The postnatal effects of perineal trauma on maternal psychological and emotional wellbeing: A longitudinal study.

OBJECTIVE: To examine the postnatal psychological health and parenting adjustment of primiparous women experiencing perineal trauma. STUDY DESIGN: Longitudinal cohort study assessing body image, perceptions of traumatic birth, psychological distress, perineal pain, impact upon parental tasks and mother-infant bonding at 6-12 weeks (n = 103) and 6-10 months postnatally (n = 91). Primiparous women were recruited following vaginal birth and perineal suturing in a UK-based maternity hospital. al. Comparisons made according to the objective classification of perineal trauma experienced; 1st/2nd degree tear, episiotomy, and Obstetric Anal Sphincter Injuries (OASI). RESULTS: At 6-12 weeks women with an episiotomy reported a more negative perception of their body image than those with OASI. Women with OASI or an episiotomy were more likely to have experienced birth as traumatic, and those with OASI reported more avoidance symptoms of post-traumatic stress and a greater negative impact on parenting tasks. At 6-10 months significantly more avoidance symptoms continued to be reported by those with OASI, whereas those with an episiotomy reported more anxiety related symptoms in general than those with OASI. CONCLUSIONS: OASI, whilst associated with traumatic birth and some early parenting impacts, may not be linked to general negative psychological outcomes when specialist routine follow-up care is provided. Psychological impacts for women with episiotomy may merit further input than currently provided. Consideration should be given with regards to widening the access to postnatal perineal care by extending the criteria for specialist follow up beyond those sustaining OASI.

Follow up of women after obstetric anal sphincter injuries (OASI)-What is the role of anorectal testing?

AIMS: To evaluate the benefit of performing anorectal studies on all women following primary obstetric anal sphincter injury (OASI) repair over performing them on symptomatic women only. METHODS: Women who attended perineal clinic between 2007 and 2020 underwent symptom assessment and anorectal studies at 6 weeks and 6 months postpartum. Anorectal studies including endo anal ultrasound (EAUS) and anal manometry (AM) were performed. The anorectal studies of symptomatic women who were the case group, were compared with asymptomatic women who were the control group. RESULTS: A total of 1348 women were seen in the perineal clinic over 13 years. A total of 454 (33.7%) women were symptomatic. A total of 894 (66.3%) women were asymptomatic. A total of 313 (35%) asymptomatic women had two abnormal anorectal studies, 274 (31%) had abnormal AM alone, and 86 (9.6%) had abnormal EAUS alone. A total of 221 (24.7%) asymptomatic women had normal anorectal studies. CONCLUSION: Almost 70% of women were asymptomatic 6 months following primary OASI repair. Most had at least one abnormal anorectal study result. Selectively performing anorectal tests on symptomatic women would not identify asymptomatic women at risk of future faecal incontinence following further vaginal birth. Without anorectal study results, women would not receive accurate counseling about the risks of vaginal birth. Anorectal studies should be offered to all women following OASI where resources allow.

The role of anal manometry in the follow-up of women with obstetric anal sphincter injuries (OASI).

INTRODUCTION AND HYPOTHESIS: Mode of birth (MOB) following OASI is determined by choice, symptoms and anorectal study results in asymptomatic women. Endoanal ultrasound (EAUS) is the gold-standard imaging modality. EAUS use in MOB counselling is supported by strong evidence. Less is understood about how anal manometry (AM) influences MOB counselling. METHODS: A retrospective observational study was conducted from 2007 to 2020. Women underwent symptom assessment using validated ePAQ and St Mark's incontinence score (SMIS). Anorectal studies using EAUS and AM were performed. The case group was the normal ultrasound group and the control group was the abnormal ultrasound group. Both groups were compared with normal and abnormal AM result groups. RESULTS: A total of 1348 women were included over 13 years. Among these, 454 women were symptomatic, 894 were asymptomatic; 274 (31%) asymptomatic women had isolated abnormal AM results, 313 (35%) had two abnormal anorectal results and 221 (24.7%) had normal anorectal results. Eighty-six asymptomatic women (10.4%) had isolated abnormal EAUS results, 138 (30.4%) symptomatic women had isolated abnormal AM, 221 (48.7%) had two abnormal anorectal results and 57 (12.6%) had normal anorectal results. Thirty-eight symptomatic women (8.4%) had an isolated abnormal EAUS result. CONCLUSIONS: AM identifies more women with sphincter function impairment than EAUS alone. Without AM, almost one third of asymptomatic women would not have been identified and could have been inadequately counselled. Performing AM and EAUS together captured most women with compromised anal sphincter function. We conclude that AM should be performed in all women with OASI alongside EAUS to enable accurate MOB counselling.

Use of strontium isotope ratios in geolocation of Guatemalan population: Potential role in identification of remains.

Within post-conflict communities, attempts to identify and repatriate unidentified and missing individuals poses a difficult task. As current forensic strategies commonly lack the capacity to provide region of origin assessments, forensic anthropologists/investigators are often unable to identify sources of DNA for kinship analysis. Using Thermal Ionization Mass Spectrometry (TIMS), hair samples from 10 volunteers were used to assess the variation in strontium isotope ratios (87 Sr/86 Sr) between extant people in Guatemala City and Coban; with a leach (external) and digest (dietary) signal analyzed for each sample. A two-way anova demonstrated that the difference between 87 Sr/86 Sr of Guatemala City and Coban was statistically significant (F [1, 16] = 259.839, p < 0.05), with no statistically significant differences observed between leach and digest 87 Sr/86 Sr (F [1,16] = 4.319, p = 0.054). Overall, individuals from Coban demonstrate 87 Sr/86 Sr comparable to previously recorded baseline values, demonstrating a minimal change in diet which is reflected in associated surveys. Volunteers from Guatemala City, however, show a marked shift in 87 Sr/86 Sr away from predicted values highlighting the potential influence of imported goods. The results here highlight the applicability of 87 Sr/86 Sr in hair to serve as a potential tool to support the identification of unknown individuals in Guatemala in a forensic context.

The effects of perineal trauma on immediate self-reported birth experience in first-time mothers.

INTRODUCTION: Childbirth can sometimes be stressful or traumatic, and previous research has considered how birth complications and interventions may contribute to a negative birth experience. One of the most frequent complications during birth is trauma to the perineum. The aim of this study was to investigate whether different levels of perineal trauma were associated with differences in women's evaluation of their birth experience. MATERIALS AND METHODS: As part of a longitudinal cohort study, the self-reported birth experiences of 202 primiparous women were compared based on the degree of perineal trauma they had experienced. Women who had given birth for the first time, vaginally and within the last 48 h in a large tertiary maternity unit in England were invited to take part. Data were collected from their hospital records with their consent and using the Childbirth Experience Questionnaire (CEQ), Experience of Birth Scale (EBS) and a perineal pain Visual Analogue Scale (VAS). RESULTS: Women with an obstetric anal sphincter injury (OASI) or episiotomy reported a more negative overall birth experience and perceived themselves as having less ability to give birth compared to those with a 1st/2nd degree sutured tear. Those with an episiotomy also reported feeling less involved in decision making processes during their birth. Significant differences remained between the OASI and 1st/2nd degree tear groups when controlling for factors known to affect birth experience, highlighting severe perineal trauma as a potential contributor to more negative birth experience. CONCLUSIONS: Perineal trauma may affect a woman's birth experience. Experiencing an episiotomy should not be overlooked as a potential contributor, especially during instrumental birth and in the absence of involved decision making. Further research is needed to disentangle the effects of episiotomy on birth experience, to explore the care needs of women with different degrees of perineal trauma and to explore how a negative birth experience may contribute to poor psychological health in the longer term.

Does water birth affect the risk of obstetric anal sphincter injury? Development of a prognostic model.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injury (OASI) is a significant complication of vaginal delivery. Water birth has become a popular preference for women giving birth in the UK, however, there is limited data on the risk of OASI following water birth. Our aim was to assess OASI risk in low-risk women giving birth in water without medical intervention compared with on land and to create a prognostic model for OASI prediction. METHODS: This was a retrospective study of 15,734 low-risk women giving birth by spontaneous vaginal delivery between January 2008 and October 2014 in a midwifery-led unit (MLU). Patient factors and delivery data were analysed to identify differences between water and land births. Univariate analysis determined factors that statistically predicted OASI and was then used to create multivariate analysis. Significant multivariate factors were used to create a prognostic model to predict likelihood of OASI. RESULTS: OASI rates were 1.6% on land and 3.3% in water [odds ratio (OR) 2.10, 95% confidence interval (CI) 1.5-2.94). Multivariate analysis confirmed water birth, ethnicity and parity as independent risk factors for OASI (adjusted OR water birth: 1.77 (CI 1.25-2.51). Our prognostic model showed Black and Asian primigravidae following water birth had the highest risk of OASI and white multiparae on land the lowest. CONCLUSION: This study of comparable low-risk women shows an increased risk of OASI following water birth compared with land birth. Use of this prognostic model will help women determine their risk of OASI following birth in water or on land.

A systematic mixed studies review of women's experiences of perineal trauma sustained during childbirth.

AIM: To explore the quantitative/qualitative literature on women's experiences of perineal trauma sustained during childbirth and the impact it may have on psychological/emotional wellbeing BACKGROUND: Obstetric complications during childbirth can be a risk factor for postpartum psychological distress. Perineal trauma is one of the most frequent obstetric complications and it is important to understand any impact on psychological/emotional wellbeing. DESIGN: A convergent qualitative design using a hybrid deductive-inductive thematic synthesis approach to data transformation was used. DATA SOURCES: Web of knowledge, CINAHL, MEDLINE, AMED, PsyArticles, PsycInfo until May 2017. REVIEW METHODS: Stage 1: transforming findings from the qualitative, quantitative and mixed methods studies into themes using thematic synthesis. Stage 2: integrating themes from the quantitative studies into those derived from the qualitative studies RESULTS: Records (N=2152) found of which 11 qualitative 22 quantitative and 1 mixed methods were included in this review. Five themes were derived from thematic synthesis of qualitative studies 'The mystery of perineal trauma', 'The misery of perineal suturing', 'The postnatal perineum', 'Normalisation and feeling dismissed' and 'Adjusting to a new normal - Coping and compromise' and five themes identified from the quantitative studies, experience of birth (N=4), Sexual functioning (N=12), Social functioning (N=2), Psychological health (N=8) and Quality of Life (N=5). CONCLUSION: Perineal trauma can have a negative impact on psychological/emotional wellbeing, however the literature is conflicted and in need of clarification. Future research should clearly describe the perineal status of the women in the sample, use validated measures and consider the timing of such measures. This article is protected by copyright. All rights reserved.

Development and Assessment of Postcranial Sex Estimation Methods for a Guatemalan Population.

This study tests whether postcranial sex estimation methods generated from Hispanic, and mainly Mexican samples, can be successfully applied to other increasingly common migrant populations from Central America. We use a sample of postcranial data from a modern (1980s) Guatemalan Maya sample (n = 219). Results indicate a decrease in classification accuracies for previously established univariate methods when applied to the Guatemalan study sample, specifically for males whose accuracies ranged from 30 to 84%. This bias toward inaccuracies for Guatemalan males is associated with the smaller skeletal sizes for the Guatemalan sample as compared to the samples used in the tested sex estimation methods. In contrast, the tested multivariate discriminant function classification yielded less sex bias and improved classification accuracies ranging from 82 to 89%. Our results highlight which of the tested univariate and multivariate methods reach acceptable levels for accuracy for sex estimation of cases where the region of origin may include Guatemala.

A simulation for exploring the effects of the "trait list" method's subjectivity on consistency and accuracy of ancestry estimations.

The nonmetric "trait list" methodology is widely used for estimating ancestry of skeletal remains. However, the effects of the method's embedded subjectivity on subsequent accuracy and consistency are largely unknown. We develop a mathematical simulation to test whether variation in the application of the "trait list" method alters the ancestry estimation for a given case. Our simulation explores how variations in (i) trait selection, (ii) number of traits employed, and (iii) ancestry choice thresholds affect the ancestry estimation of an unidentified skeleton. Using two temporally and geographically diverse samples, the simulation demonstrates that trait selection, trait quantity, threshold choices, and the exclusion of high-frequency traits had minimal effect on estimation of general ancestry. For all data sets and Runs, Accuracy(AS) was maintained above 90%. The authors close with a discussion on the logistical issues present when choosing traits, and how to avoid ancestry bias.

Differences in episiotomy technique between midwives and doctors.

OBJECTIVES: To examine the practice of making an episiotomy and to determine any differences in practice between professional groups. DESIGN: A prospective survey. SETTING: A large tertiary referral obstetric hospital and the obstetric department of a district general hospital. POPULATION: All staff routinely involved in the care of women in labour. METHODS: A novel validated pictorial questionnaire was designed, validated and distributed to the study population. Differences in outcome measures were compared by profession and by seniority. MAIN OUTCOME MEASURES: Measurements taken from the questionnaire: the length of episiotomy drawn; the distance from the sagittal plane at which the episiotomy was begun; and the angle of the episiotomy from the sagittal plane. RESULTS: Fifty doctors and 78 midwives completed the forms. Median distance of the episiotomy from the midline was 0 mm (-2 to 11). Episiotomies drawn by doctors were significantly longer and more angled than those drawn by midwives (P = 0.002 and P = 0.001). Sixteen percent of doctors and 1% of midwives drew an episiotomy longer than 20 mm (difference 15%, 95% CI 6 to 24). Twenty-three percent of midwives and 2% of doctors drew an episiotomy angled 30 degrees or less (difference 21%, 95% CI 9 to 34). CONCLUSIONS: This study has demonstrated differences in the reporting of episiotomy practice by doctors and midwives. Theoretically, the differences demonstrated could predispose to a greater risk of anal sphincter injuries. These data need to be confirmed by observational studies of actual practice and by studies to investigate the mechanics of sphincter injury during childbirth.