Perineal management: Midwives' confidence and educational needs.

OBJECTIVE: The overall aim of this study was to collate information to inform the updating of a perineal management educational programme for midwives. This paper explores midwives' confidence and educational needs in managing the woman's perineum during the second stage of labour, focusing on future quality initiatives to improve midwives' experiences and expertise in the prevention of perineal trauma during birth. DESIGN: A mixed-methods sequential exploratory design was used. PARTICIPANTS AND SETTING: Midwives and clinical midwife managers assisting with births in the labour ward of a large urban university stand-alone maternity hospital in the Republic of Ireland with approximately 9,000 births per year participated in the study. MEASUREMENTS: A questionnaire and two focus groups were used to collect the data. FINDINGS: Fifty-two midwives from a total of 64 eligible labour ward midwives completed the questionnaire, a response rate of 81.2%. Midwives indicated that perineal management workshops did not cover prevention of perineal trauma, and mainly focused on suturing and repair of the perineum. The majority of midwives (85%) indicated that they would like further education on the prevention of perineal trauma. Higher levels of confidence in making a decision to perform an episiotomy, infiltrating the perineum and at performing an episiotomy were reported in experienced midwives. Midwives want improved and additional education in the management of women's perinea during the second stage of labour and made various recommendations regarding the content, format, timing and frequency of the workshop. Suggestions for further education included techniques for preventing perineal trauma during labour and birth and how to perform an episiotomy. KEY CONCLUSIONS: This study provides key insights into midwives' confidence and educational needs in relation to managing the woman's perineum during the second stage of labour. The findings from this study demonstrates the appetite of midwives for additional education in the area of perineal management, particularly prevention strategies. IMPLICATIONS FOR PRACTICE: Midwives play an essential role in reducing the rates of perineal trauma through regular education. It is therefore important that midwives keep up to date with the best available evidence. Updating existing perineal management educational programmes that are tailor made to midwives' needs could not only improve clinical skills and perineal protection techniques but also midwives' confidence in decision making. The overall aim is to reduce perineal trauma in women having a spontaneous vaginal birth.

Perineal repair of media-lateral episiotomies and 2nd degree tears by midwives: A randomised controlled trial comparing three suture techniques.

BACKGROUND: Perineal trauma pain is associated with perineal repair and its subsequent healing. New evidence is required concerning perineal repair techniques that cause less pain and favour healing. OBJECTIVE: To compare three perineal repair suturing techniques after episiotomy or second degree tearing during a normal birth with respect to reducing pain and improving the perineal healing process. DESIGN: A randomised controlled trial. SETTING: A large public university hospital in Madrid, Spain. PARTICIPANTS: Full term pregnant women older than 18 years-of-age, who required perineal repair after episiotomy or second degree tearing and were attended for normal birth by midwives. METHODS: One hundred and eighty-three women were randomly assigned to three groups: the Continuous Suture Group (n = 58), Interrupted Cutaneous Suture Group (n = 53), or the Interrupted Subcutaneous Suture Group (n = 57). The study participants and data collectors were blinded to group allocations. Principal outcome: perineal pain 10 days after birth. Other outcomes: short (2 and 48 h) and long term (3 and 6 months) perineal pain after birth; short term healing; suture time. RESULTS: At 10 days postpartum, the presence of spontaneous pain, pain when walking or moving in bed, was almost nonexistent in the 3 suture groups. The median (P25-P75) perineal pain on palpation was similar in the 3 groups, with values of 2 (1-4) in the Continuous Suture Group, 3 (2-5) in the Interrupted Cutaneous Suture Group and 2 (1-4) in the Interrupted Subcutaneous Suture Group; also were similar the perineal pain on sitting: 1 (0-3) in the Continuous Suture Group, 1 (0-2) in the Interrupted Cutaneous Suture Group and 1 (0-3) in the Interrupted Subcutaneous Suture Group. There were no statistically significant differences between the groups. Pain measurements throughout the follow-up period only showed statistically significant differences in 2 out of 22 evaluations: pain when sitting 48 h after birth and spontaneous pain at 3 months. The mean times (standard deviation) to carry out suturing were 12.86 (4.9) minutes in the Continuous Suture Group, 13.54 (5.6) in the Interrupted Cutaneous Suture Group, and 15.59 (6.9) minutes in the Interrupted Subcutaneous Suture Group (p < 0.05). CONCLUSIONS: The three suturing methods described for perineal repair after episiotomy or second degree tearing after normal birth are comparable with respect to short, medium and long term perineal pain and the healing process. Use of the continuous suturing technique involved less time than interrupted suture methods. Tweetable abstract: proper the suturing methods for perineal repair after episiotomy or second degree tearing prevent postpartum perineal pain.

Randomized Clinical Trial of an Aquatic Physical Exercise Program During Pregnancy.

OBJECTIVE: To determine the effect of an aquatic physical exercise program performed during pregnancy on rate of intact perineum after childbirth. DESIGN: Randomized clinical trial. SETTING: Health centers in the metropolitan health district of Granada, Spain. PARTICIPANTS: A total of 129 pregnant women (control group [CG] = 64; aquatic exercise group [EG] = 65). METHODS: The intervention was an aquatic physical exercise program specifically designed for pregnant women (Study of Water Exercise During Pregnancy [SWEP] method). Participants were randomly assigned to the CG or EG by simple random sampling. Participants in the EG performed three sessions per week of physical exercises, which were led by the principal investigator. All participants received routine prenatal care. We evaluated status of the perineum after birth, including laceration and episiotomy rates. We also evaluated participants' weight, body mass index (BMI) in the first and third trimesters, parity, the administration of anesthesia, and birth weight of the neonate as potential confounding variables. RESULTS: The women in the EG had a greater rate of intact perineum than those in the CG (odds ratio [OR] = 13.54, 95% confidence interval [CI] [2.75, 66.56]). After adjusting for infant birth weight, the effect of the intervention on intact perineum was an OR of 8.57 (95% CI [1.85, 39.68]. Maternal weight gain did not influence the odds of intact perineum (OR = 1.072, 95% CI [0.896, 1.283]). Women who previously gave birth and followed the SWEP method had an OR of 10.197 (95% CI [2.190, 47.476] for an intact perineum. The administration of anesthesia and previous pregnancy also were associated with intact perineum (OR = 6.68, 95% CI [1.21, 36.84] and OR = 5.42, 95% CI [1.64, 17.89] respectively. CONCLUSION: The women who followed the SWEP method were significantly more likely to have intact perinea after childbirth.

Análise de fatores associados à prática da episiotomia / Analysis of factors associated with the practice of episiotomy

Objetivo: identificar os fatores que levam enfermeiros obstetras a realizarem uma episiotomia. Método: trata-se de uma revisão integrativa, com vistas a responder à questão norteadora << O que leva o enfermeiro obstetra a realizar uma episiotomia? >>. Para isso, realizou-se uma busca por evidências, entre 2005 a 2017, nas bases de dados LILACS e BDENF e na BIREME e SciELO, com os descritores: episiotomia, humanização da assistência e trabalho de parto, considerando os critérios de inclusão e exclusão pré-estabelecidos. Foram selecionados 9 artigos posteriormente submetidos à leitura, análise e organizados em figuras para discussão através de um instrumento adaptado e validado por Ursi 2005. Resultado: foi possível verificar que a maioria dos estudos se referem à prática da episiotomia como intimamente ligada a primiparidade, rigidez perineal, macrossomia e prematuridade. Conclusão: a literatura evidenciou que os principais fatores que levam os enfermeiros obstetras a realizarem a episiotomia são: primiparidade, à rigidez perineal, macrossomia e prematuridade. Com isso, foi possível verificar que a episiotomia não previne lacerações de 3º e 4º grau e a mesma está relacionada diretamente com a dispareunia. Isso contribui para uma preocupação científica em instituir tecnologias que auxiliem na fisiologia do parto preservando a integridade corporal.(AU)

Effect of episiotomy training with beef tongue and sponge simulators on the self-confidence building of midwifery students.

This study assesses the efficacy of simulation-based episiotomy training (SBET) with beef tongue and sponge models in terms of the self confidence of midwifery students while performing episiotomy. Third-year midwifery students from Cumhuriyet University in the fall semesters of 2011 and 2012 were enrolled in the sponge and beef tongue model groups (n = 36 and n = 37, respectively). A checklist was prepared on the required skills for performing episiotomy which can be broken into three main parts, namely preparation, cutting and repairing and completion. According to the checklist, a Likert type questionnaire was developed including 5 items for preparation, 11 items for cutting and repairing, and 6 items for completion. After SBET with the sponge and beef tongue models in our laboratories of Midwifery Department, the students performed episiotomy steps in laboring women in Sivas State Hospital and then they filled in the questionnaire to indicate whether they gained self-confidence in performing episiotomy or not. Although, participants of both groups have successfully completed all the steps of episiotomy, overall, beef tongue model was found to be more successful regarding their self-confidence (p < 0.05), including the skills in performing local anesthesia; choosing needle holder, suture material and scissor for cutting; identifying apex, hymen and skin; using needle holder properly while penetrating into the skin, suturing vaginal mucosa until hymen, knotting, and suturing perineal muscles and skin. Our results suggest that while SBET with both models are applicable for episiotomy training of midwifery students in the laboratory setting, SBET with beef tongue model provides an additional increase in their self-confidence in the clinical settings.

A promoção da integridade do períneo no cuidado à mulher no parto / The promotion of perineal integrity in the care to women at childbirth

As enfermeiras obstétricas nos partos utilizam cuidados para preservação perineal e optam pelas técnicas hands on e hands off, em que, segundo evidências científicas atuais, não há diferença nas taxas de lacerações perineais. Como objeto de pesquisa: A promoção da integridade perineal no cuidado à mulher utilizada pelas enfermeiras obstétricas no parto; e objetivos: Verificar a prevalência e os fatores associados ao cuidado de promoção da integridade do períneo feminino no parto; Identificar as estratégias adotadas para a promoção da integridade perineal da mulher na assistência ao parto; Descrever a promoção da integridade perineal realizada pelas enfermeiras obstétricas. Estudo misto, quan  QUAL, sendo a fase quantitativa um estudo transversal, retrospectivo, baseado nos registros do livro de partos assistidos pelas enfermeiras obstétricas de uma maternidade pública do Rio de Janeiro em 2015. Os dados foram armazenados no Microsoft Excel® e o processamento das variáveis foi realizado por meio do software Stata SE 13®, no qual foram avaliadas as prevalências, realizada análise bivariada das variáveis dependentes e independentes e foram procedidos os cálculos de seus respectivos intervalos de confiança a 95% e Razões de Chances (OR) bruta. Na fase qualitativa, tipo descritiva, realizaram-se entrevistas semiestruturadas com todas as enfermeiras obstétricas atuantes no centro obstétrico desta unidade e analisadas pela técnica da análise de conteúdo temática. Resultados: Realizada análise de 555 registros de partos normais assistidos por essas profissionais e a técnica de cuidado perineal mais utilizada foi a hands off (92,4%). A ocitocina foi utilizada em 21,6% das mulheres e apresentou 6,6 (RP) mais probabilidade do cuidado de proteção perineal com as mãos (hands on) ser empregado. A posição materna não supina no parto predominou (94,6%). Quando essa posição é supina, há 1,4 (OR) mais chances de ser utilizado o cuidado protetor hands on. A episiotomia foi praticada em apenas uma mulher (0,2%). As lacerações de 1º grau foram mais prevalentes (65%). As de 3º grau ocorreram em apenas duas mulheres (0,4%). A maioria (87,2%) dos RNs teve peso adequado ao nascer. Na análise qualitativa, as participantes eram jovens, com inserção recente na especialidade, na assistência ao parto normal e preferem o hands off. Relatam uso eventualmente do hands on e do óleo vegetal. Adotam como princípios do cuidado de promoção da integridade perineal: o respeito à fisiologia do parto e ao protagonismo feminino e a não intervenção no corpo feminino. Também almejam alcançar as seguintes metas de cuidado: promover o retorno sexual e atividades de vida cotidiana no pós-parto e estimular o conhecimento sobre as repercussões fisiológicas do parto sobre o períneo. Portanto, essas profissionais optam pela conduta expectante e o cuidado hands off, procedendo à prevenção quaternária no parto normal. Estas profissionais priorizam o respeito à fisiologia do parto, promovem a autonomia e protagonismo da mulher no parto. Para tal, utilizam essas estratégias de cuidados perineais com metas para uma melhor qualidade e segurança no parto e pós-parto, prestando um cuidado baseado nas evidências científicas atuais e na humanização do parto e nascimento.

Nurse midwives in childbirth take care procedures for perineal preservation and opt for hands-on and hands-off techniques, which according to current scientific evidence present no difference in rates of perineal lacerations. As research object: the promotion of perineal integrity in the care of women performed by nurse midwives in childbirth; and research objectives: to verify the prevalence and factors associated with care to promote the integrity of the female perineum at birth; to identify the strategies adopted to promote the perineal integrity of women in childbirth care; to describe the promotion of perineal integrity performed by nurse midwives. A mixed study, quan  QUAL, being the quantitative phase a cross-sectional, retrospective study based on the records, on the birth record book, of births assisted by nurse midwives at a public maternity hospital in Rio de Janeiro in 2015. The data were stored in Microsoft Excel® and the variables were processed using Stata SE 13® software, in which the prevalences have been analyzed, bivariate analysis of dependent and independent variables has been applied and their respective gross Chances Ratios (OR) and confidence intervals were calculated at 95%. In the descriptive, qualitative phase, semi-structured interviews were conducted with all the nurse midwives working at the Obstetric Center of this health unit and analyzed by the thematic content analysis technique. Results: Analysis of 555 records of normal childbirth assisted by these professionals was performed, and the most used perineal care technique was hands off (92.4%). Oxytocin was used in 21.6% of the women and presented 6.6 (RP) more probability of the perineal protection with hands (hands on) being employed. Maternal non-supine position at birth predominated (94.6%). When this position is supine, there are 1.4 (OR) more chances of using the hands-on protective care. Episiotomy was performed in only one woman (0.2%). First-degree lacerations were more prevalent (65%). Third-degree lacerations occurred only in two women (0.4%). The majority (87.2%) of the newborns had adequate birth weight. In the qualitative analysis, the participants were young, with recent entry in the specialty, in normal childbirth assistance and prefer the hands off technique. They report some use of hands-on and vegetable oil. They adopt as principles of care the promotion of the perineal integrity: the respect for the physiology of childbirth and the female protagonism and the non-intervention in the female body. They also aim to achieve the following care goals: to promote the return to sexual and daily life activities in the postpartum period and to stimulate knowledge about the physiological repercussions of childbirth on the perineum. Therefore, these professionals opt for the expectant conduct and the hands-off care, proceeding the quaternary prevention in normal childbirth. These professionals prioritize the respect for the physiology of childbirth, promote the autonomy and protagonism of the woman in childbirth. For this purpose, they use these strategies of perineal care with goals for a better quality and safety in childbirth and postpartum period, providing a care based on current scientific evidence and on the humanization of childbirth and birth.

Irish and New Zealand Midwives' expertise at preserving the perineum intact (the MEPPI study): Perspectives on preparations for birth.

OBJECTIVES: perineal trauma during birth can result in short or long term morbidity for women. Internationally, rates of episiotomy and severe perineal tears vary considerably. In New Zealand, in 2011, and in a trial of midwife-led care in Ireland, episiotomy rates were found to be considerably lower than those in many other countries. A qualitative exploratory study was undertaken to ascertain how midwives achieve these low rates, in these countries and settings. DESIGN AND PARTICIPANTS: a qualitative exploratory study was conducted. Midwives expert in preserving the perineum intact (PPI) from two maternity units in the Republic of Ireland and from varied birth settings in New Zealand, were eligible to participate. Twenty-one consenting midwives took part, seven from Ireland and 14 from New Zealand. METHODS: university ethical approval was granted. Face-to-face, semi-structured interviews were used to collect the data. Interviews were recorded and transcribed verbatim. The data were analysed using Ethnograph software and were organised into prominent themes. FINDINGS: four themes were identified; 'Sources of knowledge for PPI', 'Associated factors', 'Decision-making on episiotomy', and 'Preparations for PPI'. Participants drew heavily on multiple sources of knowledge in building their own expertise for PPI. Physical characteristics of the perineum featured prominently as factors leading to PPI. Episiotomy was, in the main, only performed when there were signs of fetal distress. Antenatal perineal massage was supported. CONCLUSION: this study provides valuable insight into the views and skills of midwives, with expertise in PPI at birth, adding to the body of evidence on this topic.

Implantación de las recomendaciones de la estrategia de atención al parto normal en un hospital nivel II / Implementation of the recommendations in the care strategy for normal childbirth in a level 2 hospital

Objetivo: analizar la adecuación de la atención al parto normal en el Hospital Universitario Severo Ochoa (HUSO), hospital de nivel II de la Comunidad de Madrid, a las recomendaciones de la Estrategia de Atención al Parto Normal (EAPN) y detectar los puntos fuertes y áreas de mejora. Método: estudio descriptivo transversal. Mediante muestreo consecutivo se incluyeron 346 partos de mujeres gestantes de 37 a 42 semanas. Se midieron 18 indicadores propuestos en la EAPN que evalúan la atención al parto. Se realizó un análisis bivariante aplicando la prueba Chi cuadrado de Pearson. Para establecer la prioridad de áreas a mejorar se utilizó́ el diagrama Pareto. Resultados: 'Área de mejora': amniotomías (44,8%), uso de oxitocina en partos espontáneos (42,6%), inducciones (42,2%), partograma cumplimentado (55,5%), posición de litotomía en expulsivo (54,3%), maniobra de Kristeller (15,7%), episiotomías en partos eutócicos (41,6%), manejo dirigido del alumbramiento (3,8%) y piel con piel (66,5%). 'Puntos fuertes': analgesia epidural (73,4%), desgarros grado III/IV con episiotomía y sin episiotomía (1,4%; 0%), y partos instrumentales (12,3%). Se evidenció asociación entre inducciones, uso de oxitocina y cesáreas urgentes (p< 0,004), el uso de epidural y partos instrumentales (p< 0,007) y la realización de Kristeller y desgarros grado III-VI (p< 0,000). Conclusiones: a la luz de los resultados un plan de mejora debería incluir estrategias para disminuir amniotomías y uso de oxitocina mediante la revisión de criterios para el ingreso por parto en curso y el número de partos inducidos. Trabajar en estos puntos prioritariamente disminuiría el intervencionismo en la atención al parto y podría revertir en mejores resultados obstétricos (AU)

Objectives: to analyze the adequacy of care for normal childbirth in the Hospital Universitario Severo Ochoa (HUSO), a Level 2 hospital in the Community of Madrid according to the recommendations in the Care Strategy for Normal Childbirth (CSNC), and to detect its strengths and areas to be improved. Method: a descriptive cross-sectional study. Through consecutive sampling, the study included 346 childbirths in women with 37 to 42 weeks of pregnancy. Eighteen (18) indicators stated in the CSNC were measured, assessing care during delivery. A bivariate analysis was conducted, applying Pearson's Chi Square Test. The Pareto Diagram was used to establish the priority of areas to be improved. Results: 'Area for improvement': amniotomy (44.8%), use of oxytocin in spontaneous labour (42.6%), inductions (42.2%), partogram completed (55.5%), lithotomy position during expulsion (54.3%), Kristeller maneuver (15.7%), episiotomy in normal delivery (41.6%), active management of the third stage of labour (3.8%) and skin-to-skin (66.5%). 'Strengths': epidural anesthesia (73.4%), third and fourth degree tears with and without episiotomy (1.4%; 0%), and instrumental delivery (12.3%). There was evidence of association between inductions, use of oxytocin and emergency Caesarean sections (p< 0.004), the use of epidural anesthesia and instrumental deliveries (p< 0.007), and the Kristeller maneuver and 3rd and 4th degree tears (p< 0.000). Conclusions: given these results, a plan for improvement should include strategies to reduce the number of amniotomies and the use of oxytocin, through the review of admission criteria for delivery in process and the number of induced childbirths. Working on these points as a priority would reduce the interventions during childbirth care, and could result in improved obstetric outcomes (AU)

Caracterização da assistência ao parto em adolescentes primigestas no município de cuiabá-mt / Caracterización de la atención al parto en adolescentes primigestas en el municipio de cuiabá-mt / Characterization of pregnancy labor assistance of primigravida adolescents in the city of cuiabá-mt

RESUMO O objetivo foi analisar a assistência ao parto de adolescentes primigestas no contexto do Sistema Único de Saúde (SUS) no município de Cuiabá, Mato Grosso. Estudo transversal, descritivo e documental com amostragem aleatória simples composta por 164 prontuários de puérperas adolescentes coletados por meio de ficha estruturada durante os meses de dezembro de 2012 a maio de 2013. Foi realizada análise descritiva simples dos dados. Os resultados indicaram que o parto cesáreo apresentou taxa de 37,2%, a amniotomia foi adotada em 62,1%, a ocitocina em 53,4% e a episiotomia em 82,4%. A desproporção céfalo-pélvica representou 27,9% das indicações de cesariana e dentre as complicações maternas, a hemorragia destacou-se em ambos os tipos de parto. Conclui-se a existência de uma forte influência do modelo tecnicista sobre os resultados maternos na assistência obstétrica de adolescentes primigestas e que o fato do desconhecimento atrelado à vulnerabilidade deste grupo populacional evidencia a soberania do profissional em relação às decisões obstétricas.

RESUMEN El objetivo ha sido analizar la atención al parto de adolescentes primigestas en el contexto del Sistema Único de Salud (SUS) en el municipio de Cuiabá, Mato Grosso. Estudio transversal, descriptivo y documental con muestreo aleatorio simple compuesto de 164 registros médicos de puérperas adolescentes recogidos a través del formulario estructurado durante los meses de diciembre de 2012 hasta mayo de 2013. Fue realizado el análisis descriptivo simple de los datos. Los resultados indicaron que el parto por cesárea ha presentado tasa de 37,2%, la amniotomía fue adoptada en 62,1%, la oxitocina en 53,4% y la episiotomía en 82,4%. La desproporción cefalopélvica ha representado 27,9% de las indicaciones de la cesárea y entre las complicaciones maternas, la hemorragia se ha destacado en ambos tipos de parto. Se concluye que existe una fuerte influencia del modelo técnico sobre los resultados maternos en la atención obstétrica a las adolescentes primigestas y que el hecho del desconocimiento relacionado a la vulnerabilidad de este grupo poblacional evidencia la soberanía del profesional en relación a las decisiones obstétricas.

ABSTRACT It aimed to analyze labor assistance for primigravida adolescents in the context of the Unified Health System (SUS) in the city of Cuiabá, Mato Grosso. Cross-sectional, descriptive and documental study with a random sample composed of 164 medical records of postpartum adolescent collected through structured file during the months of December 2012 to May 2013. Data were analyzed through simple descriptive analysis. The results indicated that cesarean section showed rate of 37.2%, amniotomy was adopted in 62.1%, oxytocin 53.4% and 82.4% in the episiotomy. Cephalopelvic disproportion represented 27.9% of cesarean section indications and among maternal complications, hemorrhage stood out in both types of delivery. It is concluded that there is a strong influence of the technicist model on maternal outcomes in obstetric care to pregnant adolescents and that the lack of knowledge linked to the vulnerability of this group shows the professional sovereignty in relation to obstetric decisions.

Better perineal outcomes in sitting birthing position cannot be explained by changing from upright to supine position for performing an episiotomy.

BACKGROUND: women who give birth in supine position are more likely to have an episiotomy than women who give birth in sitting position. A confounding effect may be that women in upright positions in second stage of labour are asked to lie down if a professional needs to perform an episiotomy. This prospective cohort study aimed to determine whether this factor can explain the lower rate of episiotomy in sitting compared to supine position. METHODS: data from 1196 women who had a spontaneous, vaginal birth were analysed. Positions during second stage and at birth were carefully recorded. Three groups of birthing positions were compared in multivariable analyses: 1) horizontal during second stage and supine at birth (horizontal/supine), 2) horizontal and upright during second stage and supine at birth (various/supine), 3) sitting at birth regardless of the position in second stage. Logistic regression analysis was used to adjust for known risk factors for perineal damage. FINDINGS: women in sitting position at birth compared to those in the horizontal/supine group had a lower episiotomy rate (adjusted OR 0.28;95%-CI 0.14-0.56) and a non-significant higher intact perineum rate (adjusted OR 1.40, 95% CI 0.96-2.04). Women in the various/supine group compared to the horizontal/supine group had a similar episiotomy rate (adjusted OR 1.12;95%-CI 0.69-1.83). CONCLUSIONS: we did not confirm our hypothesis that more women in supine compared to sitting position have an episiotomy because women in upright position are asked to lie down if an episiotomy is necessary.

How to perform an episiotomy.

RATIONALE AND KEY POINTS: An episiotomy may be necessary to assist some women to give birth. An episiotomy is a surgical incision intentionally made to increase the diameter of the vulval outlet to enable childbirth. ▶ Midwives and doctors should use their clinical judgement and skills to assess when to perform an episiotomy. ▶ An episiotomy should not be performed routinely; its use should be restricted to certain indications. ▶ Adequate pain relief should be provided before performing an episiotomy. REFLECTIVE ACTIVITY: Clinical skills articles can help update your practice and ensure it remains evidence based. Apply this article to your practice. Reflect on and write a short account of: 1. How you think this article will change your practice. 2. The risk factors that can predispose a woman to having an episiotomy. 3. What you would do if a woman refused to have an episiotomy despite the presence of a clinical indication, such as fetal distress. Subscribers can upload their reflective accounts at: rcni.com/portfolio.

Eficacia del apósito de plástico en aerosol Nobecutan. En la disminución del dolor asociado al trauma perineal tras el parto vaginal / Effectiveness of Nobecutan plastic dressing spray in reducing pain associated with perineal trauma after vaginal delivery

Objetivo. Comparar la diferencia en el dolor perineal entre las mujeres con apósito y sin apósito aplicado en el trauma perineal después de su reparación. Diseño. Estudio experimental controlado y aleatorizado. Lugar. Hospital Universitario Fundación Alcorcón, hospital público perteneciente a la Comunidad de Madrid. Muestra. En el estudio participaron ochenta y dos mujeres nulíparas, con episiotomía o desgarro perineal de segundo grado durante el parto. Método. Fueron asignadas al azar a cada uno de los grupos. Al grupo experimental se aplicó el apósito plástico directamente sobre la herida, mientras que al grupo control se le aplicó el apósito en la piel circundante a la herida. Mediciones de lo s resultados principales. Se preguntó a las participantes en relación con la sensación de dolor (escala 0-100) en reposo y durante diferentes actividades (como sentarse, caminar, micción o defecación) y con el uso de analgésicos a las 24 y 48 horas posparto. Resultados. Las mujeres tratadas con el apósito adhesivo en aerosol en la herida presentan menos dolor en reposo, al sentarse, deambulación, micción y defecación, a las 24 horas y a las 48 horas del parto, frente a las mujeres sin apósito adhesivo en la herida. Solo alcanza significación estadística (p = 0.024) la diferencia de medias del dolor en la micción a las 48 h, siendo la diferencia de 9.5 mm (IC 95 %; 1.2 a 17.4) y el tamaño de efecto (d de Cohen): d = 0.51. La necesidad de analgesia fue mayor en el grupo control que en el experimental, aunque no alcanzó significación estadística. Conclusión. Este estudio sugiere que la aplicación de apósito plástico en aerosol en el trauma perineal inmediatamente después de su reparación puede contribuir a disminuir las molestias en mujeres primíparas en las primeras 48 horas posparto (AU)

Objective. The aim of this study was to compare the difference in perineal pain between women with dressing spray versus no dressing spray applied after perineal repair. Design. Randomized controlled trial. Setting. The Hospital Universitario Fundación Alcorcón, a state hospital belonging to the Community of Madrid. Sample. The study involved eighty-two nulliparous women, who had undergone vaginal delivery with episiotomy or second-degree perineal laceration. Method. They were randomized. One group was applied the dressing spray directly on the wound (experimental group). The other group was applied the dressing spray on the skin around the wound (control group). Main outcome measures. The participants were questioned regarding the sensation of pain (0-100 scale) in repose and during different activities (such as sitting, walking, urinating and during defecation), and the use of painkillers at 24 and 48 hours postpartum. Results. Women treated with plastic dressing spray on the wound had less pain at repose, sitting, walking, urinating and during defecation at 24 hours and 48 hours postpartum. Only reached statistical significance the pain in urination at 48 hours. The difference was 9.5 mm (95 %; 1.2 to 17.4) and the effect size (Cohen’s d): d = 0.51). The need for analgesia was higher in the control group than in the experimental, but not significant differences being observed. Conclusions. Findings suggest that Nobecutan® plastic dressing spray can decrease perineal pain in nulliparous women in the first 48 hours after birth (AU)

EPI-NO más que un dispositivo favorecedor de la elasticidad perineal para el parto / Epi-No: more than a flattering deviceto improve perineal elasticity in childbirth

En la actualidad, las principales causas de lesión de las estructuras del suelo pélvico están asociadas a cambios hormonales y mecánicos que se producen durante la gestación, así como al efecto de la expulsión fetal durante el parto. Estas alteraciones pueden afectar gravemente la calidad de la vida de la mujer, por lo que se hace imprescindible su abordaje precoz. Este abordaje debe comenzar desde la prevención y llevarse a cabo por un equipo multidisciplinar que conozca las diferentes terapias o dispositivos diseñados para el manejo de cada alteración. El EPI-NO es un dispositivo vaginal diseñado a finales de los años noventa con el objetivo de ejercitar la musculatura del suelo pélvico de cara al parto y restaurar el tono muscular en el posparto. Su uso es sencillo y no resulta lesivo para la gestante o su futuro bebé; asimismo, aporta numerosos beneficios para la gestante, entre los que se encuentran: reducción en el número de episiotomías y desgarros de 2.º y 3.er grado, aumento de la incidencia de periné intacto y prevención de la incontinencia urinaria en el embarazo y posparto, entre otros. Conociendo las necesidades de la mujer y los recursos disponibles a su alcance, los profesionales podrán orientar a la gestante en el uso del EPI-NO durante su proceso de embarazo, parto y posparto, y disminuir así la morbilidad asociada al parto (AU)

Currently, the main causes of damage to the pelvic floor structures are associated with hormonal and mechanical changes occurring during pregnancy, as well as the effect of fetal expulsion during delivery. These changes can severely affect the quality of life of women, so it is essential to his early approach. This approach should start from prevention and be carried out by a multidisciplinary team who knows the different therapies or devices designed for handling each alteration. The EPI-NO is a vaginal device designed in the late 90s with the aim of exercising the muscles of the pelvic floor facing the delivery and restore muscle tone postpartum. Its use is simple and not harmful to the pregnant woman or her unborn child; likewise, brings numerous benefits to the pregnant among which are: reduction in the number of episiotomies and tears 2nd and 3rd grade, increased incidence of intact perineum and prevention of urinary incontinence in pregnancy and postpartum, among others. Knowing the needs of women and the resources available to them, professionals can guide the mother in using the EPI-NO during their pregnancy, childbirth and postpartum, decreasing the morbidity associated with childbirth (AU)

Midwives' and doctors' perceptions of their preparation for and practice in managing the perineum in the second stage of labour: a cross-sectional survey.

OBJECTIVE: to identify the perceptions of midwives and doctors at Monash Women's regarding their educational preparation and practices used for perineal management during the second stage of labour. DESIGN: anonymous cross-sectional semi-structured questionnaire ('The survey'). SETTING: the three maternity hospitals that form Monash Women's Maternity Services, Monash Health, Victoria, Australia. PARTICIPANTS: midwives and doctors attending births at one or more of the three Monash Women's maternity hospitals. METHODS: a semi-structured questionnaire was developed, drawing on key concepts from experts and peer-reviewed literature. FINDINGS: surveys were returned by 17 doctors and 69 midwives (37% response rate, from the 230 surveys sent). Midwives and doctors described a number of techniques they would use to reduce the risk of perineal trauma, for example, hands on the fetal head/perineum (11.8% of doctors, 61% of midwives), the use of warm compresses (45% of midwives) and maternal education and guidance with pushing (49.3% of midwives). When presented with a series of specific obstetric situations, respondents indicated that they would variably practice hands on the perineum during second stage labour, hands off and episiotomy. The majority of respondents indicated that they agreed or strongly agreed that an episiotomy should sometimes be performed (midwives 97%, doctors 100%). All the doctors had training in diagnosing severe perineal trauma involving anal sphincter injury (ASI), with 77% noting that they felt very confident with this. By contrast, 71% of the midwives reported that they had received training in diagnosing ASI and only 16% of these reported that they were very confident in this diagnosis. All doctors were trained in perineal repair, compared with 65% of midwives. Doctors were more likely to indicate that they were very confident in perineal repair (88%) than the midwives (44%). Most respondents were not familiar with the rates of perineal trauma either within their workplace or across Australia. KEY CONCLUSIONS: Midwives and doctors indicated that they would use the hands on or hands off approach or episiotomy depending on the specific clinical scenario and described a range of techniques that they would use in their overall approach to minimising perineal trauma during birth. Midwives were more likely than doctors to indicate their lack of training and/or confidence in conducting perineal repair and diagnosing ASI. IMPLICATIONS FOR PRACTICE: many midwives indicated that they had not received training in diagnosing ASI, perineal repair and midwives' and doctors' knowledge of the prevalence of perineal outcomes was poor. Given the importance of these skills to women cared for by midwives and doctors, the findings may be used to inform the development of quality improvement activities, including training programs and opportunities for gaining experience and expertise with perineal management. The use of episiotomy and hands on/hands off the perineum in the survey scenarios provides reassurance that doctors and midwives take a number of factors into account in their clinical practice, rather than a preference for one or more interventions over others.

Resultados maternos e neonatais dos partos normais de baixo risco assistidos por enfermeiras e médicos / Maternal and neonatal outcomes in low-risk normal deliveries assisted by nurses and physicians / Resultados maternos y neonatales de partos normales de bajo riesgo atendidos por enfermeras y médicos

O presente trabalho trata-se de pesquisa documental e retrospectiva que avaliou os registros da assistência ao parto normal e nascimentos de baixo risco em uma maternidade pública do município do Rio de Janeiro. Os objetivos foram descrever o perfil assistencial dos partos normais atendidos por enfermeiras e médicos e analisar as similaridades e as diferenças nos resultados maternos e neonatais desses atendimentos. Os dados receberam tratamento estatístico descritivo, foram aplicados os testes "F" de Fisher e o "t" de Student, com nível de significância p<0,05. As condutas de dieta zero, hidratação venosa e ocitocina no trabalho de parto são adotadas por ambos profissionais. Houve diferença significativa (p<0,01) para realização de episiotomia entre as enfermeiras (15%) e os médicos (64,3%). Os resultados maternos e neonatais dos partos normais de baixo risco atendidos pelas enfermeiras e médicos foram semelhantes...

This documental, retrospective study consisted of an evaluation of the records regarding normal and low-risk deliveries at a public maternity hospital in Rio de Janeiro. The study objectives were to describe the profiles of normal deliveries assisted by nurses and physicians, and analyze the similarities and differences in the maternal and neonatal outcomes in the service cases. Descriptive analysis of the data was performed, using Fisher's F-test and Student's t-test, with significance at p<0.05. Both professional categories adopt the conducts of zero dieting, intravenous hydration and oxytocin during labor. A significant difference was observed (p<0.01) for episiotomy performed by nurses (15%) and physicians (64.3%). Similar maternal and neonatal outcomes were observed for low-risk normal deliveries assisted by nurses and physicians...

Investigación documental, retrospectiva, que evaluó los registros de atención al parto normal y nacimientos de bajo riesgo en una maternidad pública del municipio de Rio de Janeiro. Los objetivos fueron describir el perfil de atención de partos normales atendidos por enfermeras y médicos y analizar las similitudes y diferencias en los resultados maternos y neonatales de tales atenciones. Los datos recibieron tratamiento estadístico descriptivo; fueron aplicados los tests "F" de Fisher y el "T" de Student, con nivel de significatividad p<0,05. Las conductas de dieta cero, hidratación venosa y oxitocina en el trabajo de parto son adoptadas por ambos profesionales. Hubo diferencia significativa (p<0,01) en la ejecución de episiotomía entre las enfermeras (15%) y los médicos (64,3%). Los resultados maternales y neonatales en los partos normales de bajo riesgo atendidos por enfermeras y médicos fueron semejantes...

Enhancing postnatal perineal care.

Maternal physical and psychological wellbeing during the postnatal period can be significantly impaired by perineal trauma sustained during childbirth. Current literature emphasises preventative measures, yet there is a lack of a systematic, evidence based approach to postnatal perineal care. This is concerning as the eighth 'Saving mothers' lives' report (CMACE 2011) identifies genital tract sepsis for the first time as the leading cause of maternal deaths. The aim of this article is therefore to develop a systematic approach to improve postnatal perineal care with a focus on assessment and treatment of perineal pain as well as recovery of pelvic floor function.