Midwives' approach to the prevention and repair of obstetric perineal trauma in Spain.

AIM: Different clinical practice guidelines include recommendations on how to prevent and repair obstetric perineal trauma, as well as the use of episiotomy. To evaluate the variability in midwives' professional practices for preventing and repairing perineal trauma, as well as the professional factors that may be associated with the restrictive use of episiotomy. DESIGN: Observational cross-sectional study. METHODS: Three hundred five midwives completed an anonymous questionnaire developed by the authors and distributed across various midwifery scientific societies. The main outcomes measured were the frequencies of adopting specific practices related to perineal injury prevention and repair, episiotomy technique and restrictive episiotomy use (<10%). Odds ratios (OR) and adjusted odds ratios (aOR) with 95% confidence intervals were estimated. RESULTS: Intrapartum perineal massage was not normally used by 253 (83%) of midwives, and 186 (61%) applied compresses soaked in warm water to the perineum. Regarding episiotomy, there was a great deal of variability, noting that 129 (42.3%) adopted a restrictive use of this procedure, 125 (41%) performed it between 10% and 20%, while 51 midwives (16.7%) performed it in more than 20% of cases. In addition, 165 (54.1%) midwives followed an incision angle of 60º. Concerning tears, 155 (50.8%) usually sutured first-degree tears and 273 (89.5%) always sutured second-degree tears. Midwives attending home births (aOR = 6.5; 95% CI: 2.69-15.69), working at a teaching hospital (aOR = 3.69; 95% CI: 1.39-9.84), and the ones who recently completed their professional training (aOR = 3.58; 95% CI: 1.46-8.79) were significantly more likely to adopt a restrictive use of episiotomy. CONCLUSIONS: There is a significant variability in Spanish midwives' practices for preventing and repairing perineal tears. Moreover, the restrictive use of episiotomy is associated with midwives attending home births, working in teaching hospitals and having recent professional training. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

Perineal repair performed by midwives in Australia: A cross-sectional survey study of education and practice.

PROBLEM: Perineal repair is generally not a widely practiced skill amongst Australian midwives, the reasons for this are uncertain and may result in technique variations. BACKGROUND: Many birthing women experience perineal tears that require suturing. As midwives attend the majority of vaginal births, they would be ideally placed to undertake perineal repair. AIM: To describe the current level of midwifery perineal repair skill acquisition, knowledge, techniques and utilization by Australian midwives. METHODS: An online survey was distributed to Australian College of Midwives members and shared via social media. Data on demographics, suturing techniques, reasons why midwives did or did not suture and barriers to skill acquisition were collected. Descriptive statistics were calculated for all variables including percentages, mean, standard deviation, median and range as appropriate. FINDINGS: 375 completed surveys were received between April and May 2023. 197 midwives indicated current suturing practice and 178 did not suture. Contributing to continuity of care was the most common motivating factor. The use of a continuous suturing technique for all layers of a perineal injury was reported by the majority of suturing midwives. There was greater variation in the management of labial tears. Low numbers of skilled midwives to support attaining competency and high workloads were the main barriers to attaining suturing skills. DISCUSSION: Australian midwives view perineal suturing as a valid midwifery skill that can contribute to continuity of care. Largely organisational barriers exist to skill development and greater utilisation. CONCLUSION: Perineal repair should be prioritised as a fundamental midwifery skill.

A pre-post implementation study of a care bundle to reduce perineal trauma in unassisted births conducted by midwives.

PROBLEM: The perineal-bundle is a complex intervention widely implemented in Australian maternity care facilities. BACKGROUND: Most bundle components have limited or conflicting evidence and the implementation required many midwives to change their usual practice for preventing perineal trauma. AIM: To measure the effect of perineal bundle implementation on perineal injury for women having unassisted births with midwives. METHODS: A retrospective pre-post implementation study design to determine rates of second degree, severe perineal trauma, and episiotomy. Women who had an unassisted, singleton, cephalic vaginal birth at term between two time periods: January 2011 - November 2017 and August 2018 - August 2020 with a midwife or midwifery student accoucheur. We conducted logistic regression on the primary outcomes to control for confounding variables. FINDINGS: data from 20,155 births (pre-implementation) and 6273 (post-implementation) were analysed. After implementation, no significant difference in likelihood of severe perineal trauma was demonstrated (aOR 0.86, 95% CI 0.71-1.04, p = 0.124). Nulliparous women were more likely to receive an episiotomy (aOR 1.49 95% CI 1.31-1.70 p < 0.001) and multiparous women to suffer a second degree tear (aOR 1.18 95% CI 1.09-1.27 p < 0.001). DISCUSSION: This study adds to the growing body of literature which suggests a number of bundle components are ineffective, and some potentially harmful. Why, and how, the bundle was introduced at scale without a research framework to test efficacy and safety is a key concern. CONCLUSION: Suitably designed trials should be undertaken on all proposed individual or grouped perineal protection strategies prior to broad adoption.

Effect of Perineal Massage and Warm Compresses Technique in Postpartum Pelvic Floor Dysfunction. A Secondary Analysis from a Randomised Controlled Trial.

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.

Efficacy of warm compresses in preserving perineal integrity and decreasing pain during normal labor: A systematic review and meta-Analysis.

The objective of the study was to assess the effect of warm compresses in preserving perineal integrity in women who delivered a single baby vaginally with cephalic presentation. We searched PubMed, Scopus, and the ISI Web of Science databases. Two researchers worked independently and conducted the study's search, selection, and extraction. We calculated the pooled risk ratio (R.R.)- for our categorical outcomes- and mean difference (M.D.)-for our continuous outcomes- using random or fixed-effect meta-analysis according to heterogenicity status. I2 test was used to detect heterogenicity. Studies were assessed for methodological quality using the Cochrane risk of bias assessment tool. Our study analyzed 13 controlled trials (n= 3947) to compare warm compresses versus not using it during vaginal delivery. The analysis revealed that warm compresses group had better outcomes regarding episiotomy, degree of perineal trauma (third and fourth degree), perineal trauma requiring suturing, and also in behavioral pain scales (severe muscle tense, being very restless, and constant grimacing) with the following R.R. and confidence intervals: (R.R.= 0.56, 95% C.I.[0.23, 1.37]), (R.R.= 0.69, 95% C.I.[0.54, 0.89], p= 0.004),( (R.R.= 0.37, 95% C.I.[0.18, 0.77], p= 0.004), and ( (R.R.= 0.42, 95% C.I.[0.23, 0.78], p= 0.006) respectively. We conclude that among primiparous women, warm compresses group showed better outcome in improving perineal comfort than a the good of women who did not receive warm compresses after delivery.

Antenatal perineal massage - risk of perineal injuries, pain, urinary incontinence and dyspereunia - a systematic review.

BACKGROUND: Natural childbirth is associated with the risk of damage to the perineum - a tears or a episiotomy. Adequate preparation of the woman for childbirth is essential to minimize the occurrence of perinatal injuries. AIM: The aim of the review is to assess and analyze the impact of APM (antental perineal massage) on perinatal perineal injuries and the development of pelvic pain and other complications in postpartum women, such as dyspareunia, urinary (UI), gas (GI), and fecal incontinence (FI). METHODS: PubMed, Web of Science, Scopus and Embase were searched. Three authors independently searched databases and selected articles for inclusion and exclusion criteria. Next one author did Risk of Bias 2 and ROBINS 1 analyze. FINDINGS: Of 711 articles, 18 publications were left for the review. All 18 studies examined the risk of perineal injuries (tearing and episiotomy), 7 pain in postpartum period, 6 postpartum urinary, gas/fecal incontinence and 2 described dyspareunia. Most authors described APM from 34 weeks of pregnancy until delivery. There were different techniques and times for doing APM procedures. DISCUSSION: APM has many benefits for women during labor and the postpartum period (e.g. lower rate of perineal injuries and pain). However, it can be observed that individual publications differ from each other in the time of massage, the period and frequency of its performance, the form of obtaining instruction and control of patients. These components may affect the results obtained. CONCLUSION: APM can protects the perineum from injuries during labor. It also reduces risk of fecal and gas incontinence in postpartum period.

Perineal massage and warm compresses - Randomised controlled trial for reduce perineal trauma during labor.

OBJECTIVE: The aim of this study is to evaluate the effect of perineal massage and warm compresses technique on the perineum integrity during second stage of labor. DESIGN AND SETTING: A single-center, prospective, randomized controlled trial was conducted between March 1st, 2019, and December 31st, 2020, at Hospital of Braga. PARTICIPANTS: Women with 18 years or older, between 37 weeks and 41 weeks pregnant, in whom a vaginal birth of a fetus in the cephalic presentation was planned were recruited. Eight hundred forty-eight women were randomly assigned (Perineal massage and warm compresses group, n = 424 and control group, n = 424), and 800 women, both perineal massage and warm compresses group (n = 400) and control group (n = 400) were included in the strict per protocol analysis. INTERVENTION: In the perineal massage and warm compresses group, women received perineal massage and warm compresses and in the control group, women received hands-on technique. RESULTS: The incidence of intact perineum was significantly higher in the perineal massage and warm compresses group [perineal massage and warm compresses group: 47% vs control group: 26.3%; OR 2.53, 95% CI 1.86-3.45, p<0.001], whereas second-degree tears and episiotomy rate were significantly lower in this group [perineal massage and warm compresses group: 7.2% vs control group: 12.3%; OR 1.96, 95% CI 1.17-3.29, p = 0.010 and perineal massage and warm compresses group: 9.5% vs control group: 28.5%; OR 3.478, 95% CI 2.236-5.409, p<0.001, respectively]. Also, obstetric anal sphincter injury with and without episiotomy and second-degree tears with episiotomy were significantly lower in the perineal massage and warm compresses group [perineal massage and warm compresses group: 0.5% vs control group: 2.3%; OR 5.404, 95% CI 1.077-27.126, p = 0.040 and perineal massage and warm compresses group: 0.3% vs control group: 1.8%; OR 9.253, 95% CI 1.083-79.015, p = 0.042, respectively]. CONCLUSIONS: The perineal massage and warm compresses technique increased the incidence of intact perineum and reduced the incidence of second-degree tear, episiotomy and obstetric anal sphincter injury. IMPLICATIONS FOR PRACTICE: Perineal massage and warm compresses technique is feasible, inexpensive and reproductible. Therefore, this technique should be taught and trained to midwives students and midwives team. Thus, women should have this information and have the option to decide whether they want to receive the perineal massage and warm compresses technique in the second stage of labor.

Knowledge, attitude and acceptability regarding antenatal perineal massage in Thai pregnant women.

INTRODUCTION AND HYPOTHESIS: Antenatal perineal massage for obstetric anal sphincter injury prevention is not routinely performed in Thailand. Due to the cultural conservatism in the country, attitudes and acceptability need to be evaluated before procedure implementation. This research was conducted to evaluate knowledge, attitudes, and acceptability of antenatal perineal massage and identify associated factors for acceptability in antenatal perineal massage among Thai pregnant women. METHODS: A cross-sectional study was conducted in the antenatal clinic at King Chulalongkorn Memorial Hospital, Bangkok, Thailand between July 2021 and June 2022. Thai women with singleton pregnancies at 22 weeks or more of gestation without an indication for cesarean section were enrolled. Knowledge, attitudes, and acceptability of antenatal perineal massage were assessed using a self-administered questionnaire. In-depth interviews with pregnant women who were not interested in antenatal perineal massage were also completed. RESULTS: A total of 144 pregnant women were enrolled with 119 participants (83%) having an accepting attitude about antenatal perineal massage. Results on knowledge included 22 (15%) participants aware of this practice, 46 participants (31.9%) knew it should be practiced after GA 34 weeks, 52 participants (36.1%) knew the massage should be maintained for 5-10 min, and 37 participants (25.7%) knew it should be performed daily. Factors associated with acceptability of antenatal perineal massage were prior interest in perineal massage and trust in the benefit of the perineal massage in facilitating vaginal delivery. Reasons for disagreeing in antenatal perineal massage included never hearing of perineal massage, concern about pregnancy complications, fear of pain, believing it to be a useless procedure, and previous successful vaginal delivery. CONCLUSIONS: We found high acceptability for antenatal perineal massage. This program should be routinely explained and offered to Thai pregnant women to prevent severe perineal trauma and postpartum complications.

Efficacy of perineal massage during the second stage of labor for the prevention of perineal injury: A systematic review and meta-analysis.

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.

Effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women: A systematic review and meta-analysis.

BACKGROUND: Perineal massage during childbirth has been recommended as an effective measure to prevent perineal injury. However, the overall effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women remain inconclusive. Particularly, the effects of perineal massage begun during different stages of labor need to be further investigated. OBJECTIVES: To comprehensively review the effects of perineal massage during childbirth on primiparous health outcomes, including perineal-related outcomes, duration of labor, hemorrhage and postpartum perineal pain, and neonatal outcomes, including Apgar scores and neonatal complications, and to further explore the effects of perineal massage begun during different stages of labor. DESIGN: A systematic review and meta-analysis following the Cochrane Handbook guidelines and PRISMA2020. METHODS: A systematic search strategy was developed following the three-phase search approach, and the literature search was conducted in electronic databases and clinical trial registers from inception to 7th January 2022. Study selection and data extraction were completed independently by two researchers. The updated Cochrane risk of bias 2.0 tool for randomized trials was chosen to evaluate the quality of included studies. Data analyses were conducted using the Revman5.4 software, and subgroup analyses were performed based on the different start times of perineal massage. Furthermore, the certainty of body of evidence for each outcome was assessed utilizing the GRADEpro online tool. RESULTS: Seventeen randomized controlled trials involving 3248 primiparous women were included in the review. The pooled results of meta-analyses indicated that perineal massage begun during the second stage of labor significantly increased the occurrence of intact perineum (RR = 2.78, 95 % CI: [1.52, 5.05], P < 0.001), reduced the rate of second- and third-degree perineal lacerations (P < 0.05), and decreased the incidence of episiotomy (RR = 0.63, 95 % CI: [0.50, 0.79], P < 0.001), while perineal massage during the first stage of labor effectively shortened the duration of the first and second stages of labor (P < 0.05). The available evidence also suggests the potential role of perineal massage on hemorrhage and long-term postpartum perineal pain (P < 0.05). However, the aggregated results failed to demonstrate the beneficial effects of perineal massage on neonatal outcomes (P > 0.05). CONCLUSIONS: Perineal massage begun during the second stage of labor effectively improves the perineal-related outcomes in primiparous women, while perineal massage during the first stage of labor significantly shortens the duration of labor. High-quality studies exploring the standardized procedure for perineal massage and the short- and long-term effects of perineal massage are warranted. REGISTRATION NUMBER: CRD42022302336 (PROSPERO).

Red flags for episiotomy in a midwife-led birth: Using co-production with midwives to capture clinical experience.

BACKGROUND: One of four key points in the Obstetric Anal Sphincter Injury Care Bundle, first piloted in the UK in 2016, was the directive to perform episiotomy when clinically indicated. Midwives are the primary health care professional for straightforward births in the UK and there is very little published literature that relates to their practice in this area. AIM: The aim of the study was to explore experienced midwives' decision-making processes in their assessments for episiotomy during birth. METHODS: 43 midwives self-identifying as confident in performing episiotomy were sampled across 8 NHS Trusts in England and Wales. Data collection was via online focus groups and 1:1 interviews. Primary thematic analysis was undertaken by the research team. Preliminary themes were used to structure a co-production analysis workshop where eight experienced midwives undertook a secondary analysis of the data resulting in four overall themes. FINDINGS: Four themes were identified, 'Optimising Perineal Function', 'Red Flags to Stimulate Decision-Making', 'The Midwives' Episiotomy' and 'Infiltration as a Catalyst for Birth'. DISCUSSION: Midwives use a number of visual, auditory and touch cues to inform their assessments for episiotomy during birth. CONCLUSION: This study provides valuable insight into the cues that guide experienced midwives' decision-making in relation to episiotomy and contributes evidence related to performing episiotomy when clinically indicated in spontaneous vaginal birth.

Effects of different techniques during the second stage of labour on reducing perineal laceration: An overview of systematic reviews.

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.

Effect of Prenatal Perineal Massage on Postpartum Perineal Injury and Postpartum Complications: A Meta-Analysis.

Background: The efficacy of perineal massage is controversial. The study was aimed at comparing the effects of perineal massage on perineal injury and complications. Methods: PubMed, Embase, the Cochrane Library, and ISI Web of Science were searched for literature on the relationship between prenatal perineal massage and postpartum perineal injury and complications until April 2022. Indicators included postpartum perineal tears, perineotomy, postpartum perineal pain, natural labour, and postpartum incontinence. Finally, RevMan5.4 software was used to analyze the extracted data. Results: A total of 6487 subjects in 16 studies were included, with 3211 who received perineal massage and 3276 did not. There was no significant difference in 1-2 degree perineal tearing between the intervention group and the control group (RR = 0.96, 95% CI [0.90, 1.03], P = 0.30), and there was no heterogeneity between studies (P = 0.62, I 2 = 0%), indicating publication bias. Compared with the control group, prenatal perineal massage significantly reduced the incidence of 3-4 degree perineal tears (RR = 0.56, 95% CI [0.47, 0.67], P < 0.00001), and there was no heterogeneity between studies (P = 0.16, I 2 = 30%), indicating publication bias. Compared with the control group, prenatal perineal massage reduced the risk of lateral perineal resection (RR = 0.87, 95% CI [0.80, 0.95], P = 0.001), and there was no heterogeneity between studies (P = 0.14, I 2 = 31%), and there was no publication bias. Compared with the control group, prenatal perineal massage reduced the risk of postpartum pain at 3 months (RR = 0.64, 95% CI [0.51, 0.81], P = 0.0002). There was no significant heterogeneity among studies (P = 0.23, I 2 = 31%). Conclusion: Compared with no prenatal perineal massage, prenatal perineal massage can reduce the risk of perineal injury, the incidence of lateral perineal resection, and the incidence of long-term pain.

Postpartum management of perineal injury - A critical narrative review of level 1 evidence.

BACKGROUND: Injury to the perineum is a common sequalae of vaginal birth. Lack of appropriateperineal wound care in the postnatal period is associated with increased pain and morbidity in theshort, medium, and long term. Women and maternity healthcare providers require high-levelevidence-based information to inform postnatal perineal wound care. OBJECTIVES: To review the high-level evidence informing postpartum management of perineal trauma. DESIGN: A systematic search of the literature regarding the postnatal management of perineal injury to produce a critical narrative review of the available level I evidence regarding the postnatal management of perineal trauma up to six months postpartum was undertaken. Systematic reviews were identified from searching the following databases: CINAHL, Cochrane Library, MEDLINE, PUBMED, and SCOPUS. Papers were selected if they met the following criteria: systematic reviews/level I evidence related to postnatal management of any form of perineal injury up to six months post birth, written in English, and published from January 2010 to 30th May 2021. A synthesis of the results was developed. FINDINGS: Nineteen systematic reviews met criteria for inclusion. The systematic reviews fell into one of the following categories of perineal trauma management: use of medication for pain relief, the decision to suture, suture techniques/materials, cryotherapy, use of antibiotics, ultrasound, physiotherapy treatment and complementary therapies. CONCLUSION: There is an overall lack of focused high-quality research to inform management of perineal injuries beyond the acute postnatal period. Clinical trials that include women's satisfaction and wellbeing as outcome measures are limited. IMPLICATIONS FOR PRACTICE: It is vital that women are provided with evidence-based postnatal care strategies to enhance perineal healing and resumption of normal activities. Future clinical trials for the management of perineal trauma should incorporate women's satisfaction as an outcome measure.Further research examining the follow-up care for the medium-long term for women experiencing ongoing sequalae of symptoms in the community setting is required to support clinical practice recommendations.

Detailed classification of second-degree perineal tears in the delivery ward: an inter-rater agreement study.

INTRODUCTION: Second-degree perineal tears can vary widely as to the extent of trauma, which may be relevant for women's pelvic floor health postpartum. However, the short- and long-term consequences of second-degree perineal tears are poorly understood, likely due to the lack of a detailed classification system. Such a classification system for second-degree tears has been suggested but the inter-rater agreement has not yet been assessed. The aim of this study was to assess the inter-rater agreement of the already established classification system for perineal tears recommended by the Royal College of Obstetricians and Gynaecologists (RCOG classification) among midwives. Further, we aimed to assess the inter-rater agreement of a classification system that provides three sub-categories for second-degree perineal tears. MATERIAL AND METHODS: This was an inter-rater agreement study, conducted at Akershus University Hospital in Norway from 31 August to 29 November 2020. All midwives working in the delivery ward participated in the study. Midwives classified the integrity of the perineum of all women delivering vaginally within the study period. During the first month of the study, tears were classified by two midwives who were blinded to each other's findings, and the agreement of the RCOG classification was assessed. The following month, the detailed classification system was introduced to the midwifery staff. The last month, perineal tears were classified by two midwives using the detailed classification system, and the agreement was assessed. Inter-rater agreement was measured using Fleiss multirater kappa (k) and Kendall's coefficient of concordance (KCCw ). RESULTS: The inter-rater agreement for the RCOG classification was good to very good, with k = 0.705 (95% confidence interval [CI] 0.62-0.79, P < 0.001), KCCw  = 0.928 (P < 0.001). The inter-rater agreement for the detailed classification system was good to very good, with k = 0.748 (95% CI 0.67-0.83, P < 0.001), KCCw  = 0.956 (P < 0.001). CONCLUSIONS: The inter-rater agreement among midwives using both the RCOG classification and the detailed classification system among midwives was good to very good. The detailed classification system provides additional information about the extent of tissue trauma in second-degree tears, warranted for future research on women's pelvic floor health postpartum.

"From hell to healed" - A qualitative study on women's experience of recovery, relationships and sexuality after severe obstetric perineal injury.

OBJECTIVE: Few studies have investigated women's experiences of daily life after childbirth complicated by obstetric anal sphincter injury (OASI). The aim of the present study was to explore experiences related to recovery, sexual function, relationships and coping strategies among women affected by OASI. METHODS: In-depth interviews were conducted using a purposive sample of 11 women affected by OASI. Women were interviewed 1-2 years after their first childbirth. Inductive qualitative content analysis was applied. RESULTS: The theme "From hell to healed" illustrates women's experiences of recovery, relationships and sexual function after OASI. Three categories addressing women's perceptions emerged: "Challenged to the core", "At the mercy of the care provider" and "For better or for worse". Support from partners and family and comprehensive care were important elements for the experiences of coping and healing from OASI. Elements that negatively influenced women's experiences were the pain and physical symptoms of pelvic floor dysfunction, normalization of symptoms by heath care providers, and unrealistic expectations about how this period in life should be experienced. CONCLUSION: OASI greatly affects women's experiences of their first years with their newborn child, relationships, social context and sexuality. For some women, OASI negatively affects everyday life for a long period after childbirth. However, others heal and cope quite quickly. Health care professionals need to identify and pay attention to women with persisting problems after OASI so that they can be directed to the right level of care.

Combined perineal massage and warm compress compared to massage alone during active second stage of labour in nulliparas: A randomised trial.

OBJECTIVE: To evaluate the effect of combined perineal massage and warm compress to the perineum (MassComp) compared to perineal massage alone during pushing in the second stage of labour in reducing perineal trauma requiring suturing in nulliparas. STUDY DESIGN: A randomised trial was performed in a University hospital, Malaysia from June 2020 to May 2021. 281 term nulliparas who were about to start pushing in the second stage of labour were randomised to combined perineal massage and warm compress or perineal massage alone to the perineum. Primary outcome was suturing for perineal injury (episiotomy or tear). The Chi-square test was used to analyse categorical data, Student t test to compare means and distributions for normally distributed continuous data and Mann Whitney U test for appropriate ordinal data. RESULTS: Data from 277 participants (140 MassComp arm, 137 perineal massage alone arm) were analysed based on modified intention to treat basis. Perineal suturing rates were 133/140(95.0%) [MassComp] vs. 128/137(93.4%) [perineal massage alone] RR 1.02(95%CI 0.96-1.08), P = 0.615. Of the secondary outcomes, Likert scale response to recommend allocated treatment to a friend was 103/140(73.6%) vs. 84/137(61.3%) RR 1.20(95%CI 1.02-1.42)NNTb 9(95%CI 4.3-76.4) P = 0.029, participants' satisfaction with care (visual numerical rating scale 0-10) median [interquartile range] 6[6-8] vs. 6[5-8] P = 0.392, intervention to delivery intervals were 25[15-35] vs. 19[14-30] minutes P = 0.012, major perineal injury (episiotomy, second degree or higher tears) rates 116/140(82.9%) vs. 119/137(86.9%) RR 0.95(95%CI 0.86-1.05), P = 0.404, episiotomy rates 97/140(69.3%) vs. 97/140(70.8%) RR 0.98(95%CI 0.84-1.14), P = 0.795, and spontaneous vaginal delivery rates 103/140(73.6%) vs. 106/137(77.4%) RR 0.95(95%CI 0.83-1.09), P = 0.488 for MassComp vs. perineal massage alone respectively. Other maternal and neonatal outcomes were not significantly different. CONCLUSION: Massage and warm compress during pushing did not decrease the likelihood of perineal injury requiring suturing in nulliparas when compared to perineal massage alone. Women were more likely to recommend massage and warm compress during pushing to a friend.

Massagem perineal pré-natal para prevenção do trauma: piloto de ensaio clínico randomizado / Masaje perineal prenatal para la prevención del trauma: piloto de ensayo clínico aleatorizado / Antenatal perineal massage for trauma prevention: a pilot randomized clinical trial

Resumo Objetivo Avaliar a adesão de gestantes e acompanhantes à realização da massagem perineal digital durante a gestação e seu efeito na prevenção do trauma perineal no parto e na redução de morbidade associada nos 45 e 90 dias pós-parto. Métodos Estudo piloto de ensaio clínico randomizado com 153 gestantes de risco habitual, 78 mulheres no grupo de intervenção realizaram a massagem perineal digital e 75 mulheres do grupo controle receberam os cuidados habituais. Para a análise do desfecho principal (trauma perineal) e dos desfechos secundários, permaneceram em cada grupo 44 mulheres que tiveram parto vaginal. A intervenção foi realizada pela gestante ou acompanhante de sua escolha, diariamente, a partir de 34 semanas de gestação, por 5 a 10 minutos. Resultados A massagem perineal foi fator de proteção para edema nos primeiros 10 dias pós-parto (RR 0,64 IC95%0,41-0,99) e perda involuntária de gases nos 45 dias pós-parto (RR0,57 IC95%0,38-0,86). O ajuste residual ≥ 2 observado na análise das condições do períneo pós-parto mostrou uma tendência das mulheres do grupo intervenção terem períneo íntegro. As mulheres e os acompanhantes que realizaram a massagem perineal aceitaram bem a prática, recomendariam e fariam novamente em futura gestação. Conclusão A massagem perineal digital realizada diariamente, a partir de 34 semanas de gestação, foi uma prática bem aceita pelas mulheres e acompanhantes deste estudo. Apesar de não proteger a mulher de trauma perineal, esta prática reduziu o risco de edema 10 dias pós-parto e incontinência de gases 45 dias pós-parto. Registro Brasileiro de ensaio clínico: RBR-4MSYDX

Resumen Objetivo Evaluar la participación de mujeres embarazadas y acompañantes en la realización del masaje digital perineal durante el embarazo y su efecto en la prevención del trauma perineal durante el parto y en la reducción de la morbilidad asociada con los 45 y 90 días post parto. Métodos Estudio piloto de ensayo clínico aleatorizado con 153 mujeres embarazadas con riesgo normal, 78 mujeres en el grupo de intervención realizaron el masaje digital perineal y 75 mujeres del grupo control recibieron los cuidados habituales. Para el análisis del desenlace principal (trauma perineal) y de los desenlaces secundarios, permanecieron en cada grupo 44 mujeres que tuvieron parto vaginal. La intervención la realizó la mujer embarazada o el acompañante por ella elegido, diariamente, a partir de las 34 semanas de embarazo, por 5 a 10 minutos. Resultados El masaje perineal fue factor de protección para el edema en los primeros 10 días postparto (RR 0,64 IC95%0,41-0,99) y la pérdida involuntaria de gases en los 45 días post parto (RR0,57 IC95%0,38-0,86). El ajuste residual ≥ 2 observado en el análisis de las condiciones del perineo postparto mostró una tendencia en las mujeres del grupo intervención a que tengan el perineo íntegro. Las mujeres y los acompañantes que realizaron el masaje perineal recibieron bien la práctica, la recomendarían y la harían nuevamente en un futuro embarazo. Conclusión El masaje digital perineal realizado diariamente, a partir de las 34 semanas de embarazo, fue una práctica bien recibida por las mujeres y acompañantes de este estudio. Pese a que no protege a la mujer de un trauma perineal, esta práctica redujo el riesgo de edema a los 10 días post parto y la incontinencia de gases 45 días post parto.

Abstract Objective To evaluate the adherence of pregnant women and companions to the performance of digital perineal massage during pregnancy and its effect on the prevention of perineal trauma during childbirth and on the reduction of associated morbidity at 45 and 90 days postpartum. Methods A pilot study of a randomized clinical trial with 153 normal risk pregnant women; 78 women in the intervention group underwent digital perineal massage and 75 women in the control group received usual care. For the analysis of the main outcome (perineal trauma) and secondary outcomes, 44 women who had vaginal delivery remained in each group. The intervention was performed daily by the pregnant woman or the companion of her choice from 34 weeks of gestation during 5-10 minutes. Results Perineal massage was a protective factor for edema in the first 10 days postpartum (RR 0.64 95%CI 0.41-0.99) and involuntary gas loss at 45 days postpartum (RR0.57 95%CI 0.38-0.86). The residual adjustment ≥ 2 observed in the analysis of perineal conditions postpartum showed a trend of women in the intervention group having an intact perineum. The women and companions who performed perineal massage accepted the practice well, recommended it and would do it again in a future pregnancy. Conclusion The digital perineal massage performed daily from 34 weeks of gestation was a practice well accepted by women of this study and their companions. Although not protecting women from perineal trauma, this practice reduced the risk of edema at 10 days postpartum and gas incontinence at 45 days postpartum. Brazilian Clinical Trial Registry: RBR-4MSYDX

Care for perineal tears in vaginal delivery: An update for midwife.

OBJECTIVE: The purpose of this study will be to review several studies regarding the repair or treatment of perineal tears after vaginal delivery. This is expected to be an update for a midwife in daily caring. METHODS: Two electronic databases (PubMed and Sciencedirect) were searched to locate relevant literature about perineal tears/wound/laceration/trauma that is published in 2016-2021. 124 Pubmed articles and 452 ScienceDirect articles filtered successfully. The articles that have been obtained will be evaluated based on the inclusion criteria in this study. We summarize place and date, objective, design, samples, the measurement used, and research results. RESULTS: 9 articles were found that matched the inclusion criteria. Three articles examined the effect of the type of suture on perineal pain, and another 6 discussed therapy to reduce the adverse effects of perineal tears. The therapies used are far-infrared radiation therapy, capacitive-resistive radiofrequency therapy, pelvic floor muscle training in early postpartum, cold therapy, and treatment with TheresienOl (natural oil). CONCLUSION: Sutures and technique/suturing second-degree perineal tears or a postpartum episiotomy can affect perineal pain. Cold gel pad therapy and treatment with natural oil on perineal wounds can affect perineal pain and wound healing.

Early postpartum biofeedback assisted pelvic floor muscle training in primiparous women with second degree perineal laceration: Effect on sexual function and lower urinary tract symptoms.

OBJECTIVE: To evaluate the short-term effect of routine early postpartum electromyographic biofeedback assisted pelvic floor muscle training on sexual function and lower urinary tract symptoms. MATERIALS AND METHODS: From December 2016 to November 2017, primiparous women with vaginal delivery, who experienced non-extended second-degree perineal laceration were invited to participate. Seventy-five participants were assigned into a pelvic floor muscle training (PFMT) group or control group. Women in the PFMT group received supervised biofeedback-assisted pelvic floor muscle training at the 1st week and 4th week postpartum. Exercises were performed at home with the same protocol until 6 weeks postpartum. The Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire (PISQ-12) and the Urinary Distress Inventory short form questionnaire (UDI-6) were used to evaluate sexual function and lower urinary tract symptoms respectively at immediate postpartum, 6 weeks, 3 months, and 6 months postpartum. RESULTS: Forty-five women (23 in PFMT group,22 in control group) completed all questionnaires at 6 months postpartum. For overall sexual function and the three sexual functional domains, no statistically significant difference was found in PISQ scores from baseline to 6 weeks, 3 months, and 6 months postpartum between the PFMT and control groups. For postpartum lower urinary tract symptoms, all symptoms gradually improved over time for both groups without a statistically significant difference between groups. CONCLUSION: Our study showed that supervised biofeedback-assisted pelvic floor muscle training started routinely at one week postpartum did not provide additional improvement in postpartum sexual function and lower urinary tract symptoms.