Timing of postpartum etonogestrel-releasing implant insertion and bleeding patterns, weight change, 12-month continuation and satisfaction rates: a randomized controlled trial.

OBJECTIVES: To evaluate whether timing of etonogestrel (ENG) implant insertion during the postpartum period affects maternal bleeding patterns, body mass index (BMI) and 12-month satisfaction and continuation rates. STUDY DESIGN: This is a secondary analysis of an open, randomized, controlled trial. Postpartum women were block-randomized to early (up to 48 h postpartum) or delayed (6 weeks postpartum) insertion of an ENG implant. Bleeding patterns and BMI were evaluated every 90 days for 12 months. At 12 months, we measured implant continuation rates and used Likert and face scales to measure users' satisfaction. The level of significance was 0.4% (adjusted by Bonferroni test for multiplicity). RESULTS: We enrolled 100 postpartum women; we randomized 50 to early and 50 to delayed postpartum ENG implant insertion. Bleeding patterns were similar between groups. Amenorrhea rates were high in both groups during the follow-up (52%-56% and 46%-62% in the early and delayed insertion group, respectively). Prolonged bleeding episodes were unusual in both groups during the follow-up (0-2%). Maternal BMI was similar between groups and decreased over time. Twelve-month continuation rates were similar between groups (early insertion: 98% vs. delayed insertion: 100%, p=.99). Most participants were either very satisfied or satisfied with the ENG implant in both groups (p=.9). CONCLUSION: Women who underwent immediate postpartum insertion of the ENG implant have similar bleeding patterns, BMI changes, and 12-month satisfaction and continuation rates compared to those who underwent delayed insertion. IMPLICATIONS: Our results from a secondary analysis of a clinical trial support that satisfaction, continuation and bleeding patterns do not differ when women received contraceptive implants immediately postpartum or at 6 weeks. However, the emphasis on infant growth in the trial and easy access to delayed placement may have influenced results.

Perineal Trauma in a Low-risk Maternity with High Prevalence of Upright Position during the Second Stage of Labor.

OBJECTIVE: Perineal trauma is a negative outcome during labor, and until now it is unclear if the maternal position during the second stage of labor may influence the risk of acquiring severe perineal trauma. We have aimed to determine the prevalence of perineal trauma and its risk factors in a low-risk maternity with a high incidence of upright position during the second stage of labor. METHODS: A retrospective cohort study of 264 singleton pregnancies during labor was performed at a low-risk pregnancy maternity during a 6-month period. Perineal trauma was classified according to the Royal College of Obstetricians and Gynecologists (RCOG), and perineal integrity was divided into three categories: no tears; first/second-degree tears + episiotomy; and third and fourth-degree tears. A multinomial analysis was performed to search for associated factors of perineal trauma. RESULTS: From a total of 264 women, there were 2 cases (0.75%) of severe perineal trauma, which occurred in nulliparous women younger than 25 years old. Approximately 46% (121) of the women had no tears, and 7.95% (21) performed mediolateral episiotomies. Perineal trauma was not associated with maternal position (p = 0.285), health professional (obstetricians or midwives; p = 0.231), newborns with 4 kilos or more (p = 0.672), and labor analgesia (p = 0.319). The multinomial analysis showed that white and nulliparous presented, respectively, 3.90 and 2.90 times more risk of presenting perineal tears. CONCLUSION: The incidence of severe perineal trauma was low. The prevalence of upright position during the second stage of labor was 42%. White and nulliparous women were more prone to develop perineal tears.

OBJETIVO: O trauma perineal é um desfecho negativo durante o parto, e é incerto, até o momento, se a posição maternal durante o período expulsivo pode influenciar o risco de evoluir com trauma perineal severo. Nós objetivamos determinar a prevalência de trauma perineal e seus fatores de risco em uma maternidade de baixo risco com alta prevalência de posição vertical durante o período expulsivo. MéTODOS: Um estudo de coorte retrospectivo de 264 gestações únicas durante o trabalho de parto foi realizado durante 6 meses consecutivos. O trauma perineal foi classificado de acordo com o Royal College of Obstetricianns and Gynecologists (RCOG). A integridade perineal foi dividida em três categorias: períneo íntegro; trauma perineal leve (primeiro e segundo graus + episiotomia); e trauma perineal severo (terceiro e quarto graus). Uma análise multinomial foi realizada para buscar variáveis associadas ao trauma perineal. RESULTADOS: De um total de 264 mulheres, houve 2 casos (0,75%)de trauma perineal severo m nulíparas com menos de 25 anos. Aproximadamente 46% (121) das mulheres não tiveram trauma perineal e 7,95% (21) realizaram episiotomias mediolaterais. Não houve correlação do trauma perineal com a posição de parto (p = 0,285), tipo de profissional que realizou o parto (p = 0,231), recém-nascidos com 4.000 gramas ou mais (p = 0,672), e presença de analgesia de parto (p = 0,319). Uma análise multinomial evidenciou que mulheres brancas e nulíparas apresentaram, respectivamente, um risco 3,90 e 2,90 vezes maior de apresentar trauma perineal. CONCLUSãO: A incidência de trauma perineal severo foi baixa. A prevalência de parto vertical durante o período expulsivo foi de 42%. Mulheres brancas e nulíparas foram mais suscetíveis a apresentar trauma perineal.

Perineal trauma in a low-risk maternity with high prevalence of upright position during the second stage of labor / Trauma perineal em uma maternidade de baixo risco com alta prevalência de parto vertical durante o período expulsivo

Abstract Objective Perineal trauma is a negative outcome during labor, and until now it is unclear if the maternal position during the second stage of labormay influence the risk of acquiring severe perineal trauma. We have aimed to determine the prevalence of perineal trauma and its risk factors in a low-risk maternity with a high incidence of upright position during the second stage of labor. Methods A retrospective cohort study of 264 singleton pregnancies during labor was performed at a low-risk pregnancymaternity during a 6-month period. Perineal trauma was classified according to the Royal College of Obstetricians and Gynecologists (RCOG), and perineal integrity was divided into three categories: no tears; first/ second-degree tears + episiotomy; and third and fourth-degree tears. A multinomial analysis was performed to search for associated factors of perineal trauma. Results From a total of 264 women, there were 2 cases (0.75%) of severe perineal trauma, which occurred in nulliparous women younger than 25 years old. Approximately 46% (121) of the women had no tears, and 7.95% (21) performed mediolateral episiotomies. Perineal trauma was not associated with maternal position (p = 0.285), health professional (obstetricians or midwives; p = 0.231), newborns with 4 kilos or more (p = 0.672), and labor analgesia (p = 0.319). The multinomial analysis showed that white and nulliparous presented, respectively, 3.90 and 2.90 times more risk of presenting perineal tears. Conclusion The incidence of severe perineal trauma was low. The prevalence of upright position during the second stage of labor was 42%. White and nulliparous women were more prone to develop perineal tears.

Resumo Objetivo O trauma perineal é um desfecho negativo durante o parto, e é incerto, até omomento, se a posiçãomaternal durante o período expulsivo pode influenciar o risco de evoluir com trauma perineal severo. Nós objetivamos determinar a prevalência de trauma perineal e seus fatores de risco em uma maternidade de baixo risco com alta prevalência de posição vertical durante o período expulsivo. Métodos Um estudo de coorte retrospectivo de 264 gestações únicas durante o trabalho de parto foi realizado durante 6 meses consecutivos. O trauma perineal foi classificado de acordo com o Royal College of Obstetricianns and Gynecologists (RCOG). A integridade perineal foi dividida em três categorias: períneo íntegro; trauma perineal leve (primeiro e segundo graus + episiotomia); e trauma perineal severo (terceiro e quarto graus). Uma análise multinomial foi realizada para buscar variáveis associadas ao trauma perineal. Resultados De um total de 264 mulheres, houve 2 casos (0,75%)de trauma perineal severo m nulíparas com menos de 25 anos. Aproximadamente 46% (121) das mulheres não tiveram trauma perineal e 7,95% (21) realizaram episiotomias mediolaterais. Não houve correlação do trauma perineal com a posição de parto (p = 0,285), tipo de profissional que realizou o parto (p = 0,231), recém-nascidos com 4.000 gramas ou mais (p = 0,672), e presença de analgesia de parto (p = 0,319). Uma análise multinomial evidenciou que mulheres brancas e nulíparas apresentaram, respectivamente, um risco 3,90 e 2,90 vezes maior de apresentar trauma perineal. Conclusão A incidência de trauma perineal severo foi baixa. A prevalência de parto vertical durante o período expulsivo foi de 42%. Mulheres brancas e nulíparas foram mais suscetíveis a apresentar trauma perineal.