Sexual function changes during pregnancy.

INTRODUCTION AND HYPOTHESIS: We describe changes in sexual activity and function among pregnant nulliparous women. METHODS: This secondary analysis evaluated sexual activity and function with the Female Sexual Function Index (FSFI) at baseline in the first (T1), second (T2) and early third (T3) trimester. Evaluation was repeated in T3 after 36 completed weeks of gestation. Data were assigned to the trimester in which they were collected and compared across trimesters. FSFI items were dichotomized into favorable and unfavorable responses. ANOVA and logistic regression models were used to compare values across trimesters, taking into account repeated measurements. Pair-wise comparisons of trimesters were done when there were significant overall differences. Significance was set at p < 0.05. We adjusted for baseline differences. RESULTS: Of 627 women, four did not give sexual function data. Baseline data were collected in 124 women in T1, 403 in T2, and 96 in early T3. Of these 623 women, 496 (80 %) gave data again in T3. The participants' mean age was 24.2 ± 5.1 years and 44.5 % were Hispanic. Rates of sexual activity (T1 94 %, T2 90 %, T3 77 %; p < 0.001) and mean FSFI scores decreased as pregnancy progressed (T1 26.5 ± 7.7, T2 25.6 ± 9.0, T3 21.5 ± 10.3; T1/T2 vs. T3, p < 0.001). Using the FSFI cut-off score for sexual dysfunction of 26.55, women in T3 were more likely to report dysfunction than women in T2 (57 % vs. 37 %, p < 0.001). For specific FSFI questions, the proportions of women reporting favorable responses did not change between T1 and T2 (all p > 0.05) and the proportions of women with a favorable response decreased for all questions between T2 and T3. CONCLUSIONS: As pregnancy progresses, women report poorer sexual function.

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.

Outcomes of planned home births attended by certified nurse-midwives in southeastern Pennsylvania, 1983-2008.

INTRODUCTION: In this study, we examined the perinatal outcomes of planned home births over a 25-year period (1983-2008) in a group of primarily Amish women (98%) attended by certified nurse-midwives (CNMs) in southeastern Pennsylvania. METHODS: This was a retrospective, descriptive analysis of data (N = 1836 births) from several CNM practices. Data were abstracted for 25 items, including demographics, labor, and birth. Initially, 2 investigators abstracted 15 records to compare assessments and standardize definitions. Charts were then divided and abstracted individually by one investigator. Several relationships were examined in 2 by 2 tables using the chi-square procedure for the difference in proportions. Maternal and newborn transfers to the hospital were included in the analysis. RESULTS: Of the women who planned home birth for 1836 pregnancies, 1733 of the births occurred at home. Although more than one-third of the women were of high parity (gravida 5-13), rates of postpartum hemorrhage were low (n = 96, 5.5%). There were no maternal deaths. Nearly half of the maternal transfers to the hospital (n = 103, 5.6%) were for ruptured membranes without labor (n = 25, 1.4%) and/or failure to progress (n = 23, 1.3%). The neonatal hospital admission rate also was low (n = 13, 0.75%). Of the 7 (0.4%) early neonatal deaths, all were attributed to lethal congenital anomalies that are common to this population. DISCUSSION: This study is the first to describe the outcomes of planned home births in a primarily Amish population cared for by CNMs. It also adds to the literature on planned home births in the United States and supports the findings from previous studies that women who have home births attended by CNMs have safety profiles equal to or better than profiles of women who had hospital births in similar populations.

Does epidural analgesia affect the rate of spontaneous obstetric lacerations in normal births?

The precise relationship between epidural use and genital tract lacerations in normal childbirth is unclear. Data from a clinical trial on measures to lower genital tract trauma in vaginal birth were used for a secondary analysis. The goal was to assess whether epidurals affect the rate of spontaneous obstetric lacerations in normal vaginal births. Maternal characteristics and intrapartum variables were compared in women who did and did not use an epidural in labor, and also in those with and without any sutured lacerations following vaginal birth. Variables that were statistically different in both cases were entered into regression equations for simultaneous adjustment. Epidural use was not an independent predictor of sutured lacerations. Predictors of sutured lacerations included nulliparity, a prolonged second stage, being non-Hispanic white, and an infant birthweight greater than 4000 grams. Elements of midwifery management need further research.

Factors related to genital tract trauma in normal spontaneous vaginal births.

OBJECTIVE: Episiotomy rates are declining in the United States. In settings with very low rates, evidence remains sparse on how best to facilitate birth without lacerations. The purpose of this investigation was to identify maternal and clinical factors related to genital tract trauma in normal, spontaneous vaginal births. METHODS: Data from a randomized clinical trial of perineal management techniques were used to address the study objective. Healthy women had spontaneous births with certified nurse-midwives in a medical center setting. Proportions of maternal characteristics and intrapartum variables were compared in women who did and did not sustain sufficient trauma to warrant suturing, according to parity (first vaginal births versus others). Logistic regression using a backward elimination strategy was used to identify predictors of obstetric trauma. RESULTS: In women who had a first vaginal birth, risk factors for trauma were maternal education of high school or beyond, Valsalva pushing, and infant birthweight. Risk factors in women having a second or higher vaginal birth were prior sutured trauma and infant birthweight. For all mothers, delivery of the infant's head between contractions was associated with reduced trauma to the genital tract. CONCLUSIONS: Delivery technique that is unrushed and controlled may help reduce obstetric trauma in normal, spontaneous vaginal births.

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

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