Eficacia de las infiltraciones con colágeno en el dolor pélvico causado por cicatrices de episiotomía y cesáreas. Ensayo clínico piloto aleatorizado / Efficacy of collagen infiltrations in the pelvic pain caused by episiotomy and caesarean scars. Pilot randomized clinical trial

Introducción y objetivos: El dolor pélvico es un síntoma frecuente de consulta en las unidades de rehabilitación de suelo pélvico. El objetivo de este estudio fue evaluar la eficacia de las infiltraciones con colágeno en el dolor y el aspecto de las cicatrices de desgarros perineales, episiotomías y/o cesáreas. Material y métodos: Ensayo clínico piloto aleatorizado, controlado y simple ciego. Las pacientes del grupo control (GC) recibieron el tratamiento convencional de rehabilitación. De forma adicional, las del grupo intervención (GI) recibieron de 3 a 5 infiltraciones de colágeno. Las pacientes fueron evaluadas basalmente y 6 semanas postintervención. La variable dependiente principal fue el dolor evaluado con la escala visual analógica y el cuestionario de dolor McGill. Como variable secundaria se evaluó el aspecto de la cicatriz según la escala de cicatrización de Vancouver y la Patient Scar Assessment Scale. Se analizó una muestra de 15 mujeres, 8 en el GC y 7 en el GI. Resultados: La edad media fue de 33,1 años (DE 4,1). En el análisis intragrupos se observó una disminución significativa en la valoración global del dolor según la escala visual analógica y el cuestionario de dolor McGill y en la dimensión PRI-Emocional. En el GI se observó también una disminución significativa en la dimensión PRI-Sensorial y PRI-Valorativa respecto a la situación basal. En ambos grupos se observó una mejoría significativa de la cicatrización de la lesión. En el análisis intergrupos se observó una mayor disminución del dolor pélvico en la subescala PRI-Sensorial del cuestionario de dolor McGill en el GI (−15,1 vs. −6; p=0,040). Conclusiones: Las infiltraciones de colágeno podrían mejorar el dolor y el aspecto de las cicatrices dolorosas.(AU)

Background and aims: Pelvic pain is a frequently consulted symptom in pelvic floor rehabilitation units. The aim of this study was to evaluate the efficacy of collagen infiltrations in pain and the appearance of scars from perineal tears, episiotomies and caesarean sections. Material and methods: Pilot randomized, controlled and single-blind clinical trial. Control group (CG) patients received conventional rehabilitation treatment. Additionally, those in the intervention group (IG) received 3-5 collagen infiltrations. The patients were evaluated at baseline and 6 weeks post-intervention. The main outcome was pain and it was evaluated with the visual analog scale and McGill Pain Questionnaire. As secondary outcomes, the appearance of the scar was evaluated by Vancouver Scar Scale and the Patient Scar Assessment Scale. A sample of 15 women was analyzed, 8 in the CG and 7 in the IG. Results: The mean age was 33.1 years (SD 4.1). The intragroup analysis showed a significant decrease of the visual analog scale punctuation and total McGill Pain Questionnaire score and the PRI-Emotional dimension of the McGill Pain Questionnaire. In the IG, a significant decrease was also observed in the PRI-Sensorial and PRI-Evaluative dimensions in comparison with baseline situation. In both groups, a significant improvement in the appearance of the scar was observed. In the intergroup analysis, a greater decrease in pain was observed in PRI-Sensorial subscale of the McGill Pain Questionnairein the IG (−15.1 vs. −6; P=.040). Conclusions: Collagen infiltrations may improve pain and the appearance of painful scars.(AU)

[Efficacy of collagen infiltrations in the pelvic pain caused by episiotomy and caesarean scars. Pilot randomized clinical trial]. / Eficacia de las infiltraciones con colágeno en el dolor pélvico causado por cicatrices de episiotomía y cesáreas. Ensayo clínico piloto aleatorizado.

BACKGROUND AND AIMS: Pelvic pain is a frequently consulted symptom in pelvic floor rehabilitation units. The aim of this study was to evaluate the efficacy of collagen infiltrations in pain and the appearance of scars from perineal tears, episiotomies and caesarean sections. MATERIAL AND METHODS: Pilot randomized, controlled and single-blind clinical trial. Control group (CG) patients received conventional rehabilitation treatment. Additionally, those in the intervention group (IG) received 3-5 collagen infiltrations. The patients were evaluated at baseline and 6 weeks post-intervention. The main outcome was pain and it was evaluated with the visual analog scale and McGill Pain Questionnaire. As secondary outcomes, the appearance of the scar was evaluated by Vancouver Scar Scale and the Patient Scar Assessment Scale. A sample of 15 women was analyzed, 8 in the CG and 7 in the IG. RESULTS: The mean age was 33.1 years (SD 4.1). The intragroup analysis showed a significant decrease of the visual analog scale punctuation and total McGill Pain Questionnaire score and the PRI-Emotional dimension of the McGill Pain Questionnaire. In the IG, a significant decrease was also observed in the PRI-Sensorial and PRI-Evaluative dimensions in comparison with baseline situation. In both groups, a significant improvement in the appearance of the scar was observed. In the intergroup analysis, a greater decrease in pain was observed in PRI-Sensorial subscale of the McGill Pain Questionnairein the IG (-15.1 vs. -6; P=.040). CONCLUSIONS: Collagen infiltrations may improve pain and the appearance of painful scars.

Estudio comparativo de la recuperación postparto en base a los Patrones de Marjory Gordon / Comparative study analysing maternal recovery after childbirth according to Marjory Gordon's Patterns

Objetivo: Analizar si existen diferencias en el nivel de recuperación en las distintas fases del puerperio según el tipo de lesión perineal.Material y método: Estudio cuantitativo de tipo descriptivo longitudinal prospectivo, siguiendo los Patrones Funcionales de Salud de Marjory Gordon. La recogida de datos se realiza en tres fases (puerperio inmediato, clínico y tardío), empleando entrevistas semiestructuradas que se completan en un primer momento en una entrevista personal y vía telefónica a los 10 y a los 30 días, respectivamente.Resultados: En España existe un índice de episiotomías, inducciones y partos instrumentales muy superior al recomendado. La técnica de la episiotomía produjo desgarros importantes (16,7%) en este estudio. Durante el puerperio inmediato, las mujeres con episiotomía tienen dificultades en la movilidad (p=0,0005), la eliminación (p=0,007), cuidado del bebé (p=0,015), descanso (p=0,15) y dolor percibido (p=0,005), mientras que en el puerperio clínico están afectados sólo la movilidad (p=0,05), la eliminación (p=0,042) y el dolor percibido (p=0,006). A los 30 días, en el puerperio tardío, no existen diferencias estadísticamente significativas entre ambos grupos. Se necesitan más estudios que reafirmen estos hechos y aporten nuevos conocimientos.Conclusiones: La episiotomía produce más efectos negativos que los desgarros espontáneos en el puerperio inmediato y clínico en la mujer. El dolor que genera esta técnica a corto, medio y largo plazo es el que limita muchas de las actividades cotidianas de estas mujeres

Objective: Analyse if there is any difference in recovery rate according to their puerperium stage depending on perineal lesion.Material and method: Prospective longitudinal descriptive quantitative study, following the Marjory Gordon's Functional Health Patterns. Data collection will be performed in three phases (immediate, clinical and remote puerperium), through semi-structured interview completed in first instance in a face-to-face interview and phone call interview at 10 and 30 days, respectively. Results: In Spain there is an episiotomy, induction and assisted delivery rate much higher than recommended. Episiotomy technique lead to significant tear (16,7%) in this study. During immediate puerperium, women who were practiced an episiotomy shown mobility difficulties (p=0,0005), elimination (p=0,0007), baby care (p=0,015), rest (p=0,15) and perceived pain (p=0,005), whereas in the clinical puerperium are affected only mobility (p=0,05), elimination (p=0,042) and perceived pain (p=0,006). After 30 days, remote puerperium, there is not statistical significant differences in both groups. More research is needed to confirm these facts as well as provide new knowledge.Conclusions: Episiotomy produce more negative effects than spontaneous tears at the immediate and clinical puerperium of women. Pain produced by this technique as a short, medium and long term limit many daily activities of women

Perineal prevention and protection in obstetrics: CNGOF clinical practice guidelines.

INTRODUCTION: The objective of these clinical practice guidelines was to analyse all of the interventions during pregnancy and childbirth that might prevent obstetric anal sphincter injuries (OASIS) and postnatal pelvic floor symptoms. MATERIAL AND METHODS: These guidelines were developed in accordance with the methods prescribed by the French Health Authority (HAS). RESULTS: A prenatal clinical examination of the perineum is recommended for women with a history of Crohn's disease, OASIS, genital mutilation, or perianal lesions (professional consensus). Just after delivery, a perineal examination is recommended to check for OASIS (Grade B); if there is doubt about the diagnosis, a second opinion should be requested (Grade C). In case of OASIS, the injuries (including their severity) and the technique for their repair should be described in detail (Grade C). Perineal massage during pregnancy must be encouraged among women who want it (Grade B). No intervention conducted before the start of the active phase of the second stage of labour has been shown to be effective in reducing the risk of perineal injury. The crowning of the baby's head should be manually controlled and the posterior perineum manually supported to reduce the risk of OASIS (Grade C). The performance of an episiotomy during normal deliveries is not recommended to reduce the risk of OASIS (Grade A). In instrumental deliveries, episiotomy may be indicated to avoid OASIS (Grade C). When an episiotomy is performed, a mediolateral incision is recommended (Grade B). The indication for episiotomy should be explained to the woman, and she should consent before its performance. Advising women to have a caesarean delivery for primary prevention of postnatal urinary or anal incontinence is not recommended (Grade B). During pregnancy and again in the labour room, obstetrics professionals should focus on the woman's expectations and inform her about the modes of delivery.

Early secondary repair of labial tears, 1st and 2nd degree perineal lacerations and mediolateral episiotomies in a midwifery-led clinic. A retrospective evaluation of cases based on photo documentation.

OBJECTIVES: To examine whether early secondary repair of labial tears, 1st and 2nd degree perineal lacerations and episiotomies provided an anatomically acceptable result. STUDY DESIGN: A retrospective analysis of 126 women undergoing an early secondary repair of birth lacerations not involving the sphincter complex within 21 days postpartum. Patients were included from 1 January 2014 to 11 August 2017 at Aarhus University Hospital, Denmark. Photo documentation of the wound was available just before the early secondary repair and at the follow-up visit after the repair. Photos were evaluated by two trained Urogynaecological Consultants. MAIN OUTCOME MEASURES: Whether the anatomic result of the early secondary repair was acceptable based on photo documentation. RESULTS: Early secondary repair was performed by a specialised team of midwives in 94.4% and by doctors in 5.6% of the cases. In all, 72.2% were 2nd degree perineal lacerations. The most common indications for early secondary repair were wound dehiscence (55.3%) and suboptimal primary repair (34.1%). At the follow-up clinical examination seven days after the early secondary repair, the result was considered anatomically acceptable in 67.5% of the cases, not optimal in 22.2% and not possible to evaluate in 10.3% of the cases. In 7.9% of the cases, wound infection was suspected after the early secondary repair. CONCLUSIONS: Based on photo documentation, early secondary repair of birth lacerations not involving the sphincter complex provides an anatomically acceptable result in the majority of cases without risk of serious complications.

Influence of a pelvic floor training programme to prevent perineal trauma: A quasi-randomised controlled trial.

BACKGROUND: perineal injury is common after birth and may be caused by tears or episiotomy or both. Perineal massage has been shown to prevent episiotomies in primiparous women. On the other hand, pelvic floor exercises might have an influence by shortening the first and second stages of labour in the primigravida. AIM: the aim of this study was to investigate the effects of a pelvic floor training following a birth programme on perineal trauma. DESIGN: a single-blind quasi-randomized controlled trial with two groups: standard care and intervention. SETTING: a tertiary, metropolitan hospital in Seville, Spain. PARTICIPANTS: women (n=466) who were 32 weeks pregnant, having a singleton pregnancy and anticipating a normal birth were randomised. Women in the experimental groups were asked to perform a pelvic floor training programme that included: daily perineal massage and pelvic floor exercises from 32 weeks of pregnancy until birth. They were allocated to an intervention group by clusters (antenatal education groups) randomized 1:1. The control group had standard care that did not involve a perineal/pelvic floor intervention. These women were collected in a labour ward at admission 1:3 by midwives. RESULTS: outcomes were analysed by intention-to-treat. Women assigned to the perineal/pelvic floor intervention showed a 31.63% reduction in episiotomy (50.56% versus 82.19%, p<0.001) and a higher likelihood of having an intact perineum (17.61% versus 6.85%, p<0.003). There were also fewer third (5.18% versus 13.12%, p<0.001) and fourth degree-tears (0.52% versus 2.5%, p<0.001). Women allocated to the intervention group also had less postpartum perineal pain (24.57% versus 36.30%, p<0.001) and required less analgesia in the postnatal period (21.14% versus 30.82%, p<0.001). CONCLUSIONS: a training programme composed of pelvic floor exercises and perineal massage may prevent episiotomies and tears in primiparous women. This programme can be recommended to primiparous women in order to prevent perineal trauma. KEY CONCLUSION: the pelvic floor programme was associated with significantly lower rates of episiotomies and severe perineal trauma; and higher intact perineum when compared with women who received standard care only. IMPLICATIONS FOR PRACTICE: the programme is an effective intervention that we recommend to all women at 32nd week of pregnancy to prevent perineal trauma.

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.

Lavender-thymol as a new topical aromatherapy preparation for episiotomy: A randomised clinical trial.

The objective of this study was to evaluate the effectiveness of topical lavender-thymol in promoting episiotomy healing. This placebo-controlled, single-blinded, randomised clinical trial involved 60 primiparous women. REEDA score was used to evaluate the outcome of the trial. On the 7th post-partum day, women in Placebo-treated group had worse Redness, Edema, Ecchymosis, Discharge and Approximation (REEDA) score of 3.93 ± 3.65 compared with those in Lavender-thymol-treated group (2.03 ± 1.7) with significant difference (P = 0.013). Visual analogue Scale (VAS) score for pain at episiotomy in Lavender-thymol-treated group was 3.5 ± 1.9, whereas in Placebo-treated group it was 2.1 ± 2.2 (p = 0.011) for dyschezia, 3.8 ± 1.7 and 2.8 ± 1.6 in Placebo- and Lavender-thymol-treated women, respectively (p = 0.023). At 7th post-partum week, dyspareunia was more severe in Placebo-treated group compared with that in Lavender-thymol-treated group (5.3 ± 2.7 vs 2.7 ± 1.5 and p < 0.001). Topical aromatherapy using lavender-thymol was highly effective, suitable and safe for episiotomy wound care with little or no expected side effects compared with that using placebo.

A randomised clinical trial of the effect of low-level laser therapy for perineal pain and healing after episiotomy: a pilot study.

OBJECTIVE: to evaluate the effects of low-level laser therapy for perineal pain and healing after episiotomy. DESIGN: a double-blind, randomised, controlled clinical trial comparing perineal pain scores and episiotomy healing in women treated with low-level laser therapy (LLLT) and with the simulation of the treatment. SETTING: the study was conducted in the Birth Centre and rooming-in units of Amparo Maternal, a maternity service located in the city of São Paulo, Brazil. PARTICIPANTS: fifty-two postpartum women who had had mediolateral episiotomies during their first normal delivery were randomly divided into two groups of 26: an experimental group and a control group. INTERVENTION: in the experimental group, the women were treated with LLLT. Irradiation was applied at three points directly on the episiotomy after the suture and in three postpartum sessions: up to 2 hrs postpartum, between 20 and 24 hrs postpartum and between 40 and 48 hrs postpartum. The LLLT was performed with diode laser, with a wavelength of 660 nm (red light), spot size of 0.04 cm(2), energy density of 3.8 J/cm(2), radiant power of 15 mW and 10s per point, which resulted in an energy of 0.15 J per point and a total energy of 0.45 J per session. The control group participants also underwent three treatment sessions, but without the emission of radiation (simulation group), to assess the possible effects of placebo treatment. MAIN OUTCOMES: perineal pain scores, rated on a scale from 0 to 10, were evaluated before and immediately after the irradiation in the three sessions. The healing process was assessed using the REEDA scale (Redness, Edema, Echymosis, Discharge Aproximation) before each laser therapy session and 15 and 20 days after the women's discharge. FINDINGS: comparing the pain scores before and after the LLLT sessions, the experimental group presented a significant within-group reduction in mean pain scores after the second and third sessions (p=0.003 and p<0.001, respectively), and the control group showed a significant reduction after the first treatment simulation (p=0.043). However, the comparison of the perineal pain scores between the experimental and control groups indicated no statistical difference at any of the evaluated time points. There was no significant difference in perineal healing scores between the groups. All postpartum women approved of the low-level laser therapy. CONCLUSIONS: this pilot study showed that LLLT did not accelerate episiotomy healing. Although there was a reduction in perineal pain mean scores in the experimental group, we cannot conclude that the laser relieved perineal pain. This study led to the suggestion of a new research proposal involving another irradiation protocol to evaluate LLLT's effect on perineal pain relief.

Effect of transcutaneous electrical nerve stimulation on the postpartum dyspareunia treatment.

AIM: This article will evaluate the safety and efficacy of intravaginal transcutaneous electrical nerve stimulation (TENS) for the treatment of vulvar pain and dyspareunia during the postpartum period related to perineal trauma caused by episiotomy. METHODS: From January 2007 to January 2009, 45 women presenting with postpartum dyspareunia related to perineal trauma after a vaginal delivery were educated on the importance of the pelvic floor and its part in continuing dyspareunia. The treatment consisted of weekly applications of intravaginal TENS in an outpatient setting and daily home therapy with myofascial stretching and exercises of the pelvic floor musculature. The results were evaluated using the cotton swab test, the Marinoff Dyspareunia Scale and the Visual Analog Scale, and the anovulvar distance was assessed prior to and at the end of the treatment period. RESULTS: Of the women included in the study, 84.5% reported an improvement of dyspareunia after only five applications of TENS, with a total remission of symptoms (in 95% of patients) at the end of the protocol. At follow-up, eight months after the end of treatment, all patients were pain free. CONCLUSIONS: Therapy with intravaginal transcutaneous nerve stimulation and pelvic floor relaxation exercises is safe and effective in the improvement of vulvar pain and dyspareunia in women with postpartum perineal trauma due to episiorrhaphy, after spontaneous delivery.

After the afterbirth: a critical review of postpartum health relative to method of delivery.

Four million women give birth each year in the United States, yet postpartum health has gone largely unaddressed by researchers, clinicians, and women themselves. In light of rising US cesarean birth rates, a critical need exists to elucidate the ramifications of cesarean birth and assisted vaginal birth on postpartum health. This literature review explores the current state of knowledge on postpartum health in general and relative to method of delivery. Randomized trials and other published reports were selected from relevant databases and hand searches. The literature indicates that postpartum morbidity is widespread and affects the majority of women regardless of method of delivery. Women who have spontaneous vaginal birth experience less short- and long-term morbidity than women who undergo assisted vaginal birth or cesarean birth. To maximize postpartum health, providers of obstetric care need to protect the perineum during vaginal birth and avoid unnecessary cesarean deliveries. Clinicians must initiate the discussion about postpartum health antenatally and encourage women to enlist needed support early in the postpartum period. Flexibility in the schedule of postpartum care is essential. More research from the United States is warranted.

Evolución de la episiotomía: siguiendo dos tipos de cuidados / Evolution of an episiotomy: a follow up on two types of treatment

El cuidado unificado de la episiotomía es fundamental para prevenir las complicaciones que surgen en el puerperio. Se analiza mediante un estudio clínico comparativo en dos grupos de mujeres primíparas, la evolución de la episiotomía en función de la aplicación de povidona yodada al 0,4 por ciento a través de ocho variables cualitativas analizadas de forma independiente. Por su mayor influencia en la evolución de la episiotomía se ha evaluado en profundidad una de las variables que definen su calidad: la dehiscencia. Del estudio se concluye que el fomento del autocuidado influye en una mejor evolución de la episiotomía con respecto a la aplicación del antiséptico (AU)

Episiotomía y puerperio domiciliario / Episiotomy and puerperium at home

Estudio observacional y prospectivo mediante encuesta telefónica (entre tres y seis meses posparto) posterior a un parto vaginal en 100 mujeres, con objeto de determinar las diferencias entre las episiotomías grandes, pequeñas y desgarros, y sus efectos en el puerperio, para sensibilizar a los profesionales de la importancia del dolor y las consecuencias de la episiotomía El porcentaje de respuesta a las encuestas telefónicas fue del 82 por ciento. Se practicó episiotomía mediolateral derecha en un 74,4 por ciento de pacientes, seguida de episiotomía mediolateral izquierda (12,2 por ciento). La demora en el inicio de las relaciones sexuales resultó significativa en las episiotomías grandes (>4cm) p<0,001. Así mismo la duración de la dispareunia aumentó significativamente con el tamaño de la episiotomía. (p<0,0059) y también la diferencia de hemoglobinas ante o intraparto y posparto (p<0,0153) en piel y en vagina (p=0,026). La relación entre dolor, analgesia y tamaño es significativa en las mediciones de piel (p<0,007) (AU)

[Episiotomy repair by the method of W. B. Shute]. / Vuzstanoviavane na epiziotomii po metoda na W. B. Shute.

For about 1 year 106 episiotomy are reapproximated using figure-of-eight sutures by W. B. Shute and 623 by using conventional techniques. Early (4-6 days) and lately (6 months and more) results are compared in these 2 groups. Authors have found out benefits of Shute's technique and recommend to use it as a routine procedure in current obstetric practice.

Perineal muscle function after childbirth.

Perineal muscle function was measured in a group of European women 1 year after childbirth by means of a perineometer. There was no correlation between the degree of perineal trauma and subsequent muscle function. The efficiency of the perineal muscles was found to be significantly related to the extent to which women took regular exercise.