database for randomised controlled trials from 1980 to 2015, using the following keywords: "delivery", "birth", "birthing", "bearing down, coached, uncoached, pushing", "second and stage and labour", "randomised controlled trials" and "meta-analysis". Seven randomised controlled trials were found. Interventions varied between the studies. In the intervention groups, open-glottis pushing was spontaneous or coached. The groups did not differ for perineal injuries, episiotomies or type of birth. Impact on pelvic floor structure varied between the studies. Only one study found a better 5-minute Apgar score and a better umbilical artery pH in the "open glottis" group. The low methodological quality of the studies and the differences between the protocols do not justify a recommendation of a particular pushing technique. Further studies appear necessary to study outcomes with each of these techniques. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Obstetric interventions during labor and childbirth in Brazilian low-risk women.

PubMed

Carmo Leal, Maria do; Pereira, Ana Paula Esteves; Domingues, Rosa Maria Soares Madeira; Theme Filha, Mariza Miranda; Dias, Marcos Augusto Bastos; Nakamura-Pereira, Marcos; Bastos, Maria Helena; Gama, Silvana Granado Nogueira da

2014-08-01

This study evaluated the use of best practices (eating, movement, use of nonpharmacological methods for pain relief and partograph) and obstetric interventions in labor and delivery among low-risk women. Data from the hospital-based survey Birth in Brazil conducted between 2011 and 2012 was used. Best practices during labor occurred in less than 50% of women and prevalence of the use of these practices was lower in the North, Northeast and Central West Regions. The rate of use of oxytocin drips and amniotomy was 40%, and was higher among women admitted to public hospitals and in women with a low level of education. The uterine fundal pressure, episiotomy and lithotomy were used in 37%, 56% and 92% of women, respectively. Caesarean section rates were lower in women using the public health system, nonwhites, women with a low level of education and multiparous women. To improve the health of mothers and newborns and promote quality of life, a change of approach to labor and childbirth that focuses on evidence-based care is required in both the public and private health sectors.

Post-partum streptococcal toxic shock syndrome associated with necrotizing fasciitis.

PubMed

Chua, Wei Chuan; Mazlan, Mohd Zulfakar; Ali, Saedah; Che Omar, Sanihah; Wan Hassan, Wan Mohd Nazaruddin; Seevaunnantum, S Praveena; Mohd Zaini, Rhendra Hardy; Hassan, Mohd Hasyizan; Muhd Besari, Alwi; Abd Rahman, Zaidah; Salmuna Ayub, Zeti Norfidiyati; Abd Ghani, Sabrina; Yaacob, Normalinda; Wan Rosli, Wan Rosilawati

2017-01-01

We report a fatal case of post-partum streptococcal toxic shock syndrome in a patient who was previously healthy and had presented to the emergency department with an extensive blistering ecchymotic lesions over her right buttock and thigh associated with severe pain. The pregnancy had been uncomplicated, and the mode of delivery had been spontaneous vaginal delivery with an episiotomy. She was found to have septicemic shock requiring high inotropic support. Subsequently, she was treated for necrotizing fasciitis, complicated by septicemic shock and multiple organ failures. A consensus was reached for extensive wound debridement to remove the source of infection; however, this approach was abandoned due to the patient's hemodynamic instability and the extremely high risks of surgery. Both the high vaginal swab and blister fluid culture revealed Group A beta hemolytic streptococcus infection. Intravenous carbapenem in combination with clindamycin was given. Other strategies attempted for streptococcal toxic removal included continuous veno-venous hemofiltration and administration of intravenous immunoglobulin. Unfortunately, the patient's condition worsened, and she succumbed to death on day 7 of hospitalization.

Antenatal perineal massage for reducing perineal trauma.

PubMed

Beckmann, M M; Garrett, A J

2006-01-25

Perineal trauma following vaginal birth can be associated with significant short- and long-term morbidity. Antenatal perineal massage has been proposed as one method of decreasing the incidence of perineal trauma. To assess the effect of antenatal perineal massage on the incidence of perineal trauma at birth and subsequent morbidity. We searched the Cochrane Pregnancy and Childbirth Group Trials Register (30 January 2005), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 1, 2005), PubMed (1966 to January 2005), EMBASE (1980 to January 2005) and reference lists of relevant articles. Randomised and quasi-randomised controlled trials evaluating any described method of antenatal perineal massage undertaken for at least the last four weeks of pregnancy. Both review authors independently applied the selection criteria, extracted data from the included studies and assessed study quality. We contacted study authors for additional information. Three trials (2434 women) comparing digital perineal massage with control were included. All were of good quality. Antenatal perineal massage was associated with an overall reduction in the incidence of trauma requiring suturing (three trials, 2417 women, relative risk (RR) 0.91 (95% confidence interval (CI) 0.86 to 0.96), number needed to treat (NNT) 16 (10 to 39)). This reduction was statistically significant for women without previous vaginal birth only (three trials, 1925 women, RR 0.90 (95% CI 0.84 to 0.96), NNT 14 (9 to 35)). Women who practised perineal massage were less likely to have an episiotomy (three trials, 2417 women, RR 0.85 (95% CI 0.75 to 0.97), NNT 23 (13 to 111)). Again this reduction was statistically significant for women without previous vaginal birth only (three trials, 1925 women, RR 0.85 (95% CI 0.74 to 0.97), NNT 20 (11 to 110)). No differences were seen in the incidence of 1st or 2nd degree perineal tears or 3rd/4th degree perineal trauma. Only women who have previously birthed vaginally reported a statistically significant reduction in the incidence of pain at three months postpartum (one trial, 376 women, RR 0.68 (95% CI 0.50 to 0.91) NNT 13 (7 to 60)). No significant differences were observed in the incidence of instrumental deliveries, sexual satisfaction, or incontinence of urine, faeces or flatus for any women who practised perineal massage compared with those who did not massage. Antenatal perineal massage reduces the likelihood of perineal trauma (mainly episiotomies) and the reporting of ongoing perineal pain and is generally well accepted by women. As such, women should be made aware of the likely benefit of perineal massage and provided with information on how to massage.

Female Pelvic Floor Biomechanics: Bridging the Gap

PubMed Central

Easley, Deanna C.; Abramowitch, Steven D.; Moalli, Pamela A.

2017-01-01

Purpose of review The pelvic floor is a complex assembly of connective tissues and striated muscle that simultaneously counteract gravitational forces, inertial forces, and intraabdominal pressures while maintaining the position of the pelvic organs. In 30% of women, injury or failure of the pelvic floor results in pelvic organ prolapse (POP). Surgical treatments have high recurrence rates, due, in part, to a limited understanding of physiologic loading conditions. It is critical to apply biomechanics to help elucidate how altered loading conditions of the pelvis contribute to the development of pelvic organ prolapse and to define surgeries to restore normal support. Recent findings Evidence suggests the ewe is a potential animal model for studying vaginal properties and that uterosacral and cardinal ligaments experience significant creep, which may be affecting surgical outcomes. A new method of measuring ligament displacements in vivo was developed, and finite element models that simulate urethral support, pelvic floor dynamics, and the impact of episiotomies on the pelvic floor were studied. Summary This review highlights some contributions over the past year, including mechanical testing and the creation of models, which are used to understand pelvic floor changes with loading, and the impact of surgical procedures, to illustrate how biomechanics is being utilized. PMID:28267057

How singleton breech babies at term are born in France: a survey of data from the AUDIPOG network.

PubMed

Lansac, J; Crenn-Hebert, C; Rivière, O; Vendittelli, F

2015-05-01

Based on data from the AUDIPOG sentinel network between 1994 and 2010, we can say that the rate of singleton breech presentation at term is 3% and remains unchanged despite an external cephalic version rate of 35%. The total cesarean section rate is currently 75%. This rate increased by nearly 20% after the Hannah publication in 2000, regardless of the type of breech and type of maternity unit. The rate of planned cesarean sections increased in particular, going from 40% to 60%, and even reaching 67% for footling breech presentations. The rate is higher in type I maternity units than in type II or III. This cesarean section rate has been stable since 2005 and has even decreased for the Frank breech. The average rate of external cephalic version remains stable at around 23%. The episiotomy rate is 28%. The rate of babies transferred to neonatology units is higher for breech babies at term than for babies presenting cephalically (3.9% compared to 2.9%), but the newborns most often transferred are those born by cesarean section (4.1% compared to 3.4%). Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.

A Violent Birth: Reframing Coerced Procedures During Childbirth as Obstetric Violence.

PubMed

Borges, Maria TR

2018-01-01

In the United States, women are routinely forced to undergo cesarean sections, episiotomies, and the use of forceps, despite their desire to attempt natural vaginal delivery. Yet, the current American legal system does little to provide redress for women coerced to undergo certain medical procedures during childbirth. Courts and physicians alike are prepared to override a woman's choice of childbirth procedure if they believe this choice poses risks to the fetus, and both give little value to the woman's right to bodily autonomy. This Note proposes a solution for addressing the problem of coerced medical procedures during childbirth by importing a framework created in Venezuela and Argentina that characterizes this issue as "obstetric violence." First, this Note contains an overview of the shortcomings of the existing American legal framework to address the problem. Second, it explains the advantages of the obstetric violence framework and argues that its adoption in the United States would address many of the failures of the existing system. And third, this Note introduces a few legislative and litigation strategies that can be used to implement this framework in the United States and briefly addresses some of the challenges these strategies may pose.

Foetal Gender and Obstetric Outcome

PubMed Central

Schildberger, B.; Leitner, H.

2016-01-01

Introduction: Data on specific characteristics based on the gender of the unborn baby and their significance for obstetrics are limited. The aim of this study is to analyse selected parameters of obstetric relevance in the phases pregnancy, birth and postpartum period in dependence on the gender of the foetus. Materials and Methods: The selected study method comprised a retrospective data acquisition and evaluation from the Austrian birth register of the Department of Clinical Epidemiology of Tyrolean State Hospitals. For the analysis all inpatient singleton deliveries in Austria during the period from 2008 to 2013 were taken into account (live and stillbirths n = 444 685). The gender of the baby was correlated with previously defined, obstetrically relevant parameters. Results: In proportions, significantly more premature births and sub partu medical interventions (vaginal and abdominal surgical deliveries. episiotomies) were observed for male foetuses (p < 0.001). The neonatal outcome (5-min Apgar score, umbilical pH value less than 7.1, transfer to a neonatal special unit) is significantly poorer for boys (p < 0.001). Discussion: In view of the vulnerability of male foetuses and infants, further research is needed in order to be able to react appropriately to the differing gender-specific requirements in obstetrics. PMID:27065487

'Safe', yet violent? Women's experiences with obstetric violence during hospital births in rural Northeast India.

PubMed

Chattopadhyay, Sreeparna; Mishra, Arima; Jacob, Suraj

2017-11-03

The majority of maternal health interventions in India focus on increasing institutional deliveries to reduce maternal mortality, typically by incentivising village health workers to register births and making conditional cash transfers to mothers for hospital births. Based on over 15 months of ethnographically informed fieldwork conducted between 2015 and 2017 in rural Assam, the Indian state with the highest recorded rate of maternal deaths, we find that while there has been an expansion in institutional deliveries, the experience of childbirth in government facilities is characterised by obstetric violence. Poor and indigenous women who disproportionately use state facilities report both tangible and symbolic violence including iatrogenic procedures such as episiotomies, in some instances done without anaesthesia, improper pelvic examinations, beating and verbal abuse during labour, with sometimes the shouting directed at accompanying relatives. While the expansion of institutional deliveries and access to emergency obstetric care is likely to reduce maternal mortality, in the absence of humane care during labour, institutional deliveries will continue to be characterised by the paradox of "safe" births (defined as simply reducing maternal deaths) and the deployment of violent practices during labour, underscoring the unequal and complex relationship between the bodies of the poor and reproductive governance.

Giant Vulvar Epidermoid Cyst in an Adolescent Girl

PubMed Central

Karaman, Erbil; Çim, Numan; Akdemir, Zülküf; Elçi, Erkan; Akdeniz, Hüseyin

2015-01-01

Introduction. Vulvar cyst in adolescent girls is very uncommon. Epidermoid cyst can be seen in many sites including face, trunk, and extremities but its occurrence in vulva is uncommon. This is the first case of epidermoid cyst of vulva reported in an adolescent girl. Case. A 17-year-old, adolescent girl admitted to our gynecology outpatient clinic with a complaint of painful and palpable mass in her vulva. On examination, a giant mass located in left vulva and labia majora with 11 cm in diameter was seen. The magnetic resonance imaging (MRI) showed a well-defined cystic mass without contrast enhancement. The surgery was advised to the patient and the pathologic examination of mass revealed vulvar epidermoid cyst. Discussion. Vulvar cysts generally grow slowly and the main etiologies are vulvar trauma and surgical interventions including episiotomy and female circumcision in some culture. The exact treatment is total surgical excision and pathologic examination. MRI is an important imaging modality for detection of extension to deep perineal tissue and localization of mass in vulva especially in giant ones. Conclusion. Although vulvar mass in adolescents is rare, the epidermoid cyst with benign origin should be kept in mind. PMID:25949839

Simultaneous uterine and urinary bladder rupture in an otherwise successful vaginal birth after cesarean delivery.

PubMed

Ho, Szu-Ying; Chang, Shuenn-Dhy; Liang, Ching-Chung

2010-12-01

Uterine rupture is the primary concern when a patient chooses a trial of labor after a cesarean section. Bladder rupture accompanied by uterine rupture should be taken into consideration if gross hematuria occurs. We report the case of a patient with uterine rupture during a trial of labor after cesarean delivery. She had a normal course of labor and no classic signs of uterine rupture. However, gross hematuria was noted after repair of the episiotomy. The patient began to complain of progressive abdominal pain, gross hematuria and oliguria. Cystoscopy revealed a direct communication between the bladder and the uterus. When opening the bladder peritoneum, rupture sites over the anterior uterus and posterior wall of the bladder were noted. Following primary repair of both wounds, a Foley catheter was left in place for 12 days. The patient had achieved a full recovery by the 2-year follow-up examination. Bladder injury and uterine rupture can occur at any time during labor. Gross hematuria immediately after delivery is the most common presentation. Cystoscopy is a good tool to identify the severity of bladder injury. Copyright © 2010 Elsevier. Published by Elsevier B.V. All rights reserved.

Demographic, maternal, and infant health correlates of post-partum depression in Jordan.

PubMed

Safadi, Reema R; Abushaikha, Lubna A; Ahmad, Muayyad M

2016-09-01

This cross-sectional correlational study examined post-partum depression and its relationship with demographic, maternal, and infant health problems in urban Jordanian women. Participants (n = 315) were selected from five maternal child healthcare centers and one major hospital in Amman, Jordan. Patient Health Questionnaire-9 was used to measure post-partum depression within 12 weeks of birth. A number of socio-demographic and health problems were examined for an association with post-partum depression. Results showed that 25% of post-partum women suffered moderate to severe depression and 50% of the sample had mild depression. None of the socio-demographic variables (age, education, employment, income) were significantly related to post-partum depression; however, two obstetric/infant variables (mode of birth and breastfeeding), were significantly associated with post-partum depression. There was a significant association between post-partum depression and 15 health problems of obstetric, gynecologic (i.e. episiotomy pain, infection), and general health conditions (i.e. fatigue, headache). Nurses and midwives need to emphasize post-partum depression screening, follow-up, and proper management of maternal and infant health factors predisposing to post-partum depression rather than merely focusing on women's inherent demographic factors. © 2015 Wiley Publishing Asia Pty Ltd.

Antenatal maternal education for improving postnatal perineal healing for women who have birthed in a hospital setting.

PubMed

O'Kelly, Sonia M; Moore, Zena Eh

2017-12-04

The female perineum becomes suffused and stretched during pregnancy, and further strain during vaginal childbirth contributes to approximately 85% of women experiencing some degree of trauma to the perineal region. Multiple factors play a role in the type and severity of trauma experienced, including parity, delivery method, and local practices. There is ongoing debate about best midwifery practice to reduce perineal trauma. Once perineal trauma has occurred, treatment also varies greatly, depending on its degree and severity, local practice and customs, and personal preference. In order to optimise wound-healing outcomes, it is important that wounds are assessed and managed in an appropriate and timely manner. A perineal wound may cause significant physical and/or psychological impact in the short or long term, however little evidence is available on this subject.Antenatal education serves to prepare women and their partners for pregnancy, delivery and the postpartum period. The delivery of this education varies widely in type, content, and nature. This review examined antenatal education which is specifically tailored towards perineal care and wound healing in the postnatal period via formal channels. Appropriate patient education positively impacts on wound-healing rates and compliance with wound care. Risk factors that contribute to the breakdown of wounds and poor healing rates may be addressed antenatally in order to optimise postnatal wound healing. It is important to assess whether or not antenatal wound-care education positively affects perineal healing, in order to empower women to incorporate best practice, evidence-based treatment with this important aspect of self-care in the immediate postnatal period. To evaluate the effects of antenatal education on perineal wound healing in postnatal women who have birthed in a hospital setting, and who have experienced a break in the skin of the perineum as a result of a tear or episiotomy, or both. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2017), ClinicalTrials.gov (8th September 2017), the WHO International Clinical Trials Registry Platform (ICTRP) (8th September 2017) and reference lists of retrieved studies. We considered randomised controlled trials (RCTs) which referred to all formal methods of antenatal education and addressed care of a potential perineal wound as a result of a tear or episiotomy, which was experienced by pregnant women who planned to give birth within a hospital setting.Trials using a cluster-RCT and a quasi-randomised design would have been eligible for inclusion in this review but none were identified. Cross-over trials were not eligible for inclusion in this review. Studies published in abstract form would have been eligible for inclusion in this review, but none were identified.We planned to consider all formal methods of antenatal education which addressed care of a perineal wound. We also planned to consider all contact points where there was an opportunity for formal education, including midwifery appointments, antenatal education classes, obstetrician appointments, general practitioner appointments and physiotherapist appointments. Two review authors independently assessed titles and abstracts of the studies identified by the search strategy for their eligibility. No studies met the inclusion criteria for this review. We excluded one study and one other study is ongoing. We set out to evaluate the RCT evidence pertaining to the impact of antenatal education on perineal wound healing in postnatal women who have birthed in a hospital setting, and who experienced a break in the skin of the perineum as a result of a tear or episiotomy, or both. However, no studies met the inclusion criteria. There is a lack of evidence concerning whether or not antenatal education relating to perineal wound healing in this cohort of women will change the outcome for these women in relation to wound healing, infection rate, re-attendance or re-admission to hospital, pain, health-related quality of life, maternal bonding, and negative emotional experiences. Further study is warranted in this area given the significant physical, psychological and economic impact of perineal wounds, and the large proportion of childbearing women who have experienced a postnatal wound. The benefits of any future research in this field would be maximised by incorporating women in a range of socio-economic groups, and with a range of healthcare options. This research could take both a qualitative and a quantitative approach and examine the outcomes identified in this review in order to assess fully the potential benefits of a tailored antenatal package, and to make recommendations for future practice. There is currently no evidence to inform practice in this regard.

Management of the second phase of labour: perineum protection techniques.

PubMed

Laganà, A S; Burgio, M A; Retto, G; Pizzo, A; Granese, R; Sturlese, E; Ciancimino, L; Chiofalo, B; Retto, A; Triolo, O

2015-06-01

The obstetric experience alongside scientific evidences in literature indicate several management techniques during the expulsive period of labour to minimize obstetric complications. Among the various methods that can be used for the protection of the perineum during the expulsive phase, some are performed prepartum (perineum massage), while most are used during childbirth. Among the second group, progressively increasing importance is assumed by the manual techniques to protect the perineum (using the "hands-on" and "hands-off") and by episiotomy. These techniques, when used in accordance to the guidelines, may favour the reduction of adverse outcomes for both the mother and the newborn, both immediately after birth and after a longer time. The midwife should be aware of the evidences in literature so that a critical analysis of the available techniques can be made and put in action during the expulsive phase in order to protect the mother and the foetus from any unfavourable outcomes. Currently, clinical evidence in literature is directing obstetric and medical staff towards a careful analysis of the maternal-foetal parameters, in order to achieve a precise assessment of the risks factors of intrapartum and postpartum outcomes. Increasingly, there is the need for close collaboration between the midwife and medical staff to ensure proper personalized assistance based on the peculiar characteristics of the woman and the fetus.

[Methods of pushing at vaginal delivery and pelvi-perineal consequences. Review].

PubMed

Ratier, N; Balenbois, E; Letouzey, V; Marès, P; de Tayrac, R

2015-03-01

The main objective of that review was to evaluate the pelvi-perineal consequences of the different methods of pushing at vaginal delivery. A review on PubMed, the Cochrane Library and EM-Premium was performed from 1984 to 2014. Among 29 manuscripts analysed, only nine randomised controlled trials (including one meta-analysis of three trials) comparing Valsalva and spontaneous pushing were selected. A 10 th study, secondary analysis of a randomized controlled trial comparing different methods of perineal protection (warm compresses, massage and manual protection), was also selected. Two trials have shown that spontaneous pushing reduces the risk of perineal tears, but studies were heterogeneous and discordant results do not allowed definitive conclusions. Results on the duration of the second stage of labour are conflicting. The method of pushing does not seem to affect the rate of episiotomy, instrumental delivery and cesarean section. Maternal satisfaction seems to be better after spontaneous pushing. It seems that there is no negative effect of spontaneous pushing on neonate well-being, and one study has shown a significant improvement of prenatal fetal parameters during the expulsive phase. According to current knowledge, both techniques of pushing during the expulsive phase at delivery seem comparable in terms of duration, risk of perineal tears and neonatal outcome. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Alternative model of birth to reduce the risk of assisted vaginal delivery and perineal trauma.

PubMed

Walker, Carolina; Rodríguez, Tania; Herranz, Ana; Espinosa, José A; Sánchez, Emília; Espuña-Pons, Montserrat

2012-09-01

This study was conducted to evaluate the effects of an alternative model of birth (AMB) on the incidence of assisted vaginal delivery (AVD) and perineal trauma (PT). One hundred ninety-nine women with epidural anesthesia were randomized to a traditional model of birth (TMB) (n = 96) or AMB (n = 103). Women in TMB pushed immediately after complete dilatation and delivered in lithotomy position. In AMB, women followed a postural changes protocol while they delayed pushing and used a specific lateral position for delivery. AMB was associated with a significant reduction in AVD compared with TMB (19.8% vs 42.1%, p<0.001). TMB was strongly associated with AVD (OR = 4.49; p< 0.05), which, in turn, was significantly associated with nulliparity (OR = 5.52; p<0.005) and fetal head unengaged at full dilatation (OR = 5.35; p<0.05). AMB significantly increased the intact perineum rate compared with TMB (40.3% vs 12.2%, p<0.001). Episiotomy rate was significantly reduced in AMB (21.0% vs 51.4%, p<0.001). A combination of postural changes during the passive expulsive phase of labor and lateral position during active pushing time is associated with reductions in AVD and PT.

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

PubMed

Mizrachi, Yossi; Leytes, Sophia; Levy, Michal; Ginath, Shimon; Bar, Jacob; Ezri, Tiberiu; Kovo, Michal

2018-03-01

To study whether meperidine analgesia affects the incidence of obstetric lacerations at normal vaginal deliveries. 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. 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. Meperidine analgesia may have a protective effect against first- and second-degree perineal lacerations.

Epidural analgesia and severe perineal tears: a literature review and large cohort study.

PubMed

Loewenberg-Weisband, Yiska; Grisaru-Granovsky, Sorina; Ioscovich, Alexander; Samueloff, Arnon; Calderon-Margalit, Ronit

2014-12-01

Our objectives were to study the association between epidural analgesia and risk of severe perineal tears (SPT), and identify additional risk factors for SPT. We conducted a historical cohort study of women with term delivery between 2006 and 2011. Inclusion criteria were an uncomplicated singleton pregnancy, cephalic presentation and vaginal delivery. Multivariate logistic regression models were constructed to study the association between epidural analgesia and SPT, controlling for potential confounders. Additional models studied the association between prolonged second stage and instrumental labor and SPT. During the study period, 61,308 eligible women gave birth, 31,631 (51.6%) of whom received epidural analgesia. SPT occurred in 0.3% of births. Deliveries with epidural had significantly higher rates of primiparity, induction and augmentation of labor, prolonged second stage of labor, instrumental births and midline episiotomies. The univariate analysis showed a significant association between the use of epidural and SPT (OR: 1.78, 95% CI: 1.34-2.36); however, this association disappeared when parity was introduced (OR: 0.95, 95% CI: 0.69-1.29). Instrumental deliveries and prolonged second stage of labor were both strongly associated with SPT (ORs of 1.82 and 1.77) CONCLUSIONS: Epidural analgesia was not associated with SPT once confounding factors were controlled for.

Risk factors for anal sphincter tears in vacuum-assisted delivery.

PubMed

Ryman, P; Ahlberg, M; Ekéus, C

2015-10-01

The aim of the present study was to describe the prevalence of anal sphincter tears (AST) in relation to obstetric management and technique during vacuum extraction deliveries (VE) (re: indications, the station of the fetal head at application of the cup, number of tractions, the length for the extraction, cup detachments, pain relief, episiotomy, fetal presentation, and experience of the operator) as well as maternal and infant anthropometrics. Descriptive study. Data on six hundred vacuum extraction deliveries were consecutively collected from six different delivery units in Sweden. Each unit contributed with data on 100 deliveries. The final study population included 596 women who delivered by vacuum extraction. There was no correlation between the management of the vacuum extraction and risk for anal sphincter tear. Women from Africa had nearly a fourfold risk for anal sphincter tear during vacuum-assisted delivery compared with Swedish-born women (OR 3.82 CI 1.47-9.89). Compared with infants with birth weight less than 4000 g, birth weight above 4000 g was associated with increased risk of AST (OR 1.87 CI 1.06-3.28). In this study, the obstetric management in VE-assisted deliveries did not impact the risk of AST. Copyright © 2015 Elsevier B.V. All rights reserved.

Methods of pushing during vaginal delivery and pelvic floor and perineal outcomes: a review.

PubMed

de Tayrac, Renaud; Letouzey, Vincent

2016-12-01

Over the past 20 years, several randomized studies have compared Valsalva and spontaneous pushing techniques during vaginal delivery. This review summarizes current medical knowledge concerning their maternal and fetal consequences, focusing on pelvic and perineal outcomes. We selected nine randomized controlled trials comparing Valsalva and spontaneous pushing, and a secondary analysis of a randomized controlled trial comparing different methods of perineal protection. Two trials showed that spontaneous pushing reduces the risk of perineal tears, but no firm conclusions can be drawn given the heterogeneity and inconsistent results of these studies. Conflicting results have been reported regarding the duration of the second stage of labor. Pushing technique does not seem to affect episiotomy, instrumental delivery or cesarean rates. Maternal satisfaction seems to be better after spontaneous pushing. Spontaneous pushing appears to have no adverse effects on neonatal well being, and one study showed a significant improvement in prenatal fetal parameters during the expulsive phase. Valsalva and spontaneous pushing techniques currently appear comparable in terms of duration, pelvic floor, perineal, and neonatal outcomes. In the absence of strong evidence in favor of either technique, the decision should be guided by patient preference and the clinical situation. Additional, well-designed randomized controlled trials are required.

The Obstetric Consequences of Female Genital Mutilation/Cutting: A Systematic Review and Meta-Analysis

PubMed Central

Berg, Rigmor C.; Underland, Vigdis

2013-01-01

Various forms of female genital mutilation/cutting (FGM/C) have been performed for millennia and continue to be prevalent in parts of Africa. Although the health consequences following FGM/C have been broadly investigated, divergent study results have called into question whether FGM/C is associated with obstetric consequences. To clarify the present state of empirical research, we conducted a systematic review of the scientific literature and quantitative meta-analyses of the obstetric consequences of FGM/C. We included 44 primary studies, of which 28 were comparative, involving almost 3 million participants. The methodological study quality was generally low, but several studies reported the same outcome and were sufficiently similar to warrant pooling of effect sizes in meta-analyses. The meta-analyses results showed that prolonged labor, obstetric lacerations, instrumental delivery, obstetric hemorrhage, and difficult delivery are markedly associated with FGM/C, indicating that FGM/C is a factor in their occurrence and significantly increases the risk of delivery complications. There was no significant difference in risk with respect to cesarean section and episiotomy. These results can make up the background documentation for health promotion and health care decisions that inform work to reduce the prevalence of FGM/C and improve the quality of services related to the consequences of FGM/C. PMID:23878544

Long-term outcomes of the Stop Traumatic OASI Morbidity Project (STOMP).

PubMed

Basu, Maya; Smith, Dot

2018-06-09

To evaluate long-term sustainability of the Stop Traumatic OASI Morbidity Project (STOMP) in reducing the incidence of obstetric anal sphincter injury (OASI). A prospective observational study of women undergoing vaginal delivery at a UK district general hospital between September 1, 2014, and February 28, 2017. The principles of STOMP involve encouraging upright positioning, verbal coaching to avoid expulsive pushing and to slow down delivery, and tactile support to the vertex to judge speed and slow down delivery. After a training period, STOMP was implemented for all vaginal deliveries. Clinical and demographic data on women affected by OASI were collected across a 30-month period. The primary outcome measure was the incidence of OASI. There were 8782 vaginal deliveries during the 30-month period after implementation of STOMP. There was a significant decrease in the mean incidence of OASI relative to the 9 months before implementation (P<0.001). There was a significant decrease in the incidence of OASI for both spontaneous vaginal and instrumental deliveries (both P<0.05). There was no change in the frequency of episiotomy. Implementation of STOMP led to a significant decrease in OASI, confirming the sustainability of this approach to improve outcomes. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Female genital mutilation and efforts to achieve Millennium Development Goals 3, 4, and 5 in southeast Nigeria.

PubMed

Lawani, Lucky O; Onyebuchi, Azubuike K; Iyoke, Chukwuemeka A; Okeke, Nwabunike E

2014-05-01

To determine the prevalence of female genital mutilation (FGM), the common forms of FGM, reasons for the practice, associated obstetric outcomes, and how these have affected efforts to achieve Millennium Development Goals (MDGs) 3, 4, and 5 in southeast Nigeria. A prospective descriptive study of parturients in southeast Nigeria was conducted from January to December 2012. All primigravid women attending delivery services at 2 health institutions during the study period were recruited, examined, and classified using the 2008 WHO classification for FGM. The mean age of the 516 participants was 27.24±4.80 years and most (66.3%) had undergone FGM. Type II FGM was the most common form, accounting for 59.6% of cases. Most FGM procedures were performed in infancy (97.1%) and for cultural reasons (60.8%). Women who had undergone FGM had significantly higher risk for episiotomy, perineal tear, hemorrhage, cesarean delivery, neonatal resuscitation, fresh stillbirth/early neonatal death, and longer hospitalization, with higher risk ratios associated with higher degrees of FGM. FGM is still a common practice in southeast Nigeria, where its association with adverse reproductive outcomes militates against efforts to achieve MDGs 3, 4, and 5. Copyright © 2014 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Automatic detection of motor unit innervation zones of the external anal sphincter by multichannel surface EMG.

PubMed

Ullah, Khalil; Cescon, Corrado; Afsharipour, Babak; Merletti, Roberto

2014-12-01

A method to detect automatically the location of innervation zones (IZs) from 16-channel surface EMG (sEMG) recordings from the external anal sphincter (EAS) muscle is presented in order to guide episiotomy during child delivery. The new algorithm (2DCorr) is applied to individual motor unit action potential (MUAP) templates and is based on bidimensional cross correlation between the interpolated image of each MUAP template and two images obtained by flipping upside-down (around a horizontal axis) and left-right (around a vertical axis) the original one. The method was tested on 640 simulated MUAP templates of the sphincter muscle and compared with previously developed algorithms (Radon Transform, RT; Template Match, TM). Experimental signals were detected from the EAS of 150 subjects using an intra-anal probe with 16 equally spaced circumferential electrodes. The results of the three algorithms were compared with the actual IZ location (simulated signal) and with IZ location provided by visual analysis (VA) (experimental signals). For simulated signals, the inter quartile error range (IQR) between the estimated and the actual locations of the IZ was 0.20, 0.23, 0.42, and 2.32 interelectrode distances (IED) for the VA, 2DCorr, RT and TM methods respectively. Copyright © 2014 Elsevier Ltd. All rights reserved.

Dislocation of temporo-mandibular joint - an uncommon circumstance of occurrence: vaginal delivery.

PubMed

El Bouazzaoui, Abderrahim; Labib, Smael; Derkaoui, Ali; Adnane Berdai, Mohammed; Bendadi, Azzeddine; Harandou, Mustapha

2010-06-25

Dislocation of temporo-mandibular joint (TMJ) is an infrequent disease but still spectacular. This disease consists of a permanent, to some extent complete disruption of the temporo-mandibular joint. These dislocations often occur in a context of yawning, and less frequently after a burst of laughing or relatively mild facial trauma (slap, punch on the chin). We report a case of TMJ occurring in an uncommon circumstance: vaginal delivery. A woman aged 24-years with no special past medical history; primipara was admitted in the Department of Maternity of the University Hospital Hassan II of Fez for an imminent delivery of a twin pregnancy. Ten minutes after admission, the patient delivered vaginally with episiotomy. She gave birth to twins weighing 2800 g and 2400 g. During labour, and due to efforts of crying, the patient developed a sudden and immediate loss of function of the temporo-mandibular joint, with difficulty of speaking, the mouth permanently opened and with the chin lowered and thrown forward. The examination found an empty glenoid fossa of the temporo-mandibular joint in both sides. The diagnosis of dislocation of the TMJ was established. A CT scan of facial bones was done, objectifying a bilateral dislocation of TMJ. The reduction of this dislocation was performed in the operating room under sedation.

Transcutaneous electrical nerve stimulation (TENS) for pain control after vaginal delivery and cesarean section.

PubMed

Kayman-Kose, Seda; Arioz, Dagistan Tolga; Toktas, Hasan; Koken, Gulengul; Kanat-Pektas, Mine; Kose, Mesut; Yilmazer, Mehmet

2014-10-01

The present study aims to determine the efficiency and reliability of transcutaneous electrical nerve stimulation (TENS) in the management of pain related with uterine contractions after vaginal delivery and the pain related with both abdominal incision uterine contractions after cesarean section. A hundred healthy women who underwent cesarean section under general anesthesia were randomly assigned to the placebo group (Group 1) or the TENS group (Group 2), while 100 women who delivered by vaginal route without episiotomy were randomized into the placebo group (Group 3) or the TENS group (Group 4). The patients in Group 2 had statistically lower visual analog scale (VAS) and verbal numerical scale (VNS) scores than the patients in Group 1 (p < 0.001 for both). The patients in Group 4 had statistically lower VAS and VNS scores than the patients in Group 3 (p = 0.022 and p = 0.005, respectively). The analgesic requirement at the eighth hour of cesarean section was significantly lower in the patients who were treated with TENS (p = 0.006). The need for analgesics at the eighth hour of vaginal delivery was statistically similar in the patients who were treated with TENS and the patients who received placebo (p = 0.830). TENS is an effective, reliable, practical and easily available modality of treatment for postpartum pain.

Effectiveness of nitrous oxide for postpartum perineal repair: a randomised controlled trial.

PubMed

Berlit, Sebastian; Tuschy, Benjamin; Brade, Joachim; Mayer, Jade; Kehl, Sven; Sütterlin, Marc

2013-10-01

To compare the effectiveness of self-administered 50% nitrous oxide and conventional infiltrative anaesthesia with 1% prilocaine hydrochloride in postpartum perineal repair. A total of 100 women were prospectively enrolled and randomised to receive either infiltrative anaesthesia or a self-administered nitrous oxide mixture (Livopan(©)) for pain relief during postpartum perineal suturing. Besides data concerning anaesthesia, characteristics of patients and labour were documented for statistical analysis. Pain experienced during perineal repair was assessed using the short form of the McGill Pain Questionnaire (SF-MPQ). Forty-eight women received nitrous oxide and 52 underwent perineal suturing after infiltrative anaesthesia. There were no statistically significant differences regarding maternal age, body mass index (BMI), duration of pregnancy and suturing time between the groups. The most frequent birth injury was second-degree perineal laceration in the study group [22/48; 46%] and episiotomy in the control group [18/52; 35%]. Pain experienced during genital tract suturing and patients' satisfaction showed no statistically significant differences between the groups. Thirty-seven women in the study group and 47 in the control group were satisfied with the anaesthesia during perineal repair and would recommend it to other parturients [37/48, 77% vs. 47/52, 90%; p=0.0699). Nitrous oxide self-administration during genital tract suturing after vaginal childbirth is a satisfactory and effective alternative to infiltrative anaesthesia. Copyright © 2013 Elsevier Ireland Ltd. All rights reserved.

Delays in the delivery room of a primary maternity unit: a retrospective analysis of obstetric outcomes.

PubMed

Giannella, Luca; Mfuta, Kabala; Pedroni, Deborah; Delrio, Elisabetta; Venuta, Agnese; Bergamini, Ezio; Cerami, Lillo B

2013-04-01

To compare obstetric outcomes in women undergoing vaginal delivery with or without delay in the 2nd and 3rd stage of labour (SOL). This is an observational retrospective study including 10,416 full-term vaginal deliveries occurred at a primary obstetric unit. Our sample was divided according to the length of 2nd and 3rd SOL: >2 h vs. ≤2 h; and >1 h vs. ≤1 h, respectively. Obstetric outcomes were compared using univariate and multivariate analysis. A prolonged 2nd SOL was associated with severe perineal tears (odds ratio (OR) = 3.53), episiotomy (OR = 3.25), major post-partum hemorrhage (PPH) (OR = 2.35), operative delivery (OR = 3.54), and Asian ethnicity (OR = 12.12). Likewise, a prolonged 3rd SOL was associated with operative deliveries (OR = 10.49), labor induction (OR = 3.24), non-use of oxytocin after delivery (OR = 12.39), major PPH (OR = 46.95), retained placenta (OR = 3.57) and female fetal gender (OR = 4.07). even at a primary care setting, where there are mostly low-risk pregnancies, a prolonged 2nd and 3rd SOL may occur and lead to poor obstetric outcomes. Our findings raise a very controversial issue about the meaning of "low obstetrics risk", given the unpredictability of any labor, and the management of complications in the delivery room of primary maternity units.

Risk Factors for Birth Canal Lacerations in Primiparous Women

PubMed Central

Mikolajczyk, Rafael T.; Zhang, Jun; Troendle, James; Chan, Linda

2013-01-01

Lacerations of the birth canal are common side effects of vaginal birth. They are potentially preventable. Although serious long-term consequences have been identified for severe perineal lacerations, less attention has been paid to lacerations in other locations and how the risk factors vary for different lacerations. We analyzed a dataset including 1009 primiparous women with singleton pregnancies and vaginal deliveries, and we examined risk factors for third- and fourth-degree perineal lacerations and periurethral, vaginal, and labial lacerations using logistic regression analysis. Large fetal size (≥ 3500 g) substantially increased the risk of perineal (odd ratio [OR], 3.8; 95% confidence interval [CI], 1.8 to 7.9) and periurethral (OR, 2.3; 95% CI, 1.0 to 5.0) lacerations but not other types of lacerations. Episiotomy had no impact on perineal lacerations (OR 0.9) but had very strong protective effects for other lacerations (OR 0.1). Prolonged second stage of labor (>120 minutes) increased the risk of perineal and vaginal lacerations but reduced the risk for periurethral lacerations. Instrumental deliveries were significant risk factors for third- and fourth-degree perineal lacerations, with by far the strongest effect for low forceps (OR 25.0 versus <3 for outlet forceps, outlet vacuum, and low vacuum). We concluded that separating different birth canal lacerations is critical in identifying risk factors and potential preventive strategies. PMID:18509884

Risk factors for birth canal lacerations in primiparous women.

PubMed

Mikolajczyk, Rafael T; Zhang, Jun; Troendle, James; Chan, Linda

2008-05-01

Lacerations of the birth canal are common side effects of vaginal birth. They are potentially preventable. Although serious long-term consequences have been identified for severe perineal lacerations, less attention has been paid to lacerations in other locations and how the risk factors vary for different lacerations. We analyzed a dataset including 1009 primiparous women with singleton pregnancies and vaginal deliveries, and we examined risk factors for third- and fourth-degree perineal lacerations and periurethral, vaginal, and labial lacerations using logistic regression analysis. Large fetal size (> or = 3500 g) substantially increased the risk of perineal (odd ratio [OR], 3.8; 95% confidence interval [CI], 1.8 to 7.9) and periurethral (OR, 2.3; 95% CI, 1.0 to 5.0) lacerations but not other types of lacerations. Episiotomy had no impact on perineal lacerations (OR 0.9) but had very strong protective effects for other lacerations (OR 0.1). Prolonged second stage of labor (> 120 minutes) increased the risk of perineal and vaginal lacerations but reduced the risk for periurethral lacerations. Instrumental deliveries were significant risk factors for third- and fourth-degree perineal lacerations, with by far the strongest effect for low forceps (OR 25.0 versus < 3 for outlet forceps, outlet vacuum, and low vacuum). We concluded that separating different birth canal lacerations is critical in identifying risk factors and potential preventive strategies.

Do we know enough? A quality assessment of the Finnish intervention to prevent obstetric anal sphincter injuries.

PubMed

Skriver-Møller, Anne-Cathrine; Madsen, Mia Lund; Poulsen, Mette Østergaard; Overgaard, Charlotte

2016-11-01

Especially in the Nordic countries, increases in obstetric anal sphincter injuries (OASIS) have prompted standard use of the Finnish intervention for their prevention. We performed a quality assessment of the introduction of the intervention in a Danish hospital setting. All vaginal deliveries by primiparous women the year before (N = 343) and after (N = 334) the introduction were compared in a retrospective, observational design. Fisher's exact test, Student's t-test, and multiple logistic regression analysis were performed. No significant difference in OASIS (OR: 0.5; 95% CI: 0.3-1.1) was found. The post-implementation group saw a significant increase in episiotomy (OR: 1.8; 95% CI: 1.1-2.9) and the length of second stage labor (p < 0.05) while intact perineum (OR: 0.5; 95% CI: 0.3-0.9), use of upright positions for birth (OR: 3.2; 95% CI: 1.8-5.5), and neonatal blood gas levels were significantly reduced (p < 0.05). Introduction of the Finnish intervention was not followed by a significant reduction of OASIS, but a downward trend was seen. The study results raise questions about potential side effects of the Finnish intervention on neonatal outcomes, intact perineum, and women's free choice of birth positions. More knowledge on effect and side effects from high-evidence studies are needed.

Perineal body length and perineal lacerations during delivery in primigravid patients

PubMed Central

Lane, T. Lance; Chung, Christopher P.; Yandell, Paul M.; Kuehl, Thomas J.

2017-01-01

This study assessed the relation between perineal body length and the risk of perineal laceration extending into the anal sphincter during vaginal delivery in primigravid patients at an institution with a low utilization of episiotomy. This was a prospective study of primigravid patients in active labor. Primigravid women with singleton pregnancies who were in the first stage of labor at 37 weeks gestation or greater were recruited, and the admitting physician measured the length of the perineal body. The degree of perineal laceration and other delivery characteristics were recorded. Data were analyzed using univariate analyses, receiver-operator curve analyses, and multiple logistic regression for factors associated with increased severity of vaginal lacerations. The perineal body length, duration of second stage of labor, type of delivery, and patient age were associated (P < 0.1) with third- and fourth-degree (severe) perineal lacerations in primigravid women using receiver-operator curve analysis. Using logistic regression, only the duration of second stage of labor and length of the perineal body were significant (P < 0.04) predictors of third- and fourth-degree lacerations, with odds ratios of 32 (1.3 to 807 as 95% CI) and 24 (1.3 to 456), respectively. Both a perineal body length of ≤3.5 cm and a duration of second stage of labor >99 minutes were associated with an increased risk of third- and fourth-degree lacerations in primigravid patients. PMID:28405063

[Hospital infections in the maternity department at Brest Hospital over a period from 2000 to 2005].

PubMed

Rouzic, N; Faisant, M; Scheydeker, J-L; Collet, M; Lejeune, B

2008-03-01

Hospital infections are at stake in terms of public health. They are responsible for increase in morbidity and involve the community in high costs. Epidemiologic surveillance has been initiated in the departments of gynecology, obstetrics and maternity with a view to making out the rate of hospital-acquired infections and the risk factors associated to them. It is an incidence survey over a period from 2000 to 2005. Surveillance slips are filled in for every childbirth. All suspicions of hospital infections are analysed in morbidity reviews every trimester. A request to the Medical Information Department of the hospital has allowed to look for variables which were not mentioned on the initial questionnaire and so carry out a more complete analysis. The number of hospital infections amounts to 118 over 9526 childbirths, corresponding to an incidence rate of 1.24%. After vaginal delivery the encountered risk factors are: episiotomy or perineal trauma, epidural anesthesia, urinary infection and the use of tools. After a caesarean section the risk factors are: general anesthesia and lack of antibioprophylaxy. The rate of hospital infections in the maternity department at Brest's centre hospitalier universitaire (CHU) during the considered period and the observed tendency to a decreasing of hospital infections over the same period apparently denotes the interest of surveillance in matter of hospital infections in maternity.

Antepartum or intrapartum deinfibulation for childbirth in women with type III female genital mutilation: A systematic review and meta-analysis.

PubMed

Esu, Ekpereonne; Udo, Atim; Okusanya, Babasola O; Agamse, David; Meremikwu, Martin M

2017-02-01

There remains no consensus on the best timing of deinfibulation in women with type III female genital mutilation (FGM). To conduct a systematic review of the effects of antepartum or intrapartum deinfibulation on childbirth outcomes in women with type III FGM. The following major databases were searched: Cochrane Central Register for Controlled Trials (CENTRAL), MEDLINE, Scopus, Web of Science, and ClinicalTrials.gov, from inception until August 2015 without any language restrictions. Studies of pregnant women or girls with type III FGM who were deinfibulated antepartum or intrapartum were included. Two team members independently screened and collected data. Quality of evidence was assessed using GRADE. Summary odds ratios and proportions were calculated when possible. There is no evidence of a significant difference between antepartum and intrapartum deinfibulation for obstetric outcomes such as duration of labor, perineal lacerations, episiotomies, postpartum hemorrhage, and cesarean deliveries. Outcomes in women living with type III FGM and those who have undergone deinfibulation were not statistically different; however, trends show a benefit for deinfibulation. All studies were underpowered to detect statistical differences. Larger studies are required to have full confidence in these findings. CRD42015024464. © 2017 International Federation of Gynecology and Obstetrics. The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.

Obstetric care of women with female genital mutilation attending a specialized clinic in a tertiary center.

PubMed

Abdulcadir, Jasmine; Dugerdil, Adeline; Yaron, Michal; Irion, Olivier; Boulvain, Michel

2016-02-01

To study the obstetric outcomes of women attending a specialized clinic for women with female genital mutilation (FGM). The medical charts of women with FGM who consecutively attended a specialized clinic between 2010 and 2012 were reviewed retrospectively. The present study focused on women attending for obstetric reasons. The outcome measures were type of delivery, reason for cesarean delivery or assisted delivery, blood loss, episiotomy, perineal tear, duration of the second stage of labor, postpartum complications, weight of the neonate, and Apgar score. Outcomes were compared between women with FGM type III who underwent defibulation, and patients with FGM type I and II. The clinic was attended by 129 women, 84 perinatally. Obstetric outcomes were similar to average outcomes for women without FGM presenting at the same department and in Switzerland generally. Specifically, 20 women had a cesarean delivery. An assisted delivery was performed for 18 patients; among these, only eight had experienced obstructed labor. No statistically significant differences were found for the outcome measures when women with FGM type III were compared to FGM type I and II. Routine obstetric follow-up combined with specialized care for women with FGM, including defibulation, can avoid inappropriate obstetric practices and reduce obstetric complications known to be associated with FGM. Copyright © 2015 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.

Are obstetric outcomes affected by female genital mutilation?

PubMed

Balachandran, Aswini A; Duvalla, Swapna; Sultan, Abdul H; Thakar, Ranee

2018-03-01

Female genital mutilation (FGM) has been associated with adverse obstetric and neonatal outcomes, such as postpartum haemorrhage (PPH), perineal trauma, genital fistulae, obstructed labour and stillbirth. The prevalence of FGM has increased in the UK over the last decade. There are currently no studies available that have explored the obstetric impact of FGM in the UK. The aim of our study was to investigate the obstetric and neonatal outcomes of women with FGM when compared with the general population. We conducted a retrospective case-control study of consecutive pregnant women with FGM over a 5-year period between 1 January 2009 and 31 December 2013. Each woman with FGM was matched for age, ethnicity, parity and gestation with subsequent patients without FGM (control cohort) over the same 5-year period. Outcomes assessed were mode of delivery, duration of labour, estimated blood loss, analgaesia, perineal trauma and foetal outcomes. A total of 242 eligible women (121 FGM, 121 control) were identified for the study. There was a significant increase in the use of episiotomy in the FGM group (p = 0.009) and a significant increase in minor PPH in the control group during caesarean sections (p = 0.0001). There were no differences in all other obstetric and neonatal parameters. In our unit, FGM was not associated with an increased incidence of adverse obstetric and foetal morbidity or mortality.

Somali prenatal education video use in a United States obstetric clinic: a formative evaluation of acceptability.

PubMed

DeStephano, Christopher C; Flynn, Priscilla M; Brost, Brian C

2010-10-01

Because of low health literacy and low priority in seeking prenatal information, health education videos were explored for acceptability by Somali refugee women in a clinical setting. Focus groups led to the development of six targeted Somali prenatal education videos. Topics include: preparation for pregnancy, nutrition and exercise, pregnancy myths/facts, the father's role, episiotomies, and caesarean sections. Somali participants were recruited to view programs, and completed an 8-item survey prior to regularly scheduled prenatal appointments. Following the clinical visit, providers completed a 4-item survey indicating the video's helpfulness in facilitating client-provider communication. All study participants "strongly recommended" and rated the videos as "appropriate for Somali clients", 57% indicated the information was "just the right amount," and 60% found the videos "extremely helpful." The primary language spoken at home was Somali (72.7%) and 54.5% indicated Somali as the preferred language to receive health information. Providers indicated 24% of appointments were "more interactive" with 72% finding videos "somewhat" or "extremely helpful." Preliminary results from this pilot study suggest that a video format for prenatal education is acceptable to Somali clients with most clients preferring video health education materials presented in the Somali language. Culturally tailored health education video series for Somali women appear well for use in a clinic setting to facilitate client-provider communication. (c) 2009 Elsevier Ireland Ltd. All rights reserved.

[Delivery of the IUGR fetus].

PubMed

Perrotin, F; Simon, E G; Potin, J; Laffon, M

2013-12-01

The purpose of this paper is to review available data regarding the management of delivery in intra uterine growth retarded fetuses and try to get recommendations for clinical obstetrical practice. Bibliographic research performed by consulting PubMed database and recommendations from scientific societies with the following words: small for gestational age, intra-uterine growth restriction, fetal growth restriction, very low birth weight infants, as well as mode of delivery, induction of labor, cesarean section and operative delivery. The diagnosis of severe IUGR justifies the orientation of the patient to a referral centre with all necessary resources for very low birth weight or premature infants Administration of corticosteroids for fetal maturation (before 34 WG) and a possible neuroprotective treatment by with magnesium sulphate (before 32-33 WG) should be discussed. Although elective caesarean section is common, there is no current evidence supporting the use of systematic cesarean section, especially when the woman is in labor. Induction of labor, even with unfavorable cervix is possible under continuous FHR monitoring, in favorable obstetric situations and in the absence of severe fetal hemodynamic disturbances. Instrumental delivery and routine episiotomy are not recommended. For caesarean section under spinal anesthesia, an adequate anesthetic management must ensure the maintenance of basal blood pressure. Compared with appropriate for gestational age fetus, IUGR fetus is at increased risk of metabolic acidosis or perinatal asphyxia during delivery. Copyright © 2013 Elsevier Masson SAS. All rights reserved.

A Prospective Randomized Trial of Postural Changes vs Passive Supine Lying during the Second Stage of Labor under Epidural Analgesia

PubMed Central

Simarro, María; Espinosa, José Angel; Salinas, Cecilia; Ojea, Ricardo; Salvadores, Paloma; Walker, Carolina; Schneider, José

2017-01-01

There exist very few studies comparing different postures or postural changes during labor in parturients with epidural analgesia. Aim: To disclose whether the intervention of a multidisciplinary nursing team including a physiotherapist during the second stage of labor improves the obstetric outcome in parturients with epidural analgesia. Design: Prospective randomized trial. Setting: University-affiliated hospital. Population: Women undergoing labor with epidural analgesia after a normal gestation. Methods: 150 women were randomized either to actively perform predefined postural changes during the passive phase of the second stage of labor under the guidance of the attending physiotherapist (study group), or to carry out the whole second stage of labor lying in the traditional supine position (control group). Results: There were significantly more eutocic deliveries (p = 0.005) and, conversely, significantly less instrumental deliveries (p < 0.05) and cesarean sections (p < 0.05) in the study group. The total duration of the second stage of labor was significantly shorter (p < 0.01) in the study group. This was at the expense of the passive phase of the second stage of labor (p < 0.01). Significantly less episiotomies were performed in the study group (31.2% vs 17.8%, p < 0.05). Conclusion: The intervention of a physiotherapist during the second stage of labor significantly improved the obstetric outcome. PMID:29099021

Arrival in the labour ward in second stage of labour--any prognostic significance?

PubMed

Nkyekyer, K

1998-05-01

A comparative descriptive study was carried out to determine whether, in uncomplicated term pregnancies with the foetus in vertex presentation, there were any differences in maternal or foetal outcome between women who arrived in the labour ward in second stage of labour and those who arrived in early active phase. There were two hundred and seventeen women each in the study and comparison groups. There were no significant differences between the two groups as regards age, parity, marital status and level of education. Women in the comparison group were better antenatal clinic attendants. Those in the study group were more likely to have indicated that they had problems with transportation. They also had considerably shorter labours and all achieved spontaneous vaginal deliveries; a significant proportion (10.6%) of the comparison group had interventional deliveries. The incidence of episiotomies, lower genital tract injuries, manual removal of placenta and postpartum haemorrhage after vaginal delivery were not different between the two groups. Babies born to mothers in the study group were significantly lighter, by about 170 gms, and had a lower incidence of low one-minute Apgar scores. There were no significant differences in the rates of admission to the neonatal intensive care unit or in early neonatal deaths. Arrival in the labour ward in second stage of labour prognosticates non-interventional delivery without any increased risk of adverse outcome to the mother or her baby.

Home exercises for pelvic floor in continent women one year after physical therapy treatment for urinary incontinence: an observational study.

PubMed

Krüger, Ana P; Luz, Soraia C T; Virtuoso, Janeisa F

2011-01-01

To describe the results of home exercise targeting the pelvic floor in continent women one year after the end of a physical therapy treatment for the following outcomes: functional assessment of the pelvic floor and urinary incontinence. This is an observational study that evaluated fifteen women one year after physical therapy treatment for Stress Urinary Incontinence (SUI). The outcomes for this study were: situations of urinary loss, use of daily protection, practice of home exercises for the pelvic floor, functional assessment of the pelvic floor (FAPF) and patient satisfaction. We also investigated some confounding variables such as hormonal status, number of vaginal deliveries and previous history of episiotomy. One year after completion of physical therapy treatment, we observed that the FAPF median remained stable over time (Median=5, p=0.08). The presence of urinary incontinence was reported by 40% of women in the sample, however, was characterized as mild (i.e. not requiring the use of daily protection). There was also a significant association (p=0.001) between the completion of home exercises (twice or more per week) and the normal clinical status. Confounding variables, which could compromise the clinical status, showed no significant association with the outcomes (p≥0.05). Home exercises contributed to the maintenance of continence following a physical therapy treatment.

Effect of Breathing Technique of Blowing on the Extent of Damage to the Perineum at the Moment of Delivery: A Randomized Clinical Trial

PubMed Central

Ahmadi, Zohre; Torkzahrani, Shahnaz; Roosta, Firouze; Shakeri, Nezhat; Mhmoodi, Zohre

2017-01-01

Introduction: One of the important tasks in managing labor is the protection of perineum. An important variable affecting this outcome is maternal pushing during the second stage of labor. This study was done to investigate the effect of breathing technique on perineal damage extention in laboring Iranian women. Materials and Methods: This randomized clinical trial was performed on 166 nulliparous pregnant women who had reached full-term pregnancy, had low risk pregnancy, and were candidates for vaginal delivery in two following groups: using breathing techniques (case group) and valsalva maneuver (control group). In the control group, pushing was done with holding the breath. In the case group, the women were asked to take 2 deep abdominal breaths at the onset of pain, then take another deep breath, and push 4–5 seconds with the open mouth while controlling exhalation. From the crowning stage onward, the women were directed to control their pushing, and do the blowing technique. Results: According to the results, intact perineum was more observed in the case group (P = 0.002). Posterior tears (Grade 1, 2, and 3) was considerably higher in the control group (P = 0.003). Anterior tears (labias) and episiotomy were not significantly different in the two groups. Conclusions: It was concluded that breathing technique of blowing can be a good alternative to Valsalva maneuver in order to reduce perineal damage in laboring women. PMID:28382061

A comparison of labour and birth outcomes in Jordan with WHO guidelines: a descriptive study using a new birth record.

PubMed

Khresheh, Reham; Homer, Caroline; Barclay, Lesley

2009-12-01

to examine data collected during the testing of a new birth record in Jordan from 1 July to 31 August 2004, and to compare these practices with guidelines from the World Health Organization (WHO) and evidence-based recommendations. This was part of a larger study that used an action research approach to engage practitioners in implementation of the new record. descriptive, comparative design. three Ministry of Health hospitals in Jordan. the birth records of 1254 mothers and babies were used. data on selected labour and birth practices were collected from the records. Comparisons were made using recognised evidence-based guidelines. the rates of a number of labour and birth practices were inappropriately high, and differed from WHO guidelines and evidence-based recommendations. The rates of augmentation of labour (46%) and episiotomy (53%) were particularly high, and seem to be in excess of the WHO recommendations, which state that neither of these practices should be undertaken routinely. information on labour and birth practices can assist clinicians working in these three hospitals to reflect upon their care and outcomes. Clinicians may be able to use this information to change practice to improve care for women and babies. Organisational support and clinical leadership are necessary in order to provide health professionals with time and resources to access research data and undertake comparisons that can lead to health service and system-level improvement.

Snoezelen Room and Childbirth Outcome: A Randomized Clinical Trial.

PubMed

Jamshidi Manesh, Mansoureh; Kalati, Mahnaz; Hosseini, Fatemeh

2015-05-01

One of the strategies for a good outcome and pain free childbearing is to design the delivery room. The aim of this study was to evaluate the effects of snoezelen room on childbearing outcome such as pain intensity, duration of labor, and perinea status in nulliparous women. This study was a randomized controlled clinical trial consists of 100 childbearing women. They were randomly divided into 2 groups. The experimental group went to snoezelen room when their cervix dilation was 4 cm, while the control group went to physiologic delivery room with the same cervix dilation. The mean ± SD of VAS (Visual Analogue Scale) pain intensity of the experimental and control groups before the intervention were 5.1 ± 1.95 and 5.58 ± 1.62, respectively (P = 0.13). The mean ± SD of VAS pain intensity scores of the experimental and control groups after 3 hours spending in their assigned rooms were 5.26 ± 0.86 and 9.56 ± 1.48, respectively (P = 0.01). The mean ± SD of the first stage scores of the experimental and control groups were 6.95 ± 0.97 and 8.41 ± 0.67, respectively (P = 0.042). About 92% of participants' intervention vs. 66% of control participants had perinea laceration (P = 0.041). According to the findings of the present study, distracting senses in snoezelen room decreases mother's pain intensity, the length of labor, and incidence of episiotomy.

Evaluation of third-degree and fourth-degree laceration rates as quality indicators.

PubMed

Friedman, Alexander M; Ananth, Cande V; Prendergast, Eri; D'Alton, Mary E; Wright, Jason D

2015-04-01

To examine the patterns and predictors of third-degree and fourth-degree laceration in women undergoing vaginal delivery. We identified a population-based cohort of women in the United States who underwent a vaginal delivery between 1998 and 2010 using the Nationwide Inpatient Sample. Multivariable log-linear regression models were developed to account for patient, obstetric, and hospital factors related to lacerations. Between-hospital variability of laceration rates was calculated using generalized log-linear mixed models. Among 7,096,056 women who underwent vaginal delivery in 3,070 hospitals, 3.3% (n=232,762) had a third-degree laceration and 1.1% (n=76,347) had a fourth-degree laceration. In an adjusted model for fourth-degree lacerations, important risk factors included shoulder dystocia and forceps and vacuum deliveries with and without episiotomy. Other demographic, obstetric, medical, and hospital variables, although statistically significant, were not major determinants of lacerations. Risk factors in a multivariable model for third-degree lacerations were similar to those in the fourth-degree model. Regression analysis of hospital rates (n=3,070) of lacerations demonstrated limited between-hospital variation. Risk of third-degree and fourth-degree laceration was most strongly related to operative delivery and shoulder dystocia. Between-hospital variation was limited. Given these findings and that the most modifiable practice related to lacerations would be reduction in operative vaginal deliveries (and a possible increase in cesarean delivery), third-degree and fourth-degree laceration rates may be a quality metric of limited utility.

[Does persistent occiput posterior position increase the risk of severe perineal laceration?].

PubMed

Salameh, C; Canoui-Poitrine, F; Cortet, M; Lafon, A; Rudigoz, R-C; Huissoud, C

2011-10-01

To assess the risk of severe perineal lacerations (III and IV degrees) during vaginal deliveries in occiput posterior position. We conducted a retrospective cohort study of 9097 vaginal deliveries in a teaching hospital's maternity between January 1st 2005 and December 31st 2008. Risk factors associated with tears of the 3rd or 4th degree were studied by a multivariate logistic regression. Severe perineal lacerations occurred in 1.69% of cases (n=152) and did not significantly vary between 2005 and 2008. Parity was a protective factor (OR 0.42; P<0.001; IC(95%) 0.29-0.60) whereas instrumental extraction was associated with an increased risk: vacuum (OR 3.95; P<0.001, IC(95%) 2.23-7.00) and forceps (OR 3.55; P<0.001, IC(95%) 2.33-5.42). macrosomia. Risks were also increased in fetal macrosomia and episiotomy did not protect the mother (respectively OR 1.41 P<0.001, IC(95%) 1.19-1.68 and OR 1.73; P<0.001, IC(95%) 1.16-2.57). Persistent occiput posterior position was not significantly associated with an anal sphincter injury (OR=1.70 P=0.059; IC(95%) 0.98-2.94). In our series, occiput posterior position did not significantly impact the risk of severe perineal laceration. A manual rotation of the fetal head should be performed in case of associated risk factors. Copyright © 2011 Elsevier Masson SAS. All rights reserved.

Postpartum sexual health: a principle-based concept analysis.

PubMed

O'Malley, Deirdre; Higgins, Agnes; Smith, Valerie

2015-10-01

The aim of this study is to report an analysis of the concept of postpartum sexual health. Postpartum sexual health is a minimally understood concept, most often framed within physical/biological dimensions or as a 'checklist' task in postpartum information provision. This has the potential to leave women unprepared to manage transient or normative sexual health changes after childbirth. For meaningful discussions, clarity and understanding of postpartum sexual health is required. A principle-based method of concept analysis. The databases of PubMed, CINAHL, Maternity and Infant Care, PsychInfo, Web of Science, EMBASE, SCOPUS and Social Science Index were systematically searched, from their earliest dates, using a combination of key terms, including; 'sexual health', 'sexual function', 'dyspareunia', 'sexuality', 'sexual desire', 'sexual dysfunction', 'postnatal' and 'postpartum', resulting in a final included dataset of 91 studies. Using the principle-based approach, postpartum sexual health was analysed under the four philosophical principles of epistemological, pragmatic, linguistic and logical. Philosophically, postpartum sexual health is underdeveloped as a concept. A precise theoretical definition remains elusive and, presently, postpartum sexual health cannot be separated theoretically from sexuality and sexual function. Identified antecedents include an instrument free birth, an intact perineum and avoidance of episiotomy. Attributes include sexual arousal, desire, orgasm, sexual satisfaction and resumption of sexual intercourse. Outcomes are sexual satisfaction and a satisfying intimate relationship with one's partner. Postpartum sexual health is conceptually immature with limited applicability in current midwifery practice. © 2015 John Wiley & Sons Ltd.

Snoezelen Room and Childbirth Outcome: A Randomized Clinical Trial

PubMed Central

Jamshidi Manesh, Mansoureh; Kalati, Mahnaz; Hosseini, Fatemeh

2015-01-01

Background: One of the strategies for a good outcome and pain free childbearing is to design the delivery room. Objectives: The aim of this study was to evaluate the effects of snoezelen room on childbearing outcome such as pain intensity, duration of labor, and perinea status in nulliparous women. Patients and Methods: This study was a randomized controlled clinical trial consists of 100 childbearing women. They were randomly divided into 2 groups. The experimental group went to snoezelen room when their cervix dilation was 4 cm, while the control group went to physiologic delivery room with the same cervix dilation. Results: The mean ± SD of VAS (Visual Analogue Scale) pain intensity of the experimental and control groups before the intervention were 5.1 ± 1.95 and 5.58 ± 1.62, respectively (P = 0.13). The mean ± SD of VAS pain intensity scores of the experimental and control groups after 3 hours spending in their assigned rooms were 5.26 ± 0.86 and 9.56 ± 1.48, respectively (P = 0.01). The mean ± SD of the first stage scores of the experimental and control groups were 6.95 ± 0.97 and 8.41 ± 0.67, respectively (P = 0.042). About 92% of participants’ intervention vs. 66% of control participants had perinea laceration (P = 0.041). Conclusions: According to the findings of the present study, distracting senses in snoezelen room decreases mother’s pain intensity, the length of labor, and incidence of episiotomy. PMID:26082849

Management of type III female genital mutilation in Birmingham, UK: a retrospective audit.

PubMed

Paliwal, Priya; Ali, Sarah; Bradshaw, Sally; Hughes, Alison; Jolly, Kate

2014-03-01

to audit clinical management of women with type III female genital mutilation (FGM) according to local guidelines. Secondary objectives were to describe the population that uses the service and compare obstetric outcomes of intrapartum deinfibulation and antenatal deinfibulation. retrospective audit. a hospital midwifery-led FGM specialist service in Birmingham, UK. 253 women with type III FGM who gave birth between January 2008 and December 2009 METHODS: retrospective case analysis using patient records. proportion of women managed according to locally agreed criteria for the management of FGM; obstetric outcomes including perineal tears, episiotomy rates, estimated blood loss, infant APGAR scores and indications for caesarean section. 91 (36%) women booked into antenatal care after 16 weeks gestation. Only 26 (10.3%) were managed fully according to guidelines. The area with poorest performance was child protection, where the presence of normal genitalia was documented in only 52 (38.8%) of medical notes following birth of a female infant. The majority of women (214, 84.6%) had been deinfibulated in a previous pregnancy. Of the 39 infibulated at booking, only 9 (23.1%) were deinfibulated antenatally, the rest opted for intrapartum deinfibulation. Women who had intrapartum deinfibulation had a higher average blood loss and more tears than those deinfibulated antenatally, although this was not statistically significant. alternative systems should be considered to improve documentation of child protection related information. Further research is needed to confirm or refute the adverse findings among those that delayed deinfibulation. Copyright © 2013 Elsevier Ltd. All rights reserved.

Deinfibulation for preventing or treating complications in women living with type III female genital mutilation: A systematic review and meta-analysis.

PubMed

Okusanya, Babasola O; Oduwole, Olabisi; Nwachuku, Nuria; Meremikwu, Martin M

2017-02-01

Deinfibulation is a surgical procedure carried out to re-open the vaginal introitus of women living with type III female genital mutilation (FGM). To assess the impact of deinfibulation on gynecologic or obstetric outcomes by comparing women who were deinfibulated with women with type III FGM or women without FGM. Major databases including CENTRAL, MEDLINE, and Scopus were searched until August 2015. We included nonrandomized studies that compared obstetric outcomes of women with deinfibulation, type III FGM (not deinfibulated during labor), and no FGM. Quality of evidence was determined following the GRADE methodology. Summary measures were calculated using odds ratios at 95% confidence intervals. We found no randomized controlled trials. We included four case-control studies. The quality of evidence was very low. Compared with women with type III FGM at delivery, deinfibulated women had a significant reduction in the risk of having a cesarean delivery or postpartum hemorrhage. Compared with women without FGM, deinfibulated women had a similar risk of episiotomy, cesarean delivery, vaginal lacerations, postpartum hemorrhage, and blood loss at vaginal delivery. The length of second stage of labor, mean maternal hospital stay, and Apgar scores less than 7 were also comparable. Low-quality evidence suggests deinfibulation improves birth outcomes for women with type III FGM. CRD42015024466. © 2017 International Federation of Gynecology and Obstetrics. The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.

Quality of antenatal and delivery care before and after the implementation of a prevention of mother-to-child HIV transmission programme in Côte d'Ivoire.

PubMed

Delvaux, Thérèse; Konan, Jean-Paul Diby; Aké-Tano, Odile; Gohou-Kouassi, Valérie; Bosso, Patrice Emery; Buvé, Anne; Ronsmans, Carine

2008-08-01

To assess whether implementation of a prevention of mother-to-child HIV transmission (PMTCT) programme in Côte d'Ivoire improved the quality of antenatal and delivery care services. Quality of antenatal and delivery care services was assessed in five urban health facilities before (2002-2003) and after (2005) the implementation of a PMTCT programme through review of facility data; observation of antenatal consultations (n = 606 before; n = 591 after) and deliveries (n = 229 before; n = 231 after) and exit interviews of women; and interviews of health facility staff. HIV testing was never proposed at baseline and was proposed to 63% of women at the first ANC visit after PMTCT implementation. The overall testing rate was 42% and 83% of tested HIV-infected pregnant women received nevirapine. In addition, inter-personal communication and confidentiality significantly improved in all health facilities. In the maternity ward, quality of obstetrical care at admission, delivery and post-partum care globally improved in all facilities after the implementation of the programme although some indicators remained poor, such as filling in the partograph directly during labour. Episiotomy rates among primiparous women dropped from 64% to 25% (P < 0.001) after PMTCT implementation. Global scores for quality of antenatal and delivery care significantly improved in all facilities after the implementation of the programme. Introducing comprehensive PMTCT services can improve the quality of antenatal and delivery care in general.

Understanding Consumer Perceptions and Awareness of Hospital-Based Maternity Care Quality Measures.

PubMed

Maurer, Maureen; Firminger, Kirsten; Dardess, Pam; Ikeler, Kourtney; Sofaer, Shoshanna; Carman, Kristin L

2016-06-01

To explore factors that may influence use of comparative public reports for hospital maternity care. Four focus groups conducted in 2013 with 41 women and preintervention survey data collected in 2014 to 2015 from 245 pregnant women in North Carolina. As part of a larger randomized controlled trial, we conducted qualitative formative research to develop an intervention that will be evaluated through pre- and postintervention surveys. Analysis of focus group transcripts examined participants' perceptions of high-quality maternity care and the importance of different quality measures. Quantitative analysis included descriptive results of the preintervention survey and subgroup analyses to examine the impact of race, education, and being a first-time mom on outcomes. When describing high-quality maternity care, participants focused on interactions with providers, including respect for preferences and communication. The importance of quality measures was influenced by the extent to which they focused on babies' health, were perceived as the hospital's responsibility, and were perceived as representing "standard care." At baseline, 28 percent of survey respondents had used quality information to choose a hospital. Survey respondents were more aware of some quality measures (e.g., breastfeeding support) than others (e.g., episiotomy rates). Public reporting efforts could help increase relevance of maternity care quality measures by creating measures that reflect women's concerns, clearly explaining the hospital's role in supporting quality care, and showing how available quality measures can inform decisions about childbirth. © Health Research and Educational Trust.

Fine tuning fear of childbirth: the relationship between Childbirth Fear Questionnaire subscales and demographic and reproductive variables.

PubMed

Fairbrother, Nichole; Thordarson, Dana S; Stoll, Kathrin

2018-02-01

The objective of the current study was to investigate the relationship between the newly developed Childbirth Fear Questionnaire (CFQ) and demographic and reproductive variables. The CFQ was developed in an effort to improve measurement and understanding of women's childbirth fears. To our knowledge the CFQ is the only multidimensional measure of childbirth fears in which (a) multiple domains of childbirth fear are assessed and (b) individual subscales have been psychometrically developed. Participants were 643 pregnant women residing in English-speaking countries, recruited via online forums. Participants completed a set of questionnaires, including the multidimensional CFQ, via an online survey. Given the differences in childbirth fear between nulliparous and multiparous women, findings are stratified by parity. Gestational age was largely unrelated to fear of childbirth. Age, income and education were negatively related to fear of childbirth. Assisted vaginal delivery and episiotomy in a previous pregnancy were positively associated with a fear of pain. Self-reported history of traumatic vaginal birth was associated with higher scores on all aspects of fear of childbirth. History of caesarean birth was not generally associated with increased childbirth fears, but women with a prior, self-reported traumatic caesarean birth reported more fear of future caesarean births. Findings are consistent with previous reports of fear of childbirth. However, the CFQ provides increased specificity with respect to women's childbirth fears. This information is relevant to both education and treatment planning for pregnant women and women wishing to reproduce.

Prevention of shoulder dystocia: A randomized controlled trial to evaluate an obstetric maneuver.

PubMed

Poujade, Olivier; Azria, Elie; Ceccaldi, Pierre-François; Davitian, Carine; Khater, Carine; Chatel, Paul; Pernin, Emilie; Aflak, Nizar; Koskas, Martin; Bourgeois-Moine, Agnès; Hamou-Plotkine, Laurence; Valentin, Morgane; Renner, Jean-Paul; Roy, Carine; Estellat, Candice; Luton, Dominique

2018-08-01

Shoulder dystocia is a major obstetric emergency defined as a failure of delivery of the fetal shoulder(s). This study evaluated whether an obstetric maneuver, the push back maneuver performed gently on the fetal head during delivery, could reduce the risk of shoulder dystocia. We performed a multicenter, randomized, single-blind trial to compare the push back maneuver with usual care in parturient women at term. The primary outcome, shoulder dystocia, was considered to have occurred if, after delivery of the fetal head, any additional obstetric maneuver, beginning with the McRoberts maneuver, other than gentle downward traction and episiotomy was required. We randomly assigned 522 women to the push back maneuver group (group P) and 523 women to the standard vaginal delivery group (group S). Finally, 473 women assigned to group P and 472 women assigned to group S delivered vaginally. The rate of shoulder dystocia was significantly lower in group P (1·5%) than in group S (3·8%) (odds ratio [OR] 0·38 [0·16-0·92]; P = 0·03). After adjustment for predefined main risk factors, dystocia remained significantly lower in group P than in group S. There were no significant between-group differences in neonatal complications, including brachial plexus injury, clavicle fracture, hematoma and generalized asphyxia. In this trial in 945 women who delivered vaginally, the push back maneuver significantly decreased the risk of shoulder dystocia, as compared with standard vaginal delivery. Copyright © 2018 Elsevier B.V. All rights reserved.

Female sexuality and consent in public discourse: James Burt's "love surgery".

PubMed

Rodriguez, Sarah B

2013-04-01

Beginning in the mid-1960s, gynecologist and obstetrician James Burt developed what he called "love surgery" on unknowing women after they gave birth. It was, he later told them, a modification of episiotomy repair. In the mid-1970s, Burt began promoting love surgery as an elective sexual enhancement surgery and women came to his clinic in hopes of a surgically-enabled better sex life. But though Burt now offered love surgery, he continued to perform it on patients who did not come to him for it through the late 1980s. Over the course of more than two decades, discourse on love surgery occurred twice nationally. In the late 1970s, feminists and sex therapists attacked love surgery as altering a woman's body for male sexual pleasure. Though Burt never hid his continued use of love surgery on women who had not elected for it, the public discourse at this time focused on love surgery as a reflection of larger cultural ideas about female sexuality. In the late 1980s, when Burt's love surgery again appeared in the national media, the issue of informed consent, largely absent from the discourse about love surgery in the late 1970s, moved to the center. Though significant activity happened within the local medical and legal communities beginning in the mid-1970s regarding Burt and his practice of love surgery, my interest here is on these two periods when the discourse regarding love surgery, female sexuality, and informed consent occurred within a national frame.

Comparative study analysing women's childbirth satisfaction and obstetric outcomes across two different models of maternity care

PubMed Central

Conesa Ferrer, Ma Belén; Canteras Jordana, Manuel; Ballesteros Meseguer, Carmen; Carrillo García, César; Martínez Roche, M Emilia

2016-01-01

Objectives To describe the differences in obstetrical results and women's childbirth satisfaction across 2 different models of maternity care (biomedical model and humanised birth). Setting 2 university hospitals in south-eastern Spain from April to October 2013. Design A correlational descriptive study. Participants A convenience sample of 406 women participated in the study, 204 of the biomedical model and 202 of the humanised model. Results The differences in obstetrical results were (biomedical model/humanised model): onset of labour (spontaneous 66/137, augmentation 70/1, p=0.0005), pain relief (epidural 172/132, no pain relief 9/40, p=0.0005), mode of delivery (normal vaginal 140/165, instrumental 48/23, p=0.004), length of labour (0–4 hours 69/93, >4 hours 133/108, p=0.011), condition of perineum (intact perineum or tear 94/178, episiotomy 100/24, p=0.0005). The total questionnaire score (100) gave a mean (M) of 78.33 and SD of 8.46 in the biomedical model of care and an M of 82.01 and SD of 7.97 in the humanised model of care (p=0.0005). In the analysis of the results per items, statistical differences were found in 8 of the 9 subscales. The highest scores were reached in the humanised model of maternity care. Conclusions The humanised model of maternity care offers better obstetrical outcomes and women's satisfaction scores during the labour, birth and immediate postnatal period than does the biomedical model. PMID:27566632

A large primary vaginal calculus in a woman with paraplegia.

PubMed

Avsar, Ayse Filiz; Keskin, Huseyin Levent; Catma, Tuba; Kaya, Basak; Sivaslioglu, Ahmet Akın

2013-01-01

The study aimed to report a primary vaginal stone, an extremely rare entity, without vesicovaginal fistula in a woman with disability. We describe the case of a large primary vaginal calculus in a 22-year-old woman with paraplegia, which, surprisingly, was not diagnosed until she was examined under general anesthesia during a preparation for laparoscopy for an adnexal mass. The stone had not been identified by physical examination with the patient in a recumbent position or by transabdominal ultrasonography and pelvic tomography during the preoperative preparation. Vaginoscopy was not performed because the vagina was completely filled with the mass. As a result of its size and hard consistency, a right-sided episiotomy was performed and a 136-g stone was removed using ring forceps. A vesicovaginal fistula was excluded. There was no evidence of a foreign body or other nidus on the cut section of the stone, and it was determined to be composed of 100% struvite (ammonium magnesium phosphate). Culture of urine obtained via catheter showed Escherichia coli. After the surgical removal of the calculus without complications, a program of intermittent catheterization was started. The follow-up period was uneventful, and the patient was symptom free at 6 months after the operation. We postulate that the calculus formed as a consequence of urinary contamination of the vagina in association with incontinence and prolonged maintenance in a recumbent posture. This report is important because it highlights that, although vaginal stones are very rare, their possibility should be considered in the differential diagnosis of individuals with long-term paraplegia.

Pelvic floor muscle training program increases muscular contractility during first pregnancy and postpartum: electromyographic study.

PubMed

Marques, Joseane; Botelho, Simone; Pereira, Larissa Carvalho; Lanza, Ana Helena; Amorim, Cesar Ferreira; Palma, Paulo; Riccetto, Cassio

2013-09-01

The aim of this study was to evaluate the effect of a training program over both pelvic floor muscles contractility and urinary symptoms in primigravid pregnant and postpartum primiparous women. A clinical, prospective and blinded trial was conducted with 33 women divided into three groups: (G1) 13 primigravid pregnant women; (G2) 10 postpartum primiparous women (49.3 ± 5.84 days), after vaginal delivery with right mediolateral episiotomy; (G3) 10 postpartum primiparous women (46.3 ± 3.6 days), after cesarean section delivery. The evaluation was carried out using digital palpation (Modified Oxford Grading Scale), pelvic floor electromyography and, for the investigation of urinary symptoms, validated questionnaires (International Consultation on Incontinence Questionnaire-short form-ICIQ-UI SF and International Consultation on Incontinence Questionnaire Overactive Bladder-ICIQ-OAB). The protocol consisted of 10 individual sessions carried out by the physiotherapist through home visits, three times a week, with 60 min duration each. The statistical analysis was performed using ANOVA and Spearman's correlation coefficient. The pelvic floor muscle contractility increased after the training program (P = 0.0001) for all groups. Decreases in the scores of both ICIQ-UI SF (P = 0.009) and ICIQ-OAB (P = 0.0003) were also observed after training. Pelvic floor muscle training is an effective means for the increase in its own contractility in both primigravid pregnant and primiparous postpartum women, accompanied with a concomitant decrease in urinary symptoms. Copyright © 2012 Wiley Periodicals, Inc.

Rectal analgesia for the relief of perineal pain after childbirth: a randomised controlled trial of diclofenac suppositories.

PubMed

Dodd, Jodie M; Hedayati, Hedyeh; Pearce, Elizabeth; Hotham, Neil; Crowther, Caroline A

2004-10-01

To evaluate rectal diclofenac in the relief of perineal pain after trauma during childbirth. A randomised, double-blind trial. Delivery Suite, Women's and Children's Hospital, South Australia. Women with a second-degree (or greater) perineal tear or episiotomy. Women were randomly allocated to either diclofenac or placebo suppositories (Anusol), using a computer-generated randomisation schedule with stratification for parity and mode of birth. Treatment packs contained two x 100 mg diclofenac or two placebo suppositories, the first being inserted when suturing was complete, and the second 12-24 hours after birth. Women were asked to complete questionnaires at 24 and 48 hours after birth relating to their degree of perineal pain using the validated Short Form McGill Pain Questionnaire. Pain scores at 24 and 48 hours after birth. A total of 133 women were recruited, with 67 randomised to diclofenac suppositories and 66 to placebo. Women in the diclofenac group were significantly less likely to experience pain at 24 hours while walking (RR 0.8; 95% CI 0.6 to 1.0), sitting (RR 0.8; 95% CI 0.6 to 1.0), passing urine (RR 0.6; 95% CI 0.4 to 1.0) and on opening their bowels (RR 0.6; 95% CI 0.2 to 0.9) compared with those women who received placebo. These differences were not sustained 48 hours after birth. The use of rectal non-steroidal anti-inflammatory drug suppositories is a simple, effective and safe method of reducing the pain experienced by women following perineal trauma within the first 24 hours after childbirth.

Management of persistent occiput posterior position: a substantial role of instrumental rotation in the setting of failed manual rotation.

PubMed

Guerby, Paul; Allouche, Mickael; Simon-Toulza, Caroline; Vayssiere, Christophe; Parant, Olivier; Vidal, Fabien

2018-01-01

To compare the maternal and neonatal outcomes associated with Instrumental Rotation (IR) to operative vaginal delivery in occiput posterior (OP) position with Thierry's spatulas (TS), in the setting of failed manual rotation (MR). We led a prospective observational cohort study in a tertiary referral hospital in Toulouse, France. All women presenting in labor with persistent OP position at full cervical dilatation and who delivered vaginally after failed MR and with IR or OP assisted delivery were included from January 2014 to December 2015. The main outcomes measured were maternal morbidity parameters including episiotomy rate, incidence and severity of perineal lacerations, perineal hematomas and postpartum hemorrhage. Severe perineal tears corresponded to third and fourth degree lacerations. Fetal morbidity outcomes comprised neonatal Apgar scores, acidemia, fetal injuries, birth trauma and neonatal intensive care unit admissions. Among 9762 women, 910 (9.3%) presented with persistent OP position at full cervical dilatation and 222 deliveries were enrolled. Of 111 attempted IR, 97 were successful (87.4%). The incidence of anal sphincter injuries was significantly reduced after IR attempt (1.8% vs. 12.6%; p < 0.002). Both groups were similar regarding most fetal outcomes and no birth trauma occurred in our study population. In a multivariable logistic regression analysis, OP operative delivery was a significant risk factor of severe perineal lacerations (OR = 9.5; 95% CI: 2.05-44.05). Our results support the use of IR in order to reduce perineal morbidity associated with OP assisted delivery, in the setting of a failed manual rotation.

Use of routine interventions in vaginal labor and birth: findings from the Maternity Experiences Survey.

PubMed

Chalmers, Beverley; Kaczorowski, Janusz; Levitt, Cheryl; Dzakpasu, Susie; O'Brien, Beverley; Lee, Lily; Boscoe, Madeline; Young, David

2009-03-01

Intervention rates in maternity practices vary considerably across Canadian provinces and territories. The objective of this study was to describe the use of routine interventions and practices in labor and birth as reported by women in the Maternity Experiences Survey of the Canadian Perinatal Surveillance System. Rates of interventions and practices are considered in the light of current evidence and both Canadian and international recommendations. A sample of 8,244 estimated eligible women was identified from a randomly selected sample of recently born infants drawn from the May 2006 Canadian Census and stratified primarily by province and territory. Birth mothers living with their infants at the time of interview were invited to participate in a computer-assisted telephone interview conducted by Statistics Canada on behalf of the Public Health Agency of Canada. Interviews averaged 45 minutes long and were completed when infants were between 5 and 10 months old (9-14 mo in the territories). Completed responses were obtained from 6,421 women (78%). Women frequently reported electronic fetal monitoring, a health care practitioner starting or speeding up their labor (or trying to do so), epidural anesthesia, episiotomy, and a supine position for birth. Some women also reported pubic or perineal shaves, enemas, and pushing on the top of their abdomen. Several practices and interventions were commonly reported in labor and birth in Canada, although evidence and Canadian and international guidelines recommend against their routine use. Practices not recommended for use at all, such as shaving, were also reported.

The attitudes of Canadian maternity care practitioners towards labour and birth: many differences but important similarities.

PubMed

Klein, Michael C; Kaczorowski, Janusz; Hall, Wendy A; Fraser, William; Liston, Robert M; Eftekhary, Sahba; Brant, Rollin; Mâsse, Louise C; Rosinski, Jessica; Mehrabadi, Azar; Baradaran, Nazli; Tomkinson, Jocelyn; Dore, Sharon; McNiven, Patricia C; Saxell, Lee; Lindstrom, Kathie; Grant, Jalana; Chamberlaine, Aoife

2009-09-01

Collaborative, interdisciplinary care models have the potential to improve maternity care. Differing attitudes of maternity care providers may impede this process. We sought to examine the attitudes of Canadian maternity care practitioners towards labour and birth. We performed a cross-sectional web- and paper-based survey of 549 obstetricians, 897 family physicians (400 antepartum only, 497 intrapartum), 545 nurses, 400 midwives, and 192 doulas. Participants responded to 43 Likert-type attitudinal questions. Nine themes were identified: electronic fetal monitoring, epidural analgesia, episiotomy, doula roles, Caesarean section benefits, factors decreasing Caesarean section rates, maternal choice, fear of vaginal birth, and safety of birth mode and place. Obstetrician scores reflected positive attitudes towards use of technology, in contrast to midwives' and doulas' scores. Family physicians providing only antenatal care had attitudinal scores similar to obstetricians; family physicians practising intrapartum care and nurses had intermediate scores on technology. Obstetricians' scores indicated that they had the least positive attitudes towards home birth, women's roles in their own births, and doula care, and they were the most concerned about the consequences of vaginal birth. Midwives' and doulas' scores reflected opposing views on these issues. Although 71% of obstetricians supported regulated midwifery, 88.9% were against home birth. Substantial numbers of each group held attitudes similar to dominant attitudes from other disciplines. To develop effective team practice, efforts to reconcile differing attitudes towards labour and birth are needed. However, the overlap in attitudes between disciplines holds promise for a basis upon which to begin shared problem solving and collaboration.

The effect of perineal lacerations on pelvic floor function and anatomy at six months postpartum in a prospective cohort of nulliparous women

PubMed Central

Lawrence, Leeman; Rebecca, Rogers; Noelle, Borders; Dusty, Teaf; Clifford, Qualls

2016-01-01

Objective Determine the effect of perineal lacerations on pelvic floor outcomes including urinary and anal incontinence, sexual function and perineal pain in a nulliparous cohort with low incidence of episiotomy. Methods Nulliparous women were prospectively recruited from a midwifery practice. Pelvic floor symptoms were assessed with validated questionnaires, physical examination and objective measures in pregnancy and 6 months postpartum. Two trauma groups were compared, those with an intact perineum or only 1st degree lacerations and those with 2nd, 3rd or 4th degree lacerations. Results 448 women had vaginal deliveries. 151 sustained second degree or deeper perineal trauma and 297 had an intact perineum or minor trauma. 336 (74.8%) presented for 6-month follow-up. Perineal trauma was not associated with urinary or fecal incontinence, decreased sexual activity, perineal pain, or pelvic organ prolapse. Women with trauma had similar rates of sexual activity however they had slightly lower sexual function scores (27.3 vs. 29.1, p=0.01). Objective measures of pelvic floor strength, rectal tone, urinary incontinence, and perineal anatomy were equivalent. The subgroup of women with deeper (> 2cm) perineal trauma demonstrated increased likelihood of perineal pain (15.5 vs. 6.2 %) and weaker pelvic floor muscle strength (61.0 vs. 44.3%); p=0.03 compared to women with more superficial trauma Conclusion: Women having second degree lacerations are not at increased risk for pelvic floor dysfunction other than increased pain, and slightly lower sexual function scores at 6 months postpartum. PMID:27797099

Poor compliance with standard precautions against infections during minor gynaecological procedures.

PubMed

Maharaj, Dushyant; Lawton, Beverley; Garrett, Sue

2012-06-01

Splash injuries occurring during minor surgical procedures are associated with a significant infective risk to the operator. It is a common misconception that minor operations carry low risks. To determine the prevalence of the practice of Standard Precautions by medical staff in the obstetric and gynaecology (O & G) units of two hospitals in New Zealand, and to assess self-observed splash injury rates. A cross-sectional survey of all doctors working in the O & G units of two public hospitals servicing a population of 435 000. A self-administered questionnaire was provided to 43 doctors with questions related to the use of Standard Precautions, perceived likelihood of infection from a splash and splash injuries sustained during procedures. The response rate was 76.6% (n = 33/43). Of the respondents, only 30.3% (n = 10) used Standard Precautions during minor procedures. Sixty-four per cent (n = 21) routinely used goggles/visor for eye protection. Forty-five per cent (n = 15) thought they were likely to get an infection from a splash, and 55% (n = 18) of clinicians had experienced a splash injury. Of the minor procedures during which splash injuries had occurred, repair of episiotomy 45.8% (n = 11) was the commonest. This survey shows poor compliance with guidelines for Standard Precautions to protect from infection despite self-reported rates of splash injury being high at 55%. Effective interventions are needed to increase compliance and prevent infection. © 2012 The Authors ANZJOG © 2012 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Migrants and obstetrics in Austria--applying a new questionnaire shows differences in obstetric care and outcome.

PubMed

Oberaigner, Willi; Leitner, Hermann; Oberaigner, Karin; Marth, Christian; Pinzger, Gerald; Concin, Hans; Steiner, Horst; Hofmann, Hannes; Wagner, Teresa; Mörtl, Manfred; Ramoni, Angela

2013-01-01

Immigration plays a major role in obstetrics in Austria, and about 18 % of the Austrian population are immigrants. Therefore, we aimed to (1) test the feasibility of a proposed questionnaire for assessment of migrant status in epidemiological research and (2) assess some important associations between procedures and outcomes in obstetrics and migration in selected departments in Austria. We adapted a standardized questionnaire to the main immigration groups in Austria. Information on country of origin, length of residence in Austria and German-language ability was collected from eight selected obstetrics departments. Of the 1,971 questionnaires, 1,873 questionnaires of singleton births were selected and included in the analysis. We analyzed a total of 1,873 parturients with singleton births, of which 35 % had migrant status, 12 % were from ex-Yugoslavia, 12 % were from Turkey, and 12 % were from other countries. The proportion of parturients having their first care visit after the 12th week of pregnancy was higher in migrant groups (19 %). Smoking was highest in the migrants from ex-Yugoslavia (21 %). Vaginal delivery was more frequent in migrants from ex-Yugoslavia (78 %) and Turkey (83 %) than in nonmigrants (71 %) and episiotomy was more frequently performed in migrants from other countries. All differences are statistically significant. Administration of a standardized questionnaire for assessment of migrant status in obstetric departments in Austria was shown to be feasible. We assessed differences in obstetric care and outcome and consequently recommend that action should be initiated in Austria toward harmonizing obstetric procedures among the migrant and the nonmigrant groups and toward minimizing risk factors.

Born in another country: women's experience of labour and birth in Queensland, Australia.

PubMed

Hennegan, Julie; Redshaw, Maggie; Miller, Yvette

2014-06-01

Women born outside Australia make up more than a fifth of the Queensland birthing population and like migrants in other parts of the world face the challenges of cultural dislocation and possible language barriers. Recognising that labour and birth are major life events the aim was to investigate the experiences of these women in comparison to native-born English speaking women. Secondary analysis of data from a population based survey of women who had recently birthed in Queensland. Self-reported clinical outcomes and quality of interpersonal care of 481 women born outside Australia who spoke a language other than English at home were compared with those of 5569 Australian born women speaking only English. After adjustment for demographic factors and type of birthing facility, women born in another country were less likely to be induced, but more likely to have constant electronic fetal monitoring (EFM), to give birth lying on their back or side, and to have an episiotomy. Most women felt that they were treated as an individual and with kindness and respect. However, women born outside Australia were less likely to report being looked after 'very well' during labour and birth and to be more critical of some aspects of care. In comparing the labour and birth experiences of women born outside the country who spoke another language with native-born English speaking women, the present study presents a largely positive picture. However, there were some marked differences in both clinical and interpersonal aspects of care. Copyright © 2014 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Planned home birth: benefits, risks, and opportunities

PubMed Central

Zielinski, Ruth; Ackerson, Kelly; Kane Low, Lisa

2015-01-01

While the number of women in developed countries who plan a home birth is low, the number has increased over the past decade in the US, and there is evidence that more women would choose this option if it were readily available. Rates of planned home birth range from 0.1% in Sweden to 20% in the Netherlands, where home birth has always been an integrated part of the maternity system. Benefits of planned home birth include lower rates of maternal morbidity, such as postpartum hemorrhage, and perineal lacerations, and lower rates of interventions such as episiotomy, instrumental vaginal birth, and cesarean birth. Women who have a planned home birth have high rates of satisfaction related to home being a more comfortable environment and feeling more in control of the experience. While maternal outcomes related to planned birth at home have been consistently positive within the literature, reported neonatal outcomes during planned home birth are more variable. While the majority of investigations of planned home birth compared with hospital birth have found no difference in intrapartum fetal deaths, neonatal deaths, low Apgar scores, or admission to the neonatal intensive care unit, there have been reports in the US, as well as a meta-analysis, that indicated more adverse neonatal outcomes associated with home birth. There are multiple challenges associated with research designs focused on planned home birth, in part because conducting randomized controlled trials is not feasible. This report will review current research studies published between 2004 and 2014 related to maternal and neonatal outcomes of planned home birth, and discuss strengths, limitations, and opportunities regarding planned home birth. PMID:25914559

Prevalence and predictors of urinary/anal incontinence after vaginal delivery: prospective study of Nigerian women.

PubMed

Obioha, Kingsley Chukwu; Ugwu, Emmanuel Onyebuchi; Obi, Samuel Nnamdi; Dim, Cyril Chukwudi; Oguanuo, Theophilus Chimezie

2015-09-01

Urinary and anal incontinence are major public health problems impacting on the quality of life of affected women, with resultant loss of self-esteem. Despite the anticipated magnitude of this public health problem in sub-Saharan Africa, there is paucity of data on the prevalence of urinary and/or anal incontinence after childbirth in the region. This study determined the prevalence and predictors of urinary and anal incontinence after vaginal delivery among women in Enugu, southeastern Nigeria. This was a longitudinal study of 230 consecutive parturients at the University of Nigeria Teaching Hospital, Enugu, Nigeria. Eligible women were followed up immediately, 6 weeks, and 3 months postpartum to assess the development of urinary and/or anal incontinence using validated questionnaires. Overall, 28 women had urinary incontinence, giving a cumulative prevalence rate of 12.2 %. The cumulative prevalence rate was 13.5 % for anal incontinence and 3 % for combined urinary and anal incontinence. Age, social class, parity, prolonged second stage of labor, and neonatal birth weight were significantly associated with postpartum urinary incontinence (P < 0.05). On the other hand, age, parity, prolonged second stage of labor, episiotomy, and instrumental vaginal delivery were significantly associated with postpartum anal incontinence (P < 0.05). Urinary and anal incontinence are common after vaginal delivery in Enugu, Nigeria. Modification of obstetric care and discouraging preventable predisposing factors for incontinence, such as prolonged second stage of labor and vaginal delivery of macrosomic babies, are measures that may reduce the prevalence of postpartum incontinence in our population.

A method to assess obstetric outcomes using the 10-Group Classification System: a quantitative descriptive study

PubMed Central

Rossen, Janne; Lucovnik, Miha; Eggebø, Torbjørn Moe; Tul, Natasa; Murphy, Martina; Vistad, Ingvild; Robson, Michael

2017-01-01

Objectives Internationally, the 10-Group Classification System (TGCS) has been used to report caesarean section rates, but analysis of other outcomes is also recommended. We now aim to present the TGCS as a method to assess outcomes of labour and delivery using routine collection of perinatal information. Design This research is a methodological study to describe the use of the TGCS. Setting Stavanger University Hospital (SUH), Norway, National Maternity Hospital Dublin, Ireland and Slovenian National Perinatal Database (SLO), Slovenia. Participants 9848 women from SUH, Norway, 9250 women from National Maternity Hospital Dublin, Ireland and 106 167 women, from SLO, Slovenia. Main outcome measures All women were classified according to the TGCS within which caesarean section, oxytocin augmentation, epidural analgesia, operative vaginal deliveries, episiotomy, sphincter rupture, postpartum haemorrhage, blood transfusion, maternal age >35 years, body mass index >30, Apgar score, umbilical cord pH, hypoxic–ischaemic encephalopathy, antepartum and perinatal deaths were incorporated. Results There were significant differences in the sizes of the groups of women and the incidences of events and outcomes within the TGCS between the three perinatal databases. Conclusions The TGCS is a standardised objective classification system where events and outcomes of labour and delivery can be incorporated. Obstetric core events and outcomes should be agreed and defined to set standards of care. This method provides continuous and available observations from delivery wards, possibly used for further interpretation, questions and international comparisons. The definition of quality may vary in different units and can only be ascertained when all the necessary information is available and considered together. PMID:28706102

Maternal Asian ethnicity and the risk of anal sphincter injury.

PubMed

Davies-Tuck, Miranda; Biro, Mary-Anne; Mockler, Joanne; Stewart, Lynne; Wallace, Euan M; East, Christine

2015-03-01

To examine associations between maternal Asian ethnicity (South Asian and South East/East Asian) and anal sphincter injury. Retrospective cross-sectional study, comparing outcomes for Asian women with those of Australian and New Zealand women. A large metropolitan maternity service in Victoria, Australia. Australian/New Zealand, South Asian and South East/East Asian women who had a singleton vaginal birth from 2006 to 2012. The relation between maternal ethnicity and anal sphincter injury was assessed by logistic regression, adjusting for potential confounders. Anal sphincter injury was defined as a third or fourth degree tear (with or without episiotomy). Among 32,653 vaginal births there was a significant difference in the rate of anal sphincter injury by maternal region of birth (p < 0.001). After adjustment for confounders, nulliparous women born in South Asian and South East/East Asia were 2.6 (95% confidence interval 2.2-3.3; p < 0.001) and 2.1 (95% confidence interval 1.7-2.5; p < 0.001) times more likely to sustain an anal sphincter injury than Australian/New Zealand women, respectively. Parous women born in South Asian and South East/East Asia were 2.4 (95% confidence interval 1.8-3.2; p < 0.001) and 2.0 (95% confidence interval 1.5-2.7; p < 0.001) times more likely to sustain an anal sphincter injury than Australian/New Zealand women, respectively. There are ethnic differences in the rates of anal sphincter injury not fully explained by known risk factors for such trauma. This may have implications for care provision. © 2014 Nordic Federation of Societies of Obstetrics and Gynecology.

Vaginal resection and anastomosis for treatment of vestibulovaginal stenosis in 4 dogs with recurrent urinary tract infections.

PubMed

Kieves, Nina R; Novo, Roberto E; Martin, Robert B

2011-10-01

CASE DESCRIPTION-4 dogs were evaluated because of recurrent urinary tract infections. CLINICAL FINDINGS-All dogs had recurrent urinary tract infections and similar clinical signs; 3 dogs had urinary incontinence. Digital vaginal examination revealed vestibulovaginal stenosis in all dogs, which was confirmed by results of contrast vaginourethrography. From image measurements, the vestibulovaginal ratio (ratio of the height of the vestibulovaginal junction to the maximum height of the vagina on a lateral vaginourethrogram) was calculated for each dog. Three dogs had severe stenosis (vestibulovaginal ratio, < 0.20; severe stenosis is defined as a vestibulovaginal ratio < 0.20), whereas the fourth dog had moderate stenosis (vestibulovaginal ratio, 0.24; ratio range for moderate stenosis is 0.20 to 0.25). TREATMENT AND OUTCOME-All dogs were anesthetized for surgical correction of the vestibulovaginal stenosis. Vaginal resection and anastomosis of the stenosis was performed in all 4 dogs, with 1 dog also undergoing episioplasty. Complete resolution of clinical signs was apparent in 3 dogs; 1 dog had postoperative complications including pollakiuria and stranguria, which resulted in rectal and vaginal prolapse. This dog underwent ovariohysterectomy, after which clinical signs resolved. All dogs had resolution of urinary tract infections at the time of follow-up (6 to 8 months after surgery). CLINICAL RELEVANCE-Resection and anastomosis may resolve recurrent urinary tract infections in dogs with severe or moderate vestibulovaginal stenosis. Episiotomy was not necessary for success of surgical treatment, and overall, that procedure increased morbidity, the severity of intraoperative hemorrhage, and duration of surgery.

Effects of carrying a pregnancy and of method of delivery on urinary incontinence: a prospective cohort study.

PubMed

Eason, Erica; Labrecque, Michel; Marcoux, Sylvie; Mondor, Myrto

2004-02-19

BACKGROUND: This study was carried out to identify risk factors associated with urinary incontinence in women three months after giving birth. METHODS: Urinary incontinence before and during pregnancy was assessed at study enrolment early in the third trimester. Incontinence was re-assessed three months postpartum. Logistic regression analysis was used to assess the role of maternal and obstetric factors in causing postpartum urinary incontinence. This prospective cohort study in 949 pregnant women in Quebec, Canada was nested within a randomised controlled trial of prenatal perineal massage. RESULTS: Postpartum urinary incontinence was increased with prepregnancy incontinence (adjusted odds ratio [adj0R] 6.44, 95% CI 4.15, 9.98), incontinence beginning during pregnancy (adjOR 1.93, 95% CI 1.32, 2.83), and higher prepregnancy body mass index (adjOR 1.07/unit of BMI, 95% CI 1.03,1.11). Caesarean section was highly protective (adjOR 0.27, 95% CI 0.14, 0.50). While there was a trend towards increasing incontinence with forceps delivery (adjOR 1.73, 95% CI 0.96, 3.13) this was not statistically significant. The weight of the baby, episiotomy, the length of the second stage of labour, and epidural analgesia were not predictive of urinary incontinence. Nor was prenatal perineal massage, the randomised controlled trial intervention. When the analysis was limited to women having their first vaginal birth, the same risk factors were important, with similar adjusted odds ratios. CONCLUSIONS: Urinary incontinence during pregnancy is extremely common, affecting over half of pregnant women. Urinary incontinence beginning during pregnancy roughly doubles the likelihood of urinary incontinence at 3 months postpartum, regardless whether delivery is vaginal or by Caesarean section.

A Retrospective Perinatal Data Analysis of Immigrant and German Women from Representative Birth Cohorts at the Virchow Hospital, Berlin

PubMed Central

Armbrust, R.; von Rennenberg, R.; David, M.

2016-01-01

Introduction: The aim of this study was to define and characterise differences in the level of obstetric care provided to immigrant and German women. Materials and Methods: An analysis of the Virchow Hospitalʼs birth registers was conducted for the years 1974, 1984 and 1994. The study population of 5445 patients was grouped according to ancestry/family origin on the basis of a name analysis, and subsequently also according to parity (primiparous or multiparous). On name analysis 2741 women were defined as German, 1598 were grouped as women of Turkish origin and 810 as immigrants of other origin. χ2 tests and Fisherʼs exact test were used for significance testing (significance level p < 0.05), and a logistic regression analysis was performed. Results: Rates of caesarean section, episiotomy, higher grade perineal tears and severe postpartum haemorrhage did not differ between the groups. There were however significant differences in the use of uterine stimulants, analgesics in labour and both local and regional anaesthesia, with women of Turkish origin and other immigrants receiving anaesthesia less, but oxytocin more often. Rooming-in was more common among German primipara and multipara from 1984 onwards. Discussion: This retrospective analysis of three historical birth cohorts showed significant differences in perinatal care between German and immigrant women, presumably reflecting deficits in care. It seems remarkable that this trend has not changed over a time span of three decades despite a continuous increase in immigration and acculturation. A “research paradox”, however, remains: Despite these increasing rates, there are no current or older, prospective or systematic studies of obstetric care in immigrants. PMID:27904165

A method to assess obstetric outcomes using the 10-Group Classification System: a quantitative descriptive study.

PubMed

Rossen, Janne; Lucovnik, Miha; Eggebø, Torbjørn Moe; Tul, Natasa; Murphy, Martina; Vistad, Ingvild; Robson, Michael

2017-07-12

Internationally, the 10-Group Classification System (TGCS) has been used to report caesarean section rates, but analysis of other outcomes is also recommended. We now aim to present the TGCS as a method to assess outcomes of labour and delivery using routine collection of perinatal information. This research is a methodological study to describe the use of the TGCS. Stavanger University Hospital (SUH), Norway, National Maternity Hospital Dublin, Ireland and Slovenian National Perinatal Database (SLO), Slovenia. 9848 women from SUH, Norway, 9250 women from National Maternity Hospital Dublin, Ireland and 106 167 women, from SLO, Slovenia. All women were classified according to the TGCS within which caesarean section, oxytocin augmentation, epidural analgesia, operative vaginal deliveries, episiotomy, sphincter rupture, postpartum haemorrhage, blood transfusion, maternal age >35 years, body mass index >30, Apgar score, umbilical cord pH, hypoxic-ischaemic encephalopathy, antepartum and perinatal deaths were incorporated. There were significant differences in the sizes of the groups of women and the incidences of events and outcomes within the TGCS between the three perinatal databases. The TGCS is a standardised objective classification system where events and outcomes of labour and delivery can be incorporated. Obstetric core events and outcomes should be agreed and defined to set standards of care. This method provides continuous and available observations from delivery wards, possibly used for further interpretation, questions and international comparisons. The definition of quality may vary in different units and can only be ascertained when all the necessary information is available and considered together. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

The effect of prenatal education classes on the birth expectations of Spanish women.

PubMed

Soriano-Vidal, F J; Vila-Candel, R; Soriano-Martín, P J; Tejedor-Tornero, A; Castro-Sánchez, E

2018-05-01

Maternity care has focused on lowering maternal and neonatal morbidity, though women's beliefs and expectations of care have been set aside. Women face childbirth with preconceived expectations, some of which could be expressed on their birth plan. The latter could beinfluenced by health professionals through prenatal education classes, though this has not been measured before. Antenatal classes have been argued against,since no resulting improvement in childbirth experience has been demonstrated, though some advantages may be seen: they favour communication and give time for expressing maternal expectations and beliefs. The present study evaluates the influence of prenatal educational classes led by midwives upon women birth preferences. A multicentre, observational, prospective study was carried out, measuring variables in pregnant women attending prenatal educational classes in different health centres within the health districts in Valencia (Spain) over the period January-October 2012. Birth plan preferences were compared prior to and upon completion of the classes. A total of 212 eligible pregnant women (78.3% nulliparous) with an average age of 31.39±4.0 years consented to participate in the study. There were significant differences in birth plan preferences prior to and upon completion of the prenatal classes. Three items showed an increase between the initial session and the end of the intervention: the ability to push spontaneously, episiotomy avoidance, and early breastfeeding. An adjusted general linear model was used to compare pre-post results in relation to sociodemographic and obstetric variables. The changes in birth plans could suggest that prenatal educational classes exert an influence upon maternal birth preferences. Copyright © 2018 Elsevier Ltd. All rights reserved.

Practices and obstetric interventions in women from a state in the Northeast of Brazil.

PubMed

Prado, Daniela Siqueira; Mendes, Rosemar Barbosa; Gurgel, Rosana Queiroz; Barreto, Ikaro Daniel de Carvalho; Bezerra, Felipa Daiana; Cipolotti, Rosana; Gurgel, Ricardo Queiroz

2017-12-01

To describe practices and interventions used during labor and childbirth and factors associated with such practices in puerperae in the state of Sergipe. A cross-sectional study with 768 postpartum women from 11 maternity hospitals interviewed 6 hours after delivery, and hospital records review. The associations between best practices and interventions used during labor and delivery with exposure variables were described using simple frequencies, percentages, crude and adjusted odds ratio (ORa) with the confidence interval. Of the women in the study, 10.6% received food and 27.8% moved during labor; non-pharmacological methods for pain relief were performed in 26.1%; a partogram was filled in 39.4% of the charts; and an accompanying person was present in 40.6% of deliveries. Oxytocin, amniotomy and labor analgesia were used in 59.1%, 49.3% and 4.2% of women, respectively. Lithotomy position during childbirth was used in 95.2% of the cases, episiotomy in 43.9% and Kristeller maneuver in 31.7%. The variables most associated with cesarean section were private financing (ORa=4.27, 95CI 2.44-7.47), higher levels of education (ORa=4.54, 95CI 2.56-8.3) and high obstetric risk (ORa=1.9, 95CI 1.31-2.74). Women whose delivery was funded privately were more likely to have an accompanying person present (ORa=2.12, 95CI 1.18-3.79) and to undergo labor analgesia (ORa=4.96, 95CI 1.7-14.5). Best practices are poorly performed and unnecessary interventions are frequent. The factors most associated with c-section were private funding, greater length of education and high obstetric risk.

Puerperal infections.

PubMed

Eschenbach, D A; Wager, G P

1980-12-01

This comprehensive review on puerperal infections covers risk factors, causative bacteria, pathophysiology, diagnosis, therapy of specific entities, and prevention. Puerperal infection is problematic to define especially with antibiotics that change the course of fever. I may present as endometritis (most common), myometritis, parametritis, pelvic abscess, salpingitis, septic pelvic thrombophlebitis or septicemia, and also includes infections of the urinary tract, episiotomy, surgical wounds, lacerations or breast. Each of these is discussed in terms of contributing factors, microbiology, clinical findings, diagnosis, treatment, prevention and complications. Risk factors in general are cesarean section, premature rupture of the membranes, internal fetal monitoring, general anesthesia, pelvic examinations. The most common bacterial involved are group B and other streptococci, E. coli, Gardnerella vaginalis, Gram positive anaerobic cocci, Mycoplasma and pre-existing Chlamydial infections. Diagnosis of the causative organism is difficult because of polyinfection and difficulty of getting a sterile endometrial swab. Diagnosis of the infection is equally difficult because of the wide variety of symptoms: fever, abnormal lochia, tachycardia, tenderness, mass and abnormal bowel sounds are common. Therapy depends of the responsible microorganism, although 3 empirical tactics are suggested while awaiting results of culture: 1) choose an antibiotic for the most common aerobic bacteria; 2) an antibiotic effective against B. fragilis and one for aerobic bacteria, e.g. clindamycin and an aminoglycoside; 3) a nontoxic antibiotic active against most aerobic and anaerobic organisms, e.g. doxycycline or cefoxitin. An example of an infection recently described is pudendal-paracervical block infection, often signaled by severe hip pain. It is associated with vaginal bacteria, is usually complicated by abscess even with antibiotic coverage, and may end in paraplegia or fatal sepsis. Prevention strategies are straightforward: handwashing, changing scrub clothes, isolation of infected patients, restriction of staff contact and prophylactic antibiotics for cesarean section patients at high risk, starting when the cord is clamped.

Effect of Rotation on Perineal Lacerations in Forceps-Assisted Vaginal Deliveries

PubMed Central

Bradley, Megan S.; Kaminski, Robert J.; Streitman, David C.; Dunn, Shannon L.; Krans, Elizabeth E.

2013-01-01

Objective To determine the difference in the rates of severe perineal lacerations between forceps-assisted vaginal deliveries in the occiput-posterior (OP) position compared with forceps-assisted vaginal deliveries in which the fetal head was rotated to occiput anterior (OA) prior to delivery. Methods We studied a retrospective cohort of 148 women who had a forceps-assisted vaginal delivery from 2008–2011 at the University of Pittsburgh. Mild perineal lacerations were defined as first or second degree, and severe lacerations were defined as third or fourth degree. Chi-square and t tests were used for bivariate and logistic regression was used for multivariable analyses. P<.05 was considered statistically significant. Results Of 148 forceps-assisted deliveries, 81 delivered OA after either manual or forceps rotation, 10 delivered in the OP or occiput-transverse position after an unsuccessful rotation, and 57 delivered OP without attempted rotation. No significant differences were found between demographic, obstetric and neonatal characteristics of the groups. Overall, 86 (67.7%) women had mild lacerations and 41 (32.3%) had severe lacerations. A significantly greater rate of severe perineal lacerations were found in the OP nonrotated compared with the rotated group (43.4% compared with 24.3%; P=.02). In multivariable analyses, adjusted for age, race, insurance, body mass index, gestational age, parity, episiotomy and neonatal weight, forceps-assisted vaginal delivery in the OP position without rotation remained significantly more likely to be associated with severe lacerations (OR 3.67; 95% CI 1.42–9.47). Conclusion Forceps-assisted vaginal delivery after rotation of an OP position to an OA position is associated with less severe maternal perineal trauma than forceps-assisted delivery in the OP position. PMID:23743462

Racial and ethnic disparities in maternal morbidity and obstetric care.

PubMed

Grobman, William A; Bailit, Jennifer L; Rice, Madeline Murguia; Wapner, Ronald J; Reddy, Uma M; Varner, Michael W; Thorp, John M; Leveno, Kenneth J; Caritis, Steve N; Iams, Jay D; Tita, Alan T N; Saade, George; Rouse, Dwight J; Blackwell, Sean C; Tolosa, Jorge E; VanDorsten, J Peter

2015-06-01

To evaluate whether racial and ethnic disparities exist in obstetric care and adverse outcomes. We analyzed data from a cohort of women who delivered at 25 hospitals across the United States over a 3-year period. Race and ethnicity was categorized as non-Hispanic white, non-Hispanic black, Hispanic, or Asian. Associations between race and ethnicity and severe postpartum hemorrhage, peripartum infection, and severe perineal laceration at spontaneous vaginal delivery as well as between race and ethnicity and obstetric care (eg, episiotomy) relevant to the adverse outcomes were estimated by univariable analysis and multivariable logistic regression. Of 115,502 studied women, 95% were classified by one of the race and ethnicity categories. Non-Hispanic white women were significantly less likely to experience severe postpartum hemorrhage (1.6% non-Hispanic white compared with 3.0% non-Hispanic black compared with 3.1% Hispanic compared with 2.2% Asian) and peripartum infection (4.1% non-Hispanic white compared with 4.9% non-Hispanic black compared with 6.4% Hispanic compared with 6.2% Asian) than others (P<.001 for both). Severe perineal laceration at spontaneous vaginal delivery was significantly more likely in Asian women (2.5% non-Hispanic white compared with 1.2% non-Hispanic black compared with 1.5% Hispanic compared with 5.5% Asian; P<.001). These disparities persisted in multivariable analysis. Many types of obstetric care examined also were significantly different according to race and ethnicity in both univariable and multivariable analysis. There were no significant interactions between race and ethnicity and hospital of delivery. Racial and ethnic disparities exist for multiple adverse obstetric outcomes and types of obstetric care and do not appear to be explained by differences in patient characteristics or by delivery hospital. II.

Effect of rotation on perineal lacerations in forceps-assisted vaginal deliveries.

PubMed

Bradley, Megan S; Kaminski, Robert J; Streitman, David C; Dunn, Shannon L; Krans, Elizabeth E

2013-07-01

To determine the difference in the rates of severe perineal lacerations between forceps-assisted vaginal deliveries in the occiput-posterior position compared with forceps-assisted vaginal deliveries in which the fetal head was rotated to occiput-anterior before delivery. We studied a retrospective cohort of 148 women who had a forceps-assisted vaginal delivery from 2008 to 2011 at the University of Pittsburgh. Mild perineal lacerations were defined as first or second degree, and severe lacerations were defined as third or fourth degree. χ and t tests were used for bivariate and logistic regression was used for multivariable analyses. P<.05 was considered statistically significant. Of 148 forceps-assisted deliveries, 81 delivered occiput-anterior after either manual or forceps rotation, 10 delivered in the occiput-posterior or occiput-transverse position after an unsuccessful rotation, and 57 delivered occiput-posterior without attempted rotation. No significant differences were found among demographic, obstetric, and neonatal characteristics of the groups. Overall, 86 (67.7%) women had mild lacerations and 41 (32.3%) had severe lacerations. A significantly greater rate of severe perineal lacerations was found in the occiput-posterior nonrotated compared with the rotated group (43.4% compared with 24.3%; P=.02). In multivariable analyses, adjusted for age, race, insurance, body mass index, gestational age, parity, episiotomy, and birth weight, forceps-assisted vaginal delivery in the occiput-posterior position without rotation remained significantly more likely to be associated with severe lacerations (odds ratio 3.67, 95% confidence interval 1.42-9.47). Forceps-assisted vaginal delivery after rotation of an occiput-posterior position to an occiput-anterior position is associated with less severe maternal perineal trauma than forceps-assisted delivery in the occiput-posterior position. II.

Racial and Ethnic Disparities in Maternal Morbidity and Obstetric Care

PubMed Central

Grobman, William A.; Bailit, Jennifer L.; Rice, Madeline Murguia; Wapner, Ronald J.; Reddy, Uma M.; Varner, Michael W.; Thorp, John M.; Leveno, Kenneth J.; Caritis, Steve N.; Iams, Jay D.; Tita, Alan T. N.; Saade, George; Rouse, Dwight J.; Blackwell, Sean C.; Tolosa, Jorge E.; VanDorsten, J. Peter

2015-01-01

Objective To evaluate whether racial and ethnic disparities exist in obstetric care and adverse outcomes. Methods We analyzed data from a cohort of women who delivered at 25 hospitals across the United States over a 3-year period. Race and ethnicity was categorized as Non-Hispanic white, Non-Hispanic black, Hispanic, or Asian. Associations between race and ethnicity and severe postpartum hemorrhage (PPH), peripartum infection, and severe perineal laceration at spontaneous vaginal delivery, as well as between race and ethnicity and obstetric care (eg, episiotomy) relevant to the adverse outcomes, were estimated by univariable analysis and multivariable logistic regression. Results Of 115,502 studied women, 95% were classified by one of the race and ethnicity categories. Non-Hispanic white women were significantly less likely to experience severe PPH (1.6% non-Hispanic white vs. 3.0% Non-Hispanic black vs. 3.1% Hispanic vs. 2.2%Asian) and peripartum infection (4.1% non-Hispanic white vs. 4.9% Non-Hispanic black vs. 6.4% Hispanic vs. 6.2% Asian) than others (P < 0.001 for both). Severe perineal laceration at spontaneous vaginal delivery was significantly more likely in Asian women (2.5% non-Hispanic white vs. 1.2% Non-Hispanic black vs. 1.5% Hispanic vs. 5.5% Asian) P< 0.001). These disparities persisted in multivariable analysis. Many types of obstetric care examined also were significantly different according to race and ethnicity in both univariable and multivariable analysis. There were no significant interactions between race and ethnicity and hospital of delivery. Conclusion Racial and ethnic disparities exist for multiple adverse obstetric outcomes and types of obstetric care, and do not appear to be explained by differences in patient characteristics or by delivery hospital. PMID:26000518

Third and fourth degree perineal tears--the risk of recurrence in subsequent pregnancy.

PubMed

Yogev, Yariv; Hiersch, Liran; Maresky, Lance; Wasserberg, Nir; Wiznitzer, Arnon; Melamed, Nir

2014-01-01

To assess the risk of recurrence of third- and fourth-degree perineal tears (34DPT) and to determine whether previous 34DPT is an independent risk factor for 34DPT in subsequent deliveries. The study group included all women who had a vaginal delivery complicated by 34DPT (2000-2012, N = 356) and subsequently delivered again in the same medical center (N = 204). The rate of recurrence of 34DPT was compared with a control group of women who had a previous vaginal delivery not complicated by 34DPT (N = 58 581) and had a subsequent delivery in the same time period (N = 23 045). Women in the past-34DPT group had a higher rate of CS (18.6% versus 10.1%, p < 0.001), fetal head in occiput-posterior position (POP; 2.5% versus 0.7%, p = 0.004) and mediolateral episiotomy (25.5% versus 19.4%, p = 0.03). Women in the past-34DPT group had a higher rate of 34DPT in the subsequent delivery (2.0% versus 0.3%, p < 0.001). The rate of recurrence of 34DPT was considerably higher among women with past fourth-degree tear versus women with past third-degree tear (22.2% versus 1.0%, p < 0.001). 34DPT in previous pregnancy is independently associated with increased risk of 34DPT in subsequent delivery (OR = 4.6, 95%-CI 1.3-15.3). Women who experienced 34DPT in their previous pregnancy have an increased risk for recurrence of 34DPT in subsequent pregnancy, especially in cases of past fourth-degree tears.

[Change of lower urinary tract symptoms during pregnancy and after delivery--investigations using IPSS/QOL and Urinary Incontinence Questionnaires].

PubMed

Horikawa, Shigeki; Matsumoto, Seiji; Hanai, Tadashi; Yamamoto, Toshiya; Kishimoto, Tomomi; Uemura, Hirotsugu

2009-06-01

Using International Prostate Symptom Score (IPSS)/Quality of life (QOL) and Urinary Incontinence Questionnaires, we collected a total of 89 questionnaires from 48 pregnant women (average age of 31.4 +/- 3.42) and data 4 times during each pregnancy (during the 14th, 26th and 36th weeks of pregnancy) and 1 month after delivery. We examined whether there was a relationship between the number of incontinence incidences listed in the questionnaires and other parameters: the body mass index (BMI), previous deliveries, the weight of the baby delivered, the use of episiotomy, etc. The average IPSS score was 5.84 +/- 4.65, 5.33 +/- 2.73, 7.35 +/- 4.51 for the 14, 26 and 36th week, respectively and 1.82 +/- 1.76 one month after delivery. The major symptom reported was storage symptom and the scores increased as the pregnancy progressed and recovered by one month after delivery. The average score on the Urinary Incontinence Questionnaires was 3.32 +/- 2.69, 5.05 +/- 3.02, 6.15 +/- 2.89 for the 14, 26 and 36th week, respectively and 1.59 +/- 2.03 one month after delivery. The major symptom reported was stress incontinence. The scores increased significantly as the pregnancy progressed and, one month after delivery, returned to the level at the 14th week of pregnancy. We found a positive correlation between the number of incidences of incontinence at the 36th week and the subject's BMI. Among the lower urinary tract symptoms, storage symptom and stress incontinence were found in the early stage of pregnancy. Storage symptom disappeared after delivery, but stress incontinence was reduced only to the level in the early stage of pregnancy.

Local birthing services for rural women: Adaptation of a rural New South Wales maternity service.

PubMed

Durst, Michelle; Rolfe, Margaret; Longman, Jo; Robin, Sarah; Dhnaram, Beverley; Mullany, Kathryn; Wright, Ian; Barclay, Lesley

2016-12-01

To describe the outcomes of a public hospital maternity unit in rural New South Wales (NSW) following the adaptation of the service from an obstetrician and general practitioner-obstetrician (GPO)-led birthing service to a low-risk midwifery group practice (MGP) model of care with a planned caesarean section service (PCS). A retrospective descriptive study using quantitative methodology. Maternity unit in a small public hospital in rural New South Wales, Australia. Data were extracted from the ward-based birth register for 1172 births at the service between July 2007 and June 2012. Birth numbers, maternal characteristics, labour, birthing and neonatal outcomes. There were 750 births over 29 months in GPO and 277 and 145 births over 31 months in MGP and PCS, respectively, totalling 422 births following the change in model of care. The GPO had 553 (73.7%) vaginal births and 197 (26.3%) caesarean section (CS) births (139 planned and 58 unplanned). There were almost universal normal vaginal births in MGP (>99% or 276). For normal vaginal births, more women in MGP had no analgesia (45.3% versus 25.1%) or non-invasive analgesia (47.9% versus 38.6%) and episiotomy was less common in MGP than GPO (1.9% versus 3.4%). Neonatal outcomes were similar for both groups with no difference between Apgar scores at 5 min, neonatal resuscitations or transfer to high-level special care nurseries. This study demonstrates how a rural maternity service maintained quality care outcomes for low-risk women following the adaptation from a GPO to an MGP service. © 2016 The Authors. Australian Journal of Rural Health published by John Wiley & Sons Australia, Ltd on behalf of National Rural Health Alliance.

[Guaranteeing fetal well-being in water childbirth: is it possible?].

PubMed

Dodero, D; Caporale, E; Cardamone, C; Corticelli, A; Messuti, G; Francescangeli, U; Sirito, R

2000-01-01

The criteria, which a modern obstetric department is based on, are to deliver serenely and naturally according to the mother's personal exigencies and preserving the child's right to his/her own safety. The attempt to offer the woman a natural place with respect for these principles has improved the knowledge about the physiologic changes of the female organism during labour and water birth. Our experience about water birth began on 1st of July 2000, the day of the inauguration of the new birth room of the maternal-infantile department of the hospital of Lavagna. We nursed 15 women during labour and water birth, 11 were multiparas, 4 were primiparas, the average age was 31-year-old. We used the existing criteria of maternal and fetal selection for the care of physiologic water birth with a low risk. Particularly, the fetal heart rate was monitored at least for 30 minutes before the immersion into water and then at scheduled intervals during labour. To this purpose we used a cardiotocograph provided with an ultrasound probe (with high density of crystals) and with a toco (with high sensitivity), both waterproof and wireless. In our sample the episiotomy was not performed and 3rd degree lacerations did not happen. The neonatal average weight was 3100 gr for the primiparas and 3040 gr for the multiparas, respectively. The Apgar measurement was never lower than 8. The average time of labour was 6 hours for the group of the primiparas and 4.25 hours for the multiparas, respectively. In conclusion the monitoring of fetal welfare during water labour does not substantially differ from the monitoring of traditional labour, but it requires specific equipments.

[Management of shoulder dystocia].

PubMed

Le Ray, C; Oury, J-F

2015-12-01

The objective of this review is to propose recommendations on the management of shoulder dystocia. The PubMed database, the Cochrane Library and the recommendations from the foreign obstetrical societies or colleges have been consulted. In case of shoulder dystocia, if the obstetrician is not present at delivery, he should be systematically informed as quickly as possible (professional consensus). A third person should also be called for help in order to realize McRoberts maneuver (professional consensus). The patient has to be properly installed in gynecological position (professional consensus). It is recommended not to pull excessively on the fetal head (grade C), do not perform uterine expression (grade C) and do not realize inverse rotation of the fetal head (professional consensus). McRoberts maneuver, with or without a suprapubic pressure, is simple to perform, effective and associated with low morbidity, thus, it is recommended in the first line (grade C). Regarding the maneuvers of the second line, the available data do not suggest the superiority of one maneuver in relation to another (grade C). We proposed an algorithm; however, management should be adapted to the experience of the operator. If the posterior shoulder is engaged, Wood's maneuver should be performed preferentially; if the posterior shoulder is not engaged, delivery of the posterior arm should be performed preferentially (professional consensus). Routine episiotomy is not recommended in shoulder dystocia (professional consensus). Other second intention maneuvers are described. It seems necessary to know at least two maneuvers to perform in case of shoulder dystocia unresolved by the maneuver McRoberts (professional consensus). All physicians and midwives should know and perform obstetric maneuvers if needed quickly but without precipitation. Copyright © 2015. Published by Elsevier Masson SAS.

Adherence to evidence based care practices for childbirth before and after a quality improvement intervention in health facilities of Rajasthan, India.

PubMed

Iyengar, Kirti; Jain, Motilal; Thomas, Sunil; Dashora, Kalpana; Liu, William; Saini, Paramsukh; Dattatreya, Rajesh; Parker, Indrani; Iyengar, Sharad

2014-08-13

After the launch of Janani Suraksha Yojana, a conditional cash transfer scheme in India, the proportion of women giving birth in institutions has rapidly increased. However, there are important gaps in quality of childbirth services during institutional deliveries. The aim of this intervention was to improve the quality of childbirth services in selected high caseload public health facilities of 10 districts of Rajasthan. This intervention titled "Parijaat" was designed by Action Research & Training for Health, in partnership with the state government and United Nations Population Fund. The intervention was carried out in 44 public health facilities in 10 districts of Rajasthan, India. These included district hospitals (9), community health centres (32) and primary health centres (3). The main intervention was orientation training of doctors and program managers and regular visits to facilities involving assessment, feedback, training and action. The adherence to evidence based practices before, during and after this intervention were measured using structured checklists and scoring sheets. Main outcome measures included changes in practices during labour, delivery or immediate postpartum period. Use of several unnecessary or harmful practices reduced significantly. Most importantly, proportion of facilities using routine augmentation of labour reduced (p = 0), episiotomy for primigravidas (p = 0.0003), fundal pressure (p = 0.0003), and routine suction of newborns (0 = 0.0005). Among the beneficial practices, use of oxytocin after delivery increased (p = 0.0001) and the practice of listening foetal heart sounds during labour (p = 0.0001). Some practices did not show any improvements, such as dorsal position for delivery, use of partograph, and hand-washing. An intervention based on repeated facility visits combined with actions at the level of decision makers can lead to substantial improvements in quality of childbirth practices at health facilities.

Perinatal outcome and financial impact of Eritrean and Sudanese refugees delivered in a tertiary hospital in Tel Aviv, Israel.

PubMed

Michaan, Nadav; Gil, Yaron; Amzalag, Sagi; Laskov, Ido; Lessing, Joseph; Many, Ariel

2014-06-01

A growing number of Eritrean and Sudanese refugees seek medical assistance in the labor and delivery ward of our facility. Providing treatment to this unique population is challenging since communication is limited and pregnancy follow-up is usually absent. To compare the perinatal outcome of refugees and Israeli parturients. The medical and financial records of all refugees delivered between May 2010 and April 2011 were reviewed. Perinatal outcome was compared to that of native Israeli controls. During this period 254 refugees were delivered (2.3% of deliveries). Refugees were significantly younger and leaner. They had significantly more premature deliveries under 37 weeks (23 vs. 10, P = 0.029) and under 34 weeks gestation (9 vs. 2, P = 0.036) with more admissions to the neonatal intensive care unit (15 vs. 5, P = 0.038). Overall cesarean section rate was similar but refugees required significantly more urgent surgeries (97% vs. 53%, P = 0.0001). Refugees had significantly more cases of meconium and episiotomies but fewer cases of epidural analgesia. There were 2 intrauterine fetal deaths among refugees, compared to 13 of 11,239 deliveries during this time period (P = 0.036), as well as 7 pregnancy terminations following sexual assault during their escape. Sixty-eight percent of refugees had medical fees outstanding with a total debt of 2,656,000 shekels (US$ 767,250). The phenomenon of African refugees giving birth in our center is of unprecedented magnitude and bears significant medical and ethical implications. Refugees proved susceptible to adverse perinatal outcomes compared to their Israeli counterparts. Setting a pregnancy follow-up plan could, in the long run, prevent adverse outcomes and reduce costs involved in treating this population.

Relationship Between Third-Trimester Sonographic Estimate of Fetal Weight and Mode of Delivery.

PubMed

Yee, Lynn M; Grobman, William A

2016-04-01

Some have suggested, based on limited data, that knowledge of an estimated fetal weight from a sonogram in a low-risk population, particularly in the setting of a larger fetus, is associated with increased risk of cesarean delivery. We aimed to investigate, among women delivering neonates weighing greater than 3500 g, whether having had a sonographically estimated fetal weight in temporal proximity to delivery was associated with the risk of cesarean delivery. We conducted a retrospective cohort study of term nulliparous women delivering live-born, cephalic, singleton, nonanomalous fetuses with birth weights of greater than 3500 g. The study was powered to detect a 30% change in cesarean delivery frequency with the presence of a sonographic examination after 36 weeks' gestation. Of the 2099 women meeting inclusion criteria, 419 (20%) had a sonographic examination after 36 weeks' gestation. Women were similar with respect to demographic and obstetric characteristics regardless of whether they underwent sonography. There were no differences in rates of cesarean delivery regardless of whether women had or did not undergo sonography after 36 weeks (33.2% versus 29.4%, respectively; P = .13). There also were no differences in rates of chorioamnionitis, postpartum hemorrhage, episiotomy, third- or fourth-degree perineal laceration, or neonatal adverse outcomes based on sonographic status. Findings were similar in a multivariable analysis, as well as when the study population was restricted to those with birth weights of greater than 4000 and 4500 g. In this population of neonates weighing greater than 3500 g, the presence of a sonographic examination was not associated with the frequency of cesarean delivery. © 2016 by the American Institute of Ultrasound in Medicine.

Evaluation of anogenital injuries using white and UV-light among adult volunteers following consensual sexual intercourse.

PubMed

Joki-Erkkilä, Minna; Rainio, Juha; Huhtala, Heini; Salonen, Aki; Karhunen, Pekka J

2014-09-01

New clinical forensic examination techniques for sexual assaults have not been introduced over the last few decades. We evaluated the benefit of ultraviolet light compared to white light for detecting minor anogenital injuries and scars, following consensual sexual intercourse among adult volunteers. A prospective study comparing female genital findings utilising white and ultraviolet light. A colposcopy with photographic documentation was used. Personal invitation to healthcare students, hospital employees or acquaintances to volunteer for a gynecological examination, with a focus on clinical forensic aspects. Eighty-eight adult female volunteers were recruited for the study. The examination was performed after consensual intercourse. Age ranged from 20 to 52 years (median 26.5 years). Presence of acute findings and scars in the genital area using white and UV-light. Acute genital injury rate was 14.8% under white light colposcopy and 23.0% using UV light. Submucosal hemorrhages in the genital area were documented significantly better under UV-light than white light (14.9% vs. 6.8%; p=0.016), whereas petechiaes (4.5%) and abrasions (2.3%) were detected using either method. UV-light revealed significantly more often delivery-associated genital scars compared to white light (39.8% vs. 31.8%; p=0.016). Furthermore, 10 out of 31 (33.3%) women had no residual anogenital skin or mucosal surface findings, despite a prior episiotomy or rupture of the vaginal outlet wall during delivery, supporting its enormous ability to heal even after major trauma. UV-light may provide additional value for the evaluation of physical findings in clinical forensic examinations after sexual assault, and is especially useful in detecting otherwise invisible early submucosal hemorrhages and scars. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

[Pregnancy and childbirth in a patient with a spinal cord lesion].

PubMed

Vanderbeke, I; Boll, D; Verguts, J K

2008-05-17

A 37-year-old woman with a spinal cord lesion at the level of TvIII due to a car-accident, became pregnant. She had posttraumatic syringomyely at Cv-TvIII, for which she underwent syringo-arachnoidal drainage. At approximately six weeks of amenorrhoea she presented at the emergency room with vaginal bleeding. She was treated with dalteparine 5000 IU once daily given by intramuscular injection until 6 weeks post partum. Weekly urine checks were advised. At 36 6/7 weeks of pregnancy, the patient was admitted to hospital for daily cardiotocography and 4-hourly contraction monitoring. After spontaneous rupture of the membranes she went into labour and had a vaginal delivery of a son weighing 3320 g. His Apgar score was 6 after 1 min and 9 after 5 min; arterial pH was 7.31. For three months after giving birth she received specialist care at home as well as help and counselling from a rehabilitation centre. In pregnant women with a spinal cord lesion, special attention should be paid to urinary tract infections, pressure areas, anaemia and thrombo-embolic symptoms. During partus, cardiotocographic monitoring should be carried out, also in patients with TvI-Tx lesions regularly from 36 weeks. In pregnant women with lesions from TvI, medical attendants should be aware of the possibility of autonomous dysreflection. Epidural anaesthesia should be administered and episiotomy or rupture avoided. Post partum, the bladder should always be completely emptied and pressure areas and signs ofthrombo-embolic complications monitored. A urological bladder function consultation should be requested, and, ifepisiotomy or rupture does occur, extra care should be taken to avoid infection. The ergonomic situation at home should be evaluated to ensure that any ergonomic changes necessary for the care of the patient and her newborn, take place in time.

Determination of a cutoff value for pelvic floor distensibility using the Epi-no balloon to predict perineal integrity in vaginal delivery: ROC curve analysis. Prospective observational single cohort study.

PubMed

Zanetti, Miriam Raquel Diniz; Petricelli, Carla Dellabarba; Alexandre, Sandra Maria; Paschoal, Aline; Araujo Júnior, Edward; Nakamura, Mary Uchiyama

2016-04-01

Several risk factors are involved in perineal lacerations during vaginal delivery. However, little is known about the influence of perineal distensibility as a protective factor. The aim here was to determine a cutoff value for pelvic floor distensibility measured using the Epi-no balloon, which could be used as a predictive factor for perineal integrity in vaginal delivery. Prospective observational single cohort study conducted in a maternity hospital. A convenience sample of 227 consecutive at-term parturients was used. All women had a single fetus in the vertex presentation, with up to 9.0 cm of dilation. The maximum dilation of the Epi-no balloon was measured using a tape measure after it had been inflated inside the vagina up to the parturients' maximum tolerance. The receiver operating characteristic (ROC) curve was used to obtain the Epi-no circumference measurement with best sensitivity and specificity. Among the 161 patients who were included in the study, 50.9% underwent episiotomy, 21.8% presented lacerations and 27.3% retained an intact perineum. Age > 25.9 years; number of pregnancies > 3.4; number of deliveries > 2.2 and circumference measured by Epi-no > 21.4 cm were all directly correlated with an intact perineum. Circumference measurements using the Epi-no balloon that were greater than 20.8 cm showed sensitivity and specificity of 70.5% and 66.7% (area under curve = 0.713), respectively, as a predictive factor for an intact perineum in vaginal delivery. Circumferences greater than 20.8 cm achieved using the Epi-no balloon are a predictive factor for perineal integrity in parturients.

Length of perineal pain relief after ice pack application: A quasi-experimental study.

PubMed

de Souza Bosco Paiva, Caroline; Junqueira Vasconcellos de Oliveira, Sonia Maria; Amorim Francisco, Adriana; da Silva, Renata Luana; de Paula Batista Mendes, Edilaine; Steen, Mary

2016-04-01

Ice pack is effective for alleviating postpartum perineal pain in primiparous women while multiparous women's levels of perineal pain appear to be poorly explored. Ice pack is a low-cost non-invasive localised treatment that can be used with no impact on breastfeeding. However, how long perineal analgesia persists after applying an ice pack is still unknown. To evaluate if perineal analgesia is maintained up to 2h after applying an ice pack to the perineum for 20min. A quasi-experimental study, using a pre and post-test design, was undertaken with a sample size of 50 multiparous women in Brazil. Data was collected by structured interview. The intervention involved a single application of an ice pack applied for 20min to the perineal area of women who reported perineal pain ≥3 by use of a numeric rating scale (0-10), with intact perineum, 1st or 2nd degree lacerations or episiotomy, between 6 and 24h after spontaneous vaginal birth. Perineal pain was evaluated at three points of time: before, immediately after and 2h after applying an ice pack. Immediately after applying an ice pack to the perineal area, there was a significant reduction in the severity of perineal pain reported (5.4 vs. 1.0, p<0.0005), which continued for 1h 35min up to 2h after the local application. Ice pack application for 20min is effective for alleviating postpartum perineal pain and continues to be effective between 1h 35min for up to 2h. Copyright © 2015 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Denaverine hydrochloride and carbetocin increased welfare during and after parturition and enhanced subsequent fertility in cattle.

PubMed

Zobel, Robert; Taponen, Juhani

2014-01-01

The objectives of the current study were to investigate the influence of denaverine hydrochloride and carbetocin on softening and dilatation of the birth canal, the need for assistance during parturition, calf mortality, retention of fetal membranes, endometritis, and subsequent fertility. Altogether 200 animals (100 cows and 100 heifers) of the Simmental breed were divided into 2 groups: treatment (n = 100) and control (n = 100). Animals in the treatment group received denaverine hydrochloride and carbetocin (a maximum of twice for each, depending on the progression of labor) during delivery over a maximum of 4 waiting periods (30 min each), whereas control animals experienced the same waiting periods but received no treatment. The treatment protocol had a positive influence on the ease of calving and postpartum reproductive health. The treatment increased the number of animals with the birth canal dilated by more than 25 cm, and halved the need for any assistance at parturition. In addition, treatment decreased the occurrence of difficult calving, the need for episiotomy, the appearance of birth canal lesions, and clinical endometritis. The treatment protocol had an effect throughout the entire puerperal period, as treated animals conceived with fewer artificial inseminations (1.3 vs. 1.6 artificial inseminations/pregnancy) and sooner (67 vs. 78 d open) compared with control animals. Denaverine hydrochloride and carbetocin administered in combination during parturition affected the progression and ease of calving, and thus the welfare of cows in labor and subsequently. However, further studies are needed to confirm the findings and to establish best practices. Copyright © 2014 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.

[The uterotropismus of halothane, chloroform or methoxyflurane in clinical use (author's transl)].

PubMed

Fassolt, A; Schubiger, V; Hauser, G A

1976-11-01

To perform episiotomy, 89 women after childbirth were anaesthetized with either halothane (50 patients), methoxyflurane (24 patients) or chloroform (15 patients). The activity of the uterus was registered tocodynamographically. To examine the alternate influence of narcotics and uterotonica, 57 patients were pre-medicated with sintocinon and methergin i.m. as a prophylaxis. The second group (32 patients) received no premedication to stimulate labor activity, however in 18 cases towards the end of narcosis oxytocin and methergin were given i.v. In addition to these examinations 5 vaginal deliveries were anaesthetised with halothane only. Concerning our own experimental study it can be observed: 1. The relaxative properties of halothane wich suppresses completly the activity of myometrium during the deep stages of anaesthesia are superior to chloroform and methoxyflurane. 2. More rapid relaxation of the uterus with halothane compared with chloroform and methoxyflurane. 3. After the use of halothane a quicker return of the activity of the uterus compared with chloroform and methoxyflurane. 4. The value of a prophylaxis with uterotonica can be demonstrated by a comparatively reduced slowing-down of labour-activity during anaesthesia. 5. In every one of the cases, an interuption of the labour-suppressing, caused by the anaesthesia, can be obtained by injecting intravenously oxytocin or methergin. 6. During vaginal delivery, compared to the post placentar phase, there is no need for higher concentrations of halothane to be used to suppress labour contractions. The discussion deals with the intensity of reduction of the uterus contraction caused by the above mentioned narcotics, the dangers of the atony of the uterus, and the indications and contra-indications of obstetrical anaesthesia with halothane or methoxyflurane.

Breastfeeding at 6 weeks and predictive factors.

PubMed

Chye, J K; Zain, Z; Lim, W L; Lim, C T

1997-10-01

Despite the numerous changes made in accordance with the Baby Friendly Hospital Initiative at the University Hospital, Kuala Lumpur, the low rates of breastfeeding have persisted. This study aims to examine the current trend in infant feeding, and the influences of some perinatal and sociodemographic factors on breastfeeding. Five-hundred mothers with singleton pregnancies and healthy infants were interviewed at 6 weeks post-partum. Only 124 (25 per cent) mothers were practising exclusive breastfeeding (EBF), and 132 (26 per cent) mothers were using exclusive infant formula feeding (EIF). On logistic regression analyses, mothers who followed EBF were more likely to have had antenatal plans to breastfeed (Odds ratio 2.44, 95 per cent confidence interval 1.75-3.45), not in paid employment post-natally (OR 1.76, 95 per cent CI 1.31-2.36), of older age group (> 27 years) (OR 1.48, 95 per cent CI 1.13-1.93), had female infants (OR 1.38, 95 per cent CI 1.05-1.80) and of Indian ethnicity (compared to Chinese) (OR 3.87, 95 per cent CI 2.16-6.89). Breastfeeding difficulties were associated with decreased odds of EBF (OR 0.21, 95 per cent CI 0.13-0.34). Parental education, fathers' ages and incomes, primigravida status, Caesarean section, present of episiotomy, late first breastfeed, phototherapy, and length of hospital stay were not significant predictors of failure of EBF. In comparison, predictive factors for increased use of EIF were mothers who have had breastfeeding difficulties, < or = 9 years of schooling, and of Chinese descent. In conclusions, the overall rate of EBF by 6 weeks of age in infants born in this urban hospital had remained poor. The adverse factors for EBF identified in this study warrant further in-depth studies to determine effective ways of improving EBF rates.

Parturition Events and Risk of Urinary Incontinence in Later Life

PubMed Central

Thom, David H.; Brown, Jeanette S.; Schembri, Michael; Ragins, Arona I.; Creasman, Jennifer M.; Van Den Eeden, Stephen K.

2011-01-01

Aims To examine the association between specific events during vaginal deliveries and urinary incontinence later in life. Methods A retrospective cohort study of 1521 middle-aged and older women with at least 1 vaginal delivery who were long-term members of an integrated health delivery system. Age, race/ethnicity, current incontinence status, medical, surgical history, pregnancy and parturition history, menopausal status, hormone replacement, health habits, and general health were obtained by questionnaire. Labor and delivery records, archived since 1948, were abstracted by professional medical record abstractors to obtain parturition events including induction, length of labor stages, type of anesthesia, episiotomy, instrumental delivery, and birth weight. The primary dependent variable was current weekly urinary incontinence (once per week or more often) vs urinary incontinence less than monthly (including no incontinence) in past 12 months. Associations of parturition events and later incontinence were assessed in multivariate analysis with logistic regression. Results The mean age of participants was 56 years. After adjustment for multiple risk factors, weekly urinary incontinence significantly associated with age at first birth (p=.036), greatest birth weight (p=.005), and ever having been induced for labor (OR=1.51; 95% CI=1.06–2.16, p=.02). Risk of incontinence increased from OR=1.35 (95% CI=0.92–1.97, p=0.12) for women with one induction to OR=2.67 (95% CI= 1.25–5.71, p=.01) for women with 2 or more inductions (p=0.01 for trend). No other parturition factors were associated with incontinence. Conclusions Younger age at first birth, greatest birth weight, and induction of labor were associated with an increased risk of incontinence in later life. PMID:21780171

Parturition events and risk of urinary incontinence in later life.

PubMed

Thom, David H; Brown, Jeanette S; Schembri, Michael; Ragins, Arona I; Creasman, Jennifer M; Van Den Eeden, Stephen K

2011-11-01

To examine the association between specific events during vaginal deliveries and urinary incontinence later in life. A retrospective cohort study of 1,521 middle-aged and older women with at least one vaginal delivery who were long-term members of an integrated health delivery system. Age, race/ethnicity, current incontinence status, medical, surgical history, pregnancy and parturition history, menopausal status, hormone replacement, health habits, and general health were obtained by questionnaire. Labor and delivery records, archived since 1948, were abstracted by professional medical record abstractors to obtain parturition events including induction, length of labor stages, type of anesthesia, episiotomy, instrumental delivery, and birth weight. The primary dependent variable was current weekly urinary incontinence (once per week or more often) versus urinary incontinence less than monthly (including no incontinence) in past 12 months. Associations of parturition events and later incontinence were assessed in multivariate analysis with logistic regression. The mean age of participants was 56 years. After adjustment for multiple risk factors, weekly urinary incontinence significantly associated with age at first birth (P = 0.036), greatest birth weight (P = 0.005), and ever having been induced for labor (OR = 1.51; 95%CI = 1.06-2.16, P = 0.02). Risk of incontinence increased from OR = 1.35 (95%CI = 0.92-1.97, P = 0.12) for women with one induction to OR = 2.67 (95%CI = 1.25-5.71, P = 0.01) for women with two or more inductions (P = 0.01 for trend). No other parturition factors were associated with incontinence. Younger age at first birth, greatest birth weight, and induction of labor were associated with an increased risk of incontinence in later life. Copyright © 2011 Wiley Periodicals, Inc.

National Hospital Discharge Survey: 2005 annual summary with detailed diagnosis and procedure data.

PubMed

DeFrances, Carol J; Cullen, Karen A; Kozak, Lola Jean

2007-12-01

This report presents 2005 national estimates and selected trend data on the use of nonfederal short-stay hospitals in the United States. Estimates are provided by selected patient and hospital characteristics, diagnoses, and surgical and nonsurgical procedures performed. Estimates of diagnoses and procedures are presented according to International Classification of Diseases, Ninth Revision, Clinical Modification codes. The estimates are based on data collected through the National Hospital Discharge Survey. The survey has been conducted annually since 1965. In 2005, data were collected for approximately 375,000 discharges. Of the 473 eligible nonfederal short-stay hospitals in the sample, 444 (94 percent) responded to the survey. An estimated 34.7 million discharges from nonfederal short-stay hospitals occurred in 2005. Discharges used 165.9 million days of care and had an average length of stay of 4.8 days. Persons 65 years and over accounted for 38 percent of the hospital discharges and 44 percent of the days of care. The proportion of discharges whose status was described as routine discharge or discharged to the patient's home declined with age, from 91 percent for inpatients under 45 years of age to 41 percent for those 85 years and over. Hospitalization for malignant neoplasms decreased from 1990-2005. The hospitalization rate for asthma was the highest for children under 15 years of age and those 65 years of age and over. The rate was lowest for those 15-44 years of age. Thirty-eight percent of hospital discharges had no procedures performed, whereas 12 percent had four or more procedures performed. An episiotomy was performed during a majority of vaginal deliveries in 1980 (64 percent), but by 2005, it was performed during less than one of every five vaginal deliveries (19 percent).

Outcomes of planned hospital birth attended by midwives compared with physicians in British Columbia.

PubMed

Janssen, Patricia A; Ryan, Elizabeth M; Etches, Duncan J; Klein, Michael C; Reime, Birgit

2007-06-01

The impact of midwifery versus physician care on perinatal outcomes in a population of women planning birth in hospital has not yet been explored. We compared maternal and newborn outcomes between women planning hospital birth attended by a midwife versus a physician in British Columbia, Canada. All women planning a hospital birth attended by a midwife during the 2-year study period who were of sufficiently low-risk status to meet eligibility requirements for home birth as defined by the British Columbia College of Midwives were included in the study group (n=488). The comparison group included women meeting the same eligibility requirements but planning a physician-attended birth in hospitals where midwives also practiced (n=572). Outcomes were ascertained from the British Columbia Reproductive Care Program Perinatal Registry to which all hospitals in the province submit data. Adjusted odds ratios for women planning hospital birth attended by a midwife versus a physician were significantly reduced for exposure to cesarean section (OR 0.58, 95% CI 0.39-0.86), narcotic analgesia (OR 0.26, 95% CI 0.18-0.37), electronic fetal monitoring (OR 0.22, 95% CI 0.16-0.30), amniotomy (OR 0.74, 95% CI 0.56-0.98), and episiotomy (OR 0.62, 95% CI 0.42-0.93). The odds of adverse neonatal outcomes were not different between groups, with the exception of reduced use of drugs for resuscitation at birth (OR 0.19, 95% CI 0.04-0.83) in the midwifery group. A shift toward greater proportions of midwife-attended births in hospitals could result in reduced rates of obstetric interventions, with similar rates of neonatal morbidity.

Risk Factors for the Development of Obstetric Anal Sphincter Injuries in Modern Obstetric Practice.

PubMed

Ramm, Olga; Woo, Victoria G; Hung, Yun-Yi; Chen, Hsuan-Chih; Ritterman Weintraub, Miranda L

2018-02-01

To characterize the rate of obstetric anal sphincter injuries and identify key risk factors of obstetric anal sphincter injuries, including duration of the second stage of labor. This retrospective cohort study included all singleton, term, cephalic vaginal deliveries within Kaiser Permanente Northern California between January 2013 and December 2014 (N=22,741). Incidence of obstetric anal sphincter injuries, defined as third- or fourth-degree perineal lacerations, was the primary outcome. Multiple logistic regression models were conducted to identify obstetric anal sphincter injury risk factors and high-risk subpopulations. The overall incidence rate of obstetric anal sphincter injuries was 4.9% (3.6% of women who delivered spontaneously vs 24.0% of women who had a vacuum-assisted vaginal delivery, P<.001, CI 18.1-22.6%). In bivariate and multivariate analyses, obstetric anal sphincter injury incidence was higher among women with second stage of labor longer than 2 hours, Asian race, nulliparity, vaginal birth after cesarean delivery, episiotomy, and vacuum delivery. Women with a vacuum-assisted vaginal delivery had four times the odds of obstetric anal sphincter injury (adjusted odds ratio [OR] 4.23, 95% CI 3.59-4.98) and those whose second stage of labor lasted at least 180 minutes vs less than 60 minutes had three times the odds of incurring obstetric anal sphincter injury (adjusted OR 3.20, 95% CI 2.62-3.89). Vacuum-assisted vaginal delivery conferred the highest odds of obstetric anal sphincter injury followed by prolonged duration of the second stage of labor, particularly among certain subpopulations. Understanding these risk factors and their complex interactions can inform antepartum and intrapartum decision-making with the goal of reducing obstetric anal sphincter injury incidence.

Pushing/bearing down methods for the second stage of labour.

PubMed

Lemos, Andrea; Amorim, Melania Mr; Dornelas de Andrade, Armele; de Souza, Ariani I; Cabral Filho, José Eulálio; Correia, Jailson B

2017-03-26

Maternal pushing during the second stage of labour is an important and indispensable contributor to the involuntary expulsive force developed by uterine contraction. There is no consensus on an ideal strategy to facilitate these expulsive efforts and there are contradictory results about the influence on the mother and fetus. To evaluate the benefits and possible disadvantages of different kinds of techniques regarding maternal pushing/breathing during the expulsive stage of labour on maternal and fetal outcomes. We searched Cochrane Pregnancy and Childbirth's Trials Register (19 September 2016) and reference lists of retrieved studies. Randomised controlled trials (RCTs) and quasi-RCTs assessing the effects of pushing/bearing down techniques (type and/or timing) performed during the second stage of labour on maternal and neonatal outcomes. Cluster-RCTs were eligible for inclusion, but none were identified. Studies using a cross-over design and those published in abstract form only were not eligible for inclusion in this review. Two review authors independently assessed trials for inclusion, extracted data and assessed risk of bias. Data were checked for accuracy. In this updated review, we included 21 studies in total, eight (884 women) comparing spontaneous pushing versus directed pushing, with or without epidural analgesia and 13 (2879 women) comparing delayed pushing versus immediate pushing with epidural analgesia. Our GRADE assessments of evidence ranged from moderate to very low quality; the main reasons for downgrading were study design limitations and imprecision of effect estimates. Overall, the included studies varied in their risk of bias; most were judged to be at unclear risk of bias. Comparison 1: types of pushing: spontaneous pushing versus directed pushingThere was no clear difference in the duration of the second stage of labour (mean difference (MD) 10.26 minutes; 95% confidence interval (CI) -1.12 to 21.64 minutes, six studies, 667 women, random-effects, I² = 81%) (very low-quality evidence). There was no clear difference in 3rd or 4th degree perineal laceration (risk ratio (RR) 0.87; 95% CI 0.45 to 1.66, one study, 320 women) (low-quality evidence), episiotomy (average RR 1.05; 95% CI 0.60 to 1.85, two studies, 420 women, random-effects, I² = 81%), duration of pushing (MD -9.76 minutes, 95% CI -19.54 to 0.02; two studies; 169 women; I² = 88%) (very low-quality evidence), or rate of spontaneous vaginal delivery (RR 1.01, 95% CI 0.97 to 1.05; five studies; 688 women; I² = 2%) (moderate-quality evidence). For primary neonatal outcomes such as five-minute Apgar score less than seven, there was no clear difference between groups (RR 0.35; 95% CI 0.01 to 8.43, one study, 320 infants) (very low-quality evidence), and the number of admissions to neonatal intensive care (RR 1.08; 95% CI 0.30 to 3.79, two studies, 393 infants) (very low-quality evidence) also showed no clear difference between spontaneous and directed pushing. No data were available on hypoxic ischaemic encephalopathy. Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural)For the primary maternal outcomes, delayed pushing was associated with an increase of 56 minutes in the duration of the second stage of labour (MD 56.40, 95% CI 42.05 to 70.76; 11 studies; 3049 women; I² = 91%) (very low-quality evidence), but no clear difference in third or 4th degree perineal laceration (RR 0.94; 95% CI 0.78 to 1.14, seven studies. 2775 women) (moderate-quality evidence) or episiotomy (RR 0.95; 95% CI 0.87 to 1.04, five studies, 2320 women). Delayed pushing was also associated with a 19-minute decrease in the duration of pushing (MD -19.05, 95% CI -32.27 to -5.83; 11 studies; 2932 women; I² = 95%) (very low-quality evidence) and an increase in spontaneous vaginal delivery (RR 1.07; 95% CI 1.02 to 1.11, 12 studies, 3114 women) (moderate-quality evidence).For the primary neonatal outcomes, there was no clear difference between groups in admission to neonatal intensive care (RR 0.98; 95% CI 0.67 to 1.41, three studies, n = 2197) (low-quality evidence) and five-minute Apgar score less than seven (RR 0.15; 95% CI 0.01 to 3.00; three studies; 413 infants) (very low-quality evidence). There were no data on hypoxic ischaemic encephalopathy. Delayed pushing was associated with a greater incidence of low umbilical cord blood pH (RR 2.24; 95% CI 1.37 to 3.68, 4 studies, 2145 infants) and increased the cost of intrapartum care by CDN$ 68.22 (MD 68.22, 95% CI 55.37, 81.07, one study, 1862 women). This updated review is based on 21 included studies of moderate to very low quality of evidence (with evidence mainly downgraded due to study design limitations and imprecision of effect estimates).Timing of pushing with epidural is consistent in that delayed pushing leads to a shortening of the actual time pushing and increase of spontaneous vaginal delivery at the expense of an overall longer duration of the second stage of labour and an increased risk of a low umbilical cord pH (based only on one study). Nevertheless, there was no clear difference in serious perineal laceration and episiotomy, and in other neonatal outcomes (admission to neonatal intensive care, five-minute Apgar score less than seven and delivery room resuscitation) between delayed and immediate pushing.Therefore, for the type of pushing, with or without epidural, there is no conclusive evidence to support or refute any specific style as part of routine clinical practice, and in the absence of strong evidence supporting a specific method or timing of pushing, the woman's preference and comfort and clinical context should guide decisions.Further properly well-designed RCTs, addressing clinically important maternal and neonatal outcomes are required to add evidence-based information to the current knowledge. Such trials will provide more complete data to be incorporated into a future update of this review.

Pushing/bearing down methods for the second stage of labour.

PubMed

Lemos, Andrea; Amorim, Melania M R; Dornelas de Andrade, Armele; de Souza, Ariani I; Cabral Filho, José Eulálio; Correia, Jailson B

2015-10-09

Maternal pushing during the second stage of labour is an important and indispensable contributor to the involuntary expulsive force developed by uterus contraction. Currently, there is no consensus on an ideal strategy to facilitate these expulsive efforts and there are contradictory results about the influence on mother and fetus. To evaluate the benefits and possible disadvantages of different kinds of techniques regarding maternal pushing/breathing during the expulsive stage of labour on maternal and fetal outcomes. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (28 January 2015) and reference lists of retrieved studies. Randomised and quasi-randomised assessing the effects of pushing/bearing down techniques (type and/or timing) performed during the second stage of labour on maternal and neonatal outcomes. Cluster-RCTs were eligible for inclusion but none were identified. Studies using a cross-over design and those published in abstract form only were not eligible for inclusion.We considered the following comparisons.Timing of pushing: to compare pushing, which begins as soon as full dilatation has been determined versus pushing which begins after the urge to push is felt.Type of pushing: to compare pushing techniques that involve the 'Valsalva Manoeuvre' versus all other pushing techniques. Two review authors independently assessed trials for inclusion and risk of bias. Two review authors independently extracted data. Data were checked for accuracy. We included 20 studies in total, seven studies (815 women) comparing spontaneous pushing versus directed pushing, with or without epidural analgesia and 13 studies (2879 women) comparing delayed pushing versus immediate pushing with epidural analgesia. The results come from studies with a high or unclear risk of bias, especially selection bias and selective reporting bias. Comparison 1: types of pushing: spontaneous pushing versus directed pushingOverall, for this comparison there was no difference in the duration of the second stage (mean difference (MD) 11.60 minutes; 95% confidence interval (CI) -4.37 to 27.57, five studies, 598 women, random-effects, I(2): 82%; T(2): 220.06). There was no clear difference in perineal laceration (risk ratio (RR) 0.87; 95% CI 0.45 to 1.66, one study, 320 women) and episiotomy (average RR 1.05 ; 95% CI 0.60 to 1.85, two studies, 420 women, random-effects, I(2) = 81%; T(2) = 0.14). The primary neonatal outcomes such as five-minute Apgar score less than seven was no different between groups (RR 0.35; 95% CI 0.01 to 8.43, one study, 320 infants), and the number of admissions to neonatal intensive care (RR 1.08; 95% CI 0.30 to 3.79, two studies, n = 393) also showed no difference between spontaneous and directed pushing and no data were available on hypoxic ischaemic encephalopathy.The duration of pushing (secondary maternal outcome) was five minutes less for the spontaneous group (MD -5.20 minutes; 95% CI -7.78 to -2.62, one study, 100 women). Comparison 2: timing of pushing: delayed pushing versus immediate pushing (all women with epidural)For the primary maternal outcomes, delayed pushing was associated with an increase of 54 minutes in the duration of the second stage of labour (MD 54.29 minutes; 95% CI 38.14 to 70.43; 10 studies, 2797 women, random-effects; I(2) = 91%; T(2) = 543.38), and there was no difference in perineal laceration (RR 0.94; 95% CI 0.78 to 1.14, seven studies. 2775 women) and episiotomy (RR 0.95; 95% CI 0.87 to 1.04, five studies, 2320 women). Delayed pushing was also associated with a 20-minute decrease in the duration of pushing (MD - 20.10; 95% CI -36.19 to -4.02, 10 studies, 2680 women, random-effects, I(2) = 96%; T(2) = 604.37) and an increase in spontaneous vaginal delivery (RR 1.07; 95% CI 1.03 to 1.11, 12 studies, 3114 women).For the primary neonatal outcomes, there was no difference between groups in admission to neonatal intensive care (RR 0.98; 95% CI 0.67 to 1.41, three studies, n = 2197) and five-minute Apgar score less than seven (RR 0.15; 95% CI 0.01 to 3.00, three studies, n = 413). There were no data on hypoxic ischaemic encephalopathy. Delayed pushing was associated with a greater incidence of low umbilical cord blood pH (RR 2.24; 95% CI 1.37 to 3.68) and increased the cost of intrapartum care by CDN$ 68.22 (MD 68.22, 95% CI 55.37, 81.07, one study, 1862 women). This review is based on a total of 20 included studies that were of a mixed methodological quality.Timing of pushing with epidural is consistent in that delayed pushing leads to a shortening of the actual time pushing and increase of spontaneous vaginal delivery at the expense of an overall longer duration of the second stage of labour and double the risk of a low umbilical cord pH (based only on one study). Nevertheless, there was no difference in the caesarean and instrumental deliveries, perineal laceration and episiotomy, and in the other neonatal outcomes (admission to neonatal intensive care, five-minute Apgar score less than seven and delivery room resuscitation) between delayed and immediate pushing. Futhermore, the adverse effects on maternal pelvic floor is still unclear.Therefore, there is insufficient evidence to justify routine use of any specific timing of pushing since the maternal and neonatal benefits and adverse effects of delayed and immediate pushing are not well established.For the type of pushing, with or without epidural, there is no conclusive evidence to support or refute any specific style or recommendation as part of routine clinical practice. Women should be encouraged to bear down based on their preferences and comfort.In the absence of strong evidence supporting a specific method or timing of pushing, patient preference and clinical situations should guide decisions.Further properly well-designed randomised controlled trials are required to add evidence-based information to the current knowledge. These trials should address clinically important maternal and neonatal outcomes and will provide more complete data to be incorporated into a future update of this review.

Perineal techniques during the second stage of labour for reducing perineal trauma.

PubMed

Aasheim, Vigdis; Nilsen, Anne Britt Vika; Lukasse, Mirjam; Reinar, Liv Merete

2011-12-07

Most vaginal births are associated with some form of trauma to the genital tract. The morbidity associated with perineal trauma is significant, especially when it comes to third- and fourth-degree tears. Different perineal techniques and interventions are being used to prevent perineal trauma. These interventions include perineal massage, warm compresses and perineal management techniques. The objective of this review was to assess the effect of perineal techniques during the second stage of labour on the incidence of perineal trauma. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 May 2011), the Cochrane Central Register of ControlledTrials (The Cochrane Library 2011, Issue 2 of 4), MEDLINE (January 1966 to 20 May 2011) and CINAHL (January 1983 to 20 May 2011). Published and unpublished randomised and quasi-randomised controlled trials evaluating any described perineal techniques during the second stage. Three review authors independently assessed trails for inclusion, extracted data and evaluated methodological quality. Data were checked for accuracy. We included eight trials involving 11,651 randomised women. There was a significant effect of warm compresses on reduction of third- and fourth-degree tears (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.28 to 0.84 (two studies, 1525 women)). There was also a significant effect towards favouring massage versus hands off to reduce third- and fourth-degree tears (RR 0.52, 95% CI 0.29 to 0.94 (two studies, 2147 women)). Hands off (or poised) versus hand on showed no effect on third- and fourth-degree tears, but we observed a significant effect of hands off on reduced rate of episiotomy (RR 0.69, 95% CI 0.50 to 0.96 (two studies, 6547 women)). The use of warm compresses on the perineum is associated with a decreased occurrence of perineal trauma. The procedure has shown to be acceptable to women and midwives. This procedure may therefore be offered to women.

Labor and delivery service use: indigenous women's preference and the health sector response in the Chiapas Highlands of Mexico.

PubMed

Ibáñez-Cuevas, Midiam; Heredia-Pi, Ileana B; Meneses-Navarro, Sergio; Pelcastre-Villafuerte, Blanca; González-Block, Miguel A

2015-12-23

Mexico has undertaken important efforts to decrease maternal mortality. Health authorities have introduced intercultural innovations to address barriersfaced by indigenous women accessing professional maternal and delivery services. This study examines, from the perspective of indigenous women, the barriers andfacilitators of labor and delivery care services in a context of intercultural and allopathic innovations. This is an exploratory study using a qualitative approach of discourse analysis with grounded theory techniques. Twenty-five semi-structured interviews were undertaken with users and non-users of the labor and delivery services, as well as with traditional birth attendants (TBAs) in San Andrés Larráinzar, Chiapas in 2012. The interviewees identified barriers in the availability of medical personnel and restrictive hours for health services. Additionally, they referred to barriers to access (economic, geographic, linguistic and cultural) to health services, as well as invasive and offensive hospital practices enacted by health system personnel, which limited the quality of care they can provide. Traditional birth attendants participating in intercultural settings expressed the lack of autonomy and exclusion they experience by hospital personnel, as a result of not being considered part of the care team. As facilitators, users point to the importance of having their traditional birth attendants and families present during childbirth, to allow them to use their clothing during the attention, that the staff of health care is of the female sex and speaking the language of the community. As limiting condition users referred the different medical maneuvers practiced in the attention of the delivery (vaginal examination, episiotomy, administration of oxytocin, etc.). Evidence from the study suggests the presence of important barriers to the utilization of institutional labor and delivery services in indigenous communities, in spite of the intercultural strategies implemented. It is important to consider strengthening intercultural models of care, to sensitize personnel towards cultural needs, beliefs, practices and preferences of indigenous women, with a focus on human rights, gender equity and quality of care.

Filled Prescriptions for Opioids After Vaginal Delivery.

PubMed

Jarlenski, Marian; Bodnar, Lisa M; Kim, Joo Yeon; Donohue, Julie; Krans, Elizabeth E; Bogen, Debra L

2017-03-01

To estimate the prevalence of filled opioid prescriptions after vaginal delivery. We conducted a retrospective cohort study of 164,720 Medicaid-enrolled women in Pennsylvania who delivered a liveborn neonate vaginally from 2008 to 2013, excluding women who used opioids during pregnancy or who had an opioid use disorder. We assessed overall filled prescriptions as well as filled prescriptions in the presence or absence of the following pain-inducing conditions: bilateral tubal ligation, perineal laceration, or episiotomy. Outcomes included a binary measure of whether a woman had any opioid prescription fill 5 days or less after delivery and, among those women, a second opioid prescription fill 6-60 days after delivery. Among women with no coded pain-inducing conditions at delivery, we used multivariable logistic regression with standard errors clustered to account for within-hospital correlation to assess the association between patient characteristics and odds of a filled opioid prescription. Twelve percent of women (n=18,131) filled an outpatient opioid prescription 5 days or less after vaginal delivery; among those women, 14% (n=2,592, or 1.6% of the total) filled a second opioid prescription 6-60 days after delivery. Of the former, 5,110 (28.2%) had one or more pain-inducing conditions. Predictors of filled opioid prescriptions with no observed pain-inducing condition at delivery included tobacco use (adjusted odds ratio [OR] 1.3, 95% confidence interval [CI] 1.2-1.4) and a mental health condition (adjusted OR 1.3, 95% CI 1.2-1.4). Having a diagnosis of substance use disorder other than opioid use disorder was not associated with filling an opioid prescription 5 days or less after delivery, but was associated with having a second opioid prescription 6-60 days after delivery (adjusted OR 1.4, 95% CI 1.2-1.6). More than 1 in 10 Medicaid-enrolled women fill an outpatient opioid prescription after vaginal delivery. National opioid-prescribing recommendations for common obstetrics procedures such as vaginal delivery are warranted.

Rates of interventions in labor and birth across Canada: findings of the Canadian Maternity Experiences Survey.

PubMed

Chalmers, Beverley; Kaczorowski, Janusz; O'Brien, Beverley; Royle, Cathie

2012-09-01

Rates of interventions in labor and birth should be similar across a country if evidence-based practice guidelines are followed. This assumption is tested by comparison of some practices across the 13 provinces and territories of Canada. The objective of this study was to describe the wide provincial and territorial variations in rates of routine interventions and practices during labor and birth as reported by women in the Maternity Experiences Survey of the Canadian Perinatal Surveillance System. A sample of 8,244 eligible women was identified from a randomly selected sample of recently born infants drawn from the May 2006 Canadian Census. The sample was stratified by province and territory. Computer-assisted telephone interviews were conducted with participating birth mothers by Statistics Canada on behalf of the Public Health Agency of Canada. Interviews took an average of 45 minutes and were completed when infants were between 5 and 10 months old (9-14 mo in the territories). Completed responses were obtained from 6,421 women (78%). Provincial and territorial variations in rates of routine intervention used during labor and birth are reported. The percentage range of mothers' experience of induction (range 30.9%), epidural (53.7%), continuous electronic fetal monitoring (37.9%), and medication-free pain management during labor (40.7%) are provided, in addition to the use of episiotomy (14.1%) or "stitches" (48.3%), being in a "flat lying position" (42.2%), and having their legs in stirrups for birth (35.7%). Wide variations in the use of most of the interventions were found, ranging from 14.1 percent to 53.7 percent. Rates of intervention in labor and birth showed considerable variation across Canada, suggesting that usage is not always evidence based but may be influenced by a variety of other factors. © 2012, Copyright the Authors Journal compilation © 2012, Wiley Periodicals, Inc.

No reduction in instrumental vaginal births and no increased risk for adverse perineal outcome in nulliparous women giving birth on a birth seat: results of a Swedish randomized controlled trial

PubMed Central

2011-01-01

Background The WHO advises against recumbent or supine position for longer periods during labour and birth and states that caregivers should encourage and support the woman to take the position in which she feels most comfortable. It has been suggested that upright positions may improve childbirth outcomes and reduce the risk for instrumental delivery; however RCTs of interventions to encourage upright positions are scarce. The aim of this study was to test, by means of a randomized controlled trial, the hypothesis that the use of a birthing seat during the second stage of labor, for healthy nulliparous women, decreases the number of instrumentally assisted births and may thus counterbalance any increase in perineal trauma and blood loss. Methods A randomized controlled trial in Sweden where 1002 women were randomized to birth on a birth seat (experimental group) or birth in any other position (control group). Data were collected between November 2006 and July 2009. The primary outcome measurement was the number of instrumental deliveries. Secondary outcome measurements included perineal lacerations, perineal edema, maternal blood loss and hemoglobin. Analysis was by intention to treat. Results The main findings of this study were that birth on the birth seat did not reduce the number of instrumental vaginal births, there was an increase in blood loss between 500 ml and 1000 ml in women who gave birth on the seat but no increase in bleeding over 1000 ml and no increase in perineal lacerations or perineal edema. Conclusions The birth seat did not reduce the number of instrumental vaginal births. The study confirmed an increased blood loss 500 ml - 1000 ml but not over 1000 ml for women giving birth on the seat. Giving birth on a birth seat caused no adverse consequences for perineal outcomes and may even be protective against episiotomies. Trial registration number ClinicalTrials.gov.ID: NCT01182038 PMID:21435238

Risk of obstetric anal sphincter injury increases with maternal age irrespective of parity: a population-based register study.

PubMed

Waldenström, Ulla; Ekéus, Cecilia

2017-09-15

Obstetric anal sphincter injury (OASI) is a rare but serious outcome of vaginal birth. Based on concerns about the increasing number of women who commence childbearing later than previous generation, this study aimed at investigating age-related risk of OASI in women of different parity. A population-based register study including 959,559 live singleton vaginal births recorded in the Swedish Medical Birth Register 1999 to 2011. In each parity group risks of OASI at age 25-29 years, 30-34 years, and ≥35 years compared with age < 25 years were investigated by logistic regression analyses, adjusted for year of birth, education, region of birth, smoking, Body Mass Index, infant birthweight and fetal presentation; and in parous women, history of OASI and cesarean section. Additional analyses also adjusted for mediating factors, such as epidural analgesia, episiotomy, and instrumental delivery, and maternal age-related morbidity. Rates of OASI were 6.6%, 2.3% and 0.9% in first, second and third births respectively. Age-related risk increased from 25-29 years in first births (Adjusted OR 1.66; 95% CI 1.59-1.72) and second births (Adjusted OR 1.78; 95% CI 1.58-2.01), and from 30-34 years in third births (Adjusted OR 1.60; 95% CI 1.00-2.56). In all parity groups the risk was doubled at age ≥ 35 years, compared with the respective reference group of women under 25 years. Adding mediating factors and maternal age-related morbidity only marginally reduced these risk estimates. Maternal age is an independent risk factor for OASI in first, second and third births. Although age-related risks by parity are relatively similar, more nulliparous than parous women will be exposed to OASI due to the higher baseline rate.

The Sexual Function Questionnaire's Medical Impact Scale (SFQ-MIS): validation among a sample of first-time mothers.

PubMed

Jawed-Wessel, Sofia; Schick, Vanessa; Herbenick, Debby

2013-11-01

Changes in sexual function can be difficult to capture, especially when an attempt is made to assess the effects of pregnancy or childbirth on the sexual function of first-time mothers. Commonly used sexual function measures are limited and fail to account for pregnancy or birth in assessment of function. The purpose of this study was to explore the utility of the Sexual Function Questionnaire Medical Impact Scale (SFQ-MIS) in assessing impact of childbirth on sexual function among first-time mothers with infants aged one year or younger. A total of 255 women completed a cross-sectional, web-based survey. Exploratory factor analysis was utilized to assess the factor structure of the SFQ-MIS scores in this sample. Variations in SFQ-MIS scores based upon participant characteristics were conducted to further evaluate the SFQ-MIS scores. SFQ-MIS score was the primary measure of interest. Factors related to pregnancy and childbirth, such as mode of delivery, infant date of birth, last menstrual period, need for an episiotomy or perineal stitches, breastfeeding status, and score on the Perceived Stress Scale, were also assessed in order to further evaluate the validity and predictive capacity of the SFQ-MIS. Results indicated one factor that accounted for 58.27% of the variance in impact on sexual function due to childbirth. Cronbach's α coefficient for all five items was acceptable (0.82). Women who were breastfeeding (P<0.05), those who had received perineal stitches after a vaginal delivery (P<0.05), and those who reported no sexual activity in the past month (P < 0.001) experienced significantly greater impact than those who were not breastfeeding, those who had not required stitches, and those who had been sexually active in the past month. The SFQ-MIS appears to be a useful and valid indicator of changes in sexual function following childbirth, such as those related to arousal, desire, and orgasm. © 2013 International Society for Sexual Medicine.

Effect of fetal position on second-stage duration and labor outcome.

PubMed

Senécal, Julie; Xiong, Xu; Fraser, William D

2005-04-01

To evaluate the effect of fetal position on 1) second-stage labor duration and 2) indicators of maternal and neonatal morbidity. A retrospective cohort study was conducted using a database from a previously reported randomized clinical trial. The data set includes 210 women with the fetus in a posterior position, 200 women with the fetus in a transverse position, and 1,198 women with the fetus in an anterior position. Mean durations of the second stage of labor for different fetal positions were compared using Tukey studentized test. A multivariate logistic regression model was performed to examine the determinants of prolonged second-stage duration (>or= 3 hours). Kaplan-Meier survival curves were used to graph and compare the duration of the second stage of labor for spontaneous delivery according to the fetal position at full dilatation and study group. Fetal malposition at full dilatation was associated with a significantly increased risk of instrumental vaginal delivery, cesarean delivery, oxytocin administration before full cervical dilatation, episiotomy, severe perineal laceration, and maternal blood loss of more than 500 mL (all P values < .01). Compared with the occiput anterior positions, there were significant differences in the duration of the second stage of labor, with a mean of 3.1 hours (95% confidence interval [CI] 3.0-3.2) for occiput anterior positions, 3.6 hours (95% CI 3.3-3.9) for occiput transverse positions (P < .05), and 3.8 hours (95% CI 3.5-4.1) for occiput posterior positions (P < .05) in the delayed pushing group. For the early pushing group, means were 2.2 hours (95% CI 2.1-2.3) for occiput anterior positions, 2.5 hours (95% CI 2.3-2.8) for occiput transverse positions (P < .05), and 3.0 hours (95% CI 2.7-3.3) for occiput posterior positions (P < .05). Fetal malposition at full dilatation results in a higher risk of prolonged second stage of labor and increases maternal morbidity indicators. II-2.

Perineal Pain Management with Cryotherapy after Vaginal Delivery: A Randomized Clinical Trial.

PubMed

Morais, Ítalo; Lemos, Andréa; Katz, Leila; Melo, Lorena Fernandes Rosendo de; Maciel, Mariano Maia; Amorim, Melania Maria Ramos de

2016-07-01

Introduction Systematic reviews that evaluate the perineal cryotherapy to reduce pain in the vaginal postpartum are inconclusive. Purpose To evaluate clinical effectiveness of cryotherapy in the management of humanized postpartum perineal pain and vaginal edema. Methods A double-bind randomized controlled clinical trial (UTN number: U1111-1131-8433) was conducted in a hospital in Northeastern, Brazil. Women were included following humanized childbirth. All had vaginal deliveries of a single, full-term pregnancy with cephalic presentation. Exclusion criteria included previous perineal lesion, episiotomy during the current delivery, instrumental delivery, uterine curettage and postpartum hemorrhage. In the experimental group, an ice pack was applied six times on the perineum for 20 minutes, reducing the temperature between 10 and 15 ° C, then 60 minutes without exposure to cold. In the non-cryotherapy, a water bag unable to reduce the temperature to this extent was used, compliance with the same application protocol of the first group. Perineal temperature was monitored at zero, 10 and 20 minutes for application in both groups. Evaluations were made immediately before and after the applications and 24 hours after delivery spontaneous, to determine the association between variables. Results A total of 80 women were included in the study, 40 in each group. There was no significant difference in scores of perineal pain and edema between the groups with or without cryotherapy until 24 hours after childbirth. There was no difference between groups when accomplished repeated measures analysis over the 24 hours after delivery, considering the median perineal pain (p = 0.3) and edema (p = 0.9). Perineal cryotherapy did not influence the amount of analgesics used (p = 0.07) and no adverse effect was registered. Conclusion The use of cryotherapy following normal vaginal delivery within the concept of humanized minimally interventionist childbirth had no effect on perineal pain and edema, since it was already substantially lower, nor the need for pain medicaments. Thieme Publicações Ltda Rio de Janeiro, Brazil.

Informal cash payments for birth in Hungary: Are women paying to secure a known provider, respect, or quality of care?

PubMed

Baji, Petra; Rubashkin, Nicholas; Szebik, Imre; Stoll, Kathrin; Vedam, Saraswathi

2017-09-01

In Central and Eastern Europe, many women make informal cash payments to ensure continuity of provider, i.e., to have a "chosen" doctor who provided their prenatal care, be present for birth. High rates of obstetric interventions and disrespectful maternity care are also common to the region. No previous study has examined the associations among informal payments, intervention rates, and quality of maternity care. We distributed an online cross-sectional survey in 2014 to a nationally representative sample of Hungarian internet-using women (N = 600) who had given birth in the last 5 years. The survey included items related to socio-demographics, type of provider, obstetric interventions, and experiences of care. Women reported if they paid informally, and how much. We built a two-part model, where a bivariate probit model was used to estimate conditional probabilities of women paying informally, and a GLM model to explore the amount of payments. We calculated marginal effects of the covariates (provider choice, interventions, respectful care). Many more women (79%) with a chosen doctor paid informally (191 euros on average) compared to 17% of women without a chosen doctor (86 euros). Based on regression analysis, the chosen doctor's presence at birth was the principal determinant of payment. Intervention and procedure rates were significantly higher for women with a chosen doctor versus without (cesareans 45% vs. 33%; inductions 32% vs. 19%; episiotomy 75% vs. 62%; epidural 13% vs. 5%), but had no direct effect on payments. Half of the sample (42% with a chosen doctor, 62% without) reported some form of disrespectful care, but this did not reduce payments. Despite reporting disrespect and higher rates of interventions, women rewarded the presence of a chosen doctor with informal payments. They may be unaware of evidence-based standards, and trust that their chosen doctor provided high quality maternity care. Copyright © 2017 Elsevier Ltd. All rights reserved.

Variations in childbirth interventions in high-income countries: protocol for a multinational cross-sectional study

PubMed Central

van den Akker, Thomas; Beeckman, Katrien; Bogaerts, Annick; Barros, Monalisa; Janssen, Patricia; Binfa, Lorena; Rydahl, Eva; Frith, Lucy; Gross, Mechthild; Hálfdánsdóttir, Berglind; Daly, Deirdre; Calleja-Agius, Jean; Gillen, Patricia; Vika Nilsen, Anne Britt; Declercq, Eugene

2018-01-01

Introduction There are growing concerns about the increase in rates of commonly used childbirth interventions. When indicated, childbirth interventions are crucial for preventing maternal and perinatal morbidity and mortality, but their routine use in healthy women and children leads to avoidable maternal and neonatal harm. Establishing ideal rates of interventions can be challenging. This study aims to describe the range of variations in the use of commonly used childbirth interventions in high-income countries around the world, and in outcomes in nulliparous and multiparous women. Methods and analysis This multinational cross-sectional study will use data from births in 2013 with national population data or representative samples of the population of pregnant women in high-income countries. Data from women who gave birth to a single child from 37 weeks gestation onwards will be included and the results will be presented for nulliparous and multiparous women separately. Anonymised individual level data will be analysed. Primary outcomes are rates of commonly used childbirth interventions, including induction and/or augmentation of labour, intrapartum antibiotics, epidural and pharmacological pain relief, episiotomy in vaginal births, instrument-assisted birth (vacuum or forceps), caesarean section and use of oxytocin postpartum. Secondary outcomes are maternal and perinatal mortality, Apgar score below 7 at 5 min, postpartum haemorrhage and obstetric anal sphincter injury. Univariable and multivariable logistic regression analyses will be conducted to investigate variations among countries, adjusted for maternal age, body mass index, gestational weight gain, ethnic background, socioeconomic status and infant birth weight. The overall mean rates will be considered as a reference category, weighted for the size of the study population per country. Ethics and dissemination The Medical Ethics Review Committee of VU University Medical Center Amsterdam confirmed that an official approval of this study was not required. Results will be disseminated at national and international conferences and published in peer-reviewed journals. PMID:29326182

Clinical impact of the disposable ventouse iCup® versus a metallic vacuum cup: a multicenter randomized controlled trial.

PubMed

Equy, Véronique; David-Tchouda, Sandra; Dreyfus, Michel; Riethmuller, Didier; Vendittelli, Françoise; Cabaud, Victoire; Langer, Bruno; Margier, Jennifer; Bosson, Jean-Luc; Schaal, Jean-Patrick

2015-12-15

Assisted vaginal delivery by vacuum extraction is frequent. Metallic resterilizible metallic vacuum cups have been routinely used in France. In the last few years a new disposable semi-soft vacuum extraction cup, the iCup, has been introduced. Our objective was to compare maternal and new-born outcomes between this disposable cup and the commonly used Drapier-Faure metallic cup. This was a multicenter prospective randomized controlled open clinical trial performed in the maternity units of five university hospitals and one community hospital in France from October 2009 to February 2013. We included consecutive eligible women with a singleton gestation of at least 37 weeks who required vacuum assisted delivery. Women were randomized to vacuum extraction using the iCup or usual Drapier-Faure metallic cup. The primary outcome was a composite criterion including both the risk of cup dysfunction and the most frequent maternal and neonatal harms: the use of other instruments after attempted vacuum extraction, caesarean section after attempted vacuum extraction, three detachments of the cup, caput succedaneum, cephalohaematoma, episiotomy and perineal tears. 335 women were randomized to the disposable cup and 333 to extraction using the metallic cup. There was no significant difference between the two groups for the primary outcome. However, failed instrumental delivery was more frequent in the disposable cup group, mainly due to detachment: 35.6 % vs 7.1 %, p < 0.0001. Conversely, perineal tears were more frequent in the metallic cup group, especially third or fourth grade perineal tears: 1.7 % versus 5.0 %, p = 0.003. There were no significant differences between the two groups concerning post-partum haemorrhage, transfer to a neonatal intensive care unit (NICU) or serious adverse events. While the disposable cup had more detachments and extraction failures than the standard metallic cup, this innovative disposable device had the advantage of fewer perineal injuries. www.clinicaltrials.gov : NCT01058200 on Jan. 27 2010.

Effect of vaginal delivery on anal sphincter function in Asian primigravida: a prospective study.

PubMed

Wickramasinghe, Dakshitha Praneeth; Senaratne, Supun; Senanayake, Hemantha; Samarasekera, Dharmabandhu Nandadeva

2016-09-01

The true incidence of obstetric anal sphincter injuries (OASI) among Asian primigravida is not known. This study aimed to evaluate OASI in Sri Lankan primigravida. One hundred and one consecutive primigravida in their last trimester were recruited from antenatal clinics at a tertiary care centre in Sri Lanka and followed up 6 weeks and 6 months after delivery. They were assessed using anorectal manometry (3D-ARM) and endoanal ultrasound (3D-EAUS) on both occasions. Seventy-three (75.3 %) had vaginal delivery without instrumentation, whereas 3 (3.1 %) each delivered using forceps or vacuum. Twelve (12.4 %) had emergency caesarean sections and 6 (6.2 %) had elective caesarean sections. None had clinically identified anal sphincter injuries. EAUS identified IAS defects in 3 (5.1 %) and EAS defects in 28 (47.5 %). Both resting (p = 0.3) and squeeze (p = 0.001) pressures had decreased following childbirth. Multivariate analysis identified antepartum RP and postpartum EAS defects to be associated with RP reduction (χ(2)(4)=17.825, p < 0.0005) and antepartum SP and postpartum EAS defects to be associated with SP reduction (χ(2)(5)=31.517, p < 0.0005). Episiotomy was protective, whereas delivering after 40 weeks' gestation and delivering a baby with a longer length increased the risk of SP reduction. EAS defects (χ(2) (6)=23.502, p = .001) were more common in mothers who had labour augmented by oxytocin and in those who delivered a baby with a larger head circumference. Labour induction and delivering a longer baby were protective for EAS defects. Several risk and protective factors for the structural and functional damage of sphincters were identified. These findings will help to formulate a policy to minimize future obstetric anal sphincter injuries.

Childbirth care practices in public sector facilities in Jeddah, Saudi Arabia: a descriptive study.

PubMed

Altaweli, Roa F; McCourt, Christine; Baron, Maurina

2014-07-01

to explore reported hospital policies and practices during normal childbirth in maternity wards in Jeddah, Saudi Arabia, to assess and verify whether these practices are evidence-based. quantitative design, in the form of a descriptive questionnaire, based on a tool extracted from the literature. nine government hospitals in Jeddah, Saudi Arabia. These hospitals have varied ownership, including Ministry of Health (MOH), military, teaching and other government hospitals. key individuals responsible for the day-to-day running of the maternity ward. nine interviews using descriptive structured questionnaire were conducted. Data were analysed using SPSS for Windows (version 16.0). the surveyed hospitals were found to be well equipped to deal with obstetric emergencies, and many follow evidence-based procedures. On average, the caesarean section rate was found to be 22.4%, but with considerable variances between hospitals. Some unnecessary procedures that are known to be ineffective or harmful and that are not recommended for routine use, including pubic shaving, enemas, episiotomy, electronic fetal monitoring (EFM) and intravenous (IV) infusion, were found to be frequently practiced. Only 22% of the hospitals sampled reported allowing a companion to attend labour and childbirth. many aspects of recommended EBP were used in the hospitals studied. However, the results of this study clearly indicate that there is wide variation between hospitals in Jeddah, Saudi Arabia in some obstetric practices. Furthermore, the findings suggest that some practices at these hospitals are not supported by evidence as being beneficial for mothers or infants and are positively discouraged under international guidelines. this study has specific implications for obstetricians, midwives and nurses working in maternity units. It gives an overview of current hospital policies and practices during normal childbirth. It is likely to contribute to improving the health and well-being of women, and have implications for service provision. It could also help in the development of technical information for policy-makers, and health care professionals for normal childbirth care. Copyright © 2014 Elsevier Ltd. All rights reserved.

Effects of continuity of care by a primary midwife (caseload midwifery) on caesarean section rates in women of low obstetric risk: the COSMOS randomised controlled trial.

PubMed

McLachlan, H L; Forster, D A; Davey, M A; Farrell, T; Gold, L; Biro, M A; Albers, L; Flood, M; Oats, J; Waldenström, U

2012-11-01

To determine whether primary midwife care (caseload midwifery) decreases the caesarean section rate compared with standard maternity care. Randomised controlled trial. Tertiary-care women's hospital in Melbourne, Australia. A total of 2314 low-risk pregnant women. Women randomised to caseload received antenatal, intrapartum and postpartum care from a primary midwife with some care by 'back-up' midwives. Women randomised to standard care received either midwifery or obstetric-trainee care with varying levels of continuity, or community-based general practitioner care. caesarean birth. Secondary outcomes included instrumental vaginal births, analgesia, perineal trauma, induction of labour, infant admission to special/neonatal intensive care, gestational age, Apgar scores and birthweight. In total 2314 women were randomised-1156 to caseload and 1158 to standard care. Women allocated to caseload were less likely to have a caesarean section (19.4% versus 24.9%; risk ratio [RR] 0.78; 95% CI 0.67-0.91; P = 0.001); more likely to have a spontaneous vaginal birth (63.0% versus 55.7%; RR 1.13; 95% CI 1.06-1.21; P < 0.001); less likely to have epidural analgesia (30.5% versus 34.6%; RR 0.88; 95% CI 0.79-0.996; P = 0.04) and less likely to have an episiotomy (23.1% versus 29.4%; RR 0.79; 95% CI 0.67-0.92; P = 0.003). Infants of women allocated to caseload were less likely to be admitted to special or neonatal intensive care (4.0% versus 6.4%; RR 0.63; 95% CI 0.44-0.90; P = 0.01). No infant outcomes favoured standard care. In settings with a relatively high baseline caesarean section rate, caseload midwifery for women at low obstetric risk in early pregnancy shows promise for reducing caesarean births. © 2012 The Authors BJOG An International Journal of Obstetrics and Gynaecology © 2012 RCOG.

Evidence from community level inputs to improve quality of care for maternal and newborn health: interventions and findings

PubMed Central

2014-01-01

Annually around 40 million mothers give birth at home without any trained health worker. Consequently, most of the maternal and neonatal mortalities occur at the community level due to lack of good quality care during labour and birth. Interventions delivered at the community level have not only been advocated to improve access and coverage of essential interventions but also to reduce the existing disparities and reaching the hard to reach. In this paper, we have reviewed the effectiveness of care delivered through community level inputs for improving maternal and newborn health outcomes. We considered all available systematic reviews published before May 2013 on the pre-defined community level interventions and report findings from 43 systematic reviews. Findings suggest that home visitation significantly improved antenatal care, tetanus immunization coverage, referral and early initiation of breast feeding with reductions in antenatal hospital admission, cesarean-section rates birth, maternal morbidity, neonatal mortality and perinatal mortality. Task shifting to midwives and community health workers has shown to significantly improve immunization uptake and breast feeding initiation with reductions in antenatal hospitalization, episiotomy, instrumental delivery and hospital stay. Training of traditional birth attendants as a part of community based intervention package has significant impact on referrals, early breast feeding, maternal morbidity, neonatal mortality, and perinatal mortality. Formation of community based support groups decreased maternal morbidity, neonatal mortality, perinatal mortality with improved referrals and early breast feeding rates. At community level, home visitation, community mobilization and training of community health workers and traditional birth attendants have the maximum potential to improve a range of maternal and newborn health outcomes. There is lack of data to establish effectiveness of outreach services, mass media campaigns and community education as standalone interventions. Future efforts should be concerted on increasing the availability and training of the community based skilled health workers especially in resource limited settings where the highest burden exists with limited resources to mobilize. PMID:25209692

Productivity cost due to postpartum ill health: A cross-sectional study in Sri Lanka

PubMed Central

Horton, Jennifer; Darshika, Ishani; Galgamuwa, Kaushila Dinithi; Ranasinghe, Wasantha Pradeep; Agampodi, Thilini Chanchala; Agampodi, Suneth Buddhika

2017-01-01

Objective Even though postpartum morbidity continues to cause high disease burden in maternal morbidity and mortality across the globe, the literature pertaining to resultant productivity loss is scarce. Hence, the present study aimed at determining the productivity loss and associated cost of episodes of postpartum ill health. Methods A cross sectional study was conducted in two Medical Officer of Heath areas in the Anuradhapura district, Sri Lanka in 2011, among 407 women residing in Anuradhapura district with an infant aged between 8 to 24 weeks. Validated interviewer administered questionnaires, including the IMMPACT productivity cost tool, were used to collect data on self-reported episodes of postpartum ill health. The productivity loss was calculated as the sum of days lost due to partial and total incapacitation. The adjusted productivity loss for coping strategies was calculated. Productivity cost, both total and adjusted, were calculated based on the mean daily per capita income of the study sample. Results Of the 407 participants, 161(39.6%) reported at least one episode of postpartum illness. Hospitalisations were reported by 27 (16.8%) of all symptomatic postpartum women. Common symptoms of postpartum ill health were pain/infection at either episiotomy or surgical site (n = 44, 27.3%), lower abdominal pain (n = 40, 24.8%) and backache (n = 27, 16.8%). The mean productivity loss per episode of ill health was 15 days (SD = 7.8 days) and the mean productivity loss per episode after adjusting for coping strategies was 7.9 days (SD = 4.4 days). The mean productivity cost per an episode was US$ 34.2(95%CI US$ 26.7–41.6) and the mean productivity cost per an episode after adjusting for coping strategies was US$ 18.0 (95%CI US$ 14.1–22.0) Conclusions The prevalence of self-reported postpartum ill health, associated productivity loss and cost were high in the study sample and the main contributors were preventable conditions including pain and infection. Thus, effective pain management and proper infection prevention and control measures are important in reducing the burden of postpartum illness and resultant productivity cost. PMID:29020101

Measuring progress in maternal and newborn health care in Mexico: validating indicators of health system contact and quality of care.

PubMed

Blanc, Ann K; Diaz, Claudia; McCarthy, Katharine J; Berdichevsky, Karla

2016-08-30

The majority of births in Mexico take place in a health facility and are attended by a skilled birth attendant, yet maternal mortality has not declined to anticipated levels. Coverage estimates of skilled attendance and other maternal and newborn interventions often rely on women's self-report through a population-based survey, the accuracy of which is not well established. We used a facility-based design to validate women's report of skilled birth attendance, as well as other key elements of maternal, newborn intrapartum, and immediate postnatal care. Women's reports of labor and delivery care were collected by exit interview prior to hospital discharge and were compared against direct observation by a trained third party in a Mexican public hospital (n = 597). For each indicator, validity was assessed at the individual level using the area under the receiver operating curve (AUC) and at the population level using the inflation factor (IF). Five of 47 indicators met both validation criteria (AUC > 0.60 and 0.75 < IF < 1.25): urine sample screen, injection or IV medication received during labor, before the birth of the baby (i.e., uterotonic for either induction or augmentation of labor), episiotomy, excessive bleeding, and receipt of blood products. An additional 9 indicators met criteria for the AUC and 18 met criteria for the IF. A skilled attendant indicator had high sensitivity (90.1 %: 95 % CI: 87.1-92.5 %), low specificity (14.0 %: 95 % CI: 5.8-26.7 %) and was suitable for population-level estimation only. Women are able to give valid reports on some aspects of the content of care, although questions regarding the indication for interventions are less likely to be known. Questions that include technical terms or refer to specific time periods tended to have lower response levels. A key aspect of efforts to improve maternal and newborn health requires valid measurement of women's access to maternal and newborn health interventions and the quality of such services. Additional work on improving measurement of population coverage indicators is warranted.

Comparison of midwife-led and consultant-led care of healthy women at low risk of childbirth complications in the Republic of Ireland: a randomised trial

PubMed Central

2011-01-01

Background No midwifery-led units existed in Ireland before 2004. The aim of this study was to compare midwife-led (MLU) versus consultant-led (CLU) care for healthy, pregnant women without risk factors for labour and delivery. Methods An unblinded, pragmatic randomised trial was designed, funded by the Health Service Executive (Dublin North-East). Following ethical approval, all women booking prior to 24 weeks of pregnancy at two maternity hospitals with 1,300-3,200 births annually in Ireland were assessed for trial eligibility.1,653 consenting women were centrally randomised on a 2:1 ratio to MLU or CLU care, (1101:552). 'Intention-to-treat' analysis was used to compare 9 key neonatal and maternal outcomes. Results No statistically significant difference was found between MLU and CLU in the seven key outcomes: caesarean birth (163 [14.8%] vs 84 [15.2%]; relative risk (RR) 0.97 [95% CI 0.76 to 1.24]), induction (248 [22.5%] vs 138 [25.0%]; RR 0.90 [0.75 to 1.08]), episiotomy (126 [11.4%] vs 68 [12.3%]; RR 0.93 [0.70 to 1.23]), instrumental birth (139 [12.6%] vs 79 [14.3%]; RR 0.88 [0.68 to 1.14]), Apgar scores < 8 (10 [0.9%] vs 9 [1.6%]; RR 0.56 [0.23 to 1.36]), postpartum haemorrhage (144 [13.1%] vs 75 [13.6%]; RR 0.96 [0.74 to 1.25]); breastfeeding initiation (616 [55.9%] vs 317 [57.4%]; RR 0.97 [0.89 to 1.06]). MLU women were significantly less likely to have continuous electronic fetal monitoring (397 [36.1%] vs 313 [56.7%]; RR 0.64 [0.57 to 0.71]), or augmentation of labour (436 [39.6%] vs 314 [56.9%]; RR 0.50 [0.40 to 0.61]). Conclusions Midwife-led care, as practised in this study, is as safe as consultant-led care and is associated with less intervention during labour and delivery. Trial registration number ISRCTN: ISRCTN14973283 PMID:22035427

Effects of pushing techniques in birth on mother and fetus: a randomized study.

PubMed

Yildirim, Gulay; Beji, Nezihe Kizilkaya

2008-03-01

The Valsalva pushing technique is used routinely in the second stage of labor in many countries, and it is accepted as standard obstetric management in Turkey. The purpose of this study was to determine the effects of pushing techniques on mother and fetus in birth in this setting. This randomized study was conducted between July 2003 and June 2004 in Bakirkoy Maternity and Children's Teaching Hospital in Istanbul, Turkey. One hundred low-risk primiparas between 38 and 42 weeks' gestation, who expected a spontaneous vaginal delivery, were randomized to either a spontaneous pushing group or a Valsalva-type pushing group. Spontaneous pushing women were informed during the first stage of labor about spontaneous pushing technique (open glottis pushing while breathing out) and were supported in pushing spontaneously in the second stage of labor. Similarly, Valsalva pushing women were informed during the first stage of labor about the Valsalva pushing technique (closed glottis pushing while holding their breath) and were supported in using Valsalva pushing in the second stage of labor. Perineal tears, postpartum hemorrhage, and hemoglobin levels were evaluated in mothers; and umbilical artery pH, Po(2) (mmHg), and Pco(2) (mmHg) levels and Apgar scores at 1 and 5 minutes were evaluated in newborns in both groups. No significant differences were found between the two groups in their demographics, incidence of nonreassuring fetal surveillance patterns, or use of oxytocin. The second stage of labor and duration of the expulsion phase were significantly longer with Valsalva-type pushing. Differences in the incidence of episiotomy, perineal tears, or postpartum hemorrhage were not significant between the groups. The baby fared better with spontaneous pushing, with higher 1- and 5-minute Apgar scores, and higher umbilical cord pH and Po(2) levels. After the birth, women expressed greater satisfaction with spontaneous pushing. Educating women about the spontaneous pushing technique in the first stage of labor and providing support for spontaneous pushing in the second stage result in a shorter second stage without interventions and in improved newborn outcomes. Women also stated that they pushed more effectively with the spontaneous pushing technique.

Rates of obstetric intervention during birth and selected maternal and perinatal outcomes for low risk women born in Australia compared to those born overseas.

PubMed

Dahlen, Hannah G; Schmied, Virginia; Dennis, Cindy-Lee; Thornton, Charlene

2013-05-01

There are mixed reports in the literature about obstetric intervention and maternal and neonatal outcomes for migrant women born in resource rich countries. The aim of this study was to compare the risk profile, rates of obstetric intervention and selected maternal and perinatal outcomes for low risk women born in Australia compared to those born overseas. A population-based descriptive study was undertaken in NSW of all singleton births recorded in the NSW Midwives Data Collection between 2000-2008 (n=691,738). Risk profile, obstetric intervention rates and selected maternal and perinatal outcomes were examined. Women born in Australia were slightly younger (30 vs 31 years), less likely to be primiparous (41% vs 43%), three times more likely to smoke (18% vs 6%) and more likely to give birth in a private hospital (26% vs 18%) compared to women not born in Australia. Among the seven most common migrant groups to Australia, women born in Lebanon were the youngest, least likely to be primiparous and least likely to give birth in a private hospital. Hypertension was lowest amongst Vietnamese women (3%) and gestational diabetes highest amongst women born in China (14%). The highest caesarean section (31%), instrumental birth rates (16%) and episiotomy rates (32%) were seen in Indian women, along with the highest rates of babies <10th centile (22%) and <3rd centile (8%). Lebanese women had the highest rates of stillbirth (7.2/1000). Similar trends were found in the different migrant groups when only low risk women were included. The results suggest there are significant differences in risk profiles, obstetric intervention rates and maternal and neonatal outcomes between Australian-born and women born overseas and these differences are seen overall and in low risk populations. The finding that Indian women (the leading migrant group to Australia) have the lowest normal birth rate and high rates of low birth weight babies is concerning, and attention needs to be focused on why there are disparities in outcomes and on effective models of care that might improve outcomes for this population.

Birth position and obstetric anal sphincter injury: a population-based study of 113 000 spontaneous births.

PubMed

Elvander, Charlotte; Ahlberg, Mia; Thies-Lagergren, Li; Cnattingius, Sven; Stephansson, Olof

2015-10-09

The association between birth position and obstetric anal sphincter injury (OASIS) in spontaneous vaginal deliveries is unclear. The study was based on the Stockholm-Gotland Obstetric Database (Sweden) from Jan 1(st) 2008 to Oct 22(nd) 2014 and included 113 279 singleton spontaneous vaginal births with no episiotomy. We studied risk of OASIS with respect to the following birth positions: a) sitting, b) lithotomy, c) lateral, d) standing on knees, e) birth seat, f) supine, g) squatting, h) standing and i) all fours. All analyses were stratified for parity. General linear models were used to calculate risk ratios (RR) adjusted for maternal, pregnancy and fetal characteristics. The rates of OASIS among nulliparous women, parous women and women undergoing vaginal birth after a caesarean (VBAC) were 5.7%, 1.3% and 10.6%, respectively. The rates varied by birth position: from 3.7 to 7.1% in nulliparous women, 0.6% to 2.6% in parous women and 5.6% to 18.2% in women undergoing VBAC. Regardless of parity, the lowest rates were found among women giving birth in standing position and the highest rates among women birthing in the lithotomy position. Compared with sitting position, the lithotomy position involved an increased risk of OASIS among nulliparous (adjusted RR 1.17, 95% CI 1.06-1.29) and parous women (adjusted RR 1.66, 95% CI 1.35-2.05). Birth seat and squatting position involved an increased risk of OASIS among parous women (adjusted RR [95% CI] 1.36 [1.03-1.80] and 2.16 [1.15-4.07], respectively). Independent risk factors for OASIS were maternal age, head circumference ≥35 cm, birth weight ≥4000 g, length of gestation ≥ 40 weeks, prolonged second stage of labour, non-occiput anterior presentation and oxytocin augmentation. Compared with sitting position, lateral position has a slightly protective effect in nulliparous women whilst an increased risk is noted among women in the lithotomy position, irrespective of parity. Squatting and birth seat position involve an increase in risk among parous women.

Labor and Birth Care Satisfaction Associated With Medical Interventions and Accompaniment During Labor Among Chilean Women.

PubMed

Weeks, Fiona; Pantoja, Loreto; Ortiz, Jovita; Foster, Jennifer; Cavada, Gabriel; Binfa, Lorena

2017-03-01

Satisfaction with care during labor and birth has been associated with various obstetric variables. The purpose of this study was to determine which labor and birth procedures are significant predictors of maternal patient satisfaction in a large cross-sectional sample. An observational, cross-sectional study of 1660 women giving birth in Chilean public hospital facilities was conducted from 2012 to 2013. Data were collected from 9 different hospitals in 8 regions of Chile using 2 instruments, including the American College of Nurse-Midwives Intrapartum Care Data Set and a locally validated measure of maternal well-being. Women were eligible if they arrived at the labor and delivery unit during early labor (2-3 centimeters dilated) and spent at least 4 hours in labor at the facility. In the current analysis, odds ratios were calculated using ordinal logistic regression for association with a less optimal well-being score (possible outcome values were optimal, adequate, and minimal). Odds ratios were adjusted for age, education, single status, and parity (nulliparous vs multiparous). Stepwise regression was used to identify the procedural factors that were significantly associated with labor and birth care satisfaction. Factors significantly associated with lower satisfaction were cesarean birth (odds ratio [OR], 1.4; 95% confidence interval [CI], 1.1-1.7), pharmacologic pain management (OR, 1.3; 95% CI, 1.02-1.7), continuous fetal heart rate monitoring (OR. 1.4; 95% CI, 1.2-1.8), and episiotomy (OR, 1.4; 95% CI, 1.1-1.7). Nulliparity was also associated with minimal maternal satisfaction (OR, 1.3; 95% CI, 1.0-1.5). Greater satisfaction was associated with accompaniment by a companion of choice during labor (OR, 0.49: 95% CI, 0.40-0.60). This study is one of the first to provide empirical evidence that maternal patient satisfaction is negatively affected by many common obstetric procedures in the Latin American context. These findings are consistent with World Health Organization recommendations regarding judicious and necessary, rather than routine, use of obstetric interventions. © 2016 by the American College of Nurse-Midwives.

[Analysis of potential for research on giving birth in an upright position in German hospitals].

PubMed

Mattern, Elke; Voigt-Radloff, Sebastian; Ayerle, Gertrud M

2014-01-01

In German hospitals, three quarters of all low-risk pregnant women give birth in the supine position, despite the fact that German, British and WHO guidelines do not recommend a supine birthing position which is associated with a higher risk to the health of both mother and fetus. Based on 22 RCTs with 7,280 participants, a systematic Cochrane review (Gupta et al., 2012) revealed that an upright position - compared with a supine or lithotomy position - (1) has a positive impact on fetal heart rate patterns, (2) reduces the requirement for analgesic or anaesthetic medications in the second stage of labour, and (3) results in fewer episiotomies and (4) fewer instrumental deliveries. There is a lack of evidence regarding perceived maternal autonomy, self-efficacy and anxiety when giving birth. Furthermore, evidence on long-term effects is absent. Some studies indicate that the choice of an upright birthing position might be boosted by a supporting physical and social environment and by specially trained midwives. There is a need for a feasibility study and a subsequent cluster RCT in the German healthcare context in order to investigate the effects of the upright posture for birthing on perceived maternal autonomy, self-efficacy and anxiety, on the reduction of perinatal complications and on long-term complaints. The complex experimental intervention consists of (1) evidence-based and user-friendly information for women and their partners, (2) facilitating the choice for an upright labour position by special training for midwives and (3) providing a supportive physical and social environment. Within the first study phase, the exploration of feasibility in terms of access to the target group and acceptance of the intervention by pregnant women, their partners and midwives is recommended. Thereby, the implementation of guidelines for upright labour and birth, the documentation and collection of outcome and cost data could be evaluated. Non-German instruments for measuring benefits, harms and long-term effects could be adapted to and validated for the German context. Copyright © 2014. Published by Elsevier GmbH.

[Maternal care after vaginal delivery and management of complications in immediate post-partum--Guidelines for clinical practice].

PubMed

Simon, E-G; Laffon, M

2015-12-01

To provide recommendations on maternal care after vaginal delivery, and management of complications in immediate post-partum period. Bibliographic research from the Pubmed database and recommendations issued by the main scientific societies, and assignment of a level of evidence and a recommendation grade. After a vaginal delivery, monitoring of blood pressure, heart rate, bleeding, uterine involution, genital pain, urination, temperature, transit and signs of phlebitis is recommended (professional consensus). Post-partum Anemia is defined by a hemoglobin<11 g/dL at 48 hours (grade C). Anemia must be searched only in women who have bled during delivery or who present symptoms of anemia (professional consensus). Oral iron supplementation is only proposed in cases of biologically proven anemia (professional consensus). In case of post-partum hypertension or de novo preeclampsia, the prescription rules for antihypertensive treatments and magnesium sulfate are the same as in prenatal period (professional consensus). Oral NSAIDs are effective for perineal pain and uterine involution (EL2). In case of broken down perineal wounds following childbirth, there is no argument in favor of suturing or not suturing, however the suturing is to be preferred for large dehisced perineal wounds (professional consensus). Infection of perineal scar justifies an oral broad-spectrum antibiotics, in addition to local nursing (professional consensus). In case of obstetric anal sphincter injuries, an antibiotic prophylaxis is recommended (grade B). Hygiene advice should be given to all women who had an episiotomy or a perineal tear (professional consensus). The only etiological treatment of post-dural puncture headache is the blood patch (EL2). It must not be carried out before 48 hours (professional consensus). Thromboembolic risk after a vaginal birth is about 1‰ (EL2). The prescription of thromboprophylaxis with LMWH and graduated compression stockings should be based on risk factors (professional consensus). During the immediate post-partum period, complications may be unrecognized or confused with the natural post-partum evolution, which implies a strong vigilance from practitioners. This vigilance is all the more necessary that the maternal residence durations are shortened. Copyright © 2015 Elsevier Masson SAS. All rights reserved.

Evaluating the content and quality of intrapartum care in vaginal births: An example of a state hospital.

PubMed

Karaçam, Zekiye; Arslan Kurnaz, Döndü; Güneş, Gizem

2017-03-01

The purpose of the research was to assess the content and quality of the intrapartum care offered in vaginal births in Turkey, based on the example of a state hospital. This cross-sectional study was conducted between January 1 st , 2013 and December 31 st , 2014 at Aydın Maternity and Children's Hospital. The study sample consisted of 303 women giving vaginal birth, who were recruited into the study using the method of convenience sampling. Research data were collected with a questionnaire created by the researchers and assessed using the Bologna score. Numbers and percentages were assessed in the data analysis. The mean age of the women was 25.14±5.37 years and 40.5% had given one live birth. Of the women, 45.2% were admitted to hospital in the latent phase, 76.6% were administered an enema, 3.3% had epidural anesthesia, 2.6% delivered using vacuum extraction, and 54.1% underwent an episiotomy. Some 23.8% of the women experienced spontaneous laceration that needed sutures. The babies of two women exhibited an Apgar score below 7 in the fifth minute. When the quality of the intrapartum care given to the women was assessed with the Bologna score, it was found that 92.7% went into labor spontaneously, 100% of the births were supervised by midwives and doctors, 97.7% of the women had no supporting companion, and the nonsupine position was only used in 0.3% of the women. A partogram was used to follow up on the birth process in 72.6% of the women, and 82.5% achieved contact with their babies within the first hour after birth. Induction was applied in 76.6% of the women and fundal pressure in 27.4%. The study revealed that the quality of intrapartum care in vaginal births was inadequate. Reformulating the guidelines regarding intrapartum care in accordance with World Health Organization recommendations and evidence-based practices may contribute to improving mother and infant health.

Productivity cost due to postpartum ill health: A cross-sectional study in Sri Lanka.

PubMed

Wickramasinghe, Nuwan Darshana; Horton, Jennifer; Darshika, Ishani; Galgamuwa, Kaushila Dinithi; Ranasinghe, Wasantha Pradeep; Agampodi, Thilini Chanchala; Agampodi, Suneth Buddhika

2017-01-01

Even though postpartum morbidity continues to cause high disease burden in maternal morbidity and mortality across the globe, the literature pertaining to resultant productivity loss is scarce. Hence, the present study aimed at determining the productivity loss and associated cost of episodes of postpartum ill health. A cross sectional study was conducted in two Medical Officer of Heath areas in the Anuradhapura district, Sri Lanka in 2011, among 407 women residing in Anuradhapura district with an infant aged between 8 to 24 weeks. Validated interviewer administered questionnaires, including the IMMPACT productivity cost tool, were used to collect data on self-reported episodes of postpartum ill health. The productivity loss was calculated as the sum of days lost due to partial and total incapacitation. The adjusted productivity loss for coping strategies was calculated. Productivity cost, both total and adjusted, were calculated based on the mean daily per capita income of the study sample. Of the 407 participants, 161(39.6%) reported at least one episode of postpartum illness. Hospitalisations were reported by 27 (16.8%) of all symptomatic postpartum women. Common symptoms of postpartum ill health were pain/infection at either episiotomy or surgical site (n = 44, 27.3%), lower abdominal pain (n = 40, 24.8%) and backache (n = 27, 16.8%). The mean productivity loss per episode of ill health was 15 days (SD = 7.8 days) and the mean productivity loss per episode after adjusting for coping strategies was 7.9 days (SD = 4.4 days). The mean productivity cost per an episode was US$ 34.2(95%CI US$ 26.7-41.6) and the mean productivity cost per an episode after adjusting for coping strategies was US$ 18.0 (95%CI US$ 14.1-22.0). The prevalence of self-reported postpartum ill health, associated productivity loss and cost were high in the study sample and the main contributors were preventable conditions including pain and infection. Thus, effective pain management and proper infection prevention and control measures are important in reducing the burden of postpartum illness and resultant productivity cost.

The role of obstetrical rituals in the resolution of cultural anomaly.

PubMed

Davis-Floyd, R E

1990-01-01

To a technological society like that of the United States, the natural process of childbirth presents special conceptual dilemmas, as it calls into perpetual question any boundaries American culture tries to delineate between itself and nature. The author builds on previous works in which she has argued that the American core value system centers around science and technology, the institutions through which these are disseminated into society, and the patriarchal system through which these institutions are managed. A constant reminder that babies come from women and nature, not from technology and culture, childbirth confronts American society with practical, procedural dilemmas: How to create a sense of cultural control over birth, a natural process resistant to such control? How to make birth, a powerfully female phenomenon, reinforce, instead of undermine, the patriarchal system upon which American society is still based? How to turn the natural and individual birth process into a cultural rite of passage which successfully inculcates the dominant core value system into the initiates? In the absence of universal baptism, how to enculturate a non-cultural baby? Some of the dilemmas discussed in this article are universal problems presented by the birth process to all human societies; others are specific to American culture. Each contains within it a fundamental paradox, an opposition which must be culturally reconciled lest the anomaly of its existence undermine the fragile technology-based conceptual system in terms of which American society organizes itself. After a brief discussion of the history of this technological paradigm, the author analyzes eight of the dilemmas presented by childbirth to American society, demonstrating how they have been neatly resolved by obstetrical rituals specifically designed to removed birth's conceptual threat to the technological model by making birth appear, through technological means, to confirm instead of challenge the basic tenets of that model. From this perspective, routinely used obstetrical procedures such as electronic fetal monitoring, episiotomies, the lithotomy position, and even the Cesarean section emerge as rational ritual responses to the conflicts between reality as American society has constructed it, and the physiological realities of birth.

Complementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labour

PubMed Central

Levett, Kate M; Smith, C A; Bensoussan, A; Dahlen, H G

2016-01-01

Objective To evaluate the effect of an antenatal integrative medicine education programme in addition to usual care for nulliparous women on intrapartum epidural use. Design Open-label, assessor blind, randomised controlled trial. Setting 2 public hospitals in Sydney, Australia. Population 176 nulliparous women with low-risk pregnancies, attending hospital-based antenatal clinics. Methods and intervention The Complementary Therapies for Labour and Birth protocol, based on the She Births and acupressure for labour and birth courses, incorporated 6 evidence-based complementary medicine techniques: acupressure, visualisation and relaxation, breathing, massage, yoga techniques, and facilitated partner support. Randomisation occurred at 24–36 weeks’ gestation, and participants attended a 2-day antenatal education programme plus standard care, or standard care alone. Main outcome measures Rate of analgesic epidural use. Secondary: onset of labour, augmentation, mode of birth, newborn outcomes. Results There was a significant difference in epidural use between the 2 groups: study group (23.9%) standard care (68.7%; risk ratio (RR) 0.37 (95% CI 0.25 to 0.55), p≤0.001). The study group participants reported a reduced rate of augmentation (RR=0.54 (95% CI 0.38 to 0.77), p<0.0001); caesarean section (RR=0.52 (95% CI 0.31 to 0.87), p=0.017); length of second stage (mean difference=−0.32 (95% CI −0.64 to 0.002), p=0.05); any perineal trauma (0.88 (95% CI 0.78 to 0.98), p=0.02) and resuscitation of the newborn (RR=0.47 (95% CI 0.25 to 0.87), p≤0.015). There were no statistically significant differences found in spontaneous onset of labour, pethidine use, rate of postpartum haemorrhage, major perineal trauma (third and fourth degree tears/episiotomy), or admission to special care nursery/neonatal intensive care unit (p=0.25). Conclusions The Complementary Therapies for Labour and Birth study protocol significantly reduced epidural use and caesarean section. This study provides evidence for integrative medicine as an effective adjunct to antenatal education, and contributes to the body of best practice evidence. Trial registration number ACTRN12611001126909. PMID:27406639

Variations in childbirth interventions in high-income countries: protocol for a multinational cross-sectional study.

PubMed

Seijmonsbergen-Schermers, Anna; van den Akker, Thomas; Beeckman, Katrien; Bogaerts, Annick; Barros, Monalisa; Janssen, Patricia; Binfa, Lorena; Rydahl, Eva; Frith, Lucy; Gross, Mechthild M; Hálfdánsdóttir, Berglind; Daly, Deirdre; Calleja-Agius, Jean; Gillen, Patricia; Vika Nilsen, Anne Britt; Declercq, Eugene; de Jonge, Ank

2018-01-10

There are growing concerns about the increase in rates of commonly used childbirth interventions. When indicated, childbirth interventions are crucial for preventing maternal and perinatal morbidity and mortality, but their routine use in healthy women and children leads to avoidable maternal and neonatal harm. Establishing ideal rates of interventions can be challenging. This study aims to describe the range of variations in the use of commonly used childbirth interventions in high-income countries around the world, and in outcomes in nulliparous and multiparous women. This multinational cross-sectional study will use data from births in 2013 with national population data or representative samples of the population of pregnant women in high-income countries. Data from women who gave birth to a single child from 37 weeks gestation onwards will be included and the results will be presented for nulliparous and multiparous women separately. Anonymised individual level data will be analysed. Primary outcomes are rates of commonly used childbirth interventions, including induction and/or augmentation of labour, intrapartum antibiotics, epidural and pharmacological pain relief, episiotomy in vaginal births, instrument-assisted birth (vacuum or forceps), caesarean section and use of oxytocin postpartum. Secondary outcomes are maternal and perinatal mortality, Apgar score below 7 at 5 min, postpartum haemorrhage and obstetric anal sphincter injury. Univariable and multivariable logistic regression analyses will be conducted to investigate variations among countries, adjusted for maternal age, body mass index, gestational weight gain, ethnic background, socioeconomic status and infant birth weight. The overall mean rates will be considered as a reference category, weighted for the size of the study population per country. The Medical Ethics Review Committee of VU University Medical Center Amsterdam confirmed that an official approval of this study was not required. Results will be disseminated at national and international conferences and published in peer-reviewed journals. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Quality of care provided in two Scottish rural community maternity units: a retrospective case review.

PubMed

Denham, Sara; Humphrey, Tracy; Taylor, Ruth

2017-06-21

Women in Scotland with uncomplicated pregnancies are encouraged by professional bodies and national guidelines to access community based models of midwife-led care for their labour and birth. The evidence base for these guidelines relates to comparisons of predominantly urban birth settings in England. There appears to be little evidence available about the quality of the care during the antenatal, birth and post birth periods available for women within the Scottish Community Maternity Unit (CMU) model. The research aim was to explore the safety and effectiveness of the maternity services provided at two rural Community Maternity Units in Scotland, both 40 miles by main road access from a tertiary obstetric unit. Following appropriate NHS and University ethical approval, an anonymous retrospective review of consecutive maternity records for all women who accessed care at the CMUs over a 12 month period (June 2011 to May 2012) was undertaken in 2013 -14. Data was extracted using variables chosen to provide a description of the socio-demographics of the cohort and the process and outcomes of the care provided. Data were analysed using descriptive statistics. Regarding effectiveness, the correct care pathway was allocated to 97.5% of women, early access to antenatal care achieved by 95.7% of women, 94.8% of women at one CMU received continuity of carer and 78.6% of those clinically eligible accessed care in labour. 11.9% were appropriately transferred to obstetrician-led care antenatally and 16.9% were transferred in labour. All women received one-to one care in labour and 67.1% of babies born at the CMUs were breastfed at birth. Regarding safety, severe morbidity for women was rare, perineal trauma of 3rd degree tear occurred for 0.3% of women and 1.0% experienced an episiotomy. Severe post partum haemorrhage occurred for 0.3% of women. Babies admitted to the Neonatal unit were discharged within 48 hrs. These findings support the recommendations of professional bodies and national guidelines. Maternity service provision at rural CMUs achieved a consistently high standard of safety and effectiveness when measured against national standards and international evidence.

Rates of obstetric intervention during birth and selected maternal and perinatal outcomes for low risk women born in Australia compared to those born overseas

PubMed Central

2013-01-01

Background There are mixed reports in the literature about obstetric intervention and maternal and neonatal outcomes for migrant women born in resource rich countries. The aim of this study was to compare the risk profile, rates of obstetric intervention and selected maternal and perinatal outcomes for low risk women born in Australia compared to those born overseas. Method A population-based descriptive study was undertaken in NSW of all singleton births recorded in the NSW Midwives Data Collection between 2000–2008 (n=691,738). Risk profile, obstetric intervention rates and selected maternal and perinatal outcomes were examined. Results Women born in Australia were slightly younger (30 vs 31 years), less likely to be primiparous (41% vs 43%), three times more likely to smoke (18% vs 6%) and more likely to give birth in a private hospital (26% vs 18%) compared to women not born in Australia. Among the seven most common migrant groups to Australia, women born in Lebanon were the youngest, least likely to be primiparous and least likely to give birth in a private hospital. Hypertension was lowest amongst Vietnamese women (3%) and gestational diabetes highest amongst women born in China (14%). The highest caesarean section (31%), instrumental birth rates (16%) and episiotomy rates (32%) were seen in Indian women, along with the highest rates of babies <10th centile (22%) and <3rd centile (8%). Lebanese women had the highest rates of stillbirth (7.2/1000). Similar trends were found in the different migrant groups when only low risk women were included. Conclusion The results suggest there are significant differences in risk profiles, obstetric intervention rates and maternal and neonatal outcomes between Australian-born and women born overseas and these differences are seen overall and in low risk populations. The finding that Indian women (the leading migrant group to Australia) have the lowest normal birth rate and high rates of low birth weight babies is concerning, and attention needs to be focused on why there are disparities in outcomes and on effective models of care that might improve outcomes for this population. PMID:23634802

Paracetamol/acetaminophen (single administration) for perineal pain in the early postpartum period.

PubMed

Chou, Doris; Abalos, Edgardo; Gyte, Gillian M L; Gülmezoglu, A Metin

2013-01-31

Perineal pain is a common but poorly studied adverse outcome following childbirth. Pain may result from perineal trauma due to bruising, spontaneous tears, surgical incisions (episiotomies), or in association with operative births (ventouse or forceps assisted births). To determine the efficacy of a single administration of paracetamol (acetaminophen) systemic drugs used in the relief of acute postpartum perineal pain We updated the search of the Cochrane Pregnancy and Childbirth Group's Trials Register on 6 November 2012. Randomised controlled trials (RCTs) assessing paracetamol (acetaminophen) in a single dose compared with placebo for women with early postpartum perineal pain. We excluded quasi-RCTs and cross-over studies. Two review authors assessed each paper for inclusion and extracted data. One review author reviewed the decisions and confirmed calculations for pain relief scores. We did not identify any new trials from the updated search so the results remain unchanged as follows.We have included 10 studies describing two dosages of paracetamol. Of these, five studies (526 women) assessed 500 mg to 650 mg and six studies (841 women) assessed 1000 mg of paracetamol. We chose to use random-effects meta-analyses because of the heterogeneity in dosage used. Studies were from the 1970s to the early 1990s, and there was insufficient information to assess the risk of bias adequately, hence the findings need to be interpreted within this context.More women experienced pain relief with paracetamol compared with placebo (average risk ratio (RR) 2.14, 95% confidence interval (CI) 1.59 to 2.89, 10 studies, 1279 women). In addition, there were significantly fewer women having additional pain relief with paracetamol compared with placebo (RR 0.34, 95% CI 0.21 to 0.55, eight studies, 1132 women). Both the 500 mg to 650 mg and 1000 mg doses were effective in providing more pain relief than placebo.Maternal and neonatal potential adverse drug effects were not assessed in any of the included studies. Indeed few secondary outcomes were assessed. More women experienced pain relief, and fewer had additional pain relief, with paracetamol compared with placebo, although potential adverse effects were not assessed and generally the quality of studies was unclear.

A qualitative study exploring how Somali women exposed to female genital mutilation experience and perceive antenatal and intrapartum care in England.

PubMed

Moxey, Jordan M; Jones, Laura L

2016-01-07

To explore how Somali women exposed to female genital mutilation experience and perceive antenatal and intrapartum care in England. We explored women's perceptions of deinfibulation, caesarean section and vaginal delivery; their experiences of care during pregnancy and labour; and factors that affect ability to access these services, in order to make recommendations about future practice. A descriptive, exploratory qualitative study using face-to-face semistructured interviews. Interviews were audio-recorded, transcribed and data were analysed using a thematic approach. An interpreter was used when required (n=3). Participants recruited from 2 community centres in Birmingham, England. Convenience and snowball sample of 10 Somali women resident in Birmingham, who had accessed antenatal care services in England within the past 5 years. 3 core themes were interpreted: (1) Experiences of female genital mutilation during life, pregnancy and labour: Female genital mutilation had a significant physical and psychological impact, influencing decisions to undergo deinfibulation or caesarean section. Women delayed deinfibulation until labour to avoid undergoing multiple operations if an episiotomy was anticipated. (2) Experience of care from midwives: Awareness of female genital mutilation from midwives led to open communication and stronger relationships with women, resulting in more positive experiences. (3) Adaptation to English life: Good language skills and social support networks enabled women to access these services, while unfavourable social factors (eg, inability to drive) impeded. Female genital mutilation impacts Somali women's experiences of antenatal and intrapartum care. This study suggests that midwives should routinely ask Somali women about female genital mutilation to encourage open communication and facilitate more positive experiences. As antenatal deinfibulation is unpopular, we should consider developing strategies to promote deinfibulation to non-pregnant women, to align with current guidelines. Women with unfavourable social factors may require additional support to improve access to English antenatal care services. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

A cross-sectional survey of policies guiding second stage labor in urban Japanese hospitals, clinics and midwifery birth centers.

PubMed

Baba, Kaori; Kataoka, Yaeko; Nakayama, Kaori; Yaju, Yukari; Horiuchi, Shigeko; Eto, Hiromi

2016-02-24

The Japan Academy of Midwifery developed and disseminated the '2012 Evidence-based Guidelines for Midwifery Care (Guidelines for Midwives)' for low-risk births to achieve a more uniform standard of care during childbirth in Japan. The objective of this study was to cross-sectional survey policy implementation regarding care during the second stage of labor at Japanese hospitals, clinics, and midwifery birth centers, and to compare those policies with the recommendations in Guidelines for Midwives. This study was conducted in the four major urbanized areas (e.g. Tokyo) of the Kanto region of Japan. Respondents were chiefs of the institutions (obstetricians/midwives), nurse administrators (including midwives) of the obstetrical departments, or other nurse/midwives who were well versed in the routine care of the targeted institutions. The Guidelines implementation questionnaire comprised 12 items. Data was collected from October 2010 to July 2011. The overall response was 255 of the 684 institutions (37%). Of the total responses 46% were hospitals, 26% were clinics and 28% were midwifery birth centers. Few institutions reported perineal massage education for 'almost all cases'. Using 'active birth' were all midwifery birth centers, 56% hospitals and 32% clinics. Few institutions used water births. The majority of hospitals (73%) and clinics (80%) but a minority (39%) of midwifery birth centers reported 'not implemented' about applying warm compress to the perineum. Few midwifery birth centers (10%) and more hospitals (38%) and clinics (50%) had a policy for valsalva as routine care. Many hospitals (90%) and clinics (88%) and fewer midwifery birth centers (54%) offered hands-on technique to provide perineal support during birth. A majority of institutions used antiseptic solution for perineal disinfection. Few institutions routinely used episiotomies for multiparas, however routine use for primiparas was slightly more in hospitals (21%) and clinics (25%). All respondents used fundal pressure as consistent with guidelines. Not many institutions implemented the hands and knees position for correcting fetal abnormal rotation. This survey has provided new information about the policies instituted in three types of institutions guiding second stage labor in four metropolitan areas of Japan. There existed considerable differences among institutions' practice. There were also many gaps between reported policies and evidence-based Guidelines for Midwives, therefore new strategies are needed in Japan to realign institution's care policies with evidenced based guidelines.

Effect of the type of maternal pushing during the second stage of labour on obstetric and neonatal outcome: a multicentre randomised trial-the EOLE study protocol.

PubMed

Barasinski, Chloé; Vendittelli, Françoise

2016-12-20

The scientific data currently available do not allow any definitive conclusion to be reached about what type of pushing should be recommended to women during the second stage of labour. The objective of this trial is to assess and compare the effectiveness of directed open-glottis pushing versus directed closed-glottis pushing. Secondary objectives are to assess, according to the type of pushing: immediate maternal and neonatal morbidity, intermediate-term maternal pelvic floor morbidity, uncomplicated birth, and women's satisfaction at 4 weeks post partum. This multicentre randomised clinical trial compares directed closed-glottis pushing (Valsalva) versus directed open-glottis pushing during the second stage of labour in 4 hospitals of France. The study population includes pregnant women who received instruction in both types of pushing, have no previous caesarean delivery, are at term and have a vaginal delivery planned. Randomisation takes place during labour once cervical dilation ≥7 cm. The principal end point is assessed by a composite criterion: spontaneous delivery without perineal lesion (no episiotomy or spontaneous second-degree, third-degree or fourth-degree lacerations). We will need to recruit 125 women per group. The primary analysis will be by intention-to-treat analysis, with the principal results reported as crude relative risks (RRs) with their 95% CIs. A multivariate analysis will be performed to take prognostic and confounding factors into account to obtain adjusted RRs. This study was approved by a French Institutional Review Board (Comité de Protection des Personnes Sud Est 6:N°AU1168). Results will be reported in peer-reviewed journals and at scientific meetings. This study will make it possible to assess the effectiveness of 2 types of directed pushing used in French practice and to assess their potential maternal, fetal and neonatal effects. Findings from the study will be useful for counselling pregnant women before and during labour. Agence national de sécurité du médicament et des produits de santé (ANSM): 150099B-22 and IDRCB: 2014-A01920-47. ClinicalTrials.gov: NCT02474745. Pre-result stage. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Family physicians who provide intrapartum care and those who do not

PubMed Central

Klein, Michael C.; Kaczorowski, Janusz; Tomkinson, Jocelyn; Hearps, Stephen; Baradaran, Nazli; Brant, Rollin

2011-01-01

Abstract Objective To examine FPs’ attitudes toward birth for those providing intrapartum care (IPC) and those providing only antepartum care (APC). Design National, cross-sectional Web- and paper-based survey. Setting Canada. Participants A total of 897 Canadian FPs: 503 providing both IPC and APC (FPIs), 252 providing only APC but who previously provided IPC (FPPs), and 142 providing only APC who never provided IPC (FPNs). Main outcome measures Respondents’ views (measured on a 5-point Likert scale) on routine electronic fetal monitoring, epidural analgesia, routine episiotomy, doulas, pelvic floor benefits of cesarean section, approaches to reducing cesarean section rates, maternal choice and the mother’s role in her own child’s birth, care providers’ fears of vaginal birth for themselves or their partners, and safety by mode or place of birth. Results Results showed that FPIs and FPPs were more likely than FPNs were to take additional training or advanced life support courses. The FPIs consistently demonstrated more positive attitudes toward vaginal birth than did the other 2 groups. The FPPs and FPNs showed significantly more agreement with use of routine electronic fetal monitoring and routine epidural analgesia (P < .001). The FPIs displayed significantly more acceptance of doulas (P < .001) and more disagreement with the pelvic floor benefits of cesarean section than other FPs did (P < .001). The FPIs were significantly less fearful of vaginal birth for themselves or their partners than were FPPs and FPNs (P < .001). All FP groups agreed on rejection of elective cesarean section, in the absence of indications, for themselves or their partners and on support for vaginal birth in the presence of uterine scar. While all FP groups supported licensed midwifery, three-quarters thought home birth was more dangerous than hospital birth and showed ambivalence toward birth plans. Only 7.8% of FPIs would choose obstetricians for their own or their partners’ maternity care. Conclusion The FPIs had a more positive, evidence-based view of birth. It is likely that FPs providing only APC are influencing women in their practices toward a relatively negative view of birth before referral to obstetricians, FPIs, or midwives for the actual birth. The relatively negative views of birth held by FPs providing only APC need to be addressed in family practice education and in continuing education. PMID:21490345

Early pelvic floor muscle training after obstetrical anal sphincter injuries for the reduction of anal incontinence.

PubMed

Mathé, Mélodie; Valancogne, Guy; Atallah, Anthony; Sciard, Clémentine; Doret, Muriel; Gaucherand, Pascal; Beaufils, Etienne

2016-04-01

Between 0.5 and 5% of vaginal deliveries involve obstetrical anal sphincter injuries (OASIS). Thirty to forty percent of patients with OASIS will suffer from anal incontinence in the subacute postpartum period. The aim of the present study was to assess the effectiveness of early pelvic floor muscle training (PFMT) combined with standard rehabilitation on anal incontinence after vaginal deliveries complicated by OASIS. The present work was a retrospective quantitative study performed in a tertiary-level maternity hospital. Women with 3rd or 4th degree obstetric tears were included. Women who gave birth between January 1st, 2011 and December 31st, 2012 underwent standard pelvic-perineal rehabilitation within 6-8 weeks postpartum. Women who gave birth between January 1st, 2013 and July 1st, 2014 had early rehabilitation (within 30 days after delivery) followed by the same standard rehabilitation received by the other group. Rehabilitation was performed by physiotherapists specialized in perineology. No electrostimulation was done in early rehabilitation. An in-house-validated modification of the Jorge and Wexner questionnaire was sent by mail to the patients to assess symptoms. The main judgment criterion was anal incontinence to gas, loose stools and/or solid stool. Two hundred and thirty patients were diagnosed with OASIS. Nineteen women (8.3%) were lost to follow-up. The intention-to-treat analysis included 211 patients, 109 of whom underwent standard rehabilitation and 102 early rehabilitation plus standard rehabilitation. The two groups were comparable in terms of parity, birth weight, assisted delivery, epidural anesthesia and rates of mediolateral episiotomy. Multivariate analyses adjusted for type of perineal lesion were performed. Early rehabilitation significantly reduced gas leakage: OR 0.51 [0.29-0.90] (p=0.02), liquid stool leakage: OR 0.22 [0.08-0.58] (p=0.02) and urinary stress incontinence: OR 0.43 [0.24-0.77] (p=0.004). We recommend early (during the first month postpartum) PFMT after vaginal deliveries associated with OASIS. Rehabilitation should be carried out by a physiotherapist specialized in perineology in order to prevent medium-term functional consequences. A longer follow-up may be necessary to confirm the stability of results. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia.

PubMed

Janssen, Patricia A; Lee, Shoo K; Ryan, Elizabeth M; Etches, Duncan J; Farquharson, Duncan F; Peacock, Donlim; Klein, Michael C

2002-02-05

The choice to give birth at home with a regulated midwife in attendance became available to expectant women in British Columbia in 1998. The purpose of this study was to evaluate the safety of home birth by comparing perinatal outcomes for planned home births attended by regulated midwives with those for planned hospital births. We compared the outcomes of 862 planned home births attended by midwives with those of planned hospital births attended by either midwives (n = 571) or physicians (n = 743). Comparison subjects who were similar in their obstetric risk status were selected from hospitals in which the midwives who were conducting the home births had hospital privileges. Our study population included all home births that occurred between Jan. 1, 1998, and Dec. 31, 1999. Women who gave birth at home attended by a midwife had fewer procedures during labour compared with women who gave birth in hospital attended by a physician. After adjustment for maternal age, lone parent status, income quintile, use of any versus no substances and parity, women in the home birth group were less likely to have epidural analgesia (odds ratio 0.20, 95% confidence interval [CI] 0.14-0.27), be induced, have their labours augmented with oxytocin or prostaglandins, or have an episiotomy. Comparison of home births with hospital births attended by a midwife showed very similar and equally significant differences. The adjusted odds ratio for cesarean section in the home birth group compared with physician-attended hospital births was 0.3 (95% CI 0.22-0.43). Rates of perinatal mortality, 5-minute Apgar scores, meconium aspiration syndrome or need for transfer to a different hospital for specialized newborn care were very similar for the home birth group and for births in hospital attended by a physician. The adjusted odds ratio for Apgar scores lower than 7 at 5 minutes in the home birth group compared with physician-attended hospital births was 0.84 (95% CI 0.32-2.19). There was no increased maternal or neonatal risk associated with planned home birth under the care of a regulated midwife. The rates of some adverse outcomes were too low for us to draw statistical comparisons, and ongoing evaluation of home birth is warranted.

Effect of the type of maternal pushing during the second stage of labour on obstetric and neonatal outcome: a multicentre randomised trial—the EOLE study protocol

PubMed Central

Barasinski, Chloé; Vendittelli, Françoise

2016-01-01

Introduction The scientific data currently available do not allow any definitive conclusion to be reached about what type of pushing should be recommended to women during the second stage of labour. The objective of this trial is to assess and compare the effectiveness of directed open-glottis pushing versus directed closed-glottis pushing. Secondary objectives are to assess, according to the type of pushing: immediate maternal and neonatal morbidity, intermediate-term maternal pelvic floor morbidity, uncomplicated birth, and women's satisfaction at 4 weeks post partum. Methods and analysis This multicentre randomised clinical trial compares directed closed-glottis pushing (Valsalva) versus directed open-glottis pushing during the second stage of labour in 4 hospitals of France. The study population includes pregnant women who received instruction in both types of pushing, have no previous caesarean delivery, are at term and have a vaginal delivery planned. Randomisation takes place during labour once cervical dilation ≥7 cm. The principal end point is assessed by a composite criterion: spontaneous delivery without perineal lesion (no episiotomy or spontaneous second-degree, third-degree or fourth-degree lacerations). We will need to recruit 125 women per group. The primary analysis will be by intention-to-treat analysis, with the principal results reported as crude relative risks (RRs) with their 95% CIs. A multivariate analysis will be performed to take prognostic and confounding factors into account to obtain adjusted RRs. Ethics and dissemination This study was approved by a French Institutional Review Board (Comité de Protection des Personnes Sud Est 6:N°AU1168). Results will be reported in peer-reviewed journals and at scientific meetings. This study will make it possible to assess the effectiveness of 2 types of directed pushing used in French practice and to assess their potential maternal, fetal and neonatal effects. Findings from the study will be useful for counselling pregnant women before and during labour. Trial registration number Agence national de sécurité du médicament et des produits de santé (ANSM): 150099B-22 and IDRCB: 2014-A01920-47. ClinicalTrials.gov: NCT02474745. Pre-result stage. PMID:27998899

Prenatal Lipid-Based Nutrient Supplements Do Not Affect Pregnancy or Childbirth Complications or Cesarean Delivery in Bangladesh: A Cluster-Randomized Controlled Effectiveness Trial.

PubMed

Mridha, Malay K; Matias, Susana L; Paul, Rina Rani; Hussain, Sohrab; Sarker, Mostofa; Hossain, Mokbul; Peerson, Janet M; Vosti, Stephen A; Dewey, Kathryn G

2017-09-01

Background: Pregnancy and childbirth complications and cesarean delivery are common in Bangladesh. Objective: We evaluated the effect of lipid-based nutrient supplements for pregnant and lactating women (LNS-PL) on pregnancy and childbirth complications and cesarean delivery. Methods: We conducted the Rang-Din Nutrition Study, a cluster-randomized controlled effectiveness trial within a community health program in rural Bangladesh. We enrolled 4011 pregnant women in early pregnancy. Women in 48 clusters received iron and folic acid (IFA; 60 mg Fe + 400 μg folic acid/d) and women in 16 clusters received LNS-PL (20 g/d, 118 kcal) containing essential fatty acids and 22 vitamins and minerals. Pregnancy and childbirth complications and the cesarean delivery rate were secondary outcomes of the study. Results: Women in the LNS-PL group did not differ significantly from the IFA group with respect to mean systolic blood pressure at 36 wk gestation (113 and 112 mm Hg; P = 0.17), diastolic blood pressure at 36 wk gestation (68.9 and 68.7 mmHg; P = 0.88), or mean total number of pregnancy and childbirth complications (0.32 and 0.31; P = 0.86). They also did not differ significantly with respect to the prevalence of high blood pressure at 36 wk (1.74% and 2.03%; P = 0.62), antepartum hemorrhage (0.83% and 1.39%; P = 0.21), prolonged labor (8.34% and 8.79%; P = 0.68), early rupture of membranes (9.30% and 8.45%; P = 0.43), convulsions (1.57% and 1.08%; P = 0.24), high blood pressure in labor (1.54% and 1.19%; P = 0.46), obstructed labor (2.83% and 2.91%; P = 0.90), any complications during pregnancy or childbirth (35.9% and 37.1%; P = 0.64), episiotomy (6.31% and 6.44%; P = 0.90), or cesarean delivery (15.6% and 14.2%; P = 0.48). Conclusion: Compared with IFA, antenatal LNS-PL did not increase or decrease pregnancy and childbirth complications or cesarean delivery among women in rural Bangladesh. This trial was registered at clinicaltrials.gov as NCT01715038. © 2017 American Society for Nutrition.

Family physicians who provide intrapartum care and those who do not: very different ways of viewing childbirth.

PubMed

Klein, Michael C; Kaczorowski, Janusz; Tomkinson, Jocelyn; Hearps, Stephen; Baradaran, Nazli; Brant, Rollin

2011-04-01

To examine FPs' attitudes toward birth for those providing intrapartum care (IPC) and those providing only antepartum care (APC). National, cross-sectional Web- and paper-based survey. Canada. A total of 897 Canadian FPs: 503 providing both IPC and APC (FPIs), 252 providing only APC but who previously provided IPC (FPPs), and 142 providing only APC who never provided IPC (FPNs). Respondents' views (measured on a 5-point Likert scale) on routine electronic fetal monitoring, epidural analgesia, routine episiotomy, doulas, pelvic floor benefits of cesarean section, approaches to reducing cesarean section rates, maternal choice and the mother's role in her own child's birth, care providers' fears of vaginal birth for themselves or their partners, and safety by mode or place of birth. Results showed that FPIs and FPPs were more likely than FPNs were to take additional training or advanced life support courses. The FPIs consistently demonstrated more positive attitudes toward vaginal birth than did the other 2 groups. The FPPs and FPNs showed significantly more agreement with use of routine electronic fetal monitoring and routine epidural analgesia (P < .001). The FPIs displayed significantly more acceptance of doulas (P < .001) and more disagreement with the pelvic floor benefits of cesarean section than other FPs did (P < .001). The FPIs were significantly less fearful of vaginal birth for themselves or their partners than were FPPs and FPNs (P < .001). All FP groups agreed on rejection of elective cesarean section, in the absence of indications, for themselves or their partners and on support for vaginal birth in the presence of uterine scar. While all FP groups supported licensed midwifery, three-quarters thought home birth was more dangerous than hospital birth and showed ambivalence toward birth plans. Only 7.8% of FPIs would choose obstetricians for their own or their partners' maternity care. The FPIs had a more positive, evidence-based view of birth. It is likely that FPs providing only APC are influencing women in their practices toward a relatively negative view of birth before referral to obstetricians, FPIs, or midwives for the actual birth. The relatively negative views of birth held by FPs providing only APC need to be addressed in family practice education and in continuing education.

Using the Bologna Score to assess normal delivery healthcare.

PubMed

Carvalho, Isaiane da Silva; Brito, Rosineide Santana de

2016-01-01

Describing the obstetric care provided in public maternity hospitals during normal labour using the Bologna Score in the city of Natal, Northeastern Brazil. A quantitative cross-sectional study conducted with 314 puerperal women. Data collection was carried out consecutively during the months of March to July 2014. Prenatal care was provided to 95.9% of the mothers, beginning around the 1st trimester of pregnancy (72.3%) and having seven or more consultations (51%). Spontaneous vaginal delivery was planned for 88.2% women. All laboring women were assisted by a health professional, mostly by a physician (80.6%), and none of them obtained 5 points on the Bologna Score due to the small percentage of births in non-supine position (0.3%) and absence of a partogram (2.2%). A higher number of episiotomies were observed among primiparous women (75.5%). The score obtained using the Bologna Index was low. Thus, it is necessary to improve and readjust the existing obstetrical model. Descrever a assistência obstétrica prestada em maternidades públicas municipais durante o parto normal na cidade de Natal, Nordeste do Brasil, com uso do Índice de Bologna. Estudo transversal com abordagem quantitativa, desenvolvido com 314 puérperas. A coleta de dados processou-se de forma consecutiva durante os meses de março a julho de 2014. A assistência pré-natal foi prestada a 95,9% das puérperas, com início em torno do 1º trimestre de gestação (72,3%) e realização de sete ou mais consultas (51%). O parto vaginal espontâneo foi planejado para 88,2% mulheres. Todas as parturientes foram assistidas por um profissional de saúde, especialmente pelo médico (80,6%) e nenhuma obteve 5 pontos no Índice de Bologna em virtude dos baixos percentuais de partos em posição não supina (0,3%) e ausência do partograma (2,2%). Houve maior número de episiotomias em primíparas (75,5%). A pontuação obtida por meio do Índice de Bologna foi baixa. Desse modo, é preciso melhorar e readequar o modelo obstétrico vigente.

The maternal childbirth experience more than a decade after delivery.

PubMed

Bossano, Carla M; Townsend, Kelly M; Walton, Alexandra C; Blomquist, Joan L; Handa, Victoria L

2017-09-01

Maternal satisfaction with the birth experience is multidimensional and influenced by many factors, including mode of delivery. To date, few studies have investigated maternal satisfaction outside of the immediate postpartum period. This study investigated whether differences in satisfaction based on mode of delivery are observed more than a decade after delivery. This was a planned, supplementary analysis of data collected for the Mothers' Outcomes after Delivery study, a longitudinal cohort study of pelvic floor disorders in parous women and their association with mode of delivery. Obstetric and demographic data were obtained through patient surveys and obstetrical chart review. Maternal satisfaction with childbirth experience was assessed via the Salmon questionnaire, administered to Mothers' Outcomes after Delivery study participants >10 years from their first delivery. This validated questionnaire yields 3 scores: fulfillment, distress, and difficulty. These 3 scores were compared by mode of delivery (cesarean prior to labor, cesarean during labor, spontaneous vaginal delivery, and operative vaginal delivery). In addition, the impact of race, age, education level, parity, episiotomy, labor induction, and duration of second stage of labor on maternal satisfaction were examined. Among 576 women, 10.1-17.5 years from delivery, significant differences in satisfaction scores were noted by delivery mode. Salmon scale scores differed between women delivering by cesarean and those delivering vaginally: women delivering vaginally reported greater fulfillment (0.40 [-0.37 to 0.92] vs 0.15 [-0.88 to 0.66], P < .001) and less distress (-0.34 [-0.88 to 0.38] vs 0.20 [-0.70 to 0.93], P < .001) than those who delivered by cesarean. Women who delivered by cesarean prior to labor reported the greatest median fulfillment scores and the lowest median difficulty scores. Median distress scores were lowest among those who delivered by spontaneous vaginal birth. Among women who underwent cesarean delivery, labor induction and prolonged second stage were associated with higher difficulty scores. These factors did not affect satisfaction scores among women who delivered vaginally. Among women who delivered vaginally, operative vaginal delivery was associated with less favorable scores across all 3 scores. Maternal satisfaction with childbirth is influenced by mode of delivery. The birth experience leaves an impression on women more than a decade after delivery. Copyright © 2017 Elsevier Inc. All rights reserved.

Labor and birth care by nurse with midwifery skills in Brazil.

PubMed

Gama, Silvana Granado Nogueira da; Viellas, Elaine Fernandes; Torres, Jacqueline Alves; Bastos, Maria Helena; Brüggemann, Odaléa Maria; Theme Filha, Mariza Miranda; Schilithz, Arthur Orlando Correa; Leal, Maria do Carmo

2016-10-17

The participation of nurses and midwives in vaginal birth care is limited in Brazil, and there are no national data regarding their involvement. The goal was to describe the participation of nurses and nurse-midwives in childbirth care in Brazil in the years 2011 and 2012, and to analyze the association between hospitals with nurses and nurse-midwives in labor and birth care and the use of good practices, and their influence in the reduction of unnecessary interventions, including cesarean sections. Birth in Brazil is a national, population-based study consisting of 23,894 postpartum women, carried out in the period between February 2011 and October 2012, in 266 healthcare settings. The study included all vaginal births involving physicians or nurses/nurse-midwives. A logistic regression model was used to examine the association between the implementation of good practices and suitable interventions during labor and birth, and whether care was a physician or a nurse/nurse-midwife led care. We developed another model to assess the association between the use of obstetric interventions during labor and birth to the personnel responsible for the care of the patient, comparing hospitals with decisions revolving exclusively around a physician to those that also included nurses/nurse-midwives as responsible for vaginal births. 16.2 % of vaginal births were assisted by a nurse/nurse-midwife. Good practices were significantly more frequent in those births assisted by nurses/nurse-midwives (ad lib. diet, mobility during labor, non-pharmacological means of pain relief, and use of a partograph), while some interventions were less frequently used (anesthesia, lithotomy position, uterine fundal pressure and episiotomy). In maternity wards that included a nurse/nurse-midwife in labour and birth care, the incidence of cesarean section was lower. The results of this study illustrate the potential benefit of collaborative work between physicians and nurses/nurse-midwives in labor and birth care. The adoption of good practices in managing labor and birth could be the first step toward more effective obstetric and midwifery care in Brazil. It may be easier to introduce new approaches rather than to eliminate old ones, which may explain why the reduction of unnecessary interventions during labor and birth was less pronounced than the adoption of new practices.

Complementary therapies for labour and birth study: a randomised controlled trial of antenatal integrative medicine for pain management in labour.

PubMed

Levett, Kate M; Smith, C A; Bensoussan, A; Dahlen, H G

2016-07-12

To evaluate the effect of an antenatal integrative medicine education programme in addition to usual care for nulliparous women on intrapartum epidural use. Open-label, assessor blind, randomised controlled trial. 2 public hospitals in Sydney, Australia. 176 nulliparous women with low-risk pregnancies, attending hospital-based antenatal clinics. The Complementary Therapies for Labour and Birth protocol, based on the She Births and acupressure for labour and birth courses, incorporated 6 evidence-based complementary medicine techniques: acupressure, visualisation and relaxation, breathing, massage, yoga techniques, and facilitated partner support. Randomisation occurred at 24-36 weeks' gestation, and participants attended a 2-day antenatal education programme plus standard care, or standard care alone. Rate of analgesic epidural use. Secondary: onset of labour, augmentation, mode of birth, newborn outcomes. There was a significant difference in epidural use between the 2 groups: study group (23.9%) standard care (68.7%; risk ratio (RR) 0.37 (95% CI 0.25 to 0.55), p≤0.001). The study group participants reported a reduced rate of augmentation (RR=0.54 (95% CI 0.38 to 0.77), p<0.0001); caesarean section (RR=0.52 (95% CI 0.31 to 0.87), p=0.017); length of second stage (mean difference=-0.32 (95% CI -0.64 to 0.002), p=0.05); any perineal trauma (0.88 (95% CI 0.78 to 0.98), p=0.02) and resuscitation of the newborn (RR=0.47 (95% CI 0.25 to 0.87), p≤0.015). There were no statistically significant differences found in spontaneous onset of labour, pethidine use, rate of postpartum haemorrhage, major perineal trauma (third and fourth degree tears/episiotomy), or admission to special care nursery/neonatal intensive care unit (p=0.25). The Complementary Therapies for Labour and Birth study protocol significantly reduced epidural use and caesarean section. This study provides evidence for integrative medicine as an effective adjunct to antenatal education, and contributes to the body of best practice evidence. ACTRN12611001126909. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Obstetric outcomes for women with female genital mutilation at an Australian hospital, 2006-2012: a descriptive study.

PubMed

Varol, Nesrin; Dawson, Angela; Turkmani, Sabera; Hall, John J; Nanayakkara, Susie; Jenkins, Greg; Homer, Caroline S E; McGeechan, Kevin

2016-10-28

Women, who have been subjected to female genital mutilation (FGM), can suffer serious and irreversible physical, psychological and psychosexual complications. They have more adverse obstetric outcomes as compared to women without FGM. Exploratory studies suggest radical change to abandonment of FGM by communities after migration to countries where FGM is not prevalent. Women who had been subjected to FGM as a child in their countries of origin, require specialised healthcare to reduce complications and further suffering. Our study compared obstetric outcomes in women with FGM to women without FGM who gave birth in a metropolitan Australian hospital with expertise in holistic FGM management. The obstetric outcomes of one hundred and ninety-six women with FGM who gave birth between 2006 and 2012 at a metropolitan Australian hospital were analysed. Comparison was made with 8852 women without FGM who gave birth during the same time period. Data were extracted from a database specifically designed for women with FGM and managed by midwives specialised in care of these women, and a routine obstetric database, ObstetriX. The accuracy of data collection on FGM was determined by comparing these two databases. All women with FGM type 3 were deinfibulated antenatally or during labour. The outcome measures were (1) maternal: accuracy and grade of FGM classification, caesarean section, instrumental birth, episiotomy, genital tract trauma, postpartum blood loss of more than 500 ml; and (2) neonatal: low birth weight, admission to a special care nursery, stillbirth. The prevalence of FGM in women who gave birth at the metropolitan hospital was 2 to 3 %. Women with FGM had similar obstetric outcomes to women without FGM, except for statistically significant higher risk of first and second degree perineal tears, and caesarean section. However, none of the caesarean sections were performed for FGM indications. The ObstetriX database was only 35 % accurate in recording the correct FGM type. Women with FGM had similar obstetric outcomes to women without FGM in an Australian metropolitan hospital with expertise in FGM management. Specialised FGM services with clinical practice guideline and education of healthcare professionals may increase the detection rate of FGM and improve obstetric management of women with FGM.

Hepatitis C in pregnancy: screening, treatment, and management.

PubMed

Hughes, Brenna L; Page, Charlotte M; Kuller, Jeffrey A

2017-11-01

In the United States, 1-2.5% of pregnant women are infected with hepatitis C virus, which carries an approximately 5% risk of transmission from mother to infant. Hepatitis C virus can be transmitted to the infant in utero or during the peripartum period, and infection during pregnancy is associated with increased risk of adverse fetal outcomes, including fetal growth restriction and low birthweight. The purpose of this document is to discuss the current evidence regarding hepatitis C virus in pregnancy and to provide recommendations on screening, treatment, and management of this disease during pregnancy. The following are Society for Maternal-Fetal Medicine recommendations: (1) We recommend that obstetric care providers screen women who are at increased risk for hepatitis C infection by testing for anti-hepatitis C virus antibodies at their first prenatal visit. If initial results are negative, hepatitis C screening should be repeated later in pregnancy in women with persistent or new risk factors for hepatitis C infection (eg, new or ongoing use of injected or intranasal illicit drugs) (GRADE 1B). (2) We recommend that obstetric care providers screen hepatitis C virus-positive pregnant women for other sexually transmitted diseases, including HIV, syphilis, gonorrhea, chlamydia, and hepatitis B virus (GRADE 1B). (3) We suggest that patients with hepatitis C virus, including pregnant women, be counseled to abstain from alcohol (Best Practice). (4) We recommend that direct-acting antiviral regimens only be used in the setting of a clinical trial or that antiviral treatment be deferred to the postpartum period as direct-acting antiviral regimens are not currently approved for use in pregnancy (GRADE 1C). (5) We suggest that if invasive prenatal diagnostic testing is requested, women be counseled that data on the risk of vertical transmission are reassuring but limited; amniocentesis is recommended over chorionic villus sampling given the lack of data on the latter (GRADE 2C). (6) We recommend against cesarean delivery solely for the indication of hepatitis C virus (GRADE 1B). (7) We recommend that obstetric care providers avoid internal fetal monitoring, prolonged rupture of membranes, and episiotomy in managing labor in hepatitis C virus-positive women (GRADE 1B). (8) We recommend that providers not discourage breast-feeding based on a positive hepatitis C virus infection status (GRADE 1A). Copyright © 2017 Elsevier Inc. All rights reserved.

Quality of intrapartum care by skilled birth attendants in a refugee clinic on the Thai-Myanmar border: a survey using WHO Safe Motherhood Needs Assessment.

PubMed

Hoogenboom, Gabie; Thwin, May Myo; Velink, Kris; Baaijens, Marijke; Charrunwatthana, Prakaykaew; Nosten, François; McGready, Rose

2015-02-05

Increasing the number of women birthing with skilled birth attendants (SBAs) as one of the strategies to reduce maternal mortality and morbidity must be partnered with a minimum standard of care. This manuscript describes the quality of intrapartum care provided by SBAs in Mae La camp, a low resource, protracted refugee context on the Thai-Myanmar border. In the obstetric department of Shoklo Malaria Research Unit (SMRU) the standardized WHO Safe Motherhood Needs Assessment tool was adapted to the setting and used: to assess the facility; interview SBAs; collect data from maternal records during a one year period (August 2007 - 2008); and observe practice during labour and childbirth. The facility assessment recorded no 'out of stock' or 'out of date' drugs and supplies, equipment was in operating order and necessary infrastructure e.g. a stand-by emergency car, was present. Syphilis testing was not available. SBA interviews established that danger signs and symptoms were recognized except for sepsis and endometritis. All SBAs acknowledged receiving theoretical and 'hands-on' training and regularly attended deliveries. Scores for the essential elements of antenatal care from maternal records were high (>90%) e.g. providing supplements, recording risk factors as well as regular and correct partogram use. Observed good clinical practice included: presence of a support person; active management of third stage; post-partum monitoring; and immediate and correct neonatal care. Observed incorrect practice included: improper controlled cord traction; inadequate hand washing; an episiotomy rate in nulliparous women 49% (34/70) and low rates 30% (6/20) of newborn monitoring in the first hours following birth. Overall observed complications during labour and birth were low with post-partum haemorrhage being the most common in which case the SBAs followed the protocol but were slow to recognize severity and take action. In the clinic of SMRU in Mae La refugee camp, SBAs were able to comply with evidence-based guidelines but support to improve quality of care in specific areas is required. The structure of the WHO Safe Motherhood Needs Assessment allowed significant insights into the quality of intrapartum care particularly through direct observation, identifying a clear pathway for quality improvement.

Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia

PubMed Central

Janssen, Patricia A.; Lee, Shoo K.; Ryan, Elizabeth M.; Etches, Duncan J.; Farquharson, Duncan F.; Peacock, Donlim; Klein, Michael C.

2002-01-01

Background The choice to give birth at home with a regulated midwife in attendance became available to expectant women in British Columbia in 1998. The purpose of this study was to evaluate the safety of home birth by comparing perinatal outcomes for planned home births attended by regulated midwives with those for planned hospital births. Methods We compared the outcomes of 862 planned home births attended by midwives with those of planned hospital births attended by either midwives (n = 571) or physicians (n = 743). Comparison subjects who were similar in their obstetric risk status were selected from hospitals in which the midwives who were conducting the home births had hospital privileges. Our study population included all home births that occurred between Jan. 1, 1998, and Dec. 31, 1999. Results Women who gave birth at home attended by a midwife had fewer procedures during labour compared with women who gave birth in hospital attended by a physician. After adjustment for maternal age, lone parent status, income quintile, use of any versus no substances and parity, women in the home birth group were less likely to have epidural analgesia (odds ratio 0.20, 95% confidence interval [CI] 0.14–0.27), be induced, have their labours augmented with oxytocin or prostaglandins, or have an episiotomy. Comparison of home births with hospital births attended by a midwife showed very similar and equally significant differences. The adjusted odds ratio for cesarean section in the home birth group compared with physician-attended hospital births was 0.3 (95% CI 0.22–0.43). Rates of perinatal mortality, 5-minute Apgar scores, meconium aspiration syndrome or need for transfer to a different hospital for specialized newborn care were very similar for the home birth group and for births in hospital attended by a physician. The adjusted odds ratio for Apgar scores lower than 7 at 5 minutes in the home birth group compared with physician-attended hospital births was 0.84 (95% CI 0.32–2.19). Interpretation There was no increased maternal or neonatal risk associated with planned home birth under the care of a regulated midwife. The rates of some adverse outcomes were too low for us to draw statistical comparisons, and ongoing evaluation of home birth is warranted. PMID:11868639

Midwifery practice and maternity services: A multisite descriptive study in Latin America and the Caribbean.

PubMed

Binfa, Lorena; Pantoja, Loreto; Ortiz, Jovita; Cavada, Gabriel; Schindler, Peter; Burgos, Rosa Ypania; Maganha E Melo, Célia Regina; da Silva, Lúcia Cristina Florentino Pereira; Lima, Marlise de Oliveira Pimentel; Hernández, Laura Valli; Schlenker Rm, Rosana; Sánchez, Verdún; Rojas, Mirian Solis; Huamán, Betty Cruz; Chauca, Maria Luisa Torres; Cillo, Alicia; Lofeudo, Susana; Zapiola, Sandra; Weeks, Fiona; Foster, Jennifer

2016-09-01

over the past three decades there has been a social movement in Latin American countries (LAC) to support humanised, physiologic birth. Rates of caesarean section overall in Latin America are approximately 35%, increasing up to 85% in some cases. There are many factors related to poor outcomes with regard to maternal and newborn/infant health in LAC countries. Maternal and perinatal outcome data within and between countries is scarce and inaccurate. The aims of this study were to: i) describe selected obstetric and neonatal outcomes of women who received midwifery care, ii) identify the level of maternal well-being after experiencing midwifery care in 6 Latin America countries. this was a cross sectional and descriptive study, conducted in selected maternity units in Argentina, Brazil, Chile, the Dominican Republic, Peru, and Uruguay. Quantitative methods were used to measure midwifery processes of care and maternal perceptions of well-being in labour and childbirth through a validated survey of maternal well-being and an adapted version of the American College of Nurse-Midwives (ACNM) standardized antepartum and intrapartum data set. Maternity units from 6 Latin American countries. the final sample was a convenience sample, and the total participants for all sites in the six countries was 3009 low risk women. for the countries reporting, overall, 82% of these low risk women had spontaneous vaginal deliveries. The rate of caesarean section was 16%; the Dominican Republic had the highest rate of Caesarean sections (30%) and Peru had the lowest rate (4%). The use of oxytocin in labour was widely variable, although overall there was a high proportion of women whose labour was augmented or induced. Ambulation was common, with the lowest proportion (48%) of women ambulating in labour in Chile, Uruguay (50%), Peru (65%), Brazil (85%). The presence of continuous support was highest in Uruguay (93%), Chile (75%) and Argentina (55%), and Peru had the lowest (22%). Episiotomies are still prevalent in all countries, the lowest rate was reported in the Dominican Republic (22%), and the highest rates were 52 and 53% (Chile and Peru, respectively). The Optimal Maternal well-being score had a prevalence of 43.5%, adequate score was 30.8%; 25% of the total sample of women rated their well-being during labour and childbirth as poor. despite evidence-based guidelines and recommendations, birth is not managed accordingly in most cases. Women feel that care is adequate, although some women report mistreatment. More research is needed to understand why such high levels of intervention exist and to test the implementation of evidence-based practices in local settings. Copyright © 2016 Elsevier Ltd. All rights reserved.

[Post-partum sexuality. Living in black African couple analysis].

PubMed

Kouakou, K P; Doumbia, Y; Djanhan, L E; Menin, M M; Djanhan, Y

2015-03-01

The period of the post-partum arouses a lot of questioning in the couple in particular regarding sexuality. Analyze the real-life experience of the sexuality of the African black couples in the post-partum. It was about study type attitudes and practical knowledge which took place in the department of gynecology-obstetrics and andrology of the teaching hospital of Bouaké over the period going in September 30th, 2012 on April 30th, 2013. The study took place in two stages. The first stage had consisted in a pre-test which allowed validate the questionnaire which contained 16 items. The second stage consisted submitting it directly to the patients, in postnatal consultation, who had agreed to participate in the study after an informed consent. The data were analyzed with epi-info, 2002 version. On 395 patients investigated, we noted the resumption of the sexual intercourse for 140 patients (34,2 %). The resumption was made on the initiative of the partner in 67,9 % of the cases, in particular after the return of menstruation (53,8 %). The reason to accept sexual intercourse was to satisfy the partner (60,7 %) and to maintain the harmony of the couple (57,1 %). However, the weekly frequency of the sexual intercourse had decreased in 75 % of the couples. This decrease was caused by the time dedicated to the child (66,7 %) and by the dyspareunia (57,1 %). We also observed a more important frequency of the anal sexual intercourse in the post-partum compared with the period before the childbirth (17,8 % vs. 3,57 %). Also, the use of subtleties, such as lubricants was observed more frequently in the post-partum (39,3 % vs. 3,6 %). Sixty-four comma three percent of the patients had found less satisfaction sexual intercourse. Dyspareunia was more frequent in case of episiotomy, perineal tear during the delivery and delivery assisted (vacuum). The patients, in 51 % of the cases, were themselves responsible for the refusal of the resumption of the sexual activity. The reasons of the refusal were of cultural and religious order and in touch with the absence of the return of menstruation in respectively 64,7 % and 54,9 % of the cases. The delivery had a negative impact on the resumption of couple sexual activity. Also, we noted a strong influence of the cultural and religious faiths on the sexual practice of the post-partum in the absence of reliable information. A particular attention should be concerned by the medical profession on the question of sexuality in the post-partum. Copyright © 2014. Published by Elsevier Masson SAS.

Detection of Multiple Innervation Zones from Multi-Channel Surface EMG Recordings with Low Signal-to-Noise Ratio Using Graph-Cut Segmentation.

PubMed

Marateb, Hamid Reza; Farahi, Morteza; Rojas, Monica; Mañanas, Miguel Angel; Farina, Dario

2016-01-01

Knowledge of the location of muscle Innervation Zones (IZs) is important in many applications, e.g. for minimizing the quantity of injected botulinum toxin for the treatment of spasticity or for deciding on the type of episiotomy during child delivery. Surface EMG (sEMG) can be noninvasively recorded to assess physiological and morphological characteristics of contracting muscles. However, it is not often possible to record signals of high quality. Moreover, muscles could have multiple IZs, which should all be identified. We designed a fully-automatic algorithm based on the enhanced image Graph-Cut segmentation and morphological image processing methods to identify up to five IZs in 60-ms intervals of very-low to moderate quality sEMG signal detected with multi-channel electrodes (20 bipolar channels with Inter Electrode Distance (IED) of 5 mm). An anisotropic multilayered cylinder model was used to simulate 750 sEMG signals with signal-to-noise ratio ranging from -5 to 15 dB (using Gaussian noise) and in each 60-ms signal frame, 1 to 5 IZs were included. The micro- and macro- averaged performance indices were then reported for the proposed IZ detection algorithm. In the micro-averaging procedure, the number of True Positives, False Positives and False Negatives in each frame were summed up to generate cumulative measures. In the macro-averaging, on the other hand, precision and recall were calculated for each frame and their averages are used to determine F1-score. Overall, the micro (macro)-averaged sensitivity, precision and F1-score of the algorithm for IZ channel identification were 82.7% (87.5%), 92.9% (94.0%) and 87.5% (90.6%), respectively. For the correctly identified IZ locations, the average bias error was of 0.02±0.10 IED ratio. Also, the average absolute conduction velocity estimation error was 0.41±0.40 m/s for such frames. The sensitivity analysis including increasing IED and reducing interpolation coefficient for time samples was performed. Meanwhile, the effect of adding power-line interference and using other image interpolation methods on the deterioration of the performance of the proposed algorithm was investigated. The average running time of the proposed algorithm on each 60-ms sEMG frame was 25.5±8.9 (s) on an Intel dual-core 1.83 GHz CPU with 2 GB of RAM. The proposed algorithm correctly and precisely identified multiple IZs in each signal epoch in a wide range of signal quality and is thus a promising new offline tool for electrophysiological studies.

Detection of Multiple Innervation Zones from Multi-Channel Surface EMG Recordings with Low Signal-to-Noise Ratio Using Graph-Cut Segmentation

PubMed Central

Farahi, Morteza; Rojas, Monica; Mañanas, Miguel Angel; Farina, Dario

2016-01-01

Knowledge of the location of muscle Innervation Zones (IZs) is important in many applications, e.g. for minimizing the quantity of injected botulinum toxin for the treatment of spasticity or for deciding on the type of episiotomy during child delivery. Surface EMG (sEMG) can be noninvasively recorded to assess physiological and morphological characteristics of contracting muscles. However, it is not often possible to record signals of high quality. Moreover, muscles could have multiple IZs, which should all be identified. We designed a fully-automatic algorithm based on the enhanced image Graph-Cut segmentation and morphological image processing methods to identify up to five IZs in 60-ms intervals of very-low to moderate quality sEMG signal detected with multi-channel electrodes (20 bipolar channels with Inter Electrode Distance (IED) of 5 mm). An anisotropic multilayered cylinder model was used to simulate 750 sEMG signals with signal-to-noise ratio ranging from -5 to 15 dB (using Gaussian noise) and in each 60-ms signal frame, 1 to 5 IZs were included. The micro- and macro- averaged performance indices were then reported for the proposed IZ detection algorithm. In the micro-averaging procedure, the number of True Positives, False Positives and False Negatives in each frame were summed up to generate cumulative measures. In the macro-averaging, on the other hand, precision and recall were calculated for each frame and their averages are used to determine F1-score. Overall, the micro (macro)-averaged sensitivity, precision and F1-score of the algorithm for IZ channel identification were 82.7% (87.5%), 92.9% (94.0%) and 87.5% (90.6%), respectively. For the correctly identified IZ locations, the average bias error was of 0.02±0.10 IED ratio. Also, the average absolute conduction velocity estimation error was 0.41±0.40 m/s for such frames. The sensitivity analysis including increasing IED and reducing interpolation coefficient for time samples was performed. Meanwhile, the effect of adding power-line interference and using other image interpolation methods on the deterioration of the performance of the proposed algorithm was investigated. The average running time of the proposed algorithm on each 60-ms sEMG frame was 25.5±8.9 (s) on an Intel dual-core 1.83 GHz CPU with 2 GB of RAM. The proposed algorithm correctly and precisely identified multiple IZs in each signal epoch in a wide range of signal quality and is thus a promising new offline tool for electrophysiological studies. PMID:27978535

[Delivery management for the prevention of shoulder dystocia in case of identified risk factors].

PubMed

Schmitz, T

2015-12-01

To determine the impact of (i) computed tomographic (CT) pelvimetry for the choice of the mode of delivery, (ii) cesarean, (iii) induction of labor, and of (iv) various delivery managements on the risk of shoulder dystocia in case of fetal macrosomia, with or without maternal diabetes, and in women with previous history of shoulder dystocia. The PubMed database, the Cochrane Library and the recommendations from the French and foreign obstetrical societies or colleges have been consulted. In case of clinically suspected macrosomia, a sonography should be performed to increase diagnostic performances and to assist in decision-making (Professional consensus). Because CT pelvimetry is associated with high false positive rates and increases cesarean deliveries, its use is not recommended to prevent shoulder dystocia in case of fetal macrosomia (Professional consensus). To avoid the neonatal complications of shoulder dystocia, mainly permanent brachial plexus palsy, cesarean delivery is recommended in case of estimated fetal weight (EFW) greater than 4500 g if associated with maternal diabetes (grade C), and greater than 5000 g in the absence of maternal diabetes (grade C). The published data do not provide definitive evidences to recommend systematic labor induction in case of impending fetal macrosomia (Professional consensus). In case of favourable cervix and gestational age greater than 39 weeks of gestation, labor induction should be promoted (Professional consensus). Prophylactic McRoberts maneuver is not recommended to prevent shoulder dystocia in case of fetal macrosomia (grade C). Because data are lacking, no recommendation is possible regarding the use of episiotomy. In case of fetal macrosomia and failure to progress in the second stage of labor, midpelvic and higher instrumental deliveries are not recommended and a cesarean delivery should be preferred (grade C), if the fetal head is at or lower than a +2 station, cesarean delivery is not recommended and an instrumental delivery should be preferred (grade C). Finally, cesarean delivery should be discussed when history of shoulder dystocia has been associated with severe neonatal or maternal complications (Professional consensus). To avoid shoulder dystocia and its complications, only two measures are proposed. Induction of labor is recommended in case of impending macrosomia if the cervix is favourable and gestational age greater than 39 weeks of gestation (Professional consensus). Cesarean delivery is recommended before labor in case of (i) EFW greater than 4500 g if associated with maternal diabetes (grade C), (ii) EFW greater than 5000 g in the absence of maternal diabetes (grade C), and finally (iii) during labor, in case of fetal macrosomia and failure to progress in the second stage, when the fetal head is above a +2 station (grade C). Finally, cesarean delivery should be discussed when history of shoulder dystocia has been associated with severe neonatal or maternal complications (Professional consensus). Copyright © 2015 Elsevier Masson SAS. All rights reserved.

NIH state-of-the-science conference statement on prevention of fecal and urinary incontinence in adults.

PubMed

To provide health care providers, patients, and the general public with a responsible assessment of currently available data on prevention of fecal and urinary incontinence in adults. A non-DHHS, nonadvocate 15-member panel representing the fields of geriatrics, nursing, gastroenterology, obstetrics and gynecology, internal medicine, urology, general surgery, oncology, neurosurgery, epidemiology, biostatistics, psychiatry, rehabilitation medicine, environmental health sciences, and healthcare financing. In addition, 21 experts from pertinent fields presented data to the panel and conference audience. Presentations by experts and a systematic review of the literature prepared by the Minnesota Evidence-based Practice Center, through the Agency for Healthcare Research and Quality. Scientific evidence was given precedence over anecdotal experience. The panel drafted its statement based on scientific evidence presented in open forum and on published scientific literature. The draft statement was presented on the final day of the conference and circulated to the audience for comment. The panel released a revised statement later that day at http://consensus.nih.gov. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government. (1) Fecal incontinence and urinary incontinence will affect more than one fourth of all U.S. adults during their lives. The natural history of fecal incontinence is unknown, and the natural history of urinary incontinence over several years is not well described. (2) Fecal incontinence and urinary incontinence often have serious effects on the lives of the many individuals who suffer physical discomfort, embarrassment, stigma, and social isolation, and on family members, caregivers, and society. Financial costs are substantial and may be underestimated because of underreporting. (3) Routine episiotomy is the most easily preventable risk factor for fecal incontinence. Risk factors for both fecal and urinary incontinence include female sex, older age, and neurologic disease (including stroke). Increased body mass, decreased physical activity, depression, and diabetes may also increase risk. (4) Pelvic floor muscle training and biofeedback are effective in preventing and reversing fecal and urinary incontinence in women for the first year after giving birth, and these approaches may also prevent or reduce urinary incontinence in older women and in men undergoing prostate surgery. Fecal and urinary incontinence may be prevented by lifestyle changes, such as weight loss and exercise. (5) Efforts to raise public awareness of incontinence and the benefits of prevention and management should aim to eliminate stigma, promote disclosure and care-seeking, and reduce suffering. Organized approaches to improving clinical detection of fecal and urinary incontinence are needed and require rigorous evaluation. (6) To reduce the suffering and burden of fecal and urinary incontinence, research is needed to establish underlying mechanisms, describe a classification system, determine natural history, classify persons according to their future risk for fecal or urinary incontinence, design interventions targeted to specific population groups, determine the effects of these interventions, and guide public policy.

Assessment of the implementation of the model of integrated and humanised midwifery health services in Chile.

PubMed

Binfa, Lorena; Pantoja, Loreto; Ortiz, Jovita; Gurovich, Marcela; Cavada, Gabriel; Foster, Jennifer

2016-04-01

in 2010, a pilot study was conducted among women who were attended by midwives in the public sector in Santiago, Chile. The purpose of that study was to evaluate the implementation of the 'Model of Integrated and Humanized Health Services', and the Clinical Guide for Humanized Attention during Labour and Childbirth. Results of that study indicated 92.7% of women had medically augmented labours (artificial rupture of the membranes, oxytocin and epidural analgesia). One third of the women reported discontent with the care they received. This study replicated the pilot study (2010) and was conducted in seven regional hospitals across Chile. The objectives were to : (i) describe selected obstetric and neonatal outcomes of women who received care according to this new guide, (ii) identify the level of maternal-neonatal well-being after experiencing this modality of attention, and (iii) explore professionals' perceptions (obstetricians and midwives), as well as consumers' perceptions of this humanised assistance during labour and childbirth. this is a cross sectional and descriptive, mixed methods study, conducted in two phases. The first phase was quantitative, measuring midwifery processes of care and maternal perceptions of well-being in labour and childbirth. The second phase was qualitative, exploring the perceptions of women, midwives and obstetricians regarding the discrepancy between the national guidelines and actual practice. maternity units from seven regional hospitals from the northern, central and southern regions and two metropolitan hospitals across Chile. 1882 parturient women in the quantitative phase (including the two Metropolitan hospitals published previously). Twenty-six focus groups discussions (FGD) participated from the regional and metropolitan hospitals for the qualitative phase. MEASUREMENTS/FINDINGS: all women started labour spontaneously; 74% of women had spontaneous vaginal childbirth. Caesarean section was the outcome for 20%, and 6% had childbirth assisted with forceps. A high number of medical interventions continued to be performed in all regions, deviating widely from adherence to the national clinical guidelines. Most of the women did not receive any oral hydration, almost all received intravenous hydration; most were under continuous foetal monitoring and medically augmented labour. The majority of women received artificial rupture of membranes, epidural anaesthesia and episiotomy. Most delivered in the lithotomy position. Two thirds of women surveyed perceived adequate well-being in labour and childbirth. Findings from focus group discussions of women (FGD=9; n=27 women), midwives (FGD=9; n=40) and doctors (FGD=8; n=29) indicated lack of infrastructure for family participation in birth, inadequate training and orientation to the national guidelines for practice, and lack of childbirth preparation among women. Some women reported mistreatment by personnel. Some midwives reported lack of autonomy to manage birth physiologically. birth is managed by midwives across the public sector in Chile. Despite evidence-based guidelines published in 2007 by the Ministry of Health, birth is not managed according to the guidelines in most cases. Women feel that care is adequate, although some women report mistreatment. efforts to provide midwife-led care and include women in participatory models of antenatal care are recommended to promote women-centred care in accordance with the Chilean national guidelines. Copyright © 2016 Elsevier Ltd. All rights reserved.

Survey of women׳s experiences of care in a new freestanding midwifery unit in an inner city area of London, England: 2. Specific aspects of care

PubMed Central

Macfarlane, Alison J.; Rocca-Ihenacho, Lucia; Turner, Lyle R.

2014-01-01

Objective to describe and compare women׳s experiences of specific aspects of maternity care before and after the opening of the Barkantine Birth Centre, a new freestanding midwifery unit in an inner city area. Design telephone surveys undertaken in late pregnancy and about six weeks after birth. Two separate waves of interviews were conducted, Phase 1 before the birth centre opened and Phase 2 after it had opened. Setting Tower Hamlets, a deprived inner city borough in east London, 2007–2010. Participants 620 women who were resident in Tower Hamlets and who satisfied the Barts and the London Trust’s eligibility criteria for using the birth centre. Of these, 259 women were recruited to Phase 1 and 361 to Phase 2. Measurements and findings the replies women gave show marked differences between the model of care in the birth centre and that at the obstetric unit at the Royal London Hospital with respect to experiences of care and specific practices. Women who initially booked for birth centre care were more likely to attend antenatal classes and find them useful and were less likely to be induced. Women who started labour care at the birth centre in spontaneous labour were more likely to use non-pharmacological methods of pain relief, most notably water and less likely to use pethidine than women who started care at the hospital. They were more likely to be able to move around in labour and less likely to have their membranes ruptured or have continuous CTG. They were more likely to be told to push spontaneously when they needed to rather than under directed pushing and more likely to report that they had been able to choose their position for birth and deliver in places other than the bed, in contrast to the situation at the hospital. The majority of women who had a spontaneous onset of labour delivered vaginally, with 28.6 per cent of women at the birth centre but no one at the hospital delivering in water. Primiparous women who delivered at the birth centre were less likely to have an episiotomy. Most women who delivered at the birth centre reported that they had chosen whether or not to have a physiological third stage, whereas a worrying proportion at the hospital reported that they had not had a choice. A higher proportion of women at the birth centre reported skin to skin contact with their baby in the first two hours after birth. Key conclusions and implications for practice significant differences were reported between the hospital and the birth centre in practices and information given to the women, with lower rates of intervention, more choice and significant differences in women’s experiences. This case study of a single inner-city freestanding midwifery unit, linked to the Birthplace in England Research Programme, indicates that this model of care also leads to greater choice and a better experience for women who opted for it. PMID:24929271

Survey of women's experiences of care in a new freestanding midwifery unit in an inner city area of London, England: 2. Specific aspects of care.

PubMed

Macfarlane, Alison J; Rocca-Ihenacho, Lucia; Turner, Lyle R

2014-09-01

to describe and compare women's experiences of specific aspects of maternity care before and after the opening of the Barkantine Birth Centre, a new freestanding midwifery unit in an inner city area. telephone surveys undertaken in late pregnancy and about six weeks after birth. Two separate waves of interviews were conducted, Phase 1 before the birth centre opened and Phase 2 after it had opened. Tower Hamlets, a deprived inner city borough in east London, 2007-2010. 620 women who were resident in Tower Hamlets and who satisfied the Barts and the London Trust's eligibility criteria for using the birth centre. Of these, 259 women were recruited to Phase 1 and 361 to Phase 2. the replies women gave show marked differences between the model of care in the birth centre and that at the obstetric unit at the Royal London Hospital with respect to experiences of care and specific practices. Women who initially booked for birth centre care were more likely to attend antenatal classes and find them useful and were less likely to be induced. Women who started labour care at the birth centre in spontaneous labour were more likely to use non-pharmacological methods of pain relief, most notably water and less likely to use pethidine than women who started care at the hospital. They were more likely to be able to move around in labour and less likely to have their membranes ruptured or have continuous CTG. They were more likely to be told to push spontaneously when they needed to rather than under directed pushing and more likely to report that they had been able to choose their position for birth and deliver in places other than the bed, in contrast to the situation at the hospital. The majority of women who had a spontaneous onset of labour delivered vaginally, with 28.6 per cent of women at the birth centre but no one at the hospital delivering in water. Primiparous women who delivered at the birth centre were less likely to have an episiotomy. Most women who delivered at the birth centre reported that they had chosen whether or not to have a physiological third stage, whereas a worrying proportion at the hospital reported that they had not had a choice. A higher proportion of women at the birth centre reported skin to skin contact with their baby in the first two hours after birth. significant differences were reported between the hospital and the birth centre in practices and information given to the women, with lower rates of intervention, more choice and significant differences in women's experiences. This case study of a single inner-city freestanding midwifery unit, linked to the Birthplace in England Research Programme, indicates that this model of care also leads to greater choice and a better experience for women who opted for it. Copyright © 2014. Published by Elsevier Ltd.

Etude du pronostic maternel et périnatal au cours de l’accouchement chez l’adolescente à Lubumbashi, République Démocratique du Congo

PubMed Central

Luhete, Prosper Kakudji; Mukuku, Olivier; Tambwe, Albert Mwembo; Kayamba, Prosper Kalenga Muenze

2017-01-01

Introduction L’objectif de cette étude était de déterminer la fréquence et d’évaluer le pronostic maternel et périnatal lors de l’accouchement chez les adolescentes dans la ville de Lubumbashi. Méthodes C’était une étude cas-témoin des accouchées d’une grossesse monofoetale de Décembre 2013 à Mai 2014 dans 10 maternités de référence à Lubumbashi (RD Congo). Les adolescentes (< 20 ans) ont été comparées aux femmes âgées de 20-34 ans. Les paramètres sociodémographiques maternels, la morbi-mortalité maternelle et périnatale ont été analysées. Les statistiques usuelles et la régression logistique ont été utilisées pour analyser les résultats. Le seuil de signification a été fixé à une valeur de p<0,05. Résultats La fréquence d’accouchement chez les adolescentes était de 7,7%. Nous avons observé que la césarienne (ORa=1,9 (1,1-3,1)), l’épisiotomie (ORa=4,2 (2,9-5,9)), la délivrance pathologique (ORa= 2,7 (1,1-6,5)), l’éclampsie (ORa= 4,4 (1,3-14,5)) et le faible poids de naissance (ORa=2,0 (1,3-3,0)) ont été significativement plus élevés chez les adolescentes que chez les adultes. Conclusion L’accouchement chez les adolescentes, comparativement à celui de femmes âgées de 20-34 ans, reste associé à un mauvais pronostic. D’où l’organisation des séances de sensibilisation pour une meilleure fréquentation des services consultations prénatales, une optimisation du dépistage, de la surveillance et de la prévention des pathologies de la grossesse chez les adolescentes s’avère importante et urgente. Introduction This study aimed to determine the frequency and to assess maternal and perinatal prognosis for vaginal delivery in adolescent girls in the city of Lubumbashi. Methods We conducted a case-control study of vaginal deliveries in singleton pregnancy in 10 referral hospitals in Lubumbashi (DR Congo) from December 2013 to May 2014. Adolescent girls (< 20 years) were compared to older women aged 20-34 years. Maternal sociodemographic parameters, morbi-maternal and perinatal mortality were analyzed. Usual statistics and logistic regression were used to analyze the results. The significance level was set at p <0.05. Results Vaginal delivery rate among adolescent girls was 7.7%. Cesarean section (OR=1.9 (1.1-3.1)), episiotomy (OR=4.2 (2.9-5.9)), pathological delivery (OR=2.7 (1.1-6.5)), eclampsia (OR=4.4 (1.3-14.5)) and low birth weight (OR=2.0 (1.3-3.0)) were significantly higher among adolescent girls than in adults. Conclusion Vaginal delivery in adolescent girls, compared to that of older women aged 20-34 years, is associated with a poor prognosis. Hence the importance and the urgent need to implement awareness sessions to increase attendance to prenatal consultation services, for screening optimization, monitoring and prevention for pregnancy pathologies in adolescent girls. PMID:28674575

Instrumental delivery: clinical practice guidelines from the French College of Gynaecologists and Obstetricians.

PubMed

Vayssière, Christophe; Beucher, Gael; Dupuis, Olivier; Feraud, Olivia; Simon-Toulza, Caroline; Sentilhes, Loïc; Meunier, Emmanuelle; Parant, Olivier; Schmitz, Thomas; Riethmuller, Didier; Baud, Olivier; Galley-Raulin, Fabienne; Diemunsch, Pierre; Pierre, Fabrice; Schaal, Jean-Patrick; Fournié, Alain; Oury, Jean François

2011-11-01

Routine use of a partograph is associated with a reduction in the use of forceps, but is not associated with a reduction in the use of vacuum extraction (Level A). Early artificial rupture of the membranes, associated with oxytocin perfusion, does not reduce the number of operative vaginal deliveries (Level A), but does increase the rate of fetal heart rate abnormalities (Level B). Early correction of lack of progress in dilatation by oxytocin perfusion can reduce the number of operative vaginal deliveries (Level B). The use of low-concentration epidural infusions of bupivacaine potentiated by morphinomimetics reduces the number of operative interventions compared with larger doses (Level A). Placement of an epidural before 3-cm dilatation does not increase the number of operative vaginal deliveries (Level A). Posterior positions of the fetus result in more operative vaginal deliveries (Level B). Manual rotation of the fetus from a posterior position to an anterior position may reduce the number of operative deliveries (Level C). Walking during labour is not associated with a reduction in the number of operative vaginal deliveries (Level A). Continuous support of the parturient by a midwife or partner/family member during labour reduces the number of operative vaginal deliveries (Level A). Under epidural analgesia, delayed pushing (2h after full dilatation) reduces the number of difficult operative vaginal deliveries (Level A). Ultrasound is recommended if there is any clinical doubt about the presentation of the fetus (Level B). The available scientific data are insufficient to contra-indicate attempted midoperative delivery (professional consensus). The duration of the operative intervention is slightly shorter with forceps than with a vacuum extractor (Level C). Nonetheless, the urgency of operative delivery is not a reason to choose one instrument over another (professional consensus). The cup-shaped vacuum extractor seems to be the instrument of choice for operative deliveries of fetuses in a cephalic transverse position, and may also be preferred for fetuses in a posterior position (professional consensus). Vacuum extraction deliveries fail more often than forceps deliveries (Level B). Overall, immediate maternal complications are more common for forceps deliveries than vacuum extraction deliveries (Level B). Compared with forceps, operative vaginal delivery using a vacuum extractor appears to reduce the number of episiotomies (Level B), first- and second-degree perineal lesions, and damage to the anal sphincter (Level B). Among the long-term complications, the rate of urinary incontinence is similar following forceps, vacuum extraction and spontaneous vaginal deliveries (Level B). Anal incontinence is more common following forceps delivery (Level B). Persistent anal incontinence has a similar prevalence regardless of the mode of delivery (caesarean or vaginal, instrumental or non-instrumental), suggesting the involvement of other factors (Level B). Rates of immediate neonatal mortality and morbidity are similar for forceps and vacuum extraction deliveries (Level B). It appears that difficult instrumental delivery may lead to psychological sequelae that may result in a decision not to have more children (Level C). The rates of neonatal convulsions, intracranial haemorrhage and jaundice do not differ between forceps and vacuum extraction deliveries (Levels B and C). Rapid sequence induction with a Sellick manoeuvre (pressure to the cricoid cartilage) and tracheal intubation with a balloon catheter is recommended for any general anaesthesia (Level B). Training must ensure that obstetricians can identify indications and contra-indications, choose the appropriate instrument, use the instruments correctly, and know the principles of quality control applied to operative vaginal delivery. Nowadays, traditional training can be accompanied by simulations. Training should be individualized and extended for some students. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

Midwife-led continuity models versus other models of care for childbearing women.

PubMed

Sandall, Jane; Soltani, Hora; Gates, Simon; Shennan, Andrew; Devane, Declan

2016-04-28

Midwives are primary providers of care for childbearing women around the world. However, there is a lack of synthesised information to establish whether there are differences in morbidity and mortality, effectiveness and psychosocial outcomes between midwife-led continuity models and other models of care. To compare midwife-led continuity models of care with other models of care for childbearing women and their infants. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (25 January 2016) and reference lists of retrieved studies. All published and unpublished trials in which pregnant women are randomly allocated to midwife-led continuity models of care or other models of care during pregnancy and birth. Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. The quality of the evidence was assessed using the GRADE approach. We included 15 trials involving 17,674 women. We assessed the quality of the trial evidence for all primary outcomes (i.e. regional analgesia (epidural/spinal), caesarean birth, instrumental vaginal birth (forceps/vacuum), spontaneous vaginal birth, intact perineum, preterm birth (less than 37 weeks) and all fetal loss before and after 24 weeks plus neonatal death using the GRADE methodology: all primary outcomes were graded as of high quality.For the primary outcomes, women who had midwife-led continuity models of care were less likely to experience regional analgesia (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.78 to 0.92; participants = 17,674; studies = 14; high quality), instrumental vaginal birth (average RR 0.90, 95% CI 0.83 to 0.97; participants = 17,501; studies = 13; high quality), preterm birth less than 37 weeks (average RR 0.76, 95% CI 0.64 to 0.91; participants = 13,238; studies = eight; high quality) and less all fetal loss before and after 24 weeks plus neonatal death (average RR 0.84, 95% CI 0.71 to 0.99; participants = 17,561; studies = 13; high quality evidence). Women who had midwife-led continuity models of care were more likely to experience spontaneous vaginal birth (average RR 1.05, 95% CI 1.03 to 1.07; participants = 16,687; studies = 12; high quality). There were no differences between groups for caesarean births or intact perineum.For the secondary outcomes, women who had midwife-led continuity models of care were less likely to experience amniotomy (average RR 0.80, 95% CI 0.66 to 0.98; participants = 3253; studies = four), episiotomy (average RR 0.84, 95% CI 0.77 to 0.92; participants = 17,674; studies = 14) and fetal loss less than 24 weeks and neonatal death (average RR 0.81, 95% CI 0.67 to 0.98; participants = 15,645; studies = 11). Women who had midwife-led continuity models of care were more likely to experience no intrapartum analgesia/anaesthesia (average RR 1.21, 95% CI 1.06 to 1.37; participants = 10,499; studies = seven), have a longer mean length of labour (hours) (mean difference (MD) 0.50, 95% CI 0.27 to 0.74; participants = 3328; studies = three) and more likely to be attended at birth by a known midwife (average RR 7.04, 95% CI 4.48 to 11.08; participants = 6917; studies = seven). There were no differences between groups for fetal loss equal to/after 24 weeks and neonatal death, induction of labour, antenatal hospitalisation, antepartum haemorrhage, augmentation/artificial oxytocin during labour, opiate analgesia, perineal laceration requiring suturing, postpartum haemorrhage, breastfeeding initiation, low birthweight infant, five-minute Apgar score less than or equal to seven, neonatal convulsions, admission of infant to special care or neonatal intensive care unit(s) or in mean length of neonatal hospital stay (days).Due to a lack of consistency in measuring women's satisfaction and assessing the cost of various maternity models, these outcomes were reported narratively. The majority of included studies reported a higher rate of maternal satisfaction in midwife-led continuity models of care. Similarly, there was a trend towards a cost-saving effect for midwife-led continuity care compared to other care models. This review suggests that women who received midwife-led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care with at least comparable adverse outcomes for women or their infants than women who received other models of care.Further research is needed to explore findings of fewer preterm births and fewer fetal deaths less than 24 weeks, and all fetal loss/neonatal death associated with midwife-led continuity models of care.

Midwife-led continuity models versus other models of care for childbearing women.

PubMed

Sandall, Jane; Soltani, Hora; Gates, Simon; Shennan, Andrew; Devane, Declan

2015-09-15

Midwives are primary providers of care for childbearing women around the world. However, there is a lack of synthesised information to establish whether there are differences in morbidity and mortality, effectiveness and psychosocial outcomes between midwife-led continuity models and other models of care. To compare midwife-led continuity models of care with other models of care for childbearing women and their infants. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 May 2015) and reference lists of retrieved studies. All published and unpublished trials in which pregnant women are randomly allocated to midwife-led continuity models of care or other models of care during pregnancy and birth. Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy. We included 15 trials involving 17,674 women. We assessed the quality of the trial evidence for all primary outcomes (i.e., regional analgesia (epidural/spinal), caesarean birth, instrumental vaginal birth (forceps/vacuum), spontaneous vaginal birth, intact perineum, preterm birth (less than 37 weeks) and overall fetal loss and neonatal death (fetal loss was assessed by gestation using 24 weeks as the cut-off for viability in many countries) using the GRADE methodology: All primary outcomes were graded as of high quality.For the primary outcomes, women who had midwife-led continuity models of care were less likely to experience regional analgesia (average risk ratio (RR) 0.85, 95% confidence interval (CI) 0.78 to 0.92; participants = 17,674; studies = 14; high quality), instrumental vaginal birth (average RR 0.90, 95% CI 0.83 to 0.97; participants = 17,501; studies = 13; high quality), preterm birth less than 37 weeks (average RR 0.76, 95% CI 0.64 to 0.91; participants = 13,238; studies = 8; high quality) and less overall fetal/neonatal death (average RR 0.84, 95% CI 0.71 to 0.99; participants = 17,561; studies = 13; high quality evidence). Women who had midwife-led continuity models of care were more likely to experience spontaneous vaginal birth (average RR 1.05, 95% CI 1.03 to 1.07; participants = 16,687; studies = 12; high quality). There were no differences between groups for caesarean births or intact perineum.For the secondary outcomes, women who had midwife-led continuity models of care were less likely to experience amniotomy (average RR 0.80, 95% CI 0.66 to 0.98; participants = 3253; studies = 4), episiotomy (average RR 0.84, 95% CI 0.77 to 0.92; participants = 17,674; studies = 14) and fetal loss/neonatal death before 24 weeks (average RR 0.81, 95% CI 0.67 to 0.98; participants = 15,645; studies = 11). Women who had midwife-led continuity models of care were more likely to experience no intrapartum analgesia/anaesthesia (average RR 1.21, 95% CI 1.06 to 1.37; participants = 10,499; studies = 7), have a longer mean length of labour (hours) (mean difference (MD) 0.50, 95% CI 0.27 to 0.74; participants = 3328; studies = 3) and more likely to be attended at birth by a known midwife (average RR 7.04, 95% CI 4.48 to 11.08; participants = 6917; studies = 7). There were no differences between groups for fetal loss or neonatal death more than or equal to 24 weeks, induction of labour, antenatal hospitalisation, antepartum haemorrhage, augmentation/artificial oxytocin during labour, opiate analgesia, perineal laceration requiring suturing, postpartum haemorrhage, breastfeeding initiation, low birthweight infant, five-minute Apgar score less than or equal to seven, neonatal convulsions, admission of infant to special care or neonatal intensive care unit(s) or in mean length of neonatal hospital stay (days).Due to a lack of consistency in measuring women's satisfaction and assessing the cost of various maternity models, these outcomes were reported narratively. The majority of included studies reported a higher rate of maternal satisfaction in midwife-led continuity models of care. Similarly, there was a trend towards a cost-saving effect for midwife-led continuity care compared to other care models. This review suggests that women who received midwife-led continuity models of care were less likely to experience intervention and more likely to be satisfied with their care with at least comparable adverse outcomes for women or their infants than women who received other models of care.Further research is needed to explore findings of fewer preterm births and fewer fetal deaths less than 24 weeks, and overall fetal loss/neonatal death associated with midwife-led continuity models of care.

Routine antibiotic prophylaxis after normal vaginal birth for reducing maternal infectious morbidity.

PubMed

Bonet, Mercedes; Ota, Erika; Chibueze, Chioma E; Oladapo, Olufemi T

2017-11-13

Infectious morbidities contribute to considerable maternal and perinatal morbidity and mortality, including women at no apparent increased risk of infection. To reduce the incidence of infections, antibiotics are often administered to women after uncomplicated childbirth, particularly in settings where women are at higher risk of puerperal infectious morbidities. To assess whether routine administration of prophylactic antibiotics to women after normal (uncomplicated) vaginal birth, compared with placebo or no antibiotic prophylaxis, reduces postpartum maternal infectious morbidities and improves outcomes. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2017), LILACS, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (22 August 2017) and reference lists of retrieved studies. We planned to include randomised or quasi-randomised trials evaluating the use of prophylactic antibiotics versus placebo or no antibiotic prophylaxis. Trials using a cluster-randomised design would have been eligible for inclusion, but we found none.In future updates of this review, we will include studies published in abstract form only, provided sufficient information is available to assess risks of bias. We will consider excluded abstracts for inclusion once the full publication is available, or the authors provide more information.Trials using a cross-over design are not eligible for inclusion in this review. Two review authors conducted independent assessment of trials for inclusion and risks of bias. They independently extracted data and checked them for accuracy, resolving differences in assessments by discussion. They evaluated methodological quality using standard Cochrane criteria and the GRADE approach.We present the summaries as risk ratios (RRs) and mean difference (MDs) using fixed- or random-effect models. For one primary outcome we found considerable heterogeneity and interaction. We explored further using subgroup analysis to investigate the effects of the randomisation unit. All review authors discussed and interpreted the results. One randomised controlled trial (RCT) and two quasi-RCTs contributed data on 1779 women who had uncomplicated vaginal births, comparing different antibiotic regimens with placebo or no treatment. The included trials took place in the 1960s (one trial) and 1990s (two trials). The trials were conducted in France, the USA and Brazil. Antibiotics administered included: oral sulphamethoxypyridazine or chloramphenicol for three to five days, and intravenous amoxicillin and clavulanic acid in a single dose one hour after birth. We rated most of the domains for risk of bias as high risk, with the exception of reporting bias and other potential bias.The quality of evidence ranged from low to very low, based on the GRADE quality assessment, given very serious design limitations of the included studies, few events and wide confidence intervals (CIs) of effect estimates.We found a decrease in the risk of endometritis (RR 0.28, 95% CI 0.09 to 0.83, two trials, 1364 women,very low quality). However, one trial reported zero events for this outcome and we rate the evidence as very low quality. There was little or no difference between groups for the risk of urinary tract infection (RR 0.25, 95% CI 0.05 to 1.19, two trials, 1706 women,low quality), wound infection after episiotomy (reported as wound dehiscence in the included trials) (RR 0.78, 95% CI 0.31 to 1.96, two trials, 1364 women, very low quality) and length of maternal hospital stay in days (MD -0.15, 95% CI -0.31 to 0.01, one trial, 1291 women, very low quality). Cost of care in US dollar equivalent was 2½ times higher in the control group compared to the group receiving antibiotics prophylaxis (USD 3600: USD 9000, one trial, 1291 women). There were few or no differences between treated and control groups for adverse effects of antibiotics (skin rash) reported in one woman in each of the two trials (RR 3.03, 95% CI 0.32 to 28.95, two trials, 1706 women, very low quality). The incidence of severe maternal infectious morbidity, antimicrobial resistance or women's satisfaction with care were not addressed by any of the included studies. Routine administration of antibiotics may reduce the risk of endometritis after uncomplicated vaginal birth. The small number and nature of the trials limit the interpretation of the evidence for application in practice, particularly in settings where women may be at higher risk of developing endometritis. The use of antibiotics did not reduce the incidence of urinary tract infections, wound infection or the length of maternal hospital stay. Antibiotics are not a substitute for infection prevention and control measures around the time of childbirth and the postpartum period. The decision to routinely administer prophylactic antibiotics after normal vaginal births needs to be balanced by patient features, childbirth setting and provider experience, including considerations of the contribution of indiscriminate use of antibiotics to raising antimicrobial resistance. Well-designed and high-powered randomised controlled trials would help to evaluate the added value of routine antibiotic administration as a measure to prevent maternal infections after normal vaginal delivery.

Oral non-steroidal anti-inflammatory drugs (single dose) for perineal pain in the early postpartum period.

PubMed

Wuytack, Francesca; Smith, Valerie; Cleary, Brian J

2016-07-14

Many women experience perineal pain after childbirth, especially after having sustained perineal trauma. Perineal pain-management strategies are thus an important part of postnatal care. Non-steroidal anti-inflammatory drugs (NSAIDs) are a commonly used type of medication in the management of postpartum pain and their effectiveness and safety should be assessed. To determine the effectiveness of a single dose of an oral NSAID for relief of acute perineal pain in the early postpartum period. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 March 2016), OpenSIGLE, ProQuest Dissertations and Theses, the ISRCTN Registry and ClinicalTrials.gov (31 March 2016). We also reviewed reference lists of retrieved papers and contacted experts in the field. Randomised controlled trials (RCTs) assessing a single dose of a NSAID versus a single dose of placebo, paracetamol or another NSAID for women with perineal pain in the early postpartum period. Quasi-RCTs and cross-over trials were excluded. Two review authors (FW and VS) independently assessed all identified papers for inclusion and risk of bias. Any discrepancies were resolved through discussion and consensus. Data extraction, including calculations of pain relief scores, was also conducted independently by two review authors and checked for accuracy. We included 28 studies that examined 13 different NSAIDs and involved 4181 women (none of whom were breastfeeding). Studies were published between 1967 and 2013, with the majority published in the 1980s. Of the 4181 women involved in the studies, 2642 received a NSAID and 1539 received placebo or paracetamol. Risk of bias was generally unclear due to poor reporting, but in most studies the participants and personnel were blinded, outcome data were complete and the outcomes that were specified in the methods section were reported.None of the included studies reported on any of this review's secondary outcomes: prolonged hospitalisation or re-hospitalisation due to perineal pain; breastfeeding (fully or mixed) at discharge; breastfeeding (fully or mixed) at six weeks; perineal pain at six weeks; maternal views; postpartum depression; instrumental measures of disability due to perineal pain. NSAID versus placeboCompared to women who received a placebo, more women who received a single dose NSAID achieved adequate pain relief at four hours (risk ratio (RR) 1.91, 95% confidence interval (CI) 1.64 to 2.23, 10 studies, 1573 participants (low-quality evidence)) and adequate pain relief at six hours (RR 1.92, 95% CI 1.69 to 2.17, 17 studies, 2079 participants (very low-quality evidence)). Women who received a NSAID were also less likely to need additional analgesia compared to women who received placebo at four hours (RR 0.39, 95% CI 0.26 to 0.58, four studies, 486 participants (low-quality evidence)) and at six hours after initial administration (RR 0.32, 95% CI 0.26 to 0.40, 10 studies, 1012 participants (low-quality evidence)). Fourteen maternal adverse effects were reported in the NSAID group (drowsiness (5), abdominal discomfort (2), weakness (1), dizziness (2), headache (2), moderate epigastralgia (1), not specified (1)) and eight in the placebo group (drowsiness (2), light headed (1), nausea (1), backache (1), dizziness (1), epigastric pain (1), not specified (1)), although not all studies assessed adverse effects. There was no difference in overall maternal adverse effects between NSAIDs and placebo at six hours post-administration (RR 1.38, 95% CI 0.71 to 2.70, 13 studies, 1388 participants (very low-quality evidence)). One small study (with two treatment arms) assessed maternal adverse effects at four hours post-administration, but there were no maternal adverse effects observed (one study, 90 participants (low-quality evidence)). Neonatal adverse effects were not assessed in any of the included studies. NSAID versus paracetamolNSAIDs versus paracetamol were also more effective for adequate pain relief at four hours (RR 1.54, 95% CI 1.07 to 2.22, three studies, 342 participants) but not at six hours post-administration. There was no difference in the need for additional analgesia between the two groups at four hours (RR 0.55, 95% CI 0.27 to 1.13, one study, 73 participants), but women in the NSAID group were less likely to need any additional analgesia at six hours (RR 0.28, 95% CI 0.12 to 0.67, one study, 59 participants). No maternal adverse effects were reported four hours after drug administration (one study). Six hours post-administration, there was no difference between the groups in the number of maternal adverse effects (RR 0.74, 95% CI 0.27 to 2.08, three studies, 300 participants), with one case of pruritis in the NSAID group and one case of sleepiness in the paracetamol group. Neonatal adverse effects were not assessed in any of the included studies.Comparisons of different NSAIDs and different doses of the same NSAID did not demonstrate any differences in their effectiveness on any of the primary outcome measures; however, few data were available on some NSAIDs. In women who are not breastfeeding and who sustained perineal trauma, NSAIDs (compared to placebo) provide greater pain relief for acute postpartum perineal pain and fewer women need additional analgesia when treated with a NSAID. However, the risk of bias was unclear for many of the included studies, adverse effects were often not assessed and breastfeeding women were not included in the studies. The overall quality of the evidence (GRADE) was low with the evidence for all outcomes rated as low or very low. The main reasons for downgrading were inclusion of studies with high risk of bias and inconsistency of findings of individual studies.NSAIDs also appear to be more effective in providing relief for perineal pain than paracetamol, but few studies were included in this analysis.Future studies should examine NSAIDs' adverse effects profile including neonatal adverse effects and the compatibility of NSAIDs with breastfeeding, and assess other important secondary outcomes of this review. Moreover, studies mostly included women who had episiotomies. Future research should consider women with and without perineal trauma, including perineal tears. High-quality studies should be conducted to further assess the efficacy of NSAIDs versus paracetamol and the efficacy of multimodal treatments.

Portable bladder ultrasound: an evidence-based analysis.

PubMed

2006-01-01

The aim of this review was to assess the clinical utility of portable bladder ultrasound. TARGET POPULATION AND CONDITION Data from the National Population Health Survey indicate prevalence rates of urinary incontinence are 2.5% in women and 1.4 % in men in the general population. Prevalence of urinary incontinence is higher in women than men and prevalence increases with age. Identified risk factors for urinary incontinence include female gender, increasing age, urinary tract infections (UTI), poor mobility, dementia, smoking, obesity, consuming alcohol and caffeine beverages, physical activity, pregnancy, childbirth, forceps and vacuum-assisted births, episiotomy, abdominal resection for colorectal cancer, and hormone replacement therapy. For the purposes of this review, incontinence populations will be stratified into the following; the elderly, urology patients, postoperative patients, rehabilitation settings, and neurogenic bladder populations. Urinary incontinence is defined as any involuntary leakage of urine. Incontinence can be classified into diagnostic clinical types that are useful in planning evaluation and treatment. The major types of incontinence are stress (physical exertion), urge (overactive bladder), mixed (combined urge and stress urinary incontinence), reflex (neurological impairment of the central nervous system), overflow (leakage due to full bladder), continuous (urinary tract abnormalities), congenital incontinence, and transient incontinence (temporary incontinence). Postvoid residual (PVR) urine volume, which is the amount of urine in the bladder immediately after urination, represents an important component in continence assessment and bladder management to provide quantitative feedback to the patient and continence care team regarding the effectiveness of the voiding technique. Although there is no standardized definition of normal PVR urine volume, measurements greater than 100 mL to 150 mL are considered an indication for urinary retention, requiring intermittent catheterization, whereas a PVR urine volume of 100 mL to 150 mL or less is generally considered an acceptable result of bladder training. Urinary retention has been associated with poor outcomes including UTI, bladder overdistension, and higher hospital mortality rates. The standard method of determining PVR urine volumes is intermittent catheterization, which is associated with increased risk of UTI, urethral trauma and discomfort. Portable bladder ultrasound products are transportable ultrasound devices that use automated technology to register bladder volume digitally, including PVR volume, and provide three-dimensional images of the bladder. The main clinical use of portable bladder ultrasound is as a diagnostic aid. Health care professionals (primarily nurses) administer the device to measure PVR volume and prevent unnecessary catheterization. An adjunctive use of the bladder ultrasound device is to visualize the placement and removal of catheters. Also, portable bladder ultrasound products may improve the diagnosis and differentiation of urological problems and their management and treatment, including the establishment of voiding schedules, study of bladder biofeedback, fewer UTIs, and monitoring of potential urinary incontinence after surgery or trauma. To determine the effectiveness and clinical utility of portable bladder ultrasound as reported in the published literature, the Medical Advisory Secretariat used its standard search strategy to retrieve international health technology assessments and English-language journal articles from selected databases. Nonsystematic reviews, nonhuman studies, case reports, letters, editorials, and comments were excluded. Of the 4 included studies that examined the clinical utility of portable bladder ultrasound in the elderly population, all found the device to be acceptable. One study reported that the device underestimated catheterized bladder volume In patients with urology problems, 2 of the 3 studies concerning portable bladder ultrasound found the device acceptable to use. However, one study did not find the device as accurate for small PVR volume as for catheterization and another found that the device overestimated catheterized bladder volume. In the remaining study, the authors reported that when the device's hand-held ultrasound transducers (scanheads) were aimed improperly, bladders were missed, or lateral borders of bladders were missed resulting in partial bladder volume measurements and underestimation of PVR measurements. They concluded that caution should be used in interpreting PVR volume measured by portable bladder ultrasound machines and that catheterization may be the preferred assessment modality if an accurate PVR measurement is necessary. All 3 studies with post-operative populations found portable bladder ultrasound use to be reasonably acceptable. Two studies reported that the device overestimated catheter-derived bladder volumes, one by 7% and the other by 21 mL. The third study reported the opposite, that the device underestimated catheter bladder volume by 39 mL but that the results remained acceptable In rehabilitation settings, 2 studies found portable bladder ultrasound to underestimate catheter-derived bladder volumes; yet, both authors concluded that the mean errors were within acceptable limits. In patients with neurogenic bladder problems, 2 studies found portable bladder ultrasound to be an acceptable alternative to catheterization despite the fact that it was not as accurate as catheterization for obtaining bladder volumes. Lastly, examinations concerning avoidance of negative health outcomes showed that, after use of the portable bladder ultrasound, unnecessary catheterizations and UTIs were decreased. Unnecessary catheterizations avoided ranged from 16% to 47% in the selected articles. Reductions in UTI ranged from 38% to 72%. In sum, all but one study advocated the use of portable bladder ultrasound as an alternative to catheterization. An economic analysis estimating the budget-impact of BladderScan in complex continuing care facilities was completed. The analysis results indicated a $192,499 (Cdn) cost-savings per year per facility and a cost-savings of $2,887,485 (Cdn) for all 15 CCC facilities. No economic analysis was completed for long-term care and acute care facilities due to lack of data. Rapid diffusion of portable bladder ultrasound technology is expected. Recently, the IC5 project on improving continence care in Ontario's complex continuing care centres piloted portable bladder ultrasound at 12 sites. Preliminary results were promising. Many physicians and health care facilities already have portable bladder ultrasound devices. However, portable bladder ultrasound devices for PVR measurement are not in use at most health care facilities in Ontario and Canada. The Verathon Corporation (Bothell, Wisconsin, United States), which patents BladderScan, is the sole licensed manufacturer of the portable bladder ultrasound in Canada. Field monopoly may influence the rising costs of portable bladder ultrasound, particularly when faced with rapid expansion of the technology. Several thousand residents of Ontario would benefit from portable bladder ultrasound. The number of residents of Ontario that would benefit from the technology is difficult to quantify, because the incidence and prevalence of incontinence are grossly under-reported. However, long-term care and complex continuing care institutions would benefit greatly from portable bladder ultrasound, as would numerous rehabilitation units, postsurgical care units, and urology clinics. The cost of the portable bladder ultrasound devices ranges from $17,698.90 to $19,565.95 (Cdn) (total purchase price per unit as quoted by the manufacturer). Additional training packages, batteries and battery chargers, software, gel pads, and yearly warranties are additional costs. Studies indicate that portable bladder ultrasound is a cost-effective technology, because it avoids costs associated with catheterization equipment, saves nursing time, and reduces catheter-related complications and UTIs. The use of portable bladder ultrasound device will affect the patient directly in terms of health outcomes. Its use avoids the trauma related to the urinary tract that catheterization inflicts, and does not result in UTIs. In addition, patients prefer it, because it preserves dignity and reduces discomfort.

Portable Bladder Ultrasound

PubMed Central

2006-01-01

Executive Summary Objective The aim of this review was to assess the clinical utility of portable bladder ultrasound. Clinical Need: Target Population and Condition Data from the National Population Health Survey indicate prevalence rates of urinary incontinence are 2.5% in women and 1.4 % in men in the general population. Prevalence of urinary incontinence is higher in women than men and prevalence increases with age. Identified risk factors for urinary incontinence include female gender, increasing age, urinary tract infections (UTI), poor mobility, dementia, smoking, obesity, consuming alcohol and caffeine beverages, physical activity, pregnancy, childbirth, forceps and vacuum-assisted births, episiotomy, abdominal resection for colorectal cancer, and hormone replacement therapy. For the purposes of this review, incontinence populations will be stratified into the following; the elderly, urology patients, postoperative patients, rehabilitation settings, and neurogenic bladder populations. Urinary incontinence is defined as any involuntary leakage of urine. Incontinence can be classified into diagnostic clinical types that are useful in planning evaluation and treatment. The major types of incontinence are stress (physical exertion), urge (overactive bladder), mixed (combined urge and stress urinary incontinence), reflex (neurological impairment of the central nervous system), overflow (leakage due to full bladder), continuous (urinary tract abnormalities), congenital incontinence, and transient incontinence (temporary incontinence). Postvoid residual (PVR) urine volume, which is the amount of urine in the bladder immediately after urination, represents an important component in continence assessment and bladder management to provide quantitative feedback to the patient and continence care team regarding the effectiveness of the voiding technique. Although there is no standardized definition of normal PVR urine volume, measurements greater than 100 mL to 150 mL are considered an indication for urinary retention, requiring intermittent catheterization, whereas a PVR urine volume of 100 mL to 150 mL or less is generally considered an acceptable result of bladder training. Urinary retention has been associated with poor outcomes including UTI, bladder overdistension, and higher hospital mortality rates. The standard method of determining PVR urine volumes is intermittent catheterization, which is associated with increased risk of UTI, urethral trauma and discomfort. The Technology Being Reviewed Portable bladder ultrasound products are transportable ultrasound devices that use automated technology to register bladder volume digitally, including PVR volume, and provide three-dimensional images of the bladder. The main clinical use of portable bladder ultrasound is as a diagnostic aid. Health care professionals (primarily nurses) administer the device to measure PVR volume and prevent unnecessary catheterization. An adjunctive use of the bladder ultrasound device is to visualize the placement and removal of catheters. Also, portable bladder ultrasound products may improve the diagnosis and differentiation of urological problems and their management and treatment, including the establishment of voiding schedules, study of bladder biofeedback, fewer UTIs, and monitoring of potential urinary incontinence after surgery or trauma. Review Strategy To determine the effectiveness and clinical utility of portable bladder ultrasound as reported in the published literature, the Medical Advisory Secretariat used its standard search strategy to retrieve international health technology assessments and English-language journal articles from selected databases. Nonsystematic reviews, nonhuman studies, case reports, letters, editorials, and comments were excluded. Summary of Findings Of the 4 included studies that examined the clinical utility of portable bladder ultrasound in the elderly population, all found the device to be acceptable. One study reported that the device underestimated catheterized bladder volume In patients with urology problems, 2 of the 3 studies concerning portable bladder ultrasound found the device acceptable to use. However, one study did not find the device as accurate for small PVR volume as for catheterization and another found that the device overestimated catheterized bladder volume. In the remaining study, the authors reported that when the device’s hand-held ultrasound transducers (scanheads) were aimed improperly, bladders were missed, or lateral borders of bladders were missed resulting in partial bladder volume measurements and underestimation of PVR measurements. They concluded that caution should be used in interpreting PVR volume measured by portable bladder ultrasound machines and that catheterization may be the preferred assessment modality if an accurate PVR measurement is necessary. All 3 studies with post-operative populations found portable bladder ultrasound use to be reasonably acceptable. Two studies reported that the device overestimated catheter-derived bladder volumes, one by 7% and the other by 21 mL. The third study reported the opposite, that the device underestimated catheter bladder volume by 39 mL but that the results remained acceptable In rehabilitation settings, 2 studies found portable bladder ultrasound to underestimate catheter-derived bladder volumes; yet, both authors concluded that the mean errors were within acceptable limits. In patients with neurogenic bladder problems, 2 studies found portable bladder ultrasound to be an acceptable alternative to catheterization despite the fact that it was not as accurate as catheterization for obtaining bladder volumes. Lastly, examinations concerning avoidance of negative health outcomes showed that, after use of the portable bladder ultrasound, unnecessary catheterizations and UTIs were decreased. Unnecessary catheterizations avoided ranged from 16% to 47% in the selected articles. Reductions in UTI ranged from 38% to 72%. In sum, all but one study advocated the use of portable bladder ultrasound as an alternative to catheterization. Economic Analysis An economic analysis estimating the budget-impact of BladderScan in complex continuing care facilities was completed. The analysis results indicated a $192,499 (Cdn) cost-savings per year per facility and a cost-savings of $2,887,485 (Cdn) for all 15 CCC facilities. No economic analysis was completed for long-term care and acute care facilities due to lack of data. Considerations for Policy Development Rapid diffusion of portable bladder ultrasound technology is expected. Recently, the IC5 project on improving continence care in Ontario’s complex continuing care centres piloted portable bladder ultrasound at 12 sites. Preliminary results were promising. Many physicians and health care facilities already have portable bladder ultrasound devices. However, portable bladder ultrasound devices for PVR measurement are not in use at most health care facilities in Ontario and Canada. The Verathon Corporation (Bothell, Wisconsin, United States), which patents BladderScan, is the sole licensed manufacturer of the portable bladder ultrasound in Canada. Field monopoly may influence the rising costs of portable bladder ultrasound, particularly when faced with rapid expansion of the technology. Several thousand residents of Ontario would benefit from portable bladder ultrasound. The number of residents of Ontario that would benefit from the technology is difficult to quantify, because the incidence and prevalence of incontinence are grossly under-reported. However, long-term care and complex continuing care institutions would benefit greatly from portable bladder ultrasound, as would numerous rehabilitation units, postsurgical care units, and urology clinics. The cost of the portable bladder ultrasound devices ranges from $17,698.90 to $19,565.95 (Cdn) (total purchase price per unit as quoted by the manufacturer). Additional training packages, batteries and battery chargers, software, gel pads, and yearly warranties are additional costs. Studies indicate that portable bladder ultrasound is a cost-effective technology, because it avoids costs associated with catheterization equipment, saves nursing time, and reduces catheter-related complications and UTIs. The use of portable bladder ultrasound device will affect the patient directly in terms of health outcomes. Its use avoids the trauma related to the urinary tract that catheterization inflicts, and does not result in UTIs. In addition, patients prefer it, because it preserves dignity and reduces discomfort. PMID:23074481