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OBJECTIVE: To assess the effect of lateral episiotomy, compared with no episiotomy, on obstetric anal sphincter injury in nulliparous women requiring vacuum extraction. DESIGN: A multicentre, open label, randomised controlled trial. SETTING: Eight hospitals in Sweden, 2017-23. PARTICIPANTS: 717 nulliparous women with a single live fetus of 34 gestational weeks or more, requiring vacuum extraction were randomly assigned (1:1) to lateral episiotomy or no episiotomy using sealed opaque envelopes. Randomisation was stratified by study site. INTERVENTION: A standardised lateral episiotomy was performed during the vacuum extraction, at crowning of the fetal head, starting 1-3 cm from the posterior fourchette, at a 60° (45-80°) angle from the midline, and 4 cm (3-5 cm) long. The comparison was no episiotomy unless considered indispensable. MAIN OUTCOME MEASURES: The primary outcome of the episiotomy in vacuum assisted delivery (EVA) trial was obstetric anal sphincter injury, clinically diagnosed by combined visual inspection and digital rectal and vaginal examination. The primary analysis used a modified intention-to-treat population that included all consenting women with attempted or successful vacuum extraction. As a result of an interim analysis at significance level P<0.01, the primary endpoint was tested at 4% significance level with accompanying 96% confidence interval (CI). RESULTS: From 1 July 2017 to 15 February 2023, 717 women were randomly assigned: 354 (49%) to lateral episiotomy and 363 (51%) to no episiotomy. Before vacuum extraction attempt, one woman withdrew consent and 14 had a spontaneous birth, leaving 702 for the primary analysis. In the intervention group, 21 (6%) of 344 women sustained obstetric anal sphincter injury, compared with 47 (13%) of 358 women in the comparison group (P=0.002). The risk difference was -7.0% (96% CI -11.7% to -2.5%). The risk ratio adjusted for site was 0.47 (96% CI 0.23 to 0.97) and unadjusted risk ratio was 0.46 (0.28 to 0.78). No significant differences were noted between groups in postpartum pain, blood loss, neonatal outcomes, or total adverse events, but the intervention group had more wound infections and dehiscence. CONCLUSIONS: Lateral episiotomy can be recommended for nulliparous women requiring vacuum extraction to significantly reduce the risk of obstetric anal sphincter injury. TRIAL REGISTRATION: ClinicalTrials.gov NCT02643108.
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Canal Anal , Episiotomía , Paridad , Extracción Obstétrica por Aspiración , Humanos , Femenino , Episiotomía/métodos , Episiotomía/estadística & datos numéricos , Episiotomía/efectos adversos , Embarazo , Extracción Obstétrica por Aspiración/efectos adversos , Adulto , Canal Anal/lesiones , Suecia , Complicaciones del Trabajo de Parto/prevención & control , Laceraciones/prevención & control , Laceraciones/etiología , Adulto JovenRESUMEN
Skin tears are a major problem for patients and the health care professionals who treat them. Although opinions on their prevalence differ, it is estimated that they are encountered more frequently than pressure sores but are overlooked. Recommendations based on strong evidence were presented for the prevention and treatment of skin tears as classified by the International Skin Tear Advisory Panel. This case series includes the clinical status of 3 patients who developed skin tears while receiving care in the hospital, and the corrective and preventive practices related to skin tears. This article will contribute to raising the awareness of health care professionals in predicting, preventing, evaluating, and treating skin tears.
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Laceraciones , Piel , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Laceraciones/prevención & control , Laceraciones/enfermería , Úlcera por Presión/prevención & control , Úlcera por Presión/enfermería , Piel/lesionesRESUMEN
PURPOSE: Injuries of the nasal vestibular skin caused by the rotating burr shafts can represent a tedious complication following endonasal drilling and is experienced sooner or later by every rhino-surgeon. MATERIAL AND METHODS: To protect the nasal entrance from laceration by the free rotating drill shaft we position an otology speculum in the nasal entrance. The speculum is held in place by the scrub nurse during the critical phase of bone drilling. RESULTS: Following the introduction of the ear speculum protection, we successfully treated our dacryocystostamia procedures (n = 27) and median maxillectomia procedures (n = 6) without any further soft tissue erosions. DISCUSSION: Preventive measures for injuries by endonasal drilling procedures are not reported extensively in literature. This stands in contrast to the fact that these injuries are prone to cause significant suffering as amply described in the case of nostril laceration due to nasogastric intubation or nasogastric feeding tubes. CONCLUSION: The use of a readily available, reusable ear speculum in endonasal drill application eliminated the complication of nasal entrance lacerations throughout our institution, hitherto.
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Laceraciones , Humanos , Laceraciones/prevención & control , Laceraciones/etiología , Instrumentos Quirúrgicos , Nariz/lesiones , Nariz/cirugía , Diseño de Equipo , Masculino , FemeninoRESUMEN
OBJECTIVE: Obstetric anal sphincter injuries are feared perineal injuries that are associated with increased pelvic floor disorders. The knowledge of influencing factors as the mode of delivery is therefore important. The aim of this study is to compare the rate of obstetric anal sphincter injuries in primiparae after water and bed deliveries. STUDY DESIGN: In this retrospective cohort study 3907 primiparae gave birth in water or on a bed in a Swiss teaching hospital. The diagnosis of obstetric anal sphincter injuries was confirmed by a consultant of obstetrics and gynecology and treated by them. The rates of these injuries after water and bed births were compared. Subgroup analysis was performed to detect possible associative factors, such as birth weight, episiotomy, use of oxytocin in first and second stage of labor. RESULTS: 1844 (47.2 %) of the primiparae had a water delivery and 2063 (52.8 %) a bed delivery. 193 (4.94 %) were diagnosed with obstetric anal sphincter injuries, of which 68 (3.7 %) had a water delivery and 125 (6.1 %) a bed delivery, p < 0.001. Subgroup analysis revealed that, in the first and second stage of labor, the rate of obstetric anal sphincter injuries with oxytocin was significantly lower in water than in bed deliveries; p = 0.025, p < 0.017, respectively. The rate of obstetric anal sphincter injuries in the birth weight or episiotomy subgroups did not reach significance. CONCLUSIONS: In a teaching hospital setting with standardized labor management, primiparae with a water delivery have the lowest risk for obstetric anal sphincter injuries.
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Laceraciones , Complicaciones del Trabajo de Parto , Embarazo , Femenino , Humanos , Parto Obstétrico/efectos adversos , Estudios Retrospectivos , Oxitocina/uso terapéutico , Canal Anal/lesiones , Peso al Nacer , Suiza/epidemiología , Factores de Riesgo , Episiotomía , Hospitales Públicos , Hospitales de Enseñanza , Complicaciones del Trabajo de Parto/epidemiología , Complicaciones del Trabajo de Parto/prevención & control , Laceraciones/epidemiología , Laceraciones/etiología , Laceraciones/prevención & controlRESUMEN
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.
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Laceraciones , Complicaciones del Trabajo de Parto , Embarazo , Femenino , Humanos , Peso al Nacer , Episiotomía , Paridad , Parto , Laceraciones/epidemiología , Laceraciones/prevención & control , Laceraciones/complicaciones , Canal Anal/lesiones , Factores de Riesgo , Perineo/lesiones , Complicaciones del Trabajo de Parto/epidemiología , Complicaciones del Trabajo de Parto/prevención & control , Complicaciones del Trabajo de Parto/etiologíaRESUMEN
INTRODUCTION AND HYPOTHESIS: Evidence suggests that episiotomies reduce the risk for obstetric anal sphincter injuries (OASIs) in operative vaginal deliveries (OVDs). However, there is limited evidence on the importance of episiotomy technique in this context. The primary objective of this study was to assess if an episiotomy suture angle >45° from the median line would be associated with a lower risk for OASIs at the time of OVD. METHODS: This was an ancillary study from the multicentre prospective cohort INSTRUMODA study. Of the 2,620 patients who had an OVD with a concomitant episiotomy between April 2021 and March 2022, a total of 219 fulfilled the inclusion criteria. Post-suturing photographs were used to assess episiotomy characteristics. RESULTS: Based on suture angles of ≤45° and >45° the study cohort was categorized into groups A (n = 155) and B (n = 64) respectively. The groups had comparable demographic and birth-related characteristics. The mean episiotomy length was significantly longer in group A than in group B (3.21 cm vs 2.84 cm; p = 0.009). Senior obstetricians performed more acute angled episiotomies than junior residents (p = 0.016). The total prevalence of OASIS was 2.3%, with no significant difference in rate of OASI between the two study groups. Birthweight was significantly higher in OASI births (p = 0.018) and spatula-assisted births were associated with higher risk for OASIs than ventouse or forceps (p = 0.0039). CONCLUSIONS: This study did not demonstrate a significant reduction in risk for OASI at the time of OVD when the episiotomy suture angle was >45° from the median line. However, these results should be interpreted with caution owing to the low prevalence of OASIs in our cohort.
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Episiotomía , Laceraciones , Femenino , Embarazo , Humanos , Episiotomía/efectos adversos , Estudios de Cohortes , Estudios Prospectivos , Parto Obstétrico/efectos adversos , Francia/epidemiología , Laceraciones/epidemiología , Laceraciones/etiología , Laceraciones/prevención & controlRESUMEN
Pelvic floor dysfunction (PFD) is common to be associated with pregnancy and birth. To date, no research has been done to understand whether the perineal massage and warm compresses technique has an impact on pelvic floor dysfunction. To assess the impact of perineal massage and warm compresses technique during the second stage of labor in pelvic floor dysfunction at 3 and 6 months postpartum. Of the 800 women recruited to randomised controlled trial to prevent perineal trauma, 496 were included in the study, with 242 (48.8%) assigned to the Perineal Massage and Warm Compresses (PeMWaC) group and 254 (51.2%) to the control group (hands-on). Used the Pelvic Floor Distress Inventory-20 (PFDI-20). The questionnaire is divided into three subscales: Urinary (UDI), Colorectal-Anal (CRADI), and Pelvic Organ Prolapse Distress Inventory (POPDI). The PeMWaC group had a significantly higher frequency of intact perineum (p < 0.001) and low-severity vaginal tears (tears without any other degree of perineal trauma) (p = 0.031) compared to the control group, while the control group had significantly more patients who suffered high-severity vaginal/perineal trauma (second degree perineal tears) (p = 0.031) and patients without spontaneous perineal trauma or vaginal tears who underwent episiotomy (p < 0.001). In addition, at 3 months postpartum, women in the control group had a higher Urinary Distress Inventory (UDI) score and global score, compared to the PeMWaC group, and after controlling for confounding variables, the perineal massage and warm compresses technique was associated with lower UDI scores at 3 months postpartum compared to control group. At 6 months postpartum, there were no differences in the UDI or global scores, indicating general recovery from perineal trauma. In addition to reducing perineal trauma during birth, the perineal massage and warm compresses technique was associated with a lower prevalence of early PFD symptoms, mainly urinary distress, at 3 months.Trial registration http://www.ClinicalTrials.gov NCT05854888, retrospectively registered.
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Laceraciones , Perineo , Embarazo , Humanos , Femenino , Perineo/lesiones , Diafragma Pélvico/lesiones , Periodo Posparto , Episiotomía , Laceraciones/complicaciones , Laceraciones/prevención & control , MasajeRESUMEN
INTRODUCTION: The complex process of pregnancy and childbirth significantly influences the well-being of both mother and child. Today all pregnant women without medical contraindications are recommended to start or continue regular aerobic and strength training for at least 150 min per week to prevent pregnancy-related diseases and conditions. Urinary incontinence in pregnancy, episiotomy and third- or fourth-degree perineal tear during labor can greatly impact womens' health, quality of life and ability to be physically active. The aim of this study was to examine the efficacy of pelvic floor muscle training (PFMT) during pregnancy in the prevention of urinary incontinence, episiotomy, and third- or fourth-degree perineal tear. MATERIAL AND METHODS: A systematic review and meta-analysis (CRD42022370600) was performed. Only randomized clinical trials published between 2010 and 2023 were included. The following databases were examined: EBSCO (including Academic Search Premier, Education Resources Information Center, MEDLINE, SPORTDiscus and OpenDissertations databases), Clinicaltrials.gov, Web of Science, Scopus, Cochrane Database of Systematic Reviews and Physiotherapy Evidence Database (PEDro). Three meta-analyses to investigate the effect of PFMT exclusively or implemented as a section within a physical activity program during pregnancy on urinary incontinence, episiotomy, and third- or fourth-degree perineal tear were conducted. RESULTS: Thirty studies were analyzed (N = 6691). An effective preventive action of PFMT was found for urinary incontinence (z = 3.46; p < 0.0005; relative risk [RR] = 0.72, 95% confidence interval [CI]: 0.59, 0.87, I2 = 59%) and third- or fourth-degree perineal tear (z = 2.89; p = 0.004; RR = 0.50, 95% CI: 0.31, 0.80, I2 = 48%) but not for episiotomy (z = 0.80; p = 0.42; RR = 0.95, 95% CI: 0.85, 1.07, I2 = 75%). CONCLUSIONS: PFMT during pregnancy proves to be an effective preventive intervention for reducing the risk of urinary incontinence and the occurrence of third- or fourth-degree perineal tears. These findings highlight the importance of incorporating PFMT into antenatal care and training programs to improve maternal well-being and overall childbirth outcomes.
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Episiotomía , Terapia por Ejercicio , Diafragma Pélvico , Perineo , Ensayos Clínicos Controlados Aleatorios como Asunto , Incontinencia Urinaria , Humanos , Femenino , Embarazo , Episiotomía/efectos adversos , Incontinencia Urinaria/prevención & control , Incontinencia Urinaria/etiología , Perineo/lesiones , Terapia por Ejercicio/métodos , Complicaciones del Trabajo de Parto/prevención & control , Complicaciones del Embarazo/prevención & control , Ejercicio Físico , Laceraciones/prevención & control , Laceraciones/etiologíaRESUMEN
Skin tears are traumatic wounds caused by mechanical forces, which can be caused by the removal of adhesive dressing. Although they are common - especially in individuals with vulnerable skin, such as older people - their prevalence is underestimated, they are often misdiagnosed and they have a high risk of developing into complex, chronic wounds. However, skin tears are largely preventable. There are a number of intrinsic and extrinsic factors relating to skin tears and preventive strategies that may be undertaken. Health professionals, patients and caregivers/family members should aim to manage modifiable intrinsic and extrinsic factors to promote and maintain skin integrity to prevent skin tears. Where a skin tear does occur, an evidence-based approach should be taken to management, with referral to specialist care if necessary.
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Laceraciones , Humanos , Anciano , Laceraciones/prevención & control , Piel/lesiones , Cuidadores , Prevalencia , Vendajes , Factores de RiesgoRESUMEN
Skin tears are acute wounds caused by mechanical forces resulting in the separation of the skin's outer layers. Skin tears are more likely to occur in vulnerable people such as older people and people with neurodegenerative conditions. Rising life expectancy means that the number of patients with skin tears is expected to increase. This article describes the characteristics of skin tears, details the risk factors for skin tears and explains the importance of using a holistic, evidence-based and person-centred approach to skin tear prevention, assessment and treatment. The article outlines the crucial role of nurses as part of the multidisciplinary team in the management of skin tears.
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Laceraciones , Piel , Humanos , Anciano , Piel/lesiones , Cicatrización de Heridas , Laceraciones/diagnóstico , Laceraciones/prevención & control , Factores de RiesgoRESUMEN
BACKGROUND: Perineal lacerations could lead to substantial morbidities for women. A reliable prediction model for perineal lacerations has the potential to guide the prevention. Although several prediction models have been developed to estimate the risk of perineal lacerations, especially third- and fourth-degree perineal lacerations, the evidence about the model quality and clinical applicability is scarce. OBJECTIVES: To systematically review and critically appraise the existing prediction models for perineal lacerations. METHODS: Seven databases (PubMed, Embase, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, SinoMed, China National Knowledge Infrastructure, and Wanfang Data) were systematically searched from inception to July 2022. Studies that developed prediction models for perineal lacerations or performed external validation of existing models were considered eligible to include in the systematic review. Two reviewers independently conducted data extraction according to the Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies. The risk of bias and the applicability of the included models were assessed with the Prediction Model Risk of Bias Assessment Tool. A narrative synthesis was performed to summarize the characteristics, risk of bias, and performance of existing models. RESULTS: Of 4345 retrieved studies, 14 studies with 22 prediction models for perineal lacerations were included. The included models mainly aimed to estimate the risk of third- and fourth-degree perineal lacerations. The top five predictors used were operative vaginal birth (72.7â¯%), parity/previous vaginal birth (63.6â¯%), race/ethnicity (59.1â¯%), maternal age (50.0â¯%), and episiotomy (40.1â¯%). Internal and external validation was performed in 12 (54.5â¯%) and seven (31.8â¯%) models, respectively. 13 studies (92.9â¯%) assessed model discrimination, with the c-index ranging from 0.636 to 0.830. Seven studies (50.0â¯%) evaluated the model calibration using the Hosmer-Lemeshow test, Brier score, or calibration curve. The results indicated that most of the models had fairly good calibration. All the included models were at higher risk of bias mainly due to unclear or inappropriate methods for handling missing data and continuous predictors, external validation, and model performance evaluation. Six models (27.3â¯%) showed low concerns about applicability. CONCLUSIONS: The existing models for perineal lacerations were poorly validated and evaluated, among which only two have the potential for clinical use: one for women undergoing vaginal birth after cesarean delivery, and the other one for all women undergoing vaginal birth. Future studies should focus on robust external validation of existing models and the development of novel models for second-degree perineal laceration. PROSPERO REGISTRATION NUMBER: CRD42022349786. TWEETABLE ABSTRACT: The existing models for perineal lacerations during childbirth need external validation and updating. Tools are needed for second-degree perineal laceration.
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Laceraciones , Femenino , Humanos , Embarazo , Parto Obstétrico/efectos adversos , Parto Obstétrico/métodos , Episiotomía/efectos adversos , Laceraciones/etiología , Laceraciones/prevención & control , Paridad , Perineo/lesiones , Factores de RiesgoRESUMEN
BACKGROUND: Periorbital laceration can result in complex, permanent scars, and even lead to serious complications such as cicatricial ectropion. Early intervention with laser devices has been suggested as a novel modality to reduce scar formation. However, no consensus exists regarding the optimal treatment parameters for scar management. This study evaluated the efficacy and safety of ultrapulse fractional CO 2 laser (UFCL) with different fluences and densities in preventing periorbital surgical scars. OBJECTIVE: To assess the efficacy and safety of UFCL with different fluences and densities in the prevention of periorbital laceration scars. METHODS: A prospective, randomized, blinded study was conducted on 90 patients with periorbital laceration scars of 2 weeks old. Four treatment sessions of UFCL were administered to each half of the scar at 4-week intervals, with halves treated with high fluences with low density versus low fluences with low-density treatment. Vancouver Scar Scale was used to assess the 2 portions of each individual scar at baseline, final treatment, and 6 months. The patient's 4-point satisfaction scale was used to evaluate the patient's satisfaction at baseline and 6 months. Safety was evaluated by registration of adverse events. RESULTS: Eighty-two of 90 patients completed the clinical trial and follow-up. There was no significant difference in Vancouver Scar Scale and satisfaction score between different laser settings between the two groups ( P > 0.05). Adverse events were minor and no long-term side effects were noted. CONCLUSIONS: Early application of UFCL is a safe, strategy to significantly improve the final traumatic periorbital scar appearance. Objective evaluation of scars did not identify differences in scar appearance between high fluences with low density versus low fluences with low density of UFCL treatment. LEVEL OF EVIDENCE: Level III.
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Laceraciones , Láseres de Gas , Humanos , Cicatriz/etiología , Cicatriz/prevención & control , Cicatriz/cirugía , Resultado del Tratamiento , Laceraciones/prevención & control , Laceraciones/cirugía , Estudios Prospectivos , Láseres de Gas/uso terapéuticoRESUMEN
AIM: To investigate the effectiveness of interventions to prevent the occurrence of perineal trauma in parturients. METHODS: A bibliographic search was carried out in Cochrane Library, MEDLINE via PUBMED, LILACS via Virtual Health Library (VHL), Embase, Scopus, CINAHL, Scielo, Web of Science, and PEDro databases. Randomized clinical trials evaluating the effects of any intervention to prevent perineal trauma during pregnancy and/or childbirth were included. There were no temporal or language restrictions. The risk of bias assessment was performed using the Revised Cochrane Risk-of-bias Tool for Randomized Trials. RESULTS: Fifty studies, with a total of 17,221 participants, were included in this meta-analysis. No intervention during childbirth was effective for the prevention of perineal trauma (RR = 1.07, 95% CI [0.98.1.18], p < 0.01, I2 = 83%) when compared to no intervention. However, a lower risk of perineal laceration was verified with techniques performed during pregnancy, when compared to no intervention (RR = 0.81, 95% CI [0.71, 0.93], p = 0.05, I2 = 47%). Among them, highlight the effects of perineal massage in preventing lacerations (RR = 0.69, 95% CI [0.54, 0.87], p < 0.01) when compared to no intervention. CONCLUSIONS: The techniques performed during pregnancy, especially perineal massage, are associated with a lower risk of perineal laceration.
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Laceraciones , Complicaciones del Trabajo de Parto , Embarazo , Femenino , Humanos , Laceraciones/etiología , Laceraciones/prevención & control , Complicaciones del Trabajo de Parto/prevención & control , Parto Obstétrico/efectos adversos , Parto Obstétrico/métodos , Parto , Riesgo , Perineo/lesiones , EpisiotomíaRESUMEN
BACKGROUND: Numerous interventions to reduce perineal trauma during childbirth have been studied in recent years, including perineal massage. OBJECTIVE: To determine the efficacy of perineal massage during the second stage of labor to prevent perineal damage. SEARCH STRATEGY: Systematic search in PubMed, Pedro, Scopus, Web of Science, ScienceDirect, BioMed, SpringerLink, EBSCOhost, CINAHL, and MEDLINE with the terms Massage, Second labor stage, Obstetric delivery, and Parturition. SELECTION CRITERIA: The articles must have been published in the last 10 years; the perineal massage was administered to the study sample; and the experimental design consisted of randomized controlled trial. DATA COLLECTION AND ANALYSIS: Tables were used to describe both the studies' characteristics and the extracted data. The PEDro and Jadad scales were used to assess the quality of studies. MAIN RESULTS: Of the 1172 total results identified, nine were selected. Seven studies were included in the meta-analysis and indicated a statistically significant decreased number of episiotomies in perineal massage. CONCLUSIONS: Massage during the second stage of labor appears to be effective in preventing episiotomies and reducing the duration of the second stage of labor. However, it does not appear to be effective in reducing the incidence and severity of perineal tears.
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Laceraciones , Masaje , Perineo , Humanos , Femenino , Embarazo , Laceraciones/prevención & control , Segundo Periodo del Trabajo de Parto , Parto Obstétrico/efectos adversos , Parto , Perineo/lesiones , Complicaciones del Trabajo de Parto/prevención & controlRESUMEN
AIM AND OBJECTIVE: To summarize the evidence on the effects of different techniques during the second stage of labour on reducing perineal laceration depending on available systematic reviews to provide optimal evidence for decision-making. BACKGROUND: Preventing perineal laceration has been considered an important part of improving women's health. Various techniques have been used to prevent perineal laceration during the second stage of labour. However, systematic reviews evaluating the effects of different techniques on reducing perineal laceration show inconsistent results. DESIGN: Overview of systematic reviews. METHODS: Five English and four Chinese databases were systematically searched for relevant systematic reviews and meta-analyses published between 1 January 2016 and 31 August 2021. The quality of the included reviews was assessed by the AMSTAR 2 tool. A narrative synthesis was conducted to report the results of moderate-to-high quality systematic reviews. The overview was reported according to the PRISMA statement. RESULTS: Eighteen reviews were included, of which four reviews had moderate-to-high methodological quality. Perineal massage and warm compresses significantly decreased the incidence of third- or fourth-degree perineal laceration (moderate-quality evidence). Hands-off technique had no impact on perineal laceration (low-to-moderate quality evidence). Ritgen's manoeuvre could reduce the incidence of first-degree perineal laceration but increase the incidence of second-degree perineal laceration (very low-quality evidence). Spontaneous pushing (low-quality evidence) and delayed pushing (moderate-quality evidence) had no impact on the incidence of third- or fourth-degree perineal laceration. Upright positions did not increase the risk of third- or fourth-degree perineal laceration (very low- to low-quality evidence) but increased the risk of second-degree perineal laceration for women without epidural analgesia (low-quality evidence). CONCLUSIONS: Perineal massage and warm compresses could be the better choice for preventing perineal laceration in the second stage of labour. RELEVANCE TO CLINICAL PRACTICE: Midwives and obstetricians could use perineal massage and warm compresses to prevent perineal laceration and should consider women's preferences and experience with perineal techniques.
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Segundo Periodo del Trabajo de Parto , Laceraciones , Perineo , Femenino , Humanos , Embarazo , Bases de Datos Factuales , Laceraciones/prevención & control , Masaje , Perineo/lesionesRESUMEN
OBJECTIVE: Obstetric anal sphincter injures (OASIS) have long-term implications on women's health. Administration of antibiotic prophylaxis and treatment following OASIS repair is controversial. We conducted a national survey to provide data about practice routines regarding antibiotic prophylaxis and treatment following OASIS repair in Israeli labor and delivery units. METHODS: A national survey was performed among obstetricians and gynecologists from 24 university-affiliated delivery centers within the jurisdiction of the Israeli Ministry of Health during 2020. Representatives from each center completed the "Google form" electronic survey. For each questionnaire item, the most common answer was chosen to represent the center's answer. RESULTS: The number of physicians who responded per center varied from 1 to 14 (median, 3.5). Preoperative and postoperative antibiotic treatment was given in 75% and 92% of the centers, respectively. While most centers (58.3%) recommend pelvic floor physical therapy on release, recommendations about functional radiologic tests vary. In all centers, there is a designated clinic for postpartum follow-up of OASIS. Most centers (83%) allow trial of vaginal delivery in the subsequent pregnancy, on an individual basis. CONCLUSION: Heterogeneity exists in managing OASIS in Israel, particularly regarding administration of antibiotics. Further studies are needed to examine the consequences of different management protocols.
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Incontinencia Fecal , Laceraciones , Complicaciones del Trabajo de Parto , Embarazo , Femenino , Humanos , Canal Anal/cirugía , Canal Anal/lesiones , Israel , Antibacterianos/uso terapéutico , Parto Obstétrico/efectos adversos , Parto Obstétrico/métodos , Diafragma Pélvico , Laceraciones/prevención & controlRESUMEN
BACKGROUND: Most women suffer from perineal trauma during childbirth, whether it is natural tears or episiotomy. OBJECTIVES: To perform a systematic review and network meta-analysis investigating the effectiveness of different PFMT relevant strategies in the prevention of perineal trauma. SEARCH STRATEGY: PubMed, Embase, the Cochrane Library, CINAHL, CNKI, CBM, WANFANG DATABASE, and ClinicalTrials.gov were searched for citations published in any language from inception to 1 July 2021. SELECTION CRITERIA: Randomized controlled trials (RCTs) of PFMT relevant prevention strategies for preventing perineal trauma during childbirth. DATA COLLECTION AND ANALYSIS: Data were independently extracted by two reviewers. Relative treatment effects were estimated using network meta-analysis (NMA). MAIN RESULTS: Of 12 632 citations searched, 21 RCTs were included. Comparing with usual care, "PFMT combine with perineal massage" and PFMT alone showed more superiority in intact perineum (RR = 5.37, 95% CI: 3.79 to 7.60, moderate certainty; RR = 2.58, 95% CI 1.34-4.97, moderate certainty, respectively), episiotomy (RR = 0.26, 95% CI 0.14-0.49, very low certainty; RR = 0.63, 95% CI 0.45-0.90, very low certainty, respectively), and OASIS (RR = 0.35, 95% CI 0.16-0.78, moderate certainty; RR = 0.49, 95% CI 0.28-0.85, high certainty, respectively). "PFMT combine with perineal massage" showed superiority in reducing perineal tear (RR = 0.41, 95% CI 0.20-0.85, moderate certainty). CONCLUSIONS: In view of the results, antenatal "PFMT combine with perineal massage" and PFMT were effective strategies for the prevention of perineal trauma.
Asunto(s)
Laceraciones , Parto , Femenino , Humanos , Embarazo , Parto Obstétrico/efectos adversos , Parto Obstétrico/métodos , Episiotomía , Laceraciones/prevención & control , Metaanálisis en RedRESUMEN
BACKGROUND: A recent randomized controlled trial of prophylactic antibiotics for the prevention of infection following operative vaginal birth showed that women allocated prophylactic intravenous amoxicillin and clavulanic acid had a significantly lower risk of developing confirmed or suspected infection within 6 weeks after operative vaginal birth (risk ratio [RR], 0.58; 95% confidence interval [CI], 0.49-0.69; P < .001). Some international and national guidelines have subsequently been updated to include prophylactic antibiotics after operative vaginal birth. However, the generalizability of the trial results may be limited in settings where the episiotomy rate is lower (89% of women in the trial had an episiotomy). In addition, there was a high burden of infection in the prophylactic antibiotics group despite the administration of prophylactic antibiotics. It is essential to identify modifiable risk factors for infection after operative vaginal birth, including the timing of antibiotic administration. OBJECTIVE: This study aimed to evaluate if the effectiveness of the prophylactic antibiotic in reducing confirmed or suspected infection was independent of perineal trauma, identify risk factors for infection after operative vaginal birth, and investigate variation in efficacy with the timing of antibiotic administration. STUDY DESIGN: This study was a secondary analysis of 3225 women with primary outcome data from the prophylactic antibiotics for the prevention of infection following operative vaginal birth randomized controlled trial. Women were divided into subgroups according to the perineal trauma experienced (episiotomy and/or perineal tear). The consistency of the prophylactic antibiotics in preventing infection across the subgroups was assessed using log-binomial regression and the likelihood ratio test. Multivariable log-binomial regression was used to investigate factors associated with infection. The multivariable risk factor model was subsequently fitted to the group of women who received amoxicillin and clavulanic acid to investigate the timing of antibiotic administration. RESULTS: Of the 3225 women included in the secondary analysis, 2144 (66.5%) had an episiotomy alone, 726 (22.5%) had an episiotomy and a tear, 277 (8.6%) had a tear alone, and 78 (2.4%) had neither episiotomy nor tear. Among women who experienced perineal trauma, amoxicillin and clavulanic acid administration was protective against infection in all subgroups compared with placebo with no significant interaction between subgroup and trial allocation (P=.17). Moreover, 2925 women were included in the multivariable risk factor analysis. The following were associated with adjusted risk ratios of infection: episiotomy, 2.94 (95% confidence interval, 1.62-5.31); forceps, 1.37 (95% confidence interval, 1.12-1.69) compared to vacuum extraction; primiparity, 1.34 (95% confidence interval, 1.05-1.70); amoxicillin and clavulanic acid administration, 0.60 (95% confidence interval, 0.51-0.72); body mass index of 25.0 to 29.9 kg/m2, 1.21 (95% confidence interval, 1.00-1.47), and body mass index of ≥30 kg/m2, 1.22 (95% confidence interval, 0.98-1.52) compared to body mass index of <25 kg/m2. Each 15-minute increment between birth and antibiotic administration was associated with a 3% higher risk of infection (adjusted risk ratio, 1.03; 95% confidence interval, 1.01-1.06). CONCLUSION: Timely prophylactic antibiotics should be administered to all women after operative vaginal birth, irrespective of the type of perineal trauma. The use of episiotomy, forceps birth, primiparity, and overweight were associated with an increased risk of confirmed or suspected infection after operative vaginal birth.
Asunto(s)
Laceraciones , Parto , Embarazo , Femenino , Humanos , Antibacterianos/uso terapéutico , Episiotomía/efectos adversos , Amoxicilina , Ácido Clavulánico , Laceraciones/prevención & control , Laceraciones/etiología , Perineo/lesionesRESUMEN
AIM: To assess the effect of lubricants on reducing perineal trauma during vaginal delivery. METHODS: PubMed, Embase, the Cochrane Library, CINAHL, China National Knowledge Infrastructure, China Biology Medicine disc, WanFang databases, and ClinicalTrials.gov, were searched for literature up to 25 June 2021. Randomized controlled trials published in English or Chinese that compared the vaginal application of lubricant with standard care for women were included. Two reviewers independently performed study screening, data extraction, risk of bias assessment, and certainty of evidence assessment. Pooled effect sizes and corresponding 95% confidence intervals (CI) were calculated using meta-analysis. RESULTS: Nineteen trials enrolling 5445 pregnant women were included. Compared with standard care, women using lubricants had a lower incidence of perineal trauma (risk ratio [RR] 0.84, 95% CI 0.76-0.93; low certainty evidence), second-degree perineal laceration (RR 0.72, 95% CI 0.64-0.82; moderate certainty evidence) and episiotomy (RR 0.77, 95% CI 0.62-0.96; very low certainty evidence), and had a shorter duration of the second-stage labor (MD -13.72 min, 95% CI -22.68 to -4.77; very low certainty evidence). CONCLUSION: Lubricants might reduce the incidence of perineal trauma, especially second-degree perineal laceration, and shorten the duration of the second-stage labor. More well-designed studies will continue developing high-quality evidence in this field.