Diagnostic performance of two molecular assays for the detection of vaginitis in symptomatic women.

The three main causes of vaginitis are bacterial vaginosis (BV), vulvovaginal candidiasis (VVC), and trichomoniasis (TV). Two multiplex assays are commercially available for detection of DNA from organisms associated with vaginitis: BD Affirm™ VPIII Microbial Identification Test (Affirm) and BD MAX™ Vaginal Panel (MAX VP). Here, the performance of MAX VP was compared to that of Affirm, which was considered the standard of care. Four vaginal swabs were collected from each subject with the following: BD Affirm™ VPIII Ambient Temperature Transport System (ATTS), BD MAX™ UVE Specimen Collection Kit, Hologic Aptima® Vaginal Swab Specimen Collection Kit, and BD ESwab™ collection and transport system (ESwab). Candida culture, Gram stain followed by Nugent scoring, and the Hologic Aptima® Trichomonas vaginalis assay were used for discordant analysis. Results were considered true positive if there were at least two tests positive for any vaginitis target. A total of 200 symptomatic women were evaluated in the study. The sensitivity and specificity of MAX VP for BV was 96.2% and 96.1%, respectively, compared to 96.2% and 81.6% for Affirm. The sensitivity and specificity of MAX VP for Candida spp. was 98.4% and 95.4%, respectively, compared to 69.4% and 100% for Affirm. MAX VP and Affirm showed 100% concordance for detection of TV. These results demonstrate improved accuracy of MAX VP compared to Affirm for the detection of BV and Candida spp. and no difference for detection of TV between the two tests.

The Effect of Perineal Lacerations on Pelvic Floor Function and Anatomy at 6 Months Postpartum in a Prospective Cohort of Nulliparous Women.

OBJECTIVE: To determine the effect of perineal lacerations on pelvic floor outcomes, including urinary and anal incontinence, sexual function, and perineal pain in a nulliparous cohort with low incidence of episiotomy. METHODS: Nulliparous women were prospectively recruited from a midwifery practice. Pelvic floor symptoms were assessed with validated questionnaires, physical examination, and objective measures in pregnancy and 6 months postpartum. Two trauma groups were compared, those with an intact perineum or only 1st degree lacerations and those with second-, third-, or fourth-degree lacerations. RESULTS: Four hundred and forty-eight women had vaginal deliveries. One hundred and fifty-one sustained second-degree or deeper perineal trauma and 297 had an intact perineum or minor trauma. Three hundred and thirty-six (74.8%) presented for 6-month follow-up. Perineal trauma was not associated with urinary or fecal incontinence, decreased sexual activity, perineal pain, or pelvic organ prolapse. Women with trauma had similar rates of sexual activity; however, they had slightly lower sexual function scores (27.3 vs 29.1). Objective measures of pelvic floor strength, rectal tone, urinary incontinence, and perineal anatomy were equivalent. The subgroup of women with deeper (> 2 centimeter) perineal trauma demonstrated increased likelihood of perineal pain (15.5% vs 6.2%) and weaker pelvic floor muscle strength (61.0% vs 44.3%) compared with women with more superficial trauma. CONCLUSION: Women having second-degree lacerations are not at increased risk for pelvic floor dysfunction other than increased pain, and slightly lower sexual function scores at 6 months postpartum.

Postpartum contraceptive choices among ethnically diverse women in New Mexico.

OBJECTIVE: The objective of the study was to determine if postpartum contraceptive choices by primiparous women differ by ethnicity. STUDY DESIGN: Retrospective nested cohort study analyzing women's characteristics and contraceptive choice. RESULTS: Of 652 participants, 312 (47.8%) were Hispanic, 287 (44.0%) were non-Hispanic white, and 53 (8.1%) were American Indian (AI). In multivariate analysis, depot medroxyprogesterone acetate (DMPA) and intrauterine device (IUD)/implant choice was related to AI [DMPA: odds ratio (OR) 15.28, confidence interval (CI) 4.49-52.04; IUD/implant: OR 0.46, CI 0.22-0.92] and Hispanic (DMPA: OR 3.44, CI 1.12-10.58) ethnicity. CONCLUSION: DMPA use was higher among Hispanic and AI women and IUD/implant use lower in AI women compared to non-Hispanic white women.

Midwives' verbal support of nulliparous women in second-stage labor.

OBJECTIVE: To describe how nurse-midwives verbally support nulliparous women during second-stage labor and document specific details of each second stage. DESIGN: Descriptive qualitative study. SETTING: A university hospital labor and delivery unit in the southwestern United States. PARTICIPANTS: Nulliparous women (n = 14) older than age 18 and their attendant midwives (n = 9). METHODS: A single research midwife observed the entire second stage of each woman and used a standardized data collection form to record spontaneous or directed pushing, position changes, open and closed glottis pushing. A digital audio recorder was employed to capture verbal communication between the midwife and laboring woman. The research midwife and two qualitative experts employed content analysis to analyze the audio transcripts and identify categories of verbal support. RESULTS: Analysis revealed four categories of verbal support: affirmation, information sharing, direction, and baby talk. The vast majority of verbal communication by nurse-midwives consisted of affirmation and information sharing. Nurse-midwives gave direction for specific reasons. Women pushed spontaneously the majority of the time, regardless of epidural use. CONCLUSION: Nurse-midwives use a range of verbal support strategies to guide the second stage. Directive support was relatively uncommon. Most verbal support instead affirmed a woman's ability to follow her own body's lead in second-stage labor, with or without epidural.

A clinical audit of the number of vaginal examinations in labor: a NOVEL idea.

INTRODUCTION: Clinical practice audits present an opportunity for providers to examine and reflect on their practice. Vaginal examinations are an integral part of intrapartum care but can be uncomfortable for women and can increase the risk of chorioamnionitis. Thus, vaginal examinations should be performed thoughtfully and for necessary reasons. METHODS: A busy midwifery service at a large academic center underwent an audit of the number of vaginal examinations performed in labor for 205 women admitted in spontaneous labor or with spontaneous rupture of membranes. The retrospective chart audit was performed by research midwives who queried 2 electronic medical record databases, 1 for provider progress notes and 1 for nursing notes. RESULTS: On average, a woman underwent 4 vaginal examinations during labor, a rate greater than the World Health Organization recommendation of 1 examination every 4 hours during the first stage. The rate of presumed chorioamnionitis in this group of healthy, low-risk women was 6%, and women with this diagnosis averaged 7 vaginal examinations. DISCUSSION: After presentation and discussion of the audit findings, the midwives expressed appreciation for the opportunity to explore such a fundamental element of clinical practice and a heightened awareness of the importance of performing and documenting vaginal examinations. Audits of a similar nature in other midwifery practices are needed, as are studies exploring rates and possible modifiable causes of chorioamnionitis in low-risk women.

Postpartum perineal pain in a low episiotomy setting: association with severity of genital trauma, labor care, and birth variables.

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

Does spontaneous genital tract trauma impact postpartum sexual function?

Changes in sexual function are common in postpartum women. In this comparative, descriptive study, a prospective cohort of midwifery patients consented to documentation of genital trauma at birth and assessment of sexual function at 3 months postpartum. The impact of spontaneous genital trauma on postpartum sexual function was the focus of the study. Trauma was categorized into minor trauma (no trauma or first-degree perineal or other trauma that was not sutured) or major trauma (second-, third-, or fourth-degree lacerations or any trauma that required suturing). Women who underwent episiotomy or operative delivery were excluded. Fifty-eight percent (326/565) of enrolled women gave sexual function data; of those, 276 (85%) reported sexual activity since delivery. Seventy percent (193) of women sustained minor trauma and 30% (83) sustained major trauma. Sexually active women completed the Intimate Relationship Scale (IRS), a 12-item questionnaire validated as a measure of postpartum sexual function. Both trauma groups were equally likely to be sexually active. Total IRS scores did not differ between trauma groups nor did complaints of dyspareunia. However, for two items, significant differences were demonstrated: women with major trauma reported less desire to be held, touched, and stroked by their partner than women with minor trauma, and women who required perineal suturing reported lower IRS scores than women who did not require suturing.

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

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

After the afterbirth: a critical review of postpartum health relative to method of delivery.

Four million women give birth each year in the United States, yet postpartum health has gone largely unaddressed by researchers, clinicians, and women themselves. In light of rising US cesarean birth rates, a critical need exists to elucidate the ramifications of cesarean birth and assisted vaginal birth on postpartum health. This literature review explores the current state of knowledge on postpartum health in general and relative to method of delivery. Randomized trials and other published reports were selected from relevant databases and hand searches. The literature indicates that postpartum morbidity is widespread and affects the majority of women regardless of method of delivery. Women who have spontaneous vaginal birth experience less short- and long-term morbidity than women who undergo assisted vaginal birth or cesarean birth. To maximize postpartum health, providers of obstetric care need to protect the perineum during vaginal birth and avoid unnecessary cesarean deliveries. Clinicians must initiate the discussion about postpartum health antenatally and encourage women to enlist needed support early in the postpartum period. Flexibility in the schedule of postpartum care is essential. More research from the United States is warranted.