Manual perineal protection: The know-how and the know-why.

Manual perineal protection is an obstetric intervention to mitigate the risk of perineal trauma. There are two effective techniques (Finnish and Viennese) with minor but distinctive differences in between them. The main aim of this study was to explore clinicians' knowledge about the manual perineal protection technique they use. The study took place in three maternity units that support manual perineal protection policy in three European countries (Czech Republic, Slovenia and the UK). Our study demonstrated that the majority of participants are aware of the concept of manual perineal protection. However, there were significant differences between staff responses regarding their views and experience with manual perineal protection in general. Less than 6% of respondents were able to provide an accurate account of the actual maneuvers they perform when manually protecting the perineum. Although this is not necessarily synonymous with suboptimal performance, it highlights the potential need to give more attention to the theory that underpins the technical skill in manual perineal protection training programs.

Impact of electronic and blended learning programs for manual perineal support on incidence of obstetric anal sphincter injuries: a prospective interventional study.

BACKGROUND: Obstetric anal sphincter injuries (OASIS) are associated with anal incontinence, dyspareunia and perineal pain. Bimanual perineal support technique (bPST) prevents OASIS. The aim of this study was to assess the effect of two different bPST training-methods on OASIS incidence. METHODS: This is a prospective-interventional quality improvement study conducted in two Palestinian maternity units between June 1 2015 and December 31 2016. Women having spontaneous or operative vaginal-delivery at ≥24 gestational-weeks or a birthweight of ≥1000 g (n = 1694) were recruited and examined vaginally and rectally immediately after vaginal birth by a trained assessor. Data on baseline OASIS incidence were collected during Phase-1 of the study. Subsequently, birth attendants in both maternity units were trained in bPST using two training modalities. A self-directed electronic-learning (e-learning) using an animated video was launched in phase-2 followed by a blended learning method (the animated e-learning video+ structured face-to-face training) in phase-3. OASIS incidence was monitored during phases-2 and 3. Variations in OASIS incidence between the three phases were assessed using Pearson-χ2-test (or Fisher's-Exact-test). The impact of each training-method on OASIS incidence was assessed using logistic-regression analysis. RESULTS: A total of 1694 women were included; 376 in phase-1, 626 in phase-2 and 692 in phase-3. Compared to Phase-1, OASIS incidence was reduced by 45% (12.2 to 6.7%, aOR: 0.56, CI; 0.35-0.91, p = 0.018) and 74% (12.2 to 3.2%, aOR, 0.29, CI; 0.17-0.50, p < 0.001) in phases-2 and 3, respectively. There was also a significant reduction in OASIS incidence by 52% from phase-2 to phase-3 (6.7% (42/626) to 3.2% (22/692), p = 0.003). These reductions reached statistical significance among parous-women only (aOR: 0.18, CI; 0.07-0.49, p = 0.001) after the first training method tested in phase-2. However, the reduction was significant among both primiparous (aOR: 0.39, CI; 0.21-0.74, p = 0.004) and parous-women (aOR: 0.11, CI; 0.04-0.32, p < 0.001) after implementing the blended learning method in phase-3. CONCLUSION: The animated e-learning video had a positive impact on reducing OASIS incidence. However, this reduction was enhanced by the use of a blended learning program combining both e- learning and face-to-face training modalities. STUDY REGISTRATION NUMBER: ClinicalTrialo.gov identifier: NCT02427854 , date: 28 April 2015.

Evaluation of an animated instructional video as a training tool for manual perineum support during vaginal delivery.

OBJECTIVE: To explore attitudes to an animation-based bimanual perineum-support technique (bPST) training video, and to investigate factors affecting the acceptability of the animation as a teaching modality. METHODS: A quantitative study conducted between November 1, 2014, and January 1, 2015, included obstetricians and midwives of any age and experience from relevant Norwegian professional organizations, and obstetrics and gynecology experts selected by the authors. Participants completed an anonymous online-survey evaluating the accuracy and clarity of the animation, and assessing knowledge of bPST and clinical practice. Factor and reliability analyses were conducted and the survey results were stratified based on the profession of the participants. RESULTS: The online survey was completed by 124 participants. There were 6 (5.4%) participants who reported using bPST before the study and 102 (92%) who described themselves as willing to use it afterwards, a significant increase (Z=-9.42; P<0.001). Having prior knowledge of bPST was associated with having a positive opinion of the video (t=6.43; P<0.001) and with intending to learn the technique (t=11.6; P<0.001). Participants who provided comments were more likely to evaluate the video negatively (t=-2.88; P<0.001) and to report not intending to learn the technique (t=-3.71; P<0.001). CONCLUSION: Animation-based training for bPST was feasible. The prior provision of information regarding the effectiveness of bPST could potentially increase user satisfaction with the animation.

Evaluating acupuncture and standard care for pregnant women with back pain: the EASE Back pilot randomised controlled trial (ISRCTN49955124).

BACKGROUND: Low back pain (LBP) and pelvic girdle pain (PGP) during pregnancy are common and often accepted as a 'normal' part of pregnancy. Many women receive little in the way of treatment, and yet pain interferes with sleep, daily activities and work and leads to increasing requests for induction of labour or elective caesarean section. The aim of this study was to assess the feasibility of a full RCT evaluating the benefit of acupuncture for pregnancy-related back pain. METHODS: This study is a single-centre, three-arm pilot RCT in one large maternity unit and associated antenatal and physiotherapy clinics. Women were eligible if they had pregnancy-related LBP with or without PGP. Exclusions included a history of miscarriage, high risk of early labour or pre-eclampsia, PGP only and previous acupuncture. Interventions were standard care (SC): a self-management booklet with physiotherapy if needed. SC+TA: the booklet and physiotherapy comprising true (penetrating) acupuncture, advice and exercise. SC+NPA: the booklet and physiotherapy comprising non-penetrating acupuncture, advice and exercise. Remote telephone randomisation used a 1:1:1 allocation ratio stratified by gestational weeks. Three measures of pain/function were compared to inform the primary outcome measure in a full RCT: the Pelvic Girdle Questionnaire (PGQ), Oswestry Disability Index (ODI) and 11-point 0-10 numerical rating scale for pain. Analysis focused on process evaluation of recruitment, retention, descriptive information on outcomes, adherence to treatment, occurrence of adverse events and impact of physiotherapist training. RESULTS: One hundred twenty-five women were randomised (45% of those eligible) between April and October 2013; 73% (n = 91) provided 8-week follow-up data. Three of six recruitment methods accounted for 82% of total uptake: screening questionnaire at the 20-week scan, community midwives issuing study cards, and self-referral following local awareness initiatives. Physiotherapists' self-confidence on managing pregnancy-related LBP improved post training. The PGQ is suitable as the primary outcome in a full trial. The average number of treatment sessions in both SC+TA and SC+NPA was six (in line with treatment protocols). No serious adverse events attributable to the trial treatments were reported. CONCLUSIONS: A full RCT is feasible and would provide evidence about the effectiveness of acupuncture and inform treatment choices for women with pregnancy-related LBP. TRIAL REGISTRATION: ISRCTN49955124.

The development and validation of an internet-based training package for the management of perineal trauma following childbirth: MaternityPEARLS.

BACKGROUND: Birth-related perineal trauma has a major impact on women's health. Appropriate management of perineal injuries requires clinical knowledge and skill. At present, there is no agreement as to what constitutes an effective clinical training programme, despite the presence of sufficient evidence to support standardised perineal repair techniques. To address this deficiency, we developed and validated an interactive distance learning multi-professional training package called MaternityPEARLS. METHOD: MaternityPEARLS was developed as a comprehensive e-learning package in 2010. The main aim of the MaternityPEARLS project was to develop, refine and validate this multi-professional e-learning tool. The effect of MaternityPEARLS in improving clinical skills and knowledge was compared with two other training models; traditional training (lectures + model-based hands on training) and offline computer lab-based training. Midwives and obstetricians were recruited for each training modality from three maternity units. An analysis of covariance was done to assess the effects of clinical profession and years of experience on scoring within each group. Feedback on MaternityPEARLS was also collected from participants. The project started in January 2010 and was completed in December 2010. RESULTS: Thirty-eight participants were included in the study. Pretraining and post-training scores in each group showed considerable improvement in skill scores (p<0.001 in all groups). Mean changes were similar across all three groups for knowledge (3.24 (SD 5.38), 3.00 (SD 3.74), 3.30 (SD 3.73)) and skill (25.34 (SD 8.96), 22.82 (SD 9.24), 20.7 (SD 9.76)) in the traditional, offline computer lab-based and e-learning groups, respectively. There was no evidence of any effect of clinical experience and baseline knowledge on outcomes. CONCLUSIONS: MaternityPEARLS is the first validated perineal trauma management e-learning package. It provides a level of improvement in skill and knowledge comparable to traditional methods of training. However, as an e-learning system, it has the advantage of ensuring the delivery of a standardised, continuously updated curriculum that has global accessibility.

Antiepileptic drugs and the fetal epigenome.

Antiepileptic drugs (AEDs) can lower maternal folate and increase maternal homocysteine levels, which are known to affect the methyl cycle and hence DNA methylation levels. The influence of in utero exposure to AEDs on fetal DNA methylation was investigated. Genome-wide fetal epigenomic profiles were determined using the Infinium 27K BeadArray from Illumina (San Diego, CA, U.S.A.). The Infinium array measures approximately 27,000 CpG loci associated with 14,496 genes at single-nucleotide resolution. Eighteen cord blood samples (nine samples from babies exposed to AEDs and nine controls) from otherwise uncomplicated pregnancies were compared. Unsupervised hierarchic clustering was used to compare the calculated methylation profiles. A clear distinction between the methylation profiles of samples from babies exposed to AEDs in utero compared with controls was detected. These data provide evidence of an epigenetic effect associated with antenatal AED and high-dose folate supplementation during pregnancy. The differences in fetal DNA methylation of those exposed to AEDs shows that a genome-wide effect of methylation is evident. In addition, the epigenetic changes observed appear to be, in this limited sample, independent of extremes of birth weight centiles. These preliminary data highlight possible mechanisms by which AEDs might influence fetal outcomes and the potential of optimizing AED-specific folate supplementation regimens to offset these effects.

How good are we at implementing evidence to support the management of birth related perineal trauma? A UK wide survey of midwifery practice.

BACKGROUND: The accurate assessment and appropriate repair of birth related perineal trauma require high levels of skill and competency, with evidence based guideline recommendations available to inform UK midwifery practice. Implementation of guideline recommendations could reduce maternal morbidity associated with perineal trauma, which is commonly reported and persistent, with potential to deter women from a future vaginal birth. Despite evidence, limited attention is paid to this important aspect of midwifery practice. We wished to identify how midwives in the UK assessed and repaired perineal trauma and the extent to which practice reflected evidence based guidance. Findings would be used to inform the content of a large intervention study. METHODS: A descriptive cross sectional study was completed. One thousand randomly selected midwives were accessed via the Royal College of Midwives (RCM) and sent a questionnaire. Study inclusion criteria included that the midwives were in clinical practice and undertook perineal assessment and management within their current role. Quantitative and qualitative data were collated. Associations between midwife characteristics and implementation of evidence based recommendations for perineal assessment and management were examined using chi-square tests of association. RESULTS: 405 midwives (40.5%) returned a questionnaire, 338 (83.5%) of whom met inclusion criteria. The majority worked in a consultant led unit (235, 69.5%) and over a third had been qualified for 20 years or longer (129, 38.2%). Compliance with evidence was poor. Few (6%) midwives used evidence based suturing methods to repair all layers of perineal trauma and only 58 (17.3%) performed rectal examination as part of routine perineal trauma assessment. Over half (192, 58.0%) did not suture all second degree tears. Feeling confident to assess perineal trauma all of the time was only reported by 116 (34.3%) midwives, with even fewer (73, 21.6%) feeling confident to perform perineal repair all of the time. Two thirds of midwives (63.5%) felt confident to perform an episiotomy. Midwives qualified for 20 years or longer and those on more senior clinical grades were most likely to implement evidence based recommendations and feel confident about perineal management. CONCLUSIONS: There are considerable gaps with implementation of evidence to support management of perineal trauma.

Quantitative, high-resolution epigenetic profiling of CpG loci identifies associations with cord blood plasma homocysteine and birth weight in humans.

Supplementation with folic acid during pregnancy is known to reduce the risk of neural tube defects and low birth weight. It is thought that folate and other one-carbon intermediates might secure these clinical effects via DNA methylation. We examined the effects of folate on the human methylome using quantitative interrogation of 27,578 CpG loci associated with 14,496 genes at single-nucleotide resolution across 12 fetal cord blood samples. Consistent with previous studies, the majority of CpG dinucleotides located within CpG islands exhibited hypo-methylation while those outside CpG islands showed mid-high methylation. However, for the first time in human samples, unbiased analysis of methylation across samples revealed a significant correlation of methylation patterns with plasma homocysteine, LINE-1 methylation and birth weight centile. Additionally, CpG methylation significantly correlated with either birth weight or LINE-1 methylation were predominantly located in CpG islands. These data indicate that levels of folate-associated intermediates in cord blood reflect their influence and consequences for the fetal epigenome and potentially on pregnancy outcome. In these cases, their influence might be exerted during late gestation or reflect those present during the peri-conceptual period.

LINE-1 DNA methylation is inversely correlated with cord plasma homocysteine in man: a preliminary study.

Folic acid supplementation during pregnancy has known beneficial effects. It reduces risk of neural tube defects and low birth weight. Folate and other one-carbon intermediates might secure these clinical effects via DNA methylation. However, most data on the effects of folate on the epigenome is derived from animal or in vitro models. We examined the relationship between cord blood methylation and maternal folic acid intake, cord blood folate and homocysteine using data from 24 pregnant women. Genome-wide methylation was determined by the level of methylation of LINE-1 repeats using Pyrosequencing. We show that cord plasma homocysteine (p = 0.001, r = -0.688), but not serum folate or maternal folic acid intake, is inverse correlated with LINE-1 methylation. This remained significant after correction for potential confounders (p = 0.004). These data indicate that levels of folate-associated intermediates in cord blood during late pregnancy have significant consequences for the fetal epigenome.

Acceptability of perinatal rapid point-of-care HIV testing in an area of low HIV prevalence in the UK.

OBJECTIVE: To determine the uptake of current antenatal HIV testing, the prevalence of risk factors for HIV in pregnant women and the acceptability of the rapid point-of-care HIV test (RPOCT) among pregnant women and their midwives. DESIGN: A retrospective review of 717 notes to determine current HIV screening practices and a cross-sectional survey using a self-completed questionnaire for pregnant women and midwives. SETTING: The antenatal clinic (ANC) and postnatal wards (PNW) at a university teaching hospital in the West Midlands. PARTICIPANTS: 486 women attending the ANC or admitted to the PNW during a fortnight in May-June 2006. 72 midwives on the delivery ward completed a second questionnaire. RESULTS: The questionnaire showed that 90.4% of those offered the standard HIV test accepted it, with 7.2% having at least one risk factor for HIV. Over half of the decliners perceived themselves as not at risk. 85.2% would accept the rapid test, including 35.6% of the decliners. 92.8% of midwives agreed/strongly agreed the RPOCT has a role on the delivery ward and 97.2% would be happy to offer the test with appropriate training and guidance. CONCLUSIONS: Midwives deem the RPOCT to be appropriate for a variety of perinatal settings. It is also acceptable to a clinically significant proportion of those who decline the standard test (21 of 59) and therefore has the potential to increase screening and detection rates. Hence, by allowing early diagnosis and the initiation of antenatal interventions, it could reduce the rate of mother-to-child transmission (MTCT) in the UK.