Article

The Use of Episiotomy in a Low-Risk Population in The Netherlands: A Secondary Analysis

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Abstract

To examine the episiotomy incidence and determinants and outcomes associated with its use in primary care midwifery practices. Secondary analysis of two prospective cohort studies (n = 3,404). The episiotomy incidence was 10.8 percent (20.9% for nulliparous and 6.3% for parous women). Episiotomy was associated with prolonged second stage of labor (adj. OR 12.09 [95% CI 6.0-24.2] for nulliparous and adj. OR 2.79 [1.7-4.6] for parous women) and hospital birth (adj. OR 1.75 [1.2-2.5] for parous women). Compared with episiotomy, perineal tears were associated with a lower rate of postpartum hemorrhage in parous women (adj. OR 0.58 [0.4-0.9]). Fewer women with perineal tears reported perineal discomfort (adj. OR 0.35 [0.2-0.6] for nulliparous and adj. OR 0.22 [0.1-0.3] for parous women). Among nulliparous women episiotomy was performed most frequently for prolonged second stage of labor (38.8%) and among parous women for history of episiotomy or prevention of major perineal trauma (21.1%). The incidence of episiotomy is high compared with some low-risk settings in other Western countries. Episiotomy was associated with higher rates of adverse maternal outcomes. Restricted use of episiotomy is likely to be beneficial for women.

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... No presente estudo, a idade da paciente mostrou-se associada à realização da episiotomia, corroborando com outros autores, que demonstraram que mulheres mais jovens apresentam riscos maiores de serem submetidas ao procedimento (15,16) . Tal Uma revisão de literatura, analisando 6.365 partos vaginais, evidenciou que as mulheres com parto prematuro possuíam 2,3 vezes mais chance de serem submetidas à episiotomia (17) . ...
... Este estudo apresentou apenas três pacientes com gestação gemelar, dificultando a análise desta variável, pois muitas pacientes com gestação gemelar apresentam indicação de cesariana por apresentações anômalas. Porém, outro estudo que avaliou a gestação múltipla, não encontrou associação com a realização da episiotomia (16) . (19) . ...
... Neste estudo, foi encontrada média de 3243,5kg de peso entre os recém-nascidos, porém sem mostrar significância estatística com a realização de episiotomia. A hipótese de maior realização de episiotomia em fetos grandes também não foi comprovada em outros estudos (15,16,20) . Esse achado está, porém, em desacordo com os resultados de Jiang et al, no qual recém-nascidos com peso maior que 3,500g estiveram mais associados à realização de episiotomia (3) . ...
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Objetivo: O estudo objetiva conhecer os fatores associados à realização da episiotomia no parto vaginal. Metodologia: Estudo transversal envolvendo 330 partos, de janeiro/2012 a dezembro/2013. Estudou-se a associação das variáveis independentes com a realização da episiotomia por meio de cálculo de razões de prevalência e seus respectivos intervalos de confiança, com nível de significância p < 0,05. Resultados: Na amostra estudada, 224 (67,9%) pacientes não realizaram episiotomia e 106 (32,1%) realizaram o procedimento. A idade média foi de 22,9 (± 5,9) anos e a episiotomia foi mais realizada naquelas com idade inferior a 20 anos [RP 1,61 (IC 95% 1,15; 2,25)] (p = 0,005). As mulheres com mais de 8 anos completos de estudo foram significativamente mais submetidas à episiotomia que as demais [RP 2,34 (IC 95% 1,70; 3,22)] (p < 0,001). Conclusão: A realização da episiotomia nesta população ocorreu com maior prevalência nas parturientes mais jovens e com maior escolaridade.Descritores: Episiotomia; Fatores associados; Parto vaginalEVALUATION OF THE DETERMINANT FACTORS TO EPISIOTOMY IN VAGINAL DELIVERYObjective: This study aims to evaluate the factors associated with its performance in vaginal delivery. Methodology: This is a cross-sectional study carried out with 330 births, from January / 2012 to December / 2013. The association of the independente variables with episiotomy was calculated by prevalence ratios and their respective confidence intervals, with significance level p < 0.05. Results: In the studied sample, 224 (67.9%) patients did not undergo episiotomy and 106 (32.1%) had the procedure. The mean age was 22.9 ± 5.9 years and the episiotomy was more frequently performed in those younger than 20 years old [PR 1.61 (95% CI 1.15; 2.25)] (p = 0.005). Women with more than 8 years of education were significantly more likely to undergo episiotomy than the others [PR 2.34 (95% CI 1.70; 3.22)] (p < 0.001). Conclusion: The episiotomy, in this population, occured more likely in younger and more educated parturients.Descriptors: Episiotomy; Associated factors; Vaginal birthEVALUACIÓN DE LOS FACTORES DETERMINANTES A LA REALIZACIÓN DE LA EPISIOTOMÍA EN EL PARTO VAGINALObjetivo: El estudio tiene como objetivo conocer los factores asociados a la realización de la episiotomía en el parto vaginal. Metodología: Estudio transversal que involucra 330 partos, de enero/2012 a diciembre/2013, para la asociación de las variables independientes con la episiotomía por razones de prevalencia y sus respectivos intervalos de confianza, con p <0,05. Resultados: En la muestra, 224 (67,9%) pacientes no realizaron episiotomía y 106 (32,1%) realizaron el procedimiento. La edad media fue de 22,9 (± 5,9) años y la episiotomía fue más realizada en aquellas con edad inferior a 20 años [RP 1,61 (IC 95% 1,15, 2,25)] (p = 0,005) ). Las mujeres con más de 8 años completos de estudio fueron significativamente más sometidas a la episiotomía que las demás [RP 2,34 (IC 95% 1,70; 3,22)] (p <0,001). Conclusión: La realización de la episiotomía ocurrió con mayor prevalencia en las parturientas más jóvenes y con mayor escolaridad.Descriptores: Episiotomía; Factores asociados; Parto vaginal
... Open access is preferable to routine or liberal use. 2 Episiotomies can lead to physical problems, such as postpartum urinary retention, perineal pain, dyspareunia and pelvic floor muscle strength. [10][11][12][13][14][15][16][17] It is unknown which episiotomy rate is appropriate for obtaining an optimal balance between harm caused by episiotomy and prevention of maternal and neonatal morbidity by its use. Moreover, there is a lack of uniform recommendations on indications for performing episiotomy, and there is major variation in applied indications among care providers. ...
... Moreover, there is a lack of uniform recommendations on indications for performing episiotomy, and there is major variation in applied indications among care providers. 11 This suggests that perspectives and values of care providers influence the decision to perform an episiotomy and that this decision is not only based on medical necessity. Studies into indications for episiotomy use or opinions of care providers have only been conducted among restricted subgroups of childbearing women or in settings that cannot be generalised. ...
... On the other hand, routine use of episiotomy may paradoxically result in increased rates of OASI 9 and overuse of episiotomy results in unnecessary problems and morbidity among many women. [10][11][12][13][14][15][16][17] The awareness of these insights is reflected in the literature during the last four decades 32 and has led to a decline in the episiotomy rates in many countries, with a sharper decline in some countries vs others. 33 Our study showed that most care providers were aware of the importance of a restrictive episiotomy policy, but practices often diverged from this restrictive perspective, leading to a liberal rather than restrictive episiotomy practice among some care providers. ...
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Objectives Insight into perspectives and values of care providers on episiotomy can be a first step towards reducing variation in its use. We aimed to gain insight into these perspectives and values. Setting Maternity care in the Netherlands. Participants Midwives, obstetricians and obstetric registrars working in primary, secondary or tertiary care, purposively sampled, based on their perceived episiotomy rate and/or region of work. Primary and secondary outcome measures Perspectives and values of care providers which were explored using semistructured in-depth interviews. Results The following four themes were identified, using the evidence-based practice-model of Satterfield et al as a framework: ‘Care providers’ vision on childbirth’, ‘Discrepancy between restrictive perspective and daily practice’, ‘Clinical expertise versus literature-based practice’ and ‘Involvement of women in the decision’. Perspectives, values and practices regarding episiotomy were strongly influenced by care providers’ underlying visions on childbirth. Although care providers often emphasised the importance of restrictive episiotomy policy, a discrepancy was found between this vision and the large number of varying indications for episiotomy. Although on one hand care providers cited evidence to support their practice, on the other hand, many based their decision-making to a larger extent on clinical experience. Although most care providers considered women’s autonomy to be important, at the moment of deciding on episiotomy, the involvement of women in the decision was perceived as minimal, and real informed consent generally did not take place, neither during labour, nor prenatally. Many care providers belittled episiotomy in their language. Conclusions Care providers’ underlying vision on episiotomy and childbirth was an important contributor to the large variations in episiotomy usage. Their clinical expertise was a more important component in decision-making on episiotomy than the literature. Women were minimally involved in the decision for performing episiotomy. More research is required to achieve consensus on indications for episiotomy.
... Entretanto, estudos mostram discrepância relevante na incidência de episiotomia entre países. Na Europa do Norte e Ocidental as taxas variam entre 9,7% na Suécia e 87,3% na Espanha (13) . Na França, entre 2004 e 2009, a incidência reduziu de 55,7% para 13,3%, sem aumentar de maneira significativa os traumas perineais. ...
... Na Holanda, uma pesquisa realizada com população de gestantes de risco habitual mostrou incidência de episiotomia de 10,8%, sendo que 20,9% em primíparas e 6,3% em multíparas. Em relação às justificativas, 46% por segundo período do parto (período expulsivo) prolongado, seguido por, 35% em casos de sofrimento fetal, 19% para prevenção de laceração perineal grave ou história de episiotomia anterior, 17% períneo rígido e 21% outras razões (suspeita de feto macrossômico, posição da apresentação fetal anormal, perda sanguínea durante a segunda etapa e até mesmo a pedido) (13) . Já na Arábia Saudita, em pesquisa que avaliou os indicadores de episiotomia na obstetrícia moderna, a taxa foi de 51,2%, mostrando que todas as primíparas foram submetidas a esse procedimento e para elas, a indicação mais frequente foi períneo rígido. ...
... A incidência de episiotomia é alta em comparação a algumas situações de baixo risco em países em desenvolvimento, sendo associada a maiores taxas de desfechos maternos adversos. Alguns autores recomendam episiotomia em casos em que haja sinais de sofrimento fetal, segundo estágio do trabalho de parto prolongado e para prevenir a ocorrência de lesão do esfíncter, entretanto, esse último é controverso, pois alguns estudos observacionais demonstraram um efeito protetor da episiotomia, enquanto outros mostram maior incidência de lesão de esfíncter anal se a episiotomia é realizada (13) . É preciso adoção de critérios para a realização desse procedimento, visto que estudos observacionais mostram a episiotomia como um fator de risco para o assoalho pélvico inferior, para a força muscular, dispareunia e dor perineal. ...
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ABSTRACT: Objective:to identify the frequency of and justification for episiotomy in childbirths attended by residents in obstetric nursing. Method:Descriptive and retrospective study conducted in October-November, 2016, in a public maternity hospital in the city of São Paulo. The study population consisted of 884 low-risk pregnant women. Chi-square testwas used for statistical analysis. Results:Episiotomy was performed in 174 (19.7%) deliveries and in 512 (59%) there were perineal lacerations. Perineal integrity was maintained in 187 (21.4%) deliveries. The main indications were related to perineal conditions: 54 (58.1%) perineal rigidity, 22 (23.7%) short perineum and 19 (20.4%) imminent severe laceration.Conclusion:The frequency of use of episiotomyby residents in obstetric nursingis higher than evidence based recommendations from the WHO, and regarding the reasons for the procedure, they differ from those generally reported worldwide, which leads to reflections about the model of professional training of obstetric nurses and the distance between theory and practice. DESCRIPTORS: Episiotomy; Obstetric nursing; Perineum: Vaginal delivery.
... 79 Potential risks associated with routine episiotomy include blood loss, perineal pain, dyspareunia, and pelvic floor dysfunction. 80 The International ...
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Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%. The incidence of obstetrical anal sphincter injury is approximately 3%, with a significantly higher rate in primiparous than in multiparous women (6% vs 2%). Obstetrical anal sphincter injury is a significant risk factor for the development of anal incontinence, with approximately 10% of women developing symptoms within a year following vaginal birth. Obstetrical anal sphincter injuries have significant medicolegal implications and contribute greatly to healthcare costs. For example, in 2013 and 2014, the economic burden of obstetrical anal sphincter injuries in the United Kingdom ranged between £3.7 million (with assisted vaginal birth) and £9.8 million (with spontaneous vaginal birth). In the United States, complications associated with trauma to the perineum incurred costs of approximately $83 million between 2007 and 2011. It is therefore crucial to focus on improvements in clinical care to reduce this risk and minimize the development of perineal trauma, particularly obstetrical anal sphincter injuries. Identification of risk factors allows modification of obstetrical practice with the aim of reducing the rate of perineal trauma and its attendant associated morbidity. Risk factors associated with second-degree perineal trauma include increased fetal birthweight, operative vaginal birth, prolonged second stage of labor, maternal birth position, and advanced maternal age. With obstetrical anal sphincter injury, risk factors include induction of labor, augmentation of labor, epidural, increased fetal birthweight, fetal malposition (occiput posterior), midline episiotomy, operative vaginal birth, Asian ethnicity, and primiparity. Obstetrical practice can be modified both antenatally and intrapartum. The evidence suggests that in the antenatal period, perineal massage can be commenced in the third trimester of pregnancy to increase muscle elasticity and allow stretching of the perineum during birth, thereby reducing the risk of tearing or need for episiotomy. With regard to the intrapartum period, there is a growing body of evidence from the United Kingdom, Norway, and Denmark suggesting that the implementation of quality improvement initiatives including the training of clinicians in manual perineal protection and mediolateral episiotomy can reduce the incidence of obstetrical anal sphincter injury. With episiotomy, the International Federation of Gynecology and Obstetrics recommends restrictive rather than routine use of episiotomy. This is particularly the case with unassisted vaginal births. However, there is a role for episiotomy, specifically mediolateral or lateral, with assisted vaginal births. This is specifically the case with nulliparous vacuum and forceps births, given that the use of mediolateral or lateral episiotomy has been shown to significantly reduce the incidence of obstetrical anal sphincter injury in these groups by 43% and 68%, respectively. However, the complications associated with episiotomy including perineal pain, dyspareunia, and sexual dysfunction should be acknowledged. Despite considerable research, interventions for reducing the risk of perineal trauma remain a subject of controversy. In this review article, we present the available data on the prevention of perineal trauma by describing the risk factors associated with perineal trauma and interventions that can be implemented to prevent perineal trauma, in particular obstetrical anal sphincter injury.
... Despite its adverse effects, episiotomy is still practiced widely around the world, especially in developing countries. There is a wide variation in the frequency of episiotomy among all women who have had a vaginal delivery all over the world, from developed countries such as Denmark (4%) [11], the Netherlands (11%) [12], the USA (11.6%) [3], Canada, (17%) [13], and France, (20%) [14] to developing countries including Saudi Arabia (35%) [15], Nigeria (52.0%) [8], India (60%) [16], Uganda (73%) [17], Iraq (73.9%) [18], Yemen (75.1%) [7], and Cambodia (94.5%) [19]. In Taiwan, China, the rate of episiotomy was exceptionally high (100%) [20]. ...
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Background and Objectives: Despite the controversies that prevail regarding the efficacy of episiotomy, it is still practiced widely around the world in various degrees of prevalence. This study aimed to identify and analyze the prevalence, clinical profile, and complications of episiotomy performed on women who delivered at the Asha’ab Obstetric Emergency Center. Patients and Methods: This was a cross-sectional study that involved women who had undergone vaginal delivery at the Asha’ab Obstetric Emergency Center, in Aden city, Yemen, between October 1, 2021, and March 31, 2022. Permission to conduct the study was obtained from the center’s administrative office. Results: During the study period, 858 women delivered vaginally at our center. Out of these, 443 women had had an episiotomy, representing an episiotomy prevalence of approximately 51.6%. These 443 women were enrolled in this study. The episiotomy was more common among primigravida women (n=362, 81.7%), followed by multiparous women (n=42, 9.5%). The most commonly associated medical disorder was anemia (n=167, 37.7%), followed by hypertension (n=33, 7.4%). Perineal pain (n=51, 11.5%) was the most frequently reported post-episiotomy complication, followed by perineal discomfort (n=32, 7.2%), wound infection (n=27, 6.1%), perineal bleeding (n=18, 4.1), difficulty in walking (n=9, 2.0%), wound dehiscence (n=3, 0.7%), and difficulty in defecation (n=1, 0.2%). Conclusion: The prevalence of episiotomy among women who gave birth at the Asha’ab Obstetric Emergency Center, in Aden city, Yemen, was higher than the World Health Organization recommendation, which is around 10% or less with acceptable obstetric evidence indicating the need. Further prospective large-scale studies are recommended to confirm the findings of this study.
... Reported rates of episiotomies vary greatly from one country to another across the globe. The lowest rate (1%) of episiotomy was reported in Sweden, whereas the highest (100%) was reported in Taiwan among primiparous parturients (23 (20,(23)(24)(25)(26)(27)(28). In addition, significant number of women undergone episiotomy in Asian countries, 42-98% (23,29,30). ...
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Background Episiotomy, a surgical procedure that enlarges the vaginal opening during childbirth, was common practice until the early 2000s. Other sources, including the World Health Organization (WHO), advocate for the selective use of episiotomy. Episiotomy rates, on the other hand, have remained high in developing countries, while declining in developed countries. As a result, the current study sought to determine the overall prevalence of episiotomy in Africa as well as the risk factors associated with its practice.Methods Articles were searched in international electronic databases. A standardized Microsoft Excel spreadsheet and STATA software version 14 were used for data extraction and analysis, respectively. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist was used to write this report. A random-effects meta-analysis model was used to determine the pooled prevalence of episiotomy. A heterogeneity test was conducted using I-Squared (I2) statistics. Egger's test and funnel plots were conducted to detect publication bias. Subgroup analysis was also conducted. Association was expressed through a pooled odds ratio (OR) with a 95% Confidence Interval (CI).ResultA total of 21 studies with 40,831 participants were included in the systematic review and meta-analysis. The pooled prevalence of episiotomy practice was 41.7% [95% CI (36.0–47.4), I2 = 99.3%, P < 0.001). Primiparity [OR: 6.796 (95% CI (4.862–9.498)), P < 0.001, I2: 95.1%], medical doctors- assisted delivery [OR: 3.675 (95% CI (2.034–6.640)), P < 0.001, I2: 72.6%], prolonged second stage of labor [OR: 5.539 (95% CI (4.252–7.199)), P < 0.001, I2: 0.0%], using oxytocin [OR: 4.207 (95% CI (3.100–5.709)), P < 0.001, I2: 0.0%], instrument -assisted vaginal delivery [OR: 5.578 (95% CI (4.285–7.260)), P < 0.001, I2: 65.1%], and macrosomia [OR: 5.32 (95% CI (2.738–10.339)), P < 0.001, I2: 95.1%] were factors associated with episiotomy practice.Conclusion In this review, the prevalence of episiotomy among African parturients was high. A selective episiotomy practice should be implemented to reduce the high episiotomy rates.Systematic Review Registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021293382, identifier: CRD42021293382.
... However, no significant sub-group difference was found between studies of low/moderate or high/ critical risk of bias. Our results should be interpreted with caution, as routine episiotomy is associated with a significant increase in blood loss, perineal pain, dyspareunia and pelvic floor dysfunction [64]. It is therefore important these risks are considered, including the values and preferences of the woman. ...
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Introduction and hypothesis OASI complicates approximately 6% of vaginal deliveries. This risk is increased with operative vaginal deliveries (OVDs), particularly forceps. However, there is conflicting evidence supporting the use of mediolateral/lateral episiotomy (MLE/LE) with OVD. The aim of this study was to assess whether MLE/LE affects the incidence of OASI in OVD. Methods Electronic searches were performed in OVID Medline, Embase and the Cochrane Library. Randomised and non-randomised observational studies investigating the risk of OASI in OVD with/without MLE/LE were eligible for inclusion. Pooled odds ratios (OR) were calculated using Revman 5.3. Risk of bias of was assessed using the Cochrane RoB2 and ROBINS-I tool. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). Results A total of 703,977 patients from 31 studies were pooled for meta-analysis. MLE/LE significantly reduced the rate of OASI in OVD (OR 0.60 [95% CI 0.42–0.84]). On sub-group analysis, MLE/LE significantly reduced the rate in nulliparous ventouse (OR 0.51 [95% CI 0.42–0.84]) and forceps deliveries (OR 0.32 [95% CI 0.29–0.61]). In multiparous women, although the incidence of OASI was lower when a ventouse or forceps delivery was performed with an MLE/LE, this was not statistically significant. Heterogeneity remained significant across all studies (I ² > 50). The quality of all evidence was downgraded to “very low” because of the critical risk of bias across many studies. Conclusions MLE/LE may reduce the incidence of OASI in OVDs, particularly in nulliparous ventouse or forceps deliveries. This information will be useful in aiding clinical decision-making and counselling in the antenatal period and during labour.
... In high-resource countries, the adoption of proactive measures led to a reduction in the occurrence of episiotomy (Coulm et al., 2012;Levitt et al., 2011;Seijmonsbergen-Schermers et al., 2013). In Canada, 75% of deliveries included an episiotomy in 1980, falling to 17% in 2007 (Canada, 2012). ...
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Objectives This study aimed to measure the prevalence, to describe the trend over time, and to evaluate socioeconomic inequalities in the occurrence of episiotomies in 2007, 2010, 2013, and 2016 in the municipality of Rio Grande, in Southern Brazil.Methods We included all women who had vaginal delivery in each of the studied years. All the information was obtained through a questionnaire applied at maternity wards within 48 h after delivery. The outcome consisted of episiotomy. A chi-square test was used to evaluate the linear trend. Absolute and relative inequalities were assessed from household income and schooling of the women through the Slope Index of Inequality and Relative Index of Inequality, respectively.ResultsThis study included 4,521 parturients. The episiotomy rate in the period fell from 71.0% (95%CI: 68.4–73.5) in 2007 to 40.1% (95%CI: 37.3–42.8) in 2016, and it was more frequent among women with higher income and higher schooling. We observed a reduction in the rate of episiotomy in all income and schooling levels, and this was more evident among women in the lowest socioeconomic levels. Absolute inequality declined, while relative inequality remained unchanged.Conclusions for PracticeDespite the significant reduction in the rate of episiotomy, its occurrence remains high. Women with higher income and education, therefore with lower risk for complications during childbirth, were the most frequently submitted to this procedure. Routine use of episiotomy must be reevaluated, especially among pregnant women with better socioeconomic status.
... In addition, regional variation in performing an episiotomy was considerably larger than the variation in severe perineal tears. An episiotomy is often performed to prevent severe perineal tears [43,45]. However, literature supports other methods to reduce the rate of third or fourth degree tears which do not have adverse effects [46][47][48]. ...
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Background Variations in childbirth interventions may indicate inappropriate use. Most variation studies are limited by the lack of adjustments for maternal characteristics and do not investigate variations in adverse outcomes. This study aims to explore regional variations in the Netherlands and their correlations with referral rates, birthplace, interventions, and adverse outcomes, adjusted for maternal characteristics. Methods In this nationwide retrospective cohort study, using a national data register, intervention rates were analysed between twelve regions among single childbirths after 37 weeks’ gestation in 2010–2013 (n = 614,730). These were adjusted for maternal characteristics using multivariable logistic regression. Primary outcomes were intrapartum referral, birthplace, and interventions used in midwife- and obstetrician-led care. Correlations both between primary outcomes and between adverse outcomes were calculated with Spearman’s rank correlations. Findings Intrapartum referral rates varied between 55–68% (nulliparous) and 20–32% (multiparous women), with a negative correlation with receiving midwife-led care at the onset of labour in two-thirds of the regions. Regions with higher referral rates had higher rates of severe postpartum haemorrhages. Rates of home birth varied between 6–16% (nulliparous) and 16–31% (multiparous), and was negatively correlated with episiotomy and postpartum oxytocin rates. Among midwife-led births, episiotomy rates varied between 14–42% (nulliparous) and 3–13% (multiparous) and in obstetrician-led births from 46–67% and 14–28% respectively. Rates of postpartum oxytocin varied between 59–88% (nulliparous) and 50–85% (multiparous) and artificial rupture of membranes between 43–52% and 54–61% respectively. A north-south gradient was visible with regard to birthplace, episiotomy, and oxytocin. Conclusions Our study suggests that attitudes towards interventions vary, independent of maternal characteristics. Care providers and policy makers need to be aware of reducing unwarranted variation in birthplace, episiotomy and the postpartum use of oxytocin. Further research is needed to identify explanations and explore ways to reduce unwarranted intervention rates.
... 10 Nevertheless, this rate is still high, mainly when compared with other countries such as the United States (24.5%), 11 France (13.3%) 12 and the Netherlands (10.8%). 13 Various interventions have been proposed in an attempt to reduce episiotomy rates. 14 Disseminating evidence and improving knowledge on episiotomy is important. ...
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Objective To determine the prevalence of episiotomy and the factors associated with the knowledge, attitude and practice (KAP) of Brazilian obstetricians in relation to this procedure. Methods A KAP survey was conducted with obstetricians working in Brazil. An electronic form containing structured questions previously evaluated using the Delphi method was created in Google Docs and sent by e-mail. A multivariate logistic regression was performed to determine the principal factors associated with adequate KAP. For each dependent variable (knowledge, attitude and practice) coded as adequate (1 = yes; 0 = no), a multiple logistic regression model was developed. Binary codes (1 = yes and 0 = no) were assigned to every independent or predictor variables. Prevalence ratios (PRs) and their respective 95% confidence intervals (95%CIs) were calculated as measures of relative risk, at a significance level of 5%. Results Out of the 13 thousand physicians contacted, 1,163 replied, and 50 respondents were excluded. The mean episiotomy rate reported was of 42%. Knowledge was determined as adequate in 44.5% of the cases, attitude, in 10.9%, and practice, in 26.8% of the cases. Conclusion Most respondents had inadequate knowledge, attitudes and practices regarding episiotomy. Although some factors such as age, teaching, working in the public sector and attending congresses improved knowledge, attitude and practice, we must recognize that episiotomy rates remain well above what would be considered ideal. Adequate knowledge is more prevalent than adequate attitude or practice, indicating that improving knowledge is crucial but insufficient to change the outlook of episiotomies in Brazil.
... In fact, it is currently considered to be one of the primary risk factors affecting episiotomy rates worldwide (Clesse et al. 2018b). Categorization also shows that maternal history such as previous caesarean section (Chuilon et al. 2016;Carvalho et al. 2010), episiotomy medical history (Lurie et al. 2013;Manzanares et al. 2013;Seijmonsbergen-Schermers et al. 2013;Shmueli et al. 2017) or even a short Birth Spacing (Rasouli et al. 2016) are considered to be episiotomy riskfactors. Interestingly, the age of the parturient has an impact on the episiotomy rate: being less than 25 years (Carvalho et al. 2010;Silva da et al. 2012;Ezegwui et al. 2012;Demirci et al. 2016;Socolov et al. 2017;Kozhimannil et al. 2017) or having an older age (i.e. ...
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Episiotomy practice is influenced by many factors studied in the scientific literature. Evidence-based medicine has isolated many factors that are linked to episiotomy practice, thus creating a need to group all these factors to create a relevant and useful database for scientific research. Based on the PRISMA methodology, the authors conducted a systematic literature review with the aim of covering this very need. Using 12 French and English combinations of relevant keywords, 15 databases containing publications published between 2008 and 2018 were evaluated. A total of 63 articles were identified, grouped and categorised into four main themes in the results section: (1) Individual and clinical factors related to the mother, (2) individual and clinical factors related to the child, (3) technical factors, and (4) organisation of health care and professional factors (institutional, organisational, personal and professional factors). These factors are then presented in terms of their impact on the practice of episiotomy. Then the future implications of this study on scientific research and clinical practice are discussed.
... 4 However, this perspective appears at odds with quantitative studies from the Netherlands that demonstrate increasing numbers of non-urgent referrals to obstetric-led care in the intrapartum period and a wide diversity in referral rates between midwifery practices, varying between 9.7 and 63.7%. 5 There is also wide variation in specific areas of midwifery practice, including large differences in the use of episiotomy between primary care midwives. 6 It is unlikely that the variation in practice is the result of different population characteristics; it is more likely that the observed variation is caused by differences in midwife perceptions of the probability of adverse events in birth 7 and variation in habitual patterns of practice. ...
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Background: In order to internalize the midwifery philosophy of care and to learn how to advocate for physiological childbirth, student midwives in the Netherlands need learning experiences that expose them to physiological childbirth practices. Increased hospital births, wide variation in non-urgent referrals and escalating interventions impact on learning opportunities for physiological childbirth. Midwifery educators need to find ways to support student agency in becoming advocates of physiological childbirth. Objective: To gather students' opinions of what they need to become advocates of physiological childbirth. Methods: Focus groups with student midwives (n=37), examining attitudes regarding what educational programs must do to support physiological childbirth advocacy. Results: Students reported feelings of personal power when the midwifery philosophy of care is internalized and expressed in practice. Students also identified dilemmas associated with supporting woman-centered care and promoting physiological childbirth. Perceived hierarchy in clinical settings causes difficulties, leading students to practice in accordance with the norms of midwife preceptors. Students are supported in the internalization and realization of the midwifery philosophy of care, including physiological childbirth, if they are exposed to positive examples of care in practice and have opportunities to discuss and reflect on these in the classroom. Key conclusion: Midwifery education should focus on strategies that include navigating dilemmas in practice and helping students to express the midwifery philosophy of care in communication with other professionals and with women. Preceptors need to be supported in allowing student midwives opportunities to realize the midwifery philosophy of care, also when this differs from preceptor practice.
... La primiparidad es un factor ampliamente estudiado, y se ha encontrado una relación con la realización de episiotomías en multitud de estudios 9,[14][15][16][17][18][19] . En otros casos, la primiparidad se relaciona fuertemente con la existencia de un trauma perineal 20 , e incluso ha llegado a sugerirse que realizar una episiotomía en un primer parto es un factor que condiciona la aparición de desgarros o la necesidad de episiotomía en los siguientes 21,22 . ...
Article
Objective: To analyze the factors that condition the performance of an episiotomy in spontaneous vaginal deliveries at La Ribera University Hospital (HULR). Material and method: A descriptive, cross-sectional and retrospective study was carried out. Data about spontaneous vaginal deliveries attended during 2015 were collected. Data were tabulated in Excel spreadsheet and analyzed with SPSS 17.0 statistical package. Results: Data from 1,116 spontaneous vaginal deliveries were analyzed (62% of the total). In 83% of these cases no episiotomy was performed. A statistically significant relationship was found between the performance of episiotomy and the variables: primiparity, use of epidural analgesia, stimulated/induced labour and lithotomy position. There was no statistically significant relationship to maternal age, weight of the new-born, health care professional, or perineal trauma appearance. Conclusions: Knowing the factors that are associated with the performance of episiotomy in our delivery room is determinant to restrict its use to those situations strictly necessary. The following measures have been proposed: the use of alternative positions during the second stage of labour, spontaneous onset of labour when possible, to respect the duration of second stage of labour in cases of epidural analgesia, and the elaboration of a consensus document on episiotomy indications.
... It is unlikely that these differences are caused by risk of complications because of different population characteristics alone, but could also be related to differences in the ways midwives practice or to midwife perceptions of the likelihood of adverse events in birth [6,7]. Moreover, variations in specific areas of midwifery practice have been noted, including a high variation in the incidence of episiotomy between Dutch primary care midwifery practices [8]. Another example of a less physiological approach to childbirth is the limited use of non-supine birthing positions in hospital and, notably, primary care settings [9]. ...
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Background: At present, the maternity care system in the Netherlands is being reorganized into an integrated model of care, shifting the focus of midwives to include increasing numbers of births in hospital settings and clients with medium risk profiles. In light of these changes, it is useful for midwives to have a tool which may help them in reflecting upon care practices that promote physiological childbirth practices. The Optimality Index-US is an evidence based tool, designed to measure optimal perinatal care processes and outcomes. It has been validated for use in the United States (OI-US), United Kingdom (OI-UK) and Turkey (OI-TR). The objective of this study was to adapt the OI-US for the Dutch maternity care setting (OI-NL). Methods: Translation and back translation were applied to create the OI-NL. A panel of maternity care experts (n = 10) provided input for face validation items in the OI-NL. Assessment of inter-rater reliability and ease of use was also conducted. Following this, the OI-NL was used prospectively to collect data on 266 women who commenced intrapartum care under the responsibility of a midwife. Twice groups were compared, based on parity and on care-setting at birth. Mean scores between these groups, corrected for perinatal background factors were assessed for discriminant validity. Results: Face validity was established for OI-NL on the basis of expert input. Discriminant validity was confirmed by conducting multiple regressions analyses for parity (β = 6.21, P = 0.00) and for care-setting (β = 12.1, p = 0.00). Inter-rater reliability was 98%, with one item (Apgar score) sensitive to scoring differences. Conclusion: OI-NL is a valid and reliable tool for use in the Dutch maternity care setting. In addition to its value for assessing evidence-based maternity care processes and outcomes, there is potential for use for learning and reflection. Against the backdrop of a changing maternity care system, and due to the specificity of its items OI-NL may be of value as a tool for detecting subtle changes indicative of escalating medicalization of childbirth in the Netherlands.
... Downloaded from Open Access whether an intervention is necessary, for example, planned CS for breech presentations, or after a previous CS, 8 or the use of episiotomy for prevention of major perineal tears in nulliparous and multiparous women. 49 It is important to avoid unnecessary interventions in childbearing women and at the same time ensure that those interventions that are necessary take place. ...
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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.
... Episiotomy is one of the most prevalent surgical interventions at the delivery room, ranging in frequency from <10 to 75% of vaginal births [1,2]. Presumed benefits of this procedure include preventing advanced (3rd-and 4th-degree) perineal tears by using lateral or mediolateral incision types, easier suturing, decreased postpartum pelvic organ injury, and facilitation of labor in cases of fetal distress or shoulder dystocia [3]. ...
Article
Introduction and hypothesis: The objective of this trial was to evaluate whether avoiding episiotomy can decrease the risk of advanced perineal tears. Material and methods: In this randomized (1:1) parallel-group superiority trial, primiparous women underwent randomization into standard care (155 cases) vs. no episiotomy (154 cases) groups. The primary endpoint was the incidence of advanced (3rd- and 4th-degree) perineal tears. Secondary outcomes included perineal integrity, suturing characteristics, second-stage duration, incidence of postpartum hemorrhage, neonatal variables, and various postpartum symptoms 2 days and 2 months after delivery. Results: At prespecified 1-year interim analysis, the groups did not differ in terms of baseline demographic and obstetric characteristics. Six advanced perineal tears (3.9%) were diagnosed in the standard care group vs. two in no episiotomy group (1.3%), yielding a calculated odds ratio (OR) of 0.33 [95% confidence interval (CI) 0.06-1.65). Unexpectedly, rates of episiotomy performance also did not significantly vary between groups: 26.5% (41 cases) vs. 21.4% (33 cases), respectively, p = 0.35. No significant differences were noted in any secondary outcomes. Conclusions: No difference in the rates of advanced perineal tears was found between groups; however, the main limitation of our study was unexpectedly high rates of episiotomy in the nonepisiotomy group. Thus, the main conclusion is that investigator monitoring and education should be continuously practiced throughout the trial duration, stressing the importance of adherence to the protocol.
... A Dutch study in primary care showed that prolonged second stage of labour was an important reason for performing episiotomy but low rates of prolonged second stage in that study suggest that this indication may be used too often. [46] More research is needed into strategies to reduce episiotomy rates in the Netherlands. ...
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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.
... Episiotomy is regarded as the most common maternal obstetric surgical procedure [1]. It is associated with a significant increase in blood loss, lower pelvic floor muscle strength, dyspareunia, and perineal pain compared with women who had a perineal tear [2]. The Cochrane systematic review recommends restrictive episiotomy owing to the increased morbidity associated with routine episiotomy [3]. ...
... Episiotomy is regarded as the most common maternal obstetric surgical procedure [1]. It is associated with a significant increase in blood loss, lower pelvic floor muscle strength, dyspareunia, and perineal pain compared with women who had a perineal tear [2]. The Cochrane systematic review recommends restrictive episiotomy owing to the increased morbidity associated with routine episiotomy [3]. ...
... In this sense, our work is valuable as it presents a cohort of primiparous women with spontaneous vaginal delivery. Furthermore, most studies focusing on primiparous women include a relatively small sample (4,17,18); according to these studies, the rate of episiotomies for primiparous women (including spontaneous and instrumental deliveries) following a selective episiotomy practice ranges between 20.9% (19) (20). There is a correlation between the percentage of first and second degree perineal tears (non-severe perineal trauma) and the rate of episiotomies, as this type of perineal tear is higher when no type of episiotomy is performed (2). ...
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Objectives: To estimate the incidence of perineal trauma in primiparous women with spontaneous vaginal delivery and to identify the factors associated with second-degree lacerations. Materials and Methods: A subset analysis of women with spontaneous vaginal deliveries (n=489) from an institutional review board-approved parent study in healthy, nulliparous, continent pregnant women, attending the public health care system of Catalonia (northeast Spain). Primary outcome measure was perineal trauma according to the RCOG classification. For the bivariate analysis, the Student’s t-test, ANOVA and the chi-squared test, or the corresponding non-parametric tests were used. Rates, relative risks and odds ratios (multivariate analysis) were estimated along with 95% confidence intervals (CI). Results: About 91% (95% CI: 88-93%) of women with vaginal deliveries showed some degree of perineal trauma. Nulliparous women with spontaneous deliveries who did not undergo an episiotomy were 9 times more likely to present a tear (any grade) than those who received an episiotomy [Relative risks (RR) = 9.6, 95% CI: 6.3%-14.6%, P
... Episiotomy is one of the most prevalent surgical interventions in the delivery room, ranging in frequency from about 10 % and up to 75 % [1][2][3]. The three main parameters can be used to characterize this incision are length, angle to the vertical axis, and distance of initiation point from midperineum. ...
Article
Our objective was to assess episiotomy technique used in Israeli hospitals, to determine factors influencing incision parameters, and to review relevant up-to-date professional literature. Using anonymous questionnaires, a survey was conducted among obstetricians and midwives in the four public hospitals in northern Israel over a 1-year period commencing in October 2013. In addition to demographic and professional data, the accoucheurs were asked to describe the technique they usually use to perform an episiotomy (length, angle, and distance of initiation point from midperineum). Overall, 84 obstetricians and 32 midwives participated in the survey. Only 37.6 % reported performing a mediolateral episiotomy, while the rest described the lateral type, placing the initiation point at an average distance of 2.45 ± 0.88 cm from the fourchette. Compared with midwives, obstetricians reported performing a significantly longer episiotomy (3.53 ± 1.01 vs. 2.73 ± 0.81 cm, p = 0.0002). According to our study and relevant literature review, the technique of episiotomy varies significantly between health professionals and is not uniformly congruent with international practice guidelines. In part, this is derived from unclear literature evidence and lack of consensus definition for proper technique of this procedure by the national guidelines. Thus, further higher-quality research, uniform protocols, and educational programs are needed to guide episiotomy practice.
... Episiotomy is regarded as the most common maternal obstetric surgical procedure [1]. It is associated with a significant increase in blood loss, lower pelvic floor muscle strength, dyspareunia, and perineal pain compared with women who had a perineal tear [2]. The Cochrane systematic review recommends restrictive episiotomy owing to the increased morbidity associated with routine episiotomy [3]. ...
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Episiotomy is regarded as the most common maternal obstetric surgical procedure. It is associated with a significant increase in blood loss, lower pelvic floor muscle strength, dyspareunia, and perineal pain compared with a perineal tear. We tested the hypothesis that all doctors and midwives can perform an episiotomy when prompted to, specifically cut at 60° from the midline (in a simulation model). Doctors and midwives attending the BMFMS Annual Meeting (2014), Croydon Perineal Trauma Course and staff at Poole General Hospital were invited to cut a paper replica of the perineum with a commonly used episiotomy incision pad. Participants were prompted to cut an episiotomy at 60° to the perineal midline with the anus as a reference point. The angles and distances were measured using protractors and rulers. A 58-62° band was deemed acceptable to account for measurement errors. A total of 106 delegates participated. Only 15 % of doctors and midwives cut an episiotomy between 58 and 62°. Over one third (36 %) cut the episiotomy between 55 and 65° (inclusive). Nearly two thirds either underestimated the angle (<55°; 44 %), or overestimated the angle (>66°; 18 %). Thirty-six and 7.5 % of episiotomies were cut at <50 and >70° respectively. The origination point of the episiotomy was 5 mm away from the midline (IQR 1-8 mm). This original observational study shows that doctors and midwives were poor at cutting at the prompted episiotomy angle of 60°. This highlights the need to develop structured training programmes to improve the visual accuracy of estimating angles or the use of fixed angle devices to help improve the ability to estimate the desired angle.
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Objective: To identify and analyze the prevalence, trend, and factors associated with episiotomy in Rio Grande, in the state of Rio Grande do Sul, Southern Brazil. Methods: A single, standardized questionnaire was applied to all pregnant women, residents in the municipality of Rio Grande, who had children in local hospitals between January 1 and December 12 of the years 2007, 2010, 2013, 2016 e 2019. Demographic and socioeconomic characteristics were investigated, as well as the assistance received during pregnancy and delivery. Chi-square test was used to compare proportions and Poisson regression with robust variance adjustment was used for multivariable analysis. Prevalence ratio (PR) was used as effect measure. Results: Among the 12,645 births that occurred in the five years, 5,714 (45.2%) were vaginal delivery. Of these mothers, 2,930 (51.3%; 95%CI: 50.0%-52.6%) underwent episiotomy. Over this period, the episiotomy rate decreased from 70.9% (68.4-73.5) in 2007 to 19.4% (17.1-21.7) in 2019. Adjusted analysis showed a high PR of episiotomy occurrence among women who were young (PR = 2.23; 95%CI: 1.89-2.63), had higher education (PR = 1.21; 95%Cl: 1.03-1.42), had a higher family income (PR = 1.25; 95%CI: 1.10-1.41), were primiparous (PR = 3.41; 95%CI: 2.95-3.95), had prenatal care in the private sector (PR = 1.25; 95%CI: 1.07-1.46), had oxytocin-induced labor (PR = 1.18; 95%CI:1.09-1.27), underwent forceps (PR = 1.32; 95%CI: 1.16-1.50), and whose newborn weighed 4,000 g or more (PR = 1.43; 95%CI: 1.14-1.80). Conclusion: Although the prevalence of episiotomy fell sharply within the studied period, its occurrence is more likely among women at lower risk of birth complications.
Chapter
In dit hoofdstuk wordt beschreven hoe het ongecompliceerde baringsproces verloopt en welke factoren daarop van invloed zijn. Achtereenvolgens komen aan de orde:anatomie van het baringskanaal en de foetale schedel;fysiologische en biochemische processen die de baring in gang zetten en doorzetten;baringspijn;begeleiding van de barende en de bewaking van het kind tijdens de ontsluiting, de uitdrijving en het nageboortetijdperk;observatie van moeder en kind de eerste uren post partum. anatomie van het baringskanaal en de foetale schedel; fysiologische en biochemische processen die de baring in gang zetten en doorzetten; baringspijn; begeleiding van de barende en de bewaking van het kind tijdens de ontsluiting, de uitdrijving en het nageboortetijdperk; observatie van moeder en kind de eerste uren post partum.
Article
Objective: Although episiotomies are the commonest obstetric procedure performed the technique of performing one varies amongst obstetricians and midwives. The angle of episiotomy to the midline in particular has been shown to influence the risk of developing obstetric anal sphincter injuries (OASIS). In order to identify the differences in technique and to identify targets for training we undertook a practice survey of episiotomies to analyse the differences in technique between grades of obstetricians and midwives. Study design: A prospective practice survey of staff working on delivery suite in a tertiary referral unit with 9000 deliveries/year was conducted between 01/10/2014 to 01/03/2015. Each participant was provided with a pictoral representation of a perineum and a pair of standard episiotomy scissors and asked to perform an episiotomy as per their usual practice. The profession and grade of each participant was recorded along with information regarding the incision including the angle to the midline, length of incision and lateral starting distance from the midline. One way ANOVA (unrelated) was used to perform statistical analysis using IBM SPSS v23. Results: 101 staff members participated in the practice survey including 63 midwives, 9 junior trainees, 15 senior trainees and 14 consultants. The mean angle of incision to the midline of episiotomies was 47°, 51°, 66° and 77° for midwives, junior trainees, senior trainees and consultants respectively. The mean angle of incision performed by midwives was significantly different to senior trainees (p>0.01) and consultants (p<0.01). 45% of all episiotomies undertaken by midwives were done at an angle <45° to the midline, compared to 7% by senior trainees and none by consultants. Conclusions: This study identified clear deficiencies in the performance of episiotomies amongst obstetric trainees and midwives. Both midwives and obstetric trainees need to improve their technique if episiotomies are going to influence the incidence of OASIS and, more importantly the development of faecal incontinence. These results should be used to inform future training programmes to reduce the risks of OASIS.
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Bij een vaginale bevalling ondervinden drie van de vier vrouwen bekkenbodemschade. Hierdoor krijgen zij te maken krijgen met stoornissen van de bekkenbodem. Urine-incontinentie, perineumpijn, dyspareunie en prolapsklachten blijken uit onderzoeken schrikbarend veel voor te komen. Bovenal blijkt de ziektelast die vrouwen ervan ondervinden groot. Desondanks zoeken vrouwen maar weinig medische hulp voor deze problemen. Schaamte en de aanname dat de klachten normaal zijn en vanzelf overgaan maken dat vrouwen geen hulp van professionals inroepen. Het is belangrijk dat huisartsen actief naar deze klachten vragen. Minstens zo belangrijk is het vrouwen te informeren dat deze klachten post partum kunnen optreden en welke preventieve maatregelen en behandelmogelijkheden er zijn.
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Objective: To compare perinatal outcomes, maternal outcomes, and interventions in labour by planned place of birth at the start of care in labour for women with low risk pregnancies. Design: Prospective cohort study. Setting: England: all NHS trusts providing intrapartum care at home, all freestanding midwifery units, all alongside midwifery units (midwife led units on a hospital site with an obstetric unit), and a stratified random sample of obstetric units. Participants: 64 538 eligible women with a singleton, term (≥37 weeks gestation), and “booked” pregnancy who gave birth between April 2008 and April 2010. Planned caesarean sections and caesarean sections before the onset of labour and unplanned home births were excluded. Main outcome measure: A composite primary outcome of perinatal mortality and intrapartum related neonatal morbidities (stillbirth after start of care in labour, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus, or fractured clavicle) was used to compare outcomes by planned place of birth at the start of care in labour (at home, freestanding midwifery units, alongside midwifery units, and obstetric units). Results: There were 250 primary outcome events and an overall weighted incidence of 4.3 per 1000 births (95% CI 3.3 to 5.5). Overall, there were no significant differences in the adjusted odds of the primary outcome for any of the non-obstetric unit settings compared with obstetric units. For nulliparous women, the odds of the primary outcome were higher for planned home births (adjusted odds ratio 1.75, 95% CI 1.07 to 2.86) but not for either midwifery unit setting. For multiparous women, there were no significant differences in the incidence of the primary outcome by planned place of birth. Interventions during labour were substantially lower in all non-obstetric unit settings. Transfers from non-obstetric unit settings were more frequent for nulliparous women (36% to 45%) than for multiparous women (9% to 13%). Conclusions: The results support a policy of offering healthy women with low risk pregnancies a choice of birth setting. Women planning birth in a midwifery unit and multiparous women planning birth at home experience fewer interventions than those planning birth in an obstetric unit with no impact on perinatal outcomes. For nulliparous women, planned home births also have fewer interventions but have poorer perinatal outcomes.
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In the Netherlands, midwives are autonomous medical practitioners and 78% of pregnant women start their maternity care with a primary care midwife. Scientific research to support evidence-based practice in primary care midwifery in the Netherlands has been sparse. This paper describes the research design and methodology of the multicenter multidisciplinary prospective DELIVER study which is the first large-scale study evaluating the quality and provision of primary midwifery care. Between September 2009 and April 2011, data were collected from clients and their partners, midwives and other healthcare professionals across the Netherlands. Clients from twenty midwifery practices received up to three questionnaires to assess the expectations and experiences of clients (e.g. quality of care, prenatal screening, emotions, health, and lifestyle). These client data were linked to data from the Netherlands Perinatal Register and electronic client records kept by midwives. Midwives and practice assistants from the twenty participating practices recorded work-related activities in a diary for one week, to assess workload. Besides, the midwives were asked to complete a questionnaire, to gain insight into collaboration of midwives with other care providers, their tasks and attitude towards their job, and the quality of the care they provide. Another questionnaire was sent to all Dutch midwifery practices which reveals information regarding the organisation of midwifery practices, provision of preconception care, collaboration with other care providers, and provision of care to ethnic minorities. Data at client, midwife and practice level can be linked. Additionally, partners of pregnant women and other care providers were asked about their expectations and experiences regarding the care delivered by midwives and in six practices client consults were videotaped to objectively assess daily practice. In total, 7685 clients completed at least one questionnaire, 136 midwives and assistants completed a diary with work-related activities (response 100%), 99 midwives completed a questionnaire (92%), and 319 practices across the country completed a questionnaire (61%), 30 partners of clients participated in focus groups, 21 other care providers were interviewed and 305 consults at six midwifery practices were videotaped.The multicenter DELIVER study provides an extensive database with national representative data on the quality of primary care midwifery in the Netherlands. This study will support evidence-based practice in primary care midwifery in the Netherlands and contribute to a better understanding of the maternity care system.
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The purpose of this metasynthesis is to describe and interpret qualitative research relating to midwife-led care to see if it sheds light on why low-risk women experience fewer birth interventions within this model of care. Eleven articles were included in the review. Three themes emerged: (a) relationally mediated benefits for women that resulted in increased agency and empathic care; (b) the problematic interface of midwife-led units with host maternity units, stemming from a clash of models and culture; and (c) greater agency for midwives within midwife-led models of care though bounded by the relationship with the host maternity unit. This metasynthesis suggests that lower rates of interventions could be linked to the greater agency experienced by women and midwives within midwife-led models, and that these effects are mediated, in part, by the smallness of scale in these settings.
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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. 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. 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. An intervention based on understanding and using the best available evidence can result in significant improvements in care and health outcomes.
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To examine differences in outcomes between planned home births, occurring at home or in hospital, and planned hospital births. Population-based study using South Australian perinatal data on all births and perinatal deaths during the period 1991-2006. Analysis included logistic regression adjusted for predictor variables and standardised perinatal mortality ratios. Perinatal death, intrapartum death, death attributed to intrapartum asphyxia, Apgar score < 7 at 5 minutes, use of specialised neonatal care, operative delivery, perineal injury and postpartum haemorrhage. Planned home births accounted for 0.38% of 300,011 births in South Australia. They had a perinatal mortality rate similar to that for planned hospital births (7.9 v 8.2 per 1000 births), but a sevenfold higher risk of intrapartum death (95% CI, 1.53-35.87) and a 27-fold higher risk of death from intrapartum asphyxia (95% CI, 8.02-88.83). Review of perinatal deaths in the planned home births group identified inappropriate inclusion of women with risk factors for home birth and inadequate fetal surveillance during labour. Low Apgar scores were more frequent among planned home births, and use of specialised neonatal care as well as rates of postpartum haemorrhage and severe perineal tears were lower among planned home births, but these differences were not statistically significant. Planned home births had lower caesarean section and instrumental delivery rates, and a seven times lower episiotomy rate than planned hospital births. Perinatal safety of home births may be improved substantially by better adherence to risk assessment, timely transfer to hospital when needed, and closer fetal surveillance.
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Midwives in Ontario, Canada, provide care in the home and hospital and are required to submit data for all births to the Ontario Ministry of Health database. The purpose of this study was to compare maternal and perinatal/neonatal mortality and morbidity and intrapartum intervention rates for women attended by Ontario midwives who planned a home birth compared with similar low-risk women who planned a hospital birth between 2003 and 2006. The database provided outcomes for all women planning a home birth at the onset of labor (n = 6,692) and for a cohort, stratified by parity, of similar low-risk women planning a hospital birth. The rate of perinatal and neonatal mortality was very low (1/1,000) for both groups, and no difference was shown between groups in perinatal and neonatal mortality or serious morbidity (2.4% vs 2.8%; relative risk [RR], 95% confidence intervals [CI]: 0.84 [0.68-1.03]). No maternal deaths were reported. All measures of serious maternal morbidity were lower in the planned home birth group as were rates for all interventions including cesarean section (5.2% vs 8.1%; RR [95% CI]: 0.64 [0.56, 0.73]). Nulliparas were less likely to deliver at home, and had higher rates of ambulance transport from home to hospital than multiparas planning home birth and had rates of intervention and outcomes similar to, or lower than, nulliparas planning hospital births. Midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulting in favorable outcomes for women planning both home or hospital births.
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Objective: Our purpose was to compare consequences for women of receiving versus not receiving median episiotomy early and 3 months post partum on the outcomes perineal pain, urinary and pelvic floor functioning by electromyography, and sexual functioning and to analyze the relationship between episiotomy and third- and fourth-degree tears. Study design: A secondary cohort analysis was performed of participants within a randomized clinical trial, analyzed by type of perineal trauma and pain, pelvic floor, and sexual consequences of such trauma, while controlling for trial arm. The study was conducted in three university or community hospitals; 356 primiparous and 341 multiparous women were studied. Results: Early and 3-month-postpartum perineal pain was least for women who gave birth with an intact perineum. Spontaneous perineal tears were less painful than episiotomy. Sexual functioning was best for women with an intact perineum or perineal tears. Postpartum urinary and pelvic floor symptoms were similar in all perineal groups. At 3 months post partum those delivered with an intact perineum had the strongest pelvic floor musculature, those with episiotomy the weakest. Among primiparous women third- and fourth-degree tears were associated with median episiotomy (46/47). After forceps births were removed and 21 other variables potentially associated within such tears were controlled for, episiotomy was strongly associated with third- and fourth-degree tears (odds ratio +22.08, 95% confidence interval 2.84 to 171.53). Physicians using episiotomy at high rates also used other procedures, including cesarean section, more frequently. Conclusion: Perineal and pelvic floor morbidity was greatest among women receiving median episiotomy versus those remaining intact or sustaining spontaneous perineal tears. Median episiotomy was causally related to third- and fourth-degree tears. Those using episiotomy at the highest rates were more likely use other interventions as well. Episiotomy use should be restricted to specified fetal-maternal indications.
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In het medische vakgebied neemt de verloskunde een unieke plaats in. De verloskundige zorgverlener behandelt immers niet alleen afwijkingen en ziekten, maar begeleidt ook een fysiologisch proces. Een belangrijke taak daarbij is ervoor te waken dat fysiologische grenswaarden in het zwangerschapsproces worden overschreden. Een groot deel van dit boek is dan ook gewijd aan fysiologie.Praktische verloskunde besteedt verder ruimschoots aandacht aan risicobeoordeling, begeleiding van een normale zwangerschap en een normale bevalling thuis, borstvoeding en anticonceptie post partum. Ook kleine en grote problemen van de pasgeborene, direct post partum in de eerste levensweek, komen aan de orde. Het boek biedt verder een beknopte bespreking van de huidige inzichten in de obstetrische pathologie. Daarbij gaat het in op de wijze waarop verloskundige en huisarts complicaties tijdig kunnen herkennen en kunnen trachten deze te voorkomen. Deze twaalfde druk besteedt daarnaast bijzondere aandacht aan actuele onderwerpen als prenatale screening van congenitale afwijkingen bij de foetus en pijnstilling bij de baring. Ook is er een hoofdstuk toegevoegd over preconceptionele advisering.
Article
Objective: To review systematically techniques proposed to prevent perineal trauma during childbirth and meta-analyze the evidence of their efficacy from randomized controlled trials. Data Sources: 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. Study Selection: 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 1500 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). Conclusion: 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.
Article
Objective: To examine differences in outcomes between planned home births, occurring at home or in hospital, and planned hospital births. Design and setting: Population-based study using South Australian perinatal data on all births and perinatal deaths during the period 1991-2006. Analysis included logistic regression adjusted for predictor variables and standardised perinatal mortality ratios. Main outcome measures: Perinatal death, intrapartum death, death attributed to intrapartum asphyxia, Apgar score < 7 at 5 minutes, use of specialised neonatal care, operative delivery, perineal injury and postpartum haemorrhage. Results: Planned home births accounted for 0.38% of 300011 births in South Australia. They had a perinatal mortality rate similar to that for planned hospital births (7.9 v 8.2 per 1000 births), but a sevenfold higher risk of intrapartum death (95% Cl, 1.53-35.87) and a 27-fold higher risk of death from intrapartum asphyxia (95% Cl, 8.02-88.83). Review of perinatal deaths in the planned home births group identified inappropriate inclusion of women with risk factors for home birth and inadequate fetal surveillance during labour. Low Apgar scores were more frequent among planned home births, and use of specialised neonatal care as well as rates of postpartum haemorrhage and severe perineal tears were lower among planned home births, but these differences were not statistically significant. Planned home births had lower caesarean section and instrumental delivery rates, and a seven times lower episiotomy rate than planned hospital births. Conclusions: Perinatal safety of home births may be improved substantially by better adherence to risk assessment, timely transfer to hospital when needed, and closer fetal surveillance. MJA 2010; 192: 76-80
Article
The professional literature on the benefits and risks of episiotomy was last reviewed critically in 1983, encompassing material published through 1980. This paper reviews the evidence accumulated since then. (Part II follows in this issue.) It is concluded that episiotomies prevent anterior perineal lacerations (which carry minimal morbidity), but fail to accomplish any of the other maternal or fetal benefits traditionally ascribed, including prevention of perineal damage and its sequelae, prevention of pelvic floor relaxation and its sequelae, and protection of the newborn from either intracranial hemorrhage or intrapartum asphyxia. In the process of affording this one small advantage, the incision substantially increases maternal blood loss, the average depth of posterior perineal injury, the risk of anal sphincter damage and its attendant long-term morbidity (at least for midline episiotomy), the risk of improper perineal wound healing, and the amount of pain in the first several postpartum days.
Article
Background: 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. Objectives: To assess the effect of antenatal digital perineal massage on the incidence of perineal trauma at birth and subsequent morbidity. Search methods: 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. Selection criteria: 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. Data collection and analysis: 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. Main results: 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. Authors' conclusions: 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.
Article
OBJECTIVE: To describe episiotomy usage at vaginal delivery in the United States from 1979–1997. METHODS: We used the National Hospital Discharge Survey, a federal database of a national sample of inpatient hospitals. Data from 1979 to 1997 were analyzed using International Classification of Diseases, Ninth Revision, Clinical Modification codes for diagnoses and procedures. Rates per 1000 women were calculated using the 1990 census population for women aged 15–44 years. We calculated the number of episiotomies per 100 vaginal deliveries. Rates and percentages were compared using the score test for linear trend. RESULTS: The number of episiotomies ranged from a high of 2,015,000 in 1981 to a low of 1,128,000 in 1997. The age‐adjusted annual rate for episiotomy with vaginal deliveries varied from 32.7 in 1979 to 18.7 in 1997 per 1000 women aged 15–44 years. The percentage of episiotomy with vaginal deliveries ranged from 65.3% in 1979 to 38.6% in 1997 (P < .001). Episiotomy with operative deliveries decreased over time (87.0% to 70.8%, P < .001), as did episiotomy with spontaneous deliveries (60.1% to 32.8%, P< .001). Women undergoing episiotomy were slightly younger (mean ± standard deviation, 25.7 ± 5.5 years) than women without episiotomy (26.2 ± 5.7 years, P < .001). Black women (39%) were less likely to receive episiotomy than white women (60%, P < .001). More women with private insurance (62%) had episiotomy performed than women with government insurance (43%, P < .001). CONCLUSION: Although episiotomy use has decreased over time, the most recent rate of 39 per 100 vaginal deliveries remains higher than evidence‐based recommendations for optimal patient care.
Article
Background: Midwives in Ontario, Canada, provide care in the home and hospital and are required to submit data for all births to the Ontario Ministry of Health database. The purpose of this study was to compare maternal and perinatal/neonatal mortality and morbidity and intrapartum intervention rates for women attended by Ontario midwives who planned a home birth compared with similar low-risk women who planned a hospital birth between 2003 and 2006. Methods: The database provided outcomes for all women planning a home birth at the onset of labor (n = 6, 692) and for a cohort, stratified by parity, of similar low-risk women planning a hospital birth. Results: The rate of perinatal and neonatal mortality was very low (1/1,000) for both groups, and no difference was shown between groups in perinatal and neonatal mortality or serious morbidity (2.4% vs 2.8%; relative risk (RR), 95% confidence intervals (CI): 0.84 (0.68-1.03)). No maternal deaths were reported. All measures of serious maternal morbidity were lower in the planned home birth group as were rates for all interventions including cesarean section (5.2% vs 8.1%; RR (95% CI): 0.64 (0.56, 0.73)). Nulliparas were less likely to deliver at home, and had higher rates of ambulance transport from home to hospital than multiparas planning home birth and had rates of intervention and outcomes similar to, or lower than, nulliparas planning hospital births. Conclusions: Midwives who were integrated into the health care system with good access to emergency services, consultation, and transfer of care provided care resulting in favorable outcomes for women planning both home or hospital births. (BIRTH 36:3 September 2009)
Article
OBJECTIVE. To study factors that influence the probability of episiotomy in Dutch gynaecologist-supervised deliveries. SETTING. Obstetric units of Dutch hospitals. DESIGN. Observational study. METHODS. Data of 65,313 gynaecologist-supervised, vaginal deliveries of live-born singletons registered in the Dutch National Obstetric Database of 1990, were used. Firstly, the effect of characteristics of the mother, the child, the pregnancy, and the delivery on the probability of episiotomy were assessed in univariate analyses. Subsequently logistic regression analysis was used to determine the effect of each variable, while adjusting for the other variables. RESULTS. The episiotomy rate in the total group of gynaecologist supervised deliveries was 39%. In the subgroup of vaginal deliveries of live born singletons, the rate was 46%. Besides the well-known risk factors such as parity, instrumental delivery and length of second stage of labour, ethnicity was also found to have an independent effect on the risk o
Article
Having choices and being involved in decision making contributes to women's positive childbirth experiences. During a physiological birth, women's preferences can play a leading role in the choice of birthing positions. In this study, we explored women's preferences with regard to birthing positions during second stage of labor, with a special focus on women who preferred positions other than common supine positions. A questionnaire survey was conducted among women in 54 Dutch midwifery practices. Of the 1154 women in the study, 58.9% preferred supine positions, 19.6% preferred other positions (e.g. sitting or standing), and 21.5% had no distinct preference. Women who preferred supine positions gave birth in these positions more often than women with preferences for other positions. Among the women having a preference for other positions, the actual fulfillment of their preference was related to longer duration of second stage of labor, higher levels of education, the strength of the preference, and giving birth at home. These results demonstrate differences in women's use of preferred positions during childbirth. Midwives can contribute to women-centered care by proactively exploring women's preferences for birthing positions throughout pregnancy and birth, supporting women in developing well-informed choices and facilitating these choices where possible.
Article
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.
Article
This study was performed to assess the effect of pregnancy, route of delivery, and parity on the risk of primary and subsequent anal sphincter laceration in women at first vaginal delivery (1st VD), vaginal birth after cesarean delivery (VBAC), or second vaginal delivery (2nd VD). This retrospective cohort study used data from a perinatal database that included all deliveries at Magee-Womens Hospital from 1995 to 2002. Anal sphincter laceration was the primary outcome, defined as third- and fourth-degree perineal lacerations. The adjusted odds ratio (OR) for primary and subsequent anal sphincter laceration at delivery by risk group was estimated using logistic regression models and reported with 95% confidence intervals (CIs). We assessed 20,674 live, singleton, term deliveries at Magee-Womens Hospital from 1995 to 2002, including 13,183 with 1st VD, 6068 with 2nd VD, and 1423 with VBAC. Anal sphincter laceration occurred in 16% of women with 1st VD, 18% with VBAC, and 3% with 2nd VD. Multivariable logistic regression modeling for primary anal sphincter laceration showed that 1st VD had OR of 5.1 and 95% CI 4.4, 5.9, and VBAC had OR of 5.1, 95% CI 4.2, 6.2 when compared with the reference group with 2nd VD. Shown in order for 1st VD, VBAC, and 2nd VD, the following factors, adjusted for the other listed factors, were significantly related to anal sphincter laceration except as noted: forceps, ORs of 3.0, 2.6, 5.5; midline episiotomy, ORs of 2.7, 2.9, 2.9; infant birth weight 3500 g or more, ORs of 1.9, 1.9, 1.1, not significantly different from OR of 1.0; vacuum delivery, ORs of 1.7, 1.8, 1.5, not significantly different from OR of 1.0, and 2nd stage of labor 2 hours or longer, ORs of 1.8, 0.9, 0.9, last 2 not significantly different from OR of 1.0. Of women who had anal sphincter laceration in their first vaginal delivery, 7.2% (76 of 1054 women who had 2 pregnancies) had recurrent laceration in their second vaginal delivery, compared with 2.3% (123 of 5147) of women who had a primary anal sphincter laceration in their second vaginal delivery. Multivariable logistic regression modeling for recurrent anal sphincter laceration yielded the following significant factors: episiotomy, OR 8.5, 95% CI 4.1, 17.7; vertex malpresentation (primarily occiput posterior), OR 4.3, 95% CI 1.4, 12.6; shoulder dystocia, OR 2.7, 95% CI 1.2, 5.8; and infant birth weight 3500 g or greater, OR 1.7, 95% CI 1.1, 2.7. At this institution, women undergoing VBAC are at similarly high risk of anal sphincter laceration, compared with nulliparous women. Women with prior anal sphincter laceration are at 3 times increased risk for subsequent sphincter laceration, compared with women with prior vaginal delivery without sphincter laceration. Pregnancy by itself does not appear to be an important factor in decreasing the risk of anal sphincter laceration in subsequent deliveries.
Article
The episiotomy rate has declined worldwide but remains high in several countries such as Taiwan. The effects of episiotomy on women's health should be a constant concern. Few data are available on the effect of episiotomy by validated measures. The present study examined the effect of episiotomy on pain, urinary incontinence, and sexual function up to 3 months postpartum. A prospective follow-up study of 243 women who completed the Taiwanese versions of the Short Form McGill Pain Questionnaire, International Consultation on Incontinence Questionnaire - Urinary Incontinence Short Form, Female Sexual Function Index, and a demographic questionnaire after vaginal delivery in a Taiwanese medical center. Differences between those who did and did not have an episiotomy were tested using ANCOVA, adjusting for age, parity, newborn weight, and vacuum delivery. The reliability and validity of the measuring instruments were assessed using Cronbach's α coefficient and factor analysis. Women who delivered without an episiotomy had significantly lower perineal pain scores at weeks 1, 2 and 6 postpartum compared to women who had an episiotomy (p=0.0065, 0.0391, 0.0497, respectively). Women in the no-episiotomy group had significantly lower non-localized pain scores at week 2 postpartum compared to women in the episiotomy group (p=0.0438). The mean urinary incontinence score was significantly higher in the episiotomy group 3 months postpartum (p=0.0293). No significant difference in sexual function score was found between groups. The results indicate that episiotomy increased pain at weeks 1, 2 and 6 postpartum, and urinary incontinence at 3 months postpartum. Awareness of the relationship between episiotomy and women's health will help health care professionals develop policy and promote the application of restrictive episiotomy.
Article
This article is a report of a study of the extent of postpartum sexual dysfunction associated with perineal trauma. Sexual health problems are common in the postpartum period but despite this it is a topic that lacks professional recognition. After delivery, many women experience reduced sexual desire and reduced vaginal lubrication, as well as weaker and shorter orgasms. Women giving birth in the study hospital between 2005 and 2006 and meeting the inclusion criteria were studied, i.e. women at low-risk who expected vaginal delivery at over 38 weeks' gestation with a single foetus in the vertex position. One hundred and sixty-five women were invited for postpartum check-ups 3 months later and 55 attended. A detailed gynaecologic examination was carried out and the perineum was carefully inspected by the same physician. Questionnaires were administered and 20-minute face-to-face interviews were carried out to compare the women's sexual lives before pregnancy and after giving birth. Compared to women with intact perineum, those who had both episiotomy and second degree perineal tears, had lower levels of libido, orgasm, and sexual satisfaction and more pain during intercourse. The presence of at least one sexual problem (reduced sexual desire, reduced vaginal arousal, reduced vaginal lubrication, reduced frequency of orgasm, dissatisfaction with sexual life and dyspareunia) was statistically significant more common after birth. Limiting perineal trauma during delivery is important for the resumption of sexual intercourse after childbirth. Routine episiotomy and fundal pressure should be avoided to prevent perineal trauma.
Article
Apgar scoring system was proposed in 1952 for evaluating the physical condition of neonates at 1 and 5 minutes after delivery. We designed this study to examine the original intent of Apgar system to predict neonatal survival during almost 50 years of its application. We carried out a prospective cohort analysis of 1161 live born term neonates delivered by cesarean section at 37 weeks of gestation or later at Khoram-abad Asali hospital in Iran during 2003 to 2005. Apgar score in 1 and 5 minutes after delivery were determined and charted. We evaluated two groups, neonates with Apgar score of equal or more than 5 in 5 minute after birth, and the ones with less than 5. The relation between neonatal mortality during first 48 hours after birth and 5 minute Apgar score was assessed. All analysis was performed with SPSS Software and chi(2) test. In 1161 neonates, 8 were with five minute Apgar score less than 5, and their mortality rate in first 48 hours after birth was 5, as compared with 13 in 1153 for neonates with 5 minute Apgar score equal or more than 5. Neonatal mortality rate was 625 in 1000 for neonates with 5 minute Apgar score less than 5 and 11.4 in 1000 for infants with score equal or more than 5. There was statistically significance between two groups (P approximately = 0.0001). Apgar score is still as meaningful as it was in 1952. Apgar score after birth can be used as a rapid method for assessing the survival of neonate. Although low 5 minute Scores were rare in this study but there was strongly predictive relation between it and early neonatal mortality.
Article
To examine the association between semi-sitting and sitting position at the time of birth and perineal damage amongst low-risk women in primary care. Evidence on the association between birthing positions and perineal trauma is not conclusive. Most studies did not distinguish between positions during the second stage of labour and position at the time of birth. Therefore, although birthing positions do not seem to affect the overall perineal trauma rate, an increase in trauma with upright position for birthing cannot be ruled out. Secondary analysis was performed on data from a large trial. This trial was conducted amongst primary care midwifery practices in the Netherlands. A total of 1646 women were included who had a spontaneous, vaginal delivery. Perineal outcomes were compared between women in recumbent, semi-sitting and sitting position. Logistic regression analysis was used to examine the effects of these positions after controlling for other factors. No significant differences were found in intact perineum rates between the position groups. Women in sitting position were less likely to have an episiotomy and more likely to have a perineal tear than women in recumbent position. After controlling for other factors, the odds ratios (OR) were 0.29 [95% confidence interval (CI): 0.16-0.54] and 1.83 (95% CI: 1.22-2.73) respectively. Women in semi-sitting position were more likely to have a labial tear than women in recumbent position (OR: 1.43, 95% CI: 1.00-2.04). A semi-sitting or sitting birthing position does not need to be discouraged to prevent perineal damage. Women should be encouraged to use positions that are most comfortable to them.
Article
To analyse the significance of risk factors and the role of episiotomy in preventing obstetric anal sphincter injury at vaginal delivery. This is a retrospective cross-sectional study in the Norfolk and Norwich University Hospital in the UK. All caesarean sections and non-vertex presentations were excluded, which resulted in a study population of 10,314 deliveries. Obstetric anal sphincter injury (OASI) was defined as third or fourth degree tears to the anal sphincter muscles, with or without a tear involving the anal mucosa. First a univariate analysis was done to identify factors that had a significant association with OASI. Factors included parity, age, gestation, labour induction method, duration of second stage, use of epidural analgesia, episiotomy, method of delivery, time and month of delivery, and birth weight. All factors were then combined in a multivariate logistic regression analysis. The multivariate analysis was then repeated including only factors that had a significant association with OASI in the univariate analysis. Adjusted odds ratios with 95% confidence intervals (CI) were calculated. The frequency of anal sphincter lacerations was 3.2%. There were statistically significant associations between an increased incidence of OASI and parity, birth weight, method of delivery and shoulder dystocia. Women giving birth without a mediolateral episiotomy were 1.4 times more likely to experience OASI (95% CI 1.021-1.983). Interestingly, the incidence of OASI has risen between 2005 and 2007. Parity, age, birth weight, method of delivery and shoulder dystocia are strongly associated with obstetric anal sphincter injury. Mediolateral episiotomy appears to be protective against OASI but a randomised controlled trial would be needed to confirm this. The rising incidence of OASI after normal vaginal deliveries may be related to adoption of the hands off technique or increased identification of tears.
Article
Background: The aim of the study was to determine the rates and to describe the risk factors for episiotomy and perineal tears in low-risk primigravidae. Method: A cross-sectional survey of 101 randomly selected NHS hospitals in the UK was carried out between February 1993 and January 1994. Subjects were 40 consecutive low-risk primigravidae in each hospital. The main outcome measures were number and reasons for episiotomy, and number and degree of perineal tears. Results: A large proportion of women (83 per cent) experienced some form of perineal trauma. Forty per cent of the women had an episiotomy only, 6 per cent an episiotomy and perineal tear, and 37 per cent perineal or other tears without episiotomy. The main reasons for performing an episiotomy were foetal distress (27 per cent), impending tear (25 per cent) and delay of the second stage of labour (21 per cent). Fifty-nine per cent of women with a delayed second stage had a spontaneous vaginal delivery and 41 per cent required instrumental assistance. The likelihood of having an episiotomy increased with the duration of the second stage of labour, irrespective of type of delivery. Episiotomy rates varied appreciably throughout regions and hospitals in the United Kingdom, ranging from 26 to 67 per cent. There was also a large regional variation in the rates of perineal trauma; generally, high rates of one outcome were associated with low rates of the other. Compared with white women, women from the Indian sub-continent were almost twice as likely and those from the Orient almost five times as likely to have an episiotomy. Conclusions: The magnitude of the geographical variation suggests a lack of uniformity in indications for performing episiotomies and that guidelines for performing episiotomies may need to be reviewed. The rates of episiotomy in women from the Indian sub-continent and Orient were very high compared with those for white women, and this requires clarification and explanation, as they are contrary to rates experienced in these ethnic groups in other countries.
Article
To identify risk factors for immediate postpartum hemorrhage after vaginal delivery in a South American population. This was a prospective cohort study including all vaginal births (N=11,323) between October and December 2003 and October and December 2005 from 24 maternity units in two South American countries (Argentina and Uruguay). Blood loss was measured in all births using a calibrated receptacle. Moderate postpartum hemorrhage and severe postpartum hemorrhage were defined as blood loss of at least 500 mL and at least 1,000 mL, respectively. Moderate and severe postpartum hemorrhage occurred in 10.8% and 1.9% of deliveries, respectively. The risk factors more strongly associated and the incidence of moderate postpartum hemorrhage in women with each of these factors were: retained placenta (33.3%) (adjusted odds ratio [OR] 6.02, 95% confidence interval [CI] 3.50-10.36), multiple pregnancy (20.9%) (adjusted OR 4.67, CI 2.41-9.05), macrosomia (18.6%) (adjusted OR 2.36, CI 1.93-2.88), episiotomy (16.2%) (adjusted OR 1.70, CI 1.15-2.50), and need for perineal suture (15.0%) (adjusted OR 1.66, CI 1.11-2.49). Active management of the third stage of labor, multiparity, and low birth weight were found to be protective factors. Severe postpartum hemorrhage was associated with retained placenta (17.1%) (adjusted OR 16.04, CI 7.15-35.99), multiple pregnancy (4.7%) (adjusted OR 4.34, CI 1.46-12.87), macrosomia (4.9%) (adjusted OR 3.48, CI 2.27-5.36), induced labor (3.5%) (adjusted OR 2.00, CI 1.30-3.09), and need for perineal suture (2.5%) (adjusted OR 2.50, CI 1.87-3.36). Many of the risk factors for immediate postpartum hemorrhage in this South American population are related to complications of the second and third stage of labor. II.
Article
The objective of the study was to describe episiotomy rates in the United States following recommended changes in clinical practice. The National Hospital Discharge Survey, a federal data set sampling inpatient hospitals, was used to obtain data based on International Classification of Diseases, Clinical Modification, 9th revision, diagnosis and procedure codes from 1979 to 2004. Age-adjusted rates of term, singleton, vertex, live-born spontaneous vaginal delivery, operative vaginal delivery, cesarean delivery, episiotomy, and anal sphincter laceration were calculated. Census data for 1990 for women 15-44 years of age was used for age adjustment. Regression analysis was used to evaluate trends in episiotomy. The rate of episiotomy with all vaginal deliveries decreased from 60.9% in 1979 to 24.5% in 2004. Anal sphincter laceration with spontaneous vaginal delivery declined from 5% in 1979 to 3.5% in 2004. Rates of anal sphincter laceration with operative delivery increased from 7.7% in 1979 to 15.3% in 2004. The age-adjusted rate of operative vaginal delivery declined from 8.7 in 1979 to 4.6 in 2004, whereas cesarean delivery rates increased from 8.3 in 1979 to 17.2 per 1000 women in 2004. Routine episiotomy has declined since liberal usage has been discouraged. Anal sphincter laceration rates with spontaneous vaginal delivery have decreased, likely reflecting the decreased usage of episiotomy. The decline in operative vaginal delivery corresponds to a sharp increase in cesarean delivery, which may indicate that practitioners are favoring cesarean delivery for difficult births.
Article
Vaginal tears can occur during childbirth, most often at the vaginal opening as the baby's head passes through, especially if the baby descends quickly. Tears can involve the perineal skin or extend to the muscles and the anal sphincter and anus. The midwife or obstetrician may decide to make a surgical cut to the perineum with scissors or scalpel (episiotomy) to make the baby's birth easier and prevent severe tears that can be difficult to repair. The cut is repaired with stitches (sutures). Some childbirth facilities have a policy of routine episiotomy. The review authors searched the medical literature for randomised controlled trials that compared episiotomy as needed (restrictive) compared with routine episiotomy to determine the possible benefits and harms for mother and baby. They identified eight trials involving more than 5000 women. For women randomly allocated to routine episiotomy 75.10% actually had an episiotomy whereas with a restrictive episiotomy policy 28.40% had an episiotomy. Restrictive episiotomy policies appeared to give a number of benefits compared with using routine episiotomy. Women experienced less severe perineal trauma, less posterior perineal trauma, less suturing and fewer healing complications at seven days (reducing the risks by from 12% to 31%); with no difference in occurrence of pain, urinary incontinence, painful sex or severe vaginal/perineal trauma after birth. Overall, women experienced more anterior perineal damage with restrictive episiotomy. Both restrictive compared with routine mediolateral episiotomy and restrictive compared with midline episiotomy showed similar results to the overall comparison with the limited data on episiotomy techniques available from the present trials.
Article
The benefits and risks of episiotomy in labor and delivery as recorded in the English language literature in over 350 books and articles published since 1860 are reviewed and analyzed. Episiotomy is performed in over 60 per cent of all deliveries in the United States and in a much higher per cent of primigravidas. Yet, there is no clearly defined evidence for its efficacy, particularly for routine use. In addition, although poorly studied, there is evidence that postpartum pain and discomfort are accentuated after episiotomy, and serious complications, including maternal death, can be associated with the procedure. Therefore, carefully designed controlled trials of benefit and risk should be carried out on the use of episiotomy.
Article
Data was collected about the mother, the infant and the pregnancy in women who had an episiotomy performed at delivery, and those who did not, in one district hospital and two community hospitals. Factors predisposing mothers to episiotomy were sought and compared in the different hospitals. Traditional indications for episiotomy, such as a large baby and a small mother, were found to be less important than the occurrence of fetal distress, prolongation of the second stage of labour and the presence of pupil midwives at delivery. Current practice in the use of episiotomy is discussed.
Article
In a group of 1272 primiparous women, who delivered spontaneously at the University Hospital of Leiden between 1 January 1988 and 31 December 1991, the relationship between the use of an episiotomy and the professional training of the delivery attendant has been studied, using multiple logistic regression (a random effects model to allow for patient-within-physician effects). The following factors were taken into account: birthweight, duration of the second stage of labour, supposed fetal distress, age and race of the mother, gestational age, duration of pregnancy and the year of the delivery. Based on the logistic regression model it is estimated that registrars and gynaecologists are 2.5 and 3.4 times, respectively, more likely than midwives to perform an episiotomy.
Article
To investigate the relation between the use of mediolateral episiotomy and the occurrence of severe (third degree) perineal tears in hospital deliveries in the Netherlands. An observational study. Data were derived from the Dutch National Obstetric Database (LVR) of 1990, from which 43,309 spontaneous, occipito-anterior, vaginal deliveries of live, singleton infants were investigated. Medio-lateral episiotomy. The occurrence of severe perineal tears. The severe tear rate was 1.4% in the total study group. Using multiple logistic regression to control for possible confounding variables, the use of mediolateral episiotomy was found to be associated with a more than fourfold decrease in risk of severe lacerations (odds ratio 0.22, 95% CI 0.17 to 0.29). Further, in a logistic model deliveries in hospitals with restrictive use of episiotomy (< 11%) were compared with those in hospitals with liberal use of episiotomy (> 50%). Liberal use of episiotomy was not associated with a lower frequency of severe perineal tears. Although a protective effect of mediolateral episiotomy on the occurrence of severe lacerations was found, liberal use of mediolateral episiotomy should be discouraged on the basis of our findings.
Article
To study factors that influence the probability of episiotomy in Dutch gynaecologist-supervised deliveries. Obstetric units of Dutch hospitals. Observational study. Data of 65,313 gynaecologist-supervised, vaginal deliveries of live-born singletons registered in the Dutch National Obstetric Database of 1990, were used. Firstly, the effect of characteristics of the mother, the child, the pregnancy, and the delivery on the probability of episiotomy were assessed in univariate analyses. Subsequently logistic regression analysis was used to determine the effect of each variable, while adjusting for the other variables. The episiotomy rate in the total group of gynaecologist supervised deliveries was 39%. In the subgroup of vaginal deliveries of live born singletons, the rate was 46%. Besides the well-known risk factors such as parity, instrumental delivery and length of second stage of labour, ethnicity was also found to have an independent effect on the risk of an episiotomy. Mediterranean, Creole and Hindu women had a lower episiotomy risk than Dutch women (OR: 0.47 and 95% CI: 0.44-0.51). Gynaecologists more often performed episiotomy than midwives, after adjusting for possible confounding factors (OR: 1.54; 1.46-1.63). In University hospitals fewer episiotomies were performed than in large non-university hospitals (OR: 0.81; 0.76-0.87. The decision to perform episiotomy appears not to depend solely on factors related to perineal rupture or foetal complications. The probability of episiotomy is also influenced by attendant at delivery and type of hospital.
Article
The professional literature on the benefits and risks of episiotomy was last reviewed critically in 1983, encompassing material published through 1980. This paper reviews the evidence accumulated since then. (Part II follows in this issue.) It is concluded that episiotomies prevent anterior perineal lacerations (which carry minimal morbidity), but fail to accomplish any of the other maternal or fetal benefits traditionally ascribed, including prevention of perineal damage and its sequelae, prevention of pelvic floor relaxation and its sequelae, and protection of the newborn from either intracranial hemorrhage or intrapartum asphyxia. In the process of affording this one small advantage, the incision substantially increases maternal blood loss, the average depth of posterior perineal injury, the risk of anal sphincter damage and its attendant long-term morbidity (at least for midline episiotomy), the risk of improper perineal wound healing, and the amount of pain in the first several postpartum days.
Article
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.
Article
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.
Article
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.
Article
Episiotomy is done to prevent severe perineal tears, but its routine use has been questioned. The relative effects of midline compared with midlateral episiotomy are unclear. The objective of this review was to assess the effects of restrictive use of episiotomy compared with routine episiotomy during vaginal birth. We searched the Cochrane Pregnancy and Childbirth Group trials register. Randomised trials comparing restrictive use of episiotomy with routine use of episiotomy; restrictive use of mediolateral episiotomy versus routine mediolateral episiotomy; restrictive use of midline episiotomy versus routine midline episiotomy; and use of midline episiotomy versus mediolateral episiotomy. Trial quality was assessed and data were extracted independently by two reviewers. Six studies were included. In the routine episiotomy group, 72.7% (1752/2409) of women had episiotomies, while the rate in the restrictive episiotomy group was 27.6% (673/2441). Compared with routine use, restrictive episiotomy involved less posterior perineal trauma (relative risk 0. 88, 95% confidence interval 0.84 to 0.92), less suturing (relative risk 0.74, 95% confidence interval 0.71 to 0.77) and fewer healing complications (relative risk 0.69, 95% confidence interval 0.56 to 0.85). Restrictive episiotomy was associated with more anterior perineal trauma (relative risk 1.79, 95% 1.55 to 2.07). There was no difference in severe vaginal or perineal trauma (relative risk 1.11, 95% confidence interval 0.83 to 1.50); dyspareunia (relative risk 1.02, 95% confidence interval 0.90 to 1.16); urinary incontinence (relative risk 0.98, 95% confidence interval 0.79 to 1.20) or several pain measures. Results for restrictive versus routine mediolateral versus midline episiotomy were similar to the overall comparison. Restrictive episiotomy policies appear to have a number of benefits compared to routine episiotomy policies. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy.
Article
To identify factors associated with the use of episiotomy at spontaneous vaginal delivery. We studied 1576 consecutive term, singleton, spontaneous vaginal deliveries in nulliparas at Brigham & Women's Hospital between December 1, 1994 and July 31, 1995. The association of demographic variables and obstetric factors with the rate of episiotomy use were examined. Adjusted odds ratios (OR) and confidence intervals (CI) were estimated from multiple logistic regression analysis. The overall rate of episiotomy was 40.6% (640 of 1576). Midwives performed episiotomies at a lower rate (21.4%) than faculty (33.3%) and private providers (55.6%) (P =. 001). After controlling for confounding factors with logistic regression, private practice provider was the strongest predictor of episiotomy use (OR, 4.1; 95% CI, 3.1, 5.4) followed by faculty provider (OR, 1.7; 95% CI, 1.1, 2.5), prolonged second stage of labor (OR, 1.8; 95% CI, 1.2, 2.7), fetal macrosomia (OR, 1.6; 95% CI, 1.1, 2.5), and epidural analgesia (OR 1.4, 95% CI, 1.1, 1.8). The strongest factor associated with episiotomy at delivery was the category of obstetric provider. Obstetric and demographic factors evaluated did not readily explain this association.
Article
The 10-point Apgar score has been used to assess the condition and prognosis of newborn infants throughout the world for almost 50 years. Some investigators have proposed that measurement of pH in umbilical-artery blood is a more objective method of assessing newborn infants. We carried out a retrospective cohort analysis of 151,891 live-born singleton infants without malformations who were delivered at 26 weeks of gestation or later at an inner-city public hospital between January 1988 and December 1998. Paired Apgar scores and umbilical-artery blood pH values were determined for 145,627 infants to assess which test best predicted neonatal death during the first 28 days after birth. For 13,399 infants born before term (at 26 to 36 weeks of gestation), the neonatal mortality rate was 315 per 1000 for infants with five-minute Apgar scores of 0 to 3, as compared with 5 per 1000 for infants with five-minute Apgar scores of 7 to 10. For 132,228 infants born at term (37 weeks of gestation or later), the mortality rate was 244 per 1000 for infants with five-minute Apgar scores of 0 to 3, as compared with 0.2 per 1000 for infants with five-minute Apgar scores of 7 to 10. The risk of neonatal death in term infants with five-minute Apgar scores of 0 to 3 (relative risk, 1460; 95 percent confidence interval, 835 to 2555) was eight times the risk in term infants with umbilical-artery blood pH values of 7.0 or less (180; 95 percent confidence interval, 97 to 334). The Apgar scoring system remains as relevant for the prediction of neonatal survival today as it was almost 50 years ago.