Implicações físicas e psicológicas da episiotomia no puerpério / Physical and psychological implications of episiotomy in the puerperium

A episiotomia é um procedimento cuja aplicação rotineira ou seletiva vem sendo discutida desde a publicação do Manual de Boas Práticas de Atenção ao Parto e Nascimento pela Organização Mundial da Saúd e (OMS) em 1996. Esta revisão de bibliografia procurou, então, investigar as informações disponíveis até o momento sobre as implicações físicas e emocionais da episiotomia no puerpério, levando em consideração o nível de conhecimento das puérperas sobre o procedimento, a dor, as limitações físicas percebidas e as repercussões na sexualidade da mulher nesse período. A análise dos dados apontou para a exclusão da mulher na tomada de decisões de seu trabalho de parto e para o impacto negativo na autoestima e na sexualidade, trazendo, também, limitações físicas ausentes nos casos de laceração. A comparação do nível de dor entre mulheres com episiotomias e lacerações foi inconclusivo, sugerindo a necessidade de maiores estudos.(AU)

Episiotomy is a procedure which's routine or selective application has been discussed since the publication of the Good Practices for Attention to Childbirth and Birth Manual by World Health Organization (WHO) in 1996. This bibliography review aims to investigate the available information regarding the physical and emotional aspects of episiotomy`s healing in the puerperium. Women's level of knowledge about the subject, pain, perceived physical limitations and the impact on sexuality during this period were the main points taken into consideration. Results pointed to the exclusion of women in the decision-making process of their labors and to a negative impact on self-esteem and sexuality, also inflicting physical limitations that were absent in cases of laceration. The comparison of pain level between women with episiotomies and lacerations was inconclusive, suggesting the need for further studies.(AU)

Health care workers' perceptions of episiotomy in the era of respectful maternity care: a qualitative study of an obstetric training program in Mexico.

BACKGROUND: Episiotomy in Mexico is highly prevalent and often routine - performed in up to 95% of births to primiparous women. The WHO suggests that episiotomy be used in selective cases, with an expected prevalence of 15%. Training programs to date have been unsuccessful in changing this practice. This research aims to understand how and why this practice persists despite shifts in knowledge and attitudes facilitated by the implementation of an obstetric training program. METHODS: This is a descriptive and interpretative qualitative study. We conducted 53 pre and post-intervention (PRONTO© Program) semi-structured interviews with general physician, gynecologists and nurses (N = 32, 56% women). Thematic analysis was carried out using Atlas-ti© software to iteratively organize codes. Through interpretive triangulation, the team found theoretical saturation and explanatory depth on key analytical categories. RESULTS: Themes fell into five major themes surrounding their perceptions of episiotomy: as a preventive measure, as a procedure that resolves problems in the moment, as a practice that gives the clinician control, as a risky practice, and the role of social norms in practicing it. Results show contradictory discourses among professionals. Despite the growing support for the selective use of episiotomy, it remains positively perceived as an effective prophylaxis for the complications of childbirth while maintaining control in the hands of health care providers. CONCLUSIONS: Perceptions of episiotomy shed light on how and why routine episiotomy persists, and provides insight into the multi-faceted approaches that will be required to affect this harmful obstetrical practice.

The effects of cryotherapy on perineal pain after childbirth: A systematic review and meta-analysis.

BACKGROUND: Most women experience perineal pain after childbirth. Sustained perineal pain affects mother's daily living. Various methods have been used to relieve postpartum perineal pain, such as cold or warm therapy, but the pain-control effects of cryotherapy are still controversial. AIMS: The purpose of this study was to verify the effectiveness of cryotherapy in relieving perineal pain in women after childbirth. METHODS: The researchers searched the CINAHL, Cochrane, EMBASE, PubMed, Korea Education and Research Information Service, NDSL, KoreaMed, LILACS and SciELO databases for studies to include in this review, and selected studies using PICO criteria. Methodological quality was assessed based on Cochrane's risk of bias 2 for randomized controlled trials. Data were analyzed with the Comprehensive Meta-Analysis program. FINDINGS: Eleven published studies encompassing 1,492 participants were included. Cryotherapy significantly reduced pain two days postpartum. Ice packs and gel packs had similar pain-relieving effects. Cryotherapy did not differ significantly from Epifoam therapy (hydrocortisone-pramoxine) in its effects on perineal pain one day or five days after childbirth. CONCLUSIONS: Cryotherapy can be an effective non-pharmacological nursing intervention to reduce pain after childbirth.

Women's experience of episiotomy: a qualitative study from China.

OBJECTIVE: To describe women's experience of episiotomy in urban China. DESIGN: This is a semistructured, indepth interview with women after episiotomy. We analysed transcriptions using thematic analysis in Chinese. Emerging themes were debated in English to finalise interpretation. SETTING: Two community health centres and four hospitals in Shanghai, China. PARTICIPANTS: Purposive sampling of 30 postpartum women who had experienced episiotomy; 25 were primiparous and 4 had deliveries by forceps. We interviewed health providers to complement the data. RESULTS: We identified four main themes: (1) women's views of the procedure vary considerably; (2) pain interferes with daily life for weeks; (3) long-term anxiety is a consequence for some, described as a 'psychological shadow'; and (4) societal norms assume women will not complain. CONCLUSION: Women receive little information in advance about episiotomy, yet the procedure has a wide range of physical and psychological consequences. This includes long-term anxiety about the damage done to them as women.

Análise da percepção de puérperas sobre a assistência ao parto em uma maternidade do Tocantins / Analysis of the perception of puerperal women about maternity care assistance in a maternity of Tocantins

Objetivo: No decorrer dos séculos, o parto migrou do ambiente domiciliar para o hospitalar, sendo então repleto de procedimentos que, embora tenham o intuito de ajudar, nem sempre são adequados ou baseados em evidências. Por isso, o objetivo deste estudo é identificar os procedimentos realizados com parturientes durante o parto em uma maternidade do Tocantins, além de caracterizar o perfil dessas pacientes. Método: Foi aplicado um questionário a 70 puérperas de parto normal, maiores e menores de idade, durante quatro meses. O questionário de referência foi o utilizado do estudo Nascer no Brasil. Resultados: A maioria das pacientes se autodeclarou parda, tinha ao menos o ensino médio completo e era maior de 18 anos. Mais da metade delas tiveram alguma alteração no períneo, 25% sofreram manobra de Kristeller e 88% submeteram-se à litotomia. Além disso, a grande maioria avaliou o serviço da maternidade como bom/ótimo/excelente. Conclusão: A assistência ao parto no Tocantins ainda se divide em práticas adequadas e técnicas ultrapassadas. Trata-se de um estudo original e um dos primeiros nesse sentido realizado no estado mais novo do Brasil.(AU)

Objective: Throughout the centuries, childbirth has migrated from the home environment to the hospital, being then full of procedures that although they are intended to help, are not always adequate or based on evidence. Therefore, the objective of this study is to identify the procedures performed with parturients during childbirth in a maternity hospital in Tocantins, in addition to characterizing the profile of these patients. Method: A questionnaire was applied to 70 mothers of normal birth, older and younger, for four months. The reference questionnaire was used in the Nascer no Brasil study. Results: Most patients declared themselves to be brown, had at least completed high school, and were over 18 years old. More than half of them had some alteration in the perineum, 25% underwent a Kristeller maneuver and 88% underwent lithotomy. In addition, the vast majority rated the maternity service as good/excellent/excellent. Conclusion: Assistance to childbirth in Tocantins is still divided into outdated technical and appropriate practices. This is an original study and one of the first in this sense carried out in the newest state of Brazil.(AU)

Evidence-based intrapartum practice and its associated factors at a tertiary teaching hospital in the Philippines, a descriptive mixed-methods study.

BACKGROUND: Evidenced-based practice is a key component of quality care. However, studies in the Philippines have identified gaps between evidence and actual maternity practices. This study aims to describe the practice of evidence-based intrapartum care and its associated factors, as well as exploring the perceptions of healthcare providers in a tertiary hospital in the Philippines. METHODS: A mixed-methods study was conducted, which consisted of direct observation of intrapartum practices during the second and third stages, as well as semi-structured interviews and focus group discussions with care providers to determine their perceptions and reasoning behind decisions to perform episiotomy or fundal pressure. Univariate and multivariate logistic regression were used to analyse the relationship between observed practices and maternal, neonatal, and environmental factors. Qualitative data were parsed and categorised to identify themes related to the decision-making process. RESULTS: A total of 170 deliveries were included. Recommended care, such as prophylactic use of oxytocin and controlled cord traction in the third stage, were applied in almost all the cases. However, harmful practices were also observed, such as intramuscular or intravenous oxytocin use in the second stage (14%) and lack of foetal heart rate monitoring (57%). Of primiparae, 92% received episiotomy and 31% of all deliveries received fundal pressure. Factors associated with the implementation of episiotomy included primipara (adjusted Odds Ratio [aOR] 62.3), duration of the second stage of more than 30 min (aOR 4.6), and assisted vaginal delivery (aOR 15.0). Factors associated with fundal pressure were primipara (aOR 3.0), augmentation with oxytocin (aOR 3.3), and assisted delivery (aOR 4.8). Healthcare providers believe that these practices can prevent laceration. The rate of obstetric anal sphincter injuries (OASIS) was 17%. Associated with OASIS were assisted delivery (aOR 6.0), baby weights of more than 3.5 kg (aOR 7.8), episiotomy (aOR 26.4), and fundal pressure (aOR 6.2). CONCLUSIONS: Our study found that potentially harmful practices are still conducted that contribute to the occurrence of OASIS. The perception of these practices is divergent with current evidence, and empirical knowledge has more influence. To improve practices the scientific evidence and its underlying basis should be understood among providers.

Resumption of sex after a second birth: An Australian prospective cohort.

BACKGROUND: Few longitudinal studies have examined women's experiences of sex after childbirth. Much of the advice given to couples about what to expect in relation to sex after childbirth is based on cross-sectional studies. OBJECTIVE: To investigate timing of resumption of sex after a second birth and assess associations with obstetric factors (method of birth and perineal trauma) and time interval between first and second births. METHOD: Prospective cohort of 1507 nulliparous women recruited before 25 weeks' gestation in Melbourne, Australia followed up at 3, 6, 9, and 12 months after first births, and 6 and 12 months after second births. Measures include: obstetric factors and resumption of vaginal sex after first and second births. RESULTS: By 8 weeks after their second birth, 56% of women had resumed vaginal sex, compared with 65% after their first birth. Women were more likely to resume sex later than 8 weeks postpartum if they had a spontaneous vaginal birth with episiotomy or sutured perineal tear (aOR: 2.21, 95% CI: 1.5-3.2), operative vaginal birth (aOR: 2.60, 95% CI: 1.3-5.3) or cesarean delivery (aOR: 2.15, 95% CI: 1.4-3.3) compared with a vaginal birth with minimal or no perineal trauma. There was no association between timing of resumption of sex and the time interval between births. CONCLUSION: For almost half of the cohort, sex was not resumed until at least 8 weeks after the second birth. Timing of resumption of sex was influenced by obstetric factors, but not the time interval between births.

Knowledge and perception of episiotomy among women attending antenatal clinic in a secondary health facility in North-West Nigeria.

BACKGROUND: Episiotomy is a common surgical procedure experienced by women worldwide to ease labor and improve its outcome. However, it could influence the use of delivery services because of its associated complications. The study assessed knowledge and perception of episiotomy among antenatal clinic (ANC) attendees. METHODS: It was a cross-sectional study conducted among 218 women attending ANC in a secondary health facility in Northwestern Nigeria. Data were collected using a structured, interviewer-administered questionnaire and were analyzed using IBM SPSS Statistics 20. RESULTS: The mean age of women attending ANC was 24.2 ± 6.6 years, and 31 (14.2%) of them had had an episiotomy in the past. A majority of them were aware of episiotomy (87.6%) and had good knowledge (83.5%) and good perception (77.5%) of it. In addition, a majority (89.0%) were willing to deliver at the facility even if episiotomy would be given during labor. Knowledge of episiotomy showed statistically significant association with only a history of previous delivery while perception did not show statistically significant association with any of the independent variables. CONCLUSIONS: Awareness and knowledge of episiotomy among women attending ANC were high and perception of it was generally good. The major factor associated with the knowledge of episiotomy was a history of previous delivery. Effort should be channeled toward improving awareness and knowledge on episiotomy among intending mothers, and health workers should always ensure that women are adequately informed and counseled before an episiotomy is given to them.

The effect of prenatal education classes on the birth expectations of Spanish women.

BACKGROUND: Maternity care has focused on lowering maternal and neonatal morbidity, though women's beliefs and expectations of care have been set aside. Women face childbirth with preconceived expectations, some of which could be expressed on their birth plan. The latter could beinfluenced by health professionals through prenatal education classes, though this has not been measured before. Antenatal classes have been argued against,since no resulting improvement in childbirth experience has been demonstrated, though some advantages may be seen: they favour communication and give time for expressing maternal expectations and beliefs. The present study evaluates the influence of prenatal educational classes led by midwives upon women birth preferences. METHODS: A multicentre, observational, prospective study was carried out, measuring variables in pregnant women attending prenatal educational classes in different health centres within the health districts in Valencia (Spain) over the period January-October 2012. Birth plan preferences were compared prior to and upon completion of the classes. RESULTS: A total of 212 eligible pregnant women (78.3% nulliparous) with an average age of 31.39±4.0 years consented to participate in the study. There were significant differences in birth plan preferences prior to and upon completion of the prenatal classes. Three items showed an increase between the initial session and the end of the intervention: the ability to push spontaneously, episiotomy avoidance, and early breastfeeding. An adjusted general linear model was used to compare pre-post results in relation to sociodemographic and obstetric variables. DISCUSSION: The changes in birth plans could suggest that prenatal educational classes exert an influence upon maternal birth preferences.

Episiotomia: sentimentos vivenciados pelas puérperas / Episiotomy: feelings experienced by mothers / Episiotomía: sentimientos experimentados por las puérperas

Objetivos: conhecer os sentimentos e repercussões vivenciadas pelas puérperas submetidas à episiotomia sem conhecimento prévio. Método: estudo descritivo, quantiqualitativo, com 12 mulheres de uma unidade obstétrica no Município do Rio de Janeiro. Os dados foram coletados entre março e abril de 2015, através de entrevista semiestruturada, submetidos à análise de conteúdo e sistematizados em duas categorias: Déficit quanto ao esclarecimento das mulheres sobre a episiotomia; e repercussão dos sentimentos vivenciados pelas mulheres no puerpério. O estudo foi aprovado pelo comitê de ética com o número de parecer: 950.963 e CAAE:39652614.8.0000.5279. Resultados: evidenciaram déficit quanto ao esclarecimento das mulheres sobre a episiotomia e repercussão dos sentimentos vivenciados pelas mulheres no puerpério. As episiotomias foram realizadas sem informação e sem autorização prévia. Conclusão: há supressão de informações, além de não solicitar o consentimento das mulheres para o procedimento.

Objective: to learn the feelings and their impacts experienced by parturients who underwent episiotomy without prior knowledge. Method: this descriptive, qualitative study involved twelve women at an obstetrics unit in Rio de Janeiro city. Data were collected in March and April 2015 by semi-structured interview, submitted to content analysis and systematized into two categories: a deficit in clarifications to the women about episiotomy; and the impact of the women's feelings postpartum. The study was approved by the Ethics Committee (Opinion 950.963 and CAAE 39652614.8.0000.5279). Results: revealed a deficit in clarifications to the women about episiotomy, and the impact of the women's feelings postpartum. Episiotomies were performed without prior information or permission. Conclusion: there is suppression of information, and women's consent for the procedure is not being requested.

Objetivos: conocer los sentimientos y las consecuencias experimentadas por las puérperas sometidas a episiotomía sin conocimiento previo. Método: estudio descriptivo, cualitativo y cuantitativo, junto a doce mujeres de una unidad obstétrica en la ciudad de Río de Janeiro. Los datos han sido recolectados entre marzo y abril de 2015, a través de entrevistas semiestructuradas y sometidos al análisis de contenido. Fueron sistematizados en dos categorías: Déficit en cuanto a la explicación a las mujeres sobre la episiotomía; y el impacto de los sentimientos experimentados por las mujeres en el período post-parto. El estudio fue aprobado por el comité de ética cuyo dictamen tiene el número: 950.963 y CAAE: 39652614.8.0000.5279. Resultados: manifestaron déficit en cuanto a la explicación a las mujeres acerca de la episiotomía y el impacto de los sentimientos experimentados por las mujeres en el período post-parto. Las episiotomías se realizaron sin información y sin permiso previo. Conclusión: existe supresión de la información, y no se solicita el consentimiento previo de las mujeres para el procedimiento.

Indications for episiotomy performance - a cross-sectional survey and review of the literature.

Our objective was to assess the reported reasons for episiotomy performance in Israel and to review the relevant professional literature. Using anonymous questionnaires, a survey was conducted among obstetricians and midwives in four northern Israel hospitals, and the accoucheurs were asked to score their agreement with 13 proposed indications for episiotomy. Overall, 84 doctors and 32 midwives completed the questionnaires. 86.1% of the responders reported performing episiotomy in all or most cases of shoulder dystocia, and more than half reported performing it in most cases of vacuum deliveries, fetal macrosomia and advanced perineal tear in previous delivery. Subjective assessment of perineal characteristics constituted a justified reason for episiotomy for 15.8-43.9% of the accoucheurs. In conclusion, there is a wide variation in reported reasons for episiotomy between the obstetricians, and many of these indications are not congruent with international practice guidelines. Uniform protocols and educational programmes are needed to guide episiotomy practice.

Autoethnography and severe perineal trauma--an unexpected journey from disembodiment to embodiment.

BACKGROUND: There is a lack of research reporting on the physical and emotional experiences of women who sustain severe perineal trauma (third and fourth degree tears). When the researcher identifies with the group being researched, autoethnography can allow an insight into the experiences of the marginalised group through the telling of a personal story. The aim of this paper is to share the journey travelled by an autoethnographer who on examining the issue of severe perineal trauma came to understand the challenges and rewards she experienced through this reflective and analytic process. METHODS: A transformative emancipatory approach guided the design, data collection and analysis of findings from this study. For this paper, a multivocal narrative approach was taken in presenting the findings, which incorporated the words of both the autoethnographer and the twelve women who were interviewed as a component of the study, all of whom had sustained severe perineal trauma. RESULTS: As an autoethnographer, being a member of the group being researched, can be confronting as the necessary reflection upon one's personal journey may lead to feelings of vulnerability, sadness, and emotional pain. The transformation from disembodied to embodied self, resulted in a physical and emotional breakdown that occurred for this autoethnographer. CONCLUSION: Autoethnographers may experience unexpected emotional and physical challenges as they reflect upon their experiences and research the experiences of others. When incorporating a transformative emancipatory framework, the hardships are somewhat balanced by the rewards of witnessing 'self-transformation' as a result of the research.

Reasons for routine episiotomy: A mixed-methods study in a large maternity hospital in Phnom Penh, Cambodia.

First documented in 1741, the practice of episiotomy substantially increased worldwide during the 20th century. However, research shows that episiotomy is not effective in reducing severe perineal trauma and may be harmful. Using a mixed-methods approach, we conducted a study in 2013-14 on why obstetricians and midwives in a large maternity hospital in Phnom Penh, Cambodia, still do routine episiotomies. The study included the extent of the practice, based on medical records; a retrospective analysis of the delivery notes of a random sample of 365 patients; and 22 in-depth interviews with obstetricians, midwives and recently delivered women. Of the 365 women, 345 (94.5%, 95% CI: 91.7-96.6) had had an episiotomy. Univariate analysis showed that nulliparous women underwent episiotomy more frequently than multiparous women (OR 7.1, 95% CI 2.0-24.7). The reasons given for this practice by midwives and obstetricians were: fear of perineal tears, the strong belief that Asian women have a shorter and harder perineum than others, lack of time in overcrowded delivery rooms, and the belief that Cambodian women would be able to have a tighter and prettier vagina through this practice. A restrictive episiotomy policy and information for pregnant women about birthing practices through antenatal classes should be implemented as soon as possible.

The relationship between mode of delivery and sexual health outcomes after childbirth.

INTRODUCTION: Several factors are implicated in the women's sexuality after childbirth. Nevertheless, there is conflicting evidence about the influence of mode of delivery (MD) AIM: To prospectively evaluate the relationship between MD and sexual health outcomes after childbirth METHODS: A prospective cohort study conducted between May 2005 and March 2007 included 831 pregnant women recruited from primary care clinics of the public sector in São Paulo, Brazil. The exposure variable was MD: uncomplicated vaginal delivery (spontaneous vaginal delivery without episiotomy or any kind of perineal laceration); complicated vaginal delivery (either forceps or normal, with episiotomy or any kind of perineal laceration) and cesarean delivery. Socio-demographic and obstetric data were obtained through a questionnaire applied during the antenatal and postnatal period. Crude and adjusted risk ratios, with 95% confidence intervals, were calculated using Poisson regression to examine the associations between MD and sexual health outcomes. MAIN OUTCOME MEASURES: The three main sexual health outcomes were later resumption of sexual life, self-perception of decline of sexual life (DSL), and presence of sexual desire. RESULTS: One hundred and forty-one women (21.9%) resumed sexual life 3 or more months after delivery. Although 87.1% of women had desire, DSL occurred in 21.1% of the cohort. No associations were found between MD and sexual health outcomes. CONCLUSIONS: Women's sexuality after childbirth were not influenced by the type of delivery. Efforts to improve the treatment of sexual problems after childbirth should focus beyond MD.

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)

Prevalence and predictors of genito-pelvic pain in pregnancy and postpartum: the prospective impact of fear avoidance.

INTRODUCTION: There is limited knowledge regarding the symptom profile of genito-pelvic pain in pregnancy and postpartum, and potential psychosocial predictors of this pain. Prior studies have reported a positive association between prepregnancy pain and postpartum genito-pelvic pain. Greater fear avoidance has been associated with increased genital pain intensity in women, unrelated to childbirth. This relationship has not been examined prospectively in a postpartum population. AIMS: The study aims were to examine the symptom profile of genito-pelvic pain during pregnancy and at 3 months postpartum, and the impact of prepregnancy nongenito-pelvic pain and fear avoidance in pregnancy on genito-pelvic pain at 3 months postpartum. METHODS: First-time expectant mothers (N = 150) completed measures of fear avoidance (pain-related anxiety, catastrophizing, hypervigilance to pain), prepregnancy nongenito-pelvic pain, childbirth-related risk factors (e.g., episiotomy), and breastfeeding. MAIN OUTCOME MEASURES: Those reporting genito-pelvic pain in pregnancy and/or at 3 months postpartum answered questions about the onset (prepregnancy, during pregnancy, postpartum) and location (genital, pelvic, or both) of the pain and rated the intensity and unpleasantness of the pain on numerical rating scales. RESULTS: Of 150 women, 49% reported genito-pelvic pain in pregnancy. The pain resolved for 59% of women, persisted for 41%, and 7% of women reported a new onset of genito-pelvic pain after childbirth. Prepregnancy nongenito-pelvic pain was associated with an increased likelihood of postpartum onset of genito-pelvic pain. Greater pain-related anxiety was associated with greater average genito-pelvic pain intensity at 3 months postpartum. CONCLUSIONS: Results suggest that about half of women may develop genito-pelvic pain during pregnancy, which will persist for about a third, and a subset will develop this pain after childbirth. Prior recurrent nongenito-pelvic pain may enhance the risk of developing genito-pelvic pain postpartum, while greater pain-related anxiety in pregnancy may increase the risk for greater intensity of postpartum genito-pelvic pain.

Morbidity experienced by women before and after operative vaginal delivery: prospective cohort study nested within a two-centre randomised controlled trial of restrictive versus routine use of episiotomy.

OBJECTIVE: To explore: (1) the antenatal and postnatal morbidity experienced by women in relation to operative vaginal delivery (OVD); and (2) the impact of restrictive versus routine use of episiotomy. DESIGN: Longitudinal prospective cohort study embedded within a two-centre randomised controlled trial (RCT). SETTING: Two UK tertiary-level maternity units. POPULATION: Antenatally recruited participants of an RCT of restrictive versus routine use of episiotomy at OVD. METHODS: A self-completing questionnaire was administered antenatally, before hospital discharge, at 6 weeks and at 1 year postpartum. MAIN OUTCOME MEASURES: Urinary and anal incontinence, dyspareunia, perineal pain and psychological morbidity. RESULTS: Longitudinal data have revealed that morbidities historically associated with OVD were often as prevalent, if not more prevalent, in the third trimester of pregnancy than postpartum. Restrictive episiotomy use was associated with: a higher incidence of perineal pain in the immediate postpartum period (98.9% restrictive versus 87.8% routine, RR 1.10, 95% CI 1.01-1.21); greater psychological morbidity in the immediate postpartum period (mean scores on the Edinburgh Postnatal Depression Scale, Edinburgh Postnatal Depression Score (EPDS) 6.7 restrictive versus 5.1 routine; P = 0.01 ); and more stress urinary incontinence at 6 weeks postpartum (42.2% restrictive versus 27.2% routine, RR 1.55, 95% CI 1.00-2.40); however, this had resolved by 1 year. No other differences were found between the groups at 6 weeks and 1 year postpartum. CONCLUSIONS: Morbidities previously attributed to OVD may in fact be present antenatally, to a greater or similar degree. A restrictive approach to the use of episiotomy at OVD may increase rates of urinary morbidity, in particular stress incontinence and perineal pain, in the immediate postpartum period.