Is water delivery a good idea to prevent obstetric anal sphincter injuries in low risk primiparae? An exploratory study in a Swiss public teaching hospital.

OBJECTIVE: Obstetric anal sphincter injuries are feared perineal injuries that are associated with increased pelvic floor disorders. The knowledge of influencing factors as the mode of delivery is therefore important. The aim of this study is to compare the rate of obstetric anal sphincter injuries in primiparae after water and bed deliveries. STUDY DESIGN: In this retrospective cohort study 3907 primiparae gave birth in water or on a bed in a Swiss teaching hospital. The diagnosis of obstetric anal sphincter injuries was confirmed by a consultant of obstetrics and gynecology and treated by them. The rates of these injuries after water and bed births were compared. Subgroup analysis was performed to detect possible associative factors, such as birth weight, episiotomy, use of oxytocin in first and second stage of labor. RESULTS: 1844 (47.2 %) of the primiparae had a water delivery and 2063 (52.8 %) a bed delivery. 193 (4.94 %) were diagnosed with obstetric anal sphincter injuries, of which 68 (3.7 %) had a water delivery and 125 (6.1 %) a bed delivery, p < 0.001. Subgroup analysis revealed that, in the first and second stage of labor, the rate of obstetric anal sphincter injuries with oxytocin was significantly lower in water than in bed deliveries; p = 0.025, p < 0.017, respectively. The rate of obstetric anal sphincter injuries in the birth weight or episiotomy subgroups did not reach significance. CONCLUSIONS: In a teaching hospital setting with standardized labor management, primiparae with a water delivery have the lowest risk for obstetric anal sphincter injuries.

Prevention of obstetric anal sphincter injuries with perineal support and lateral episiotomy: A historical cohort study.

INTRODUCTION: There are many risk factors for obstetric anal sphincter injury (OASIS) and the interaction between these risk factors is complex and understudied. The many observational studies that have shown a reduction of OASIS rates after implementation of perineal support have short follow-up time. We aimed to study the effect of integration of active perineal support and lateral episiotomy on OASIS rates over a 15-year period and to study interactions between risk factors known before delivery. MATERIAL AND METHODS: We performed a historical cohort study over the periods 1999-2006 and 2007-2021 at Stavanger University Hospital, Norway. The main outcome was OASIS rates. Women without a previous cesarean section and a live singleton fetus in cephalic presentation at term were eligible. The department implemented in 2007 the Finnish concept of active perineal protection, which includes support of perineum, control of fetal expulsion, good communication with the mother and observation of perineal stretching. The practice of mediolateral episiotomy was replaced with lateral episiotomy when indicated. We analyzed the OASIS rates in groups with and without episiotomy stratified for delivery mode, fetal position at delivery and for parity, and adjusted for possible confounders (maternal age, gestational age, oxytocin augmentation and epidural analgesia). RESULTS: We observed a long-lasting reduction in OASIS rates from 4.9% to 1.9% and an increase in episiotomy rates from 14.4% to 21.8%. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with instrumental vaginal deliveries and occiput anterior (OA) position; 3.4% vs 10.1% (OR 0.31; 95% CI: 0.24-0.40) and 6.1 vs 13.9% (OR 0.40; 95% CI: 0.19-0.82) in women with occiput posterior (OP) position. Lateral episiotomy was also associated with lower OASIS rates in nulliparous women with spontaneous deliveries and OA position; 2.1% vs 3.2% (OR 0.62; 95% CI: 0.49-0.80). The possible confounders had little confounding effects on the risk of OASIS in groups with and without episiotomy. CONCLUSIONS: We observed a long-lasting reduction in OASIS rates after implementation of preventive procedures. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with an instrumental delivery. Special attention should be paid to deliveries with persistent OP position.

The effects of warm perineal compress on perineal trauma and postpartum pain: a systematic review with meta-analysis and trial sequential analysis.

BACKGROUND: In order to reduce the complications of perineal damage and the pain caused by it for the mother, this study was conducted to determine the effect of warm perineal compress on perineal trauma (1st-, 2nd-, 3rd-, and 4th-degree perineal tears), postpartum pain, intact perineum (primary outcomes), episiotomy, length of the second stage, and APGAR score at 1 and 5 min after childbirth (secondary outcome). METHODS: PubMed, Scopus, Cochrane Central Register of Controlled Trials, Google Scholar, Web of Science, SID, Magiran, and ClinicalTrials.gov were searched to identify the relevant articles from inception to November 1, 2022, with language restriction (only English and Persian). A manual search was also performed. Risk of bias 2 (RoB2) and ROBIN-I were employed to evaluate the quality of the included papers. Meta-analysis was conducted using RevMan 5.3. Heterogeneity was assessed using I2. In cases with high heterogeneity, subgroup analysis was utilized based on the parity and ethnicity, and time of pain measurement after delivery also a random-effects model was used instead of a fixed-effects model. Trial sequential analysis (TSA) was performed for the primary outcomes. The certainty of evidence was assessed using the GRADE approach. RESULTS: A total number of 228 articles were found in databases. Of these articles, eighty-six were screened by title, 27 by abstract, and 21 by full text. Finally, 14 articles were included, of which ten were RCT and four were non-RCT. Meta-analysis results revealed that warm perineal compress significantly reduced perineal pain (RR 0.23, 95% CI 0.08-0.66; P = 0.0006), average pain (SMD - 0.73, 95% CI 1.23 to - 0.23; P = 0.004), second-degree perineal tear (RR 0.65, 95% CI 0.54-0.79; P˂0.00001), third-degree perineal tear (RR 0.32, 95% CI 0.15-0.67; P = 0.003), fourth-degree perineal tear (RR 0.11, 95% CI 0.01-0.87; P = 0.04), episiotomy (RR 0.63, 95% CI 0.46-0.86; P = 0.004), and intact perineum significantly increased (RR 3.06, 95% CI 1.79-5.22; P < 0.0001) compared to the control group. However, there was no statistically significant difference in terms of first-degree tear (RR 1.04, 95% CI 0.86-1.25; P = 0.72), length of the second stage of labor (MD - 0.60, 95% CI - 2.43 to 1.22; P = 0.52), the first minute (MD - 0.03, 95% CI - 0.07 to 0.02; P = 0.24) and the fifth minute Apgar score (MD - 0.02, 95% CI - 0.07 to 0.03; P = 0.46) between the two groups. CONCLUSION: Warm perineal compress administered during the second stage of labor reduce postpartum pain, second and third-degree perineal tears, and episiotomy rate while it increases the incidence of intact perineum compared to the control group.

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

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

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

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

Is an episiotomy always necessary during an operative vaginal delivery with vacuum? A longitudinal study.

Objective: The use of episiotomy during operative vaginal birth (OVB) is rather debated among operators and in literature. It is also important to evaluate the indications for which episiotomy is performed. In fact, the consequences of an episiotomy can be invalidating for patients with long-lasting results. The aim of this study is the evaluation of the role of episiotomy during OVB with the vacuum extractor and its correlation with Obstetric Anal Sphincter Injuries (OASIs).Methods: On of 9165 vaginal births, a total of 498 OVB (5.4%) were enrolled in a longitudinal prospective observational study. The incidence of OASIs was evaluated in our population after OVB performed with the vacuum extractor, during which the execution of episiotomy was performed indicated by clinician in charge.Results: OASIs occurred in 4% of the patients (n = 20). Episiotomy was performed in 39% of them (n = 181). OASIs incidence was 6% (n = 17) in the No Episiotomy and 1.8% (n = 3) in Episiotomy group (p<.001). Performance of episiotomy during OVB determined a protective effect against OASIs (p = 0.025 in full cohort and p = 0.013 in the primiparous group). An expulsive phase under one hour was an almost significant protective factor (p = 0.052).Conclusions: The use of episiotomy during OVB was associated with much lower OASIs rates in nulliparous women with a vacuum extraction; OR 0.23 (CI 95% 0.07-0.81) p = 0.037 in nulliparous women and the number necessary to treat was 18 among nulliparous women to prevent 1 OASIs. A further risk factor that emerged from the analysis is a prolonged expulsive period, whereas fundal pressure does not seem to have a statistically significant influence.

Tendência temporal de nascidos prematuros no estado de Santa Catarina entre 2011 e 2021 / Temporal trend of premature birth in the state of Santa Catarina between 2011 and 2021

Objetivo: Analisar a tendência temporal de nascimentos prematuros no estado de Santa Catarina entre 2011 e 2021. Métodos: Estudo observacional ecológico de tendência temporal realizado com informações do banco de dados do Sistema de Informação sobre Nascidos Vivos do estado de Santa Catarina (2011-2021), disponibilizado pela Diretoria de Vigilância Epidemiológica. Foram analisados todos os nascidos vivos prematuros segundo o ano de processamento e o local de residência em Santa Catarina (110.422). Foram incluídos os nascidos vivos de gestação com menos de 37 semanas completas. As taxas de nascimentos prematuros foram calculadas proporcionalmente à totalidade de nascimentos e calculadas segundo macrorregião, idade materna, número de consultas do pré-natal, instrução materna e cor de pele. Para o cálculo da tendência temporal, foi utilizada a regressão linear simples, com intervalo de confiança de 95% (p ≤ 0,05). Resultados: A taxa média de nascimentos prematuros no estado de Santa Catarina foi de 10,57%, com tendência estável (p < 0,001). Maiores taxas específicas foram encontradas nas macrorregiões Meio Oeste e Serra e Planalto Norte e Nordeste (11,46%), extremos de idade (10-14 anos e 45-64 anos) e menor escolaridade. Maior número de consultas de pré-natal apresentou taxa de prematuridade menor (7,69%). Tendências crescentes das taxas foram apenas encontradas na macrorregião Grande Oeste, faixa etária materna entre 40-44 anos e entre 4-6 consultas de pré-natal. Conclusão: A tendência da taxa de prematuridade manteve-se estável em Santa Catarina. Baixo número de consultas de pré-natal, extremos de idades e baixa escolaridade mostraram taxas maiores de prematuridade. (AU)

Objective: Analyzing the temporal trend of premature births in the state of Santa Catarina between 2011 and 2021. Methods: Observational ecological temporal trend study carried out with information from the database of the Information System on Live Births in the state of Santa Catarina (2011-2021), made available by the Epidemiological Surveillance Directorate. All premature live births were analyzed according to the year of processing and place of residence in Santa Catarina (110,422). Live births of less than 37 completed weeks were included. The rates of premature births were calculated in proportion to the total number of births and calculated according to macro-region, maternal age, number of prenatal consultations, maternal education and skin color. Simple linear regression was used to calculate the temporal trend, with a confidence interval of 95% (p ≤ 0.05). Results: The average rate of premature births in the state of Santa Catarina was 10.57%, with a stable trend (p < 0.001). Higher specific rates were found in the Midwest and Serra, North Plateau and Northeast macro-regions (11.46%), age extremes (10-14 years and 45-64 years) and lower schooling. A greater number of prenatal consultations had a lower prematurity rate (7.69%). Increasing trends in rates were only found in the Grande Oeste macro-region, maternal age group between 40-44 years and between 4-6 prenatal consultations. Conclusion: The prematurity rate trend remained stable in Santa Catarina. Low number of prenatal consultations, extremes of age and low education showed higher rates of prematurity. (AU)

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

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

Magnitude and factors associated with birth preparedness and complication readiness among pregnant women in Wolaita Zone, Ethiopia.

OBJECTIVE: To assess the magnitude and factors associated with birth preparedness and complication readiness (BPCR) among pregnant women in Humbo district, Wolaita Zone, Ethiopia. METHODS: A community-based cross-sectional study was conducted from August 1 to 30, 2020. A total of 506 pregnant women were randomly selected and interviewed using a questionnaire. Data were entered using EpiData version 4.6.0, and analysis was made using SPSS version 24. An adjusted odds ratio (aOR) with a 95% confidence interval (CI) was calculated. RESULTS: The magnitude of BPCR in the Humbo district was 26.0%. The odds of being prepared for birth and its complications were higher among women who had a history of obstetric complications (aOR 2.77; 95% CI 1.18-6.52), participated in pregnant women's conferences (aOR 3.84; 95% CI 2.13-6.93), received advice on BPCR (aOR 2.39; 95% CI 1.36-4.22), and were knowledgeable on labor and childbirth danger signs (aOR 2.64; 95% CI 1.55-4.49). CONCLUSION: The magnitude of birth preparedness and complication readiness was low in the study area. The healthcare provider should encourage the women to participate in conferences and provide continuous counseling during their prenatal care visits.

Intrapartum amnioinfusion reduces meconium aspiration syndrome and improves neonatal outcomes in patients with meconium-stained fluid: a systematic review and meta-analysis.

OBJECTIVE: This study aimed to reassess the effect of prophylactic transcervical amnioinfusion for intrapartum meconium-stained amniotic fluid on meconium aspiration syndrome and other adverse neonatal and maternal outcomes. DATA SOURCES: From inception to November 2021, a systematic search of the literature was performed in PubMed, Embase, Web of Science, and Scopus databases and gray literature sources. STUDY ELIGIBILITY CRITERIA: We identified randomized controlled trials of patients with intrapartum moderate to thick meconium-stained amniotic fluid that evaluated the effect of amnioinfusion on adverse neonatal and maternal outcomes. METHODS: Of note, 2 reviewers independently abstracted data and gauged study quality by assigning a modified Jadad score. Meconium aspiration syndrome constituted the primary outcome. The secondary outcomes were meconium below the cords, Apgar scores of <7 at 5 minutes, neonatal acidosis, cesarean delivery, cesarean delivery for fetal heart rate abnormalities, neonatal intensive care unit admission, and postpartum endometritis. This study calculated the odds ratios with 95% confidence intervals for categorical outcomes and weighted mean differences with 95% confidence intervals for continuous outcomes. RESULTS: A total of 24 randomized studies with 5994 participants met the inclusion criteria. The overall odds of meconium aspiration syndrome was reduced by 67% in the amnioinfusion group (pooled odds ratio, 0.33; 95% confidence interval, 0.21-0.51). Except for postpartum endometritis, amnioinfusion was associated with a significant reduction in all secondary outcomes. CONCLUSION: Our study found that the use of intrapartum amnioinfusion in the setting of meconium-stained amniotic fluid significantly reduces the odds of meconium aspiration syndrome and other adverse neonatal outcomes.

Trends in obstetric anal sphincter injury in spontaneous vaginal delivery versus operative vaginal delivery over a 10-year period: Lessons learned.

OBJECTIVE: To evaluate trends in the incidence of women with obstetric anal sphincter injuries (OASIS) over a 10-year period comparing spontaneous vaginal delivery (SVD) and operative vaginal delivery (OVD). METHODS: A retrospective study was performed in which all women who underwent vaginal delivery over a 10-year period (n = 86 242, 2009-2018) at the Rotunda Hospital were reviewed. The overall incidence of OASIS was compared with incidence rates stratified by parity and type of vaginal birth. RESULTS: The 10-year vaginal delivery rate was 69% (n = 59 187) where 24 580 women (42%) were primiparous and 34 607 women (58%) were multiparous. SVD rate was 74% and OVD rate was 26%. The overall incidence of OASIS was 2.9%. The incidence of OASIS in OVD was 5.5% and the incidence in SVD was 2%. Of 498 multipara who sustained OASIS, 366 (73%) had an SVD without episiotomy compared with 14 (3%) who had an episiotomy. There was a significant reduction of OASIS over the 10-year period in primipara who had an OVD but no reduction in the other groups. CONCLUSION: The primiparous OVD group had a significant reduction of OASIS. Continued education around perineal protection and episiotomy at SVD could positively impact further reduction in OASIS, particularly in the SVD groups.

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

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

Implementation of Episcissors-60 for Prevention of Obstetric Anal Sphincter Injuries (OASIS) in a Centre with Low Episiotomy Rates.

OBJECTIVE: The purpose of this study was to determine whether introduction of Episcissors-60 into a labour and birth unit would decrease the incidence of obstetric anal sphincter injuries (OASIS). METHODS: A before and after quality improvement study was conducted between April 1, 2020, and March 31, 2021. All patients who had a vaginal delivery were included in this study. All healthcare providers who perform vaginal deliveries were offered an educational session. Episcissors-60 were then introduced into a labour and birth unit. The primary outcome measure was the change in incidence of OASIS before and after introduction of Episcissors-60. Secondary outcome measures were episiotomy rates before and after introduction of Episcissors-60, device-related adverse events, and provider satisfaction and feedback. Data were analyzed using chi-square tests, independent t tests, and Mann-Whitney tests. RESULTS: A total of 1383 vaginal deliveries occurred before and 1254 vaginal deliveries after introduction of Episcissors-60. There was a decrease in the total OASIS rate from 7.37% of all vaginal deliveries before and 5.37% after introduction of Episcissors-60 (P = 0.037). The episiotomy rate was 11.42% before and 9.97% after introduction of Episcissors-60 (P = 0.228). OASIS rate in women who had an episiotomy was 12.02% before and 13.60% after introduction of Episcissors-60 (P = 0.421). CONCLUSION: Although introduction of Episcissors-60 was associated with a statistically significant decrease in total OASIS rate, there was no difference in OASIS rate within the subgroup that received an episiotomy. Therefore, reduction in the total OASIS rate in this study cannot be attributed to the use of Episcissors-60.

Effectiveness of episiotomy to prevent OASIS in nulliparous women at term.

OBJECTIVE: To assess the association between episiotomy and severe obstetric anal sphincter injury (OASIS) in nulliparous women at term according to the use of an instrument for delivery with control confounding by indication. METHODS: This was an observational retrospective cohort study including 12 346 women from 2004 to 2020. All nulliparous women with a cephalic singleton pregnancy were included. The primary outcome was the occurrence of OASIS. Association between episiotomy and OASIS was assessed by multivariate logistic regression with adjustment for confounding factors and stratification on the use of an instrument at delivery. Propensity score matching was used to account for indication bias. RESULTS: Among 12 346 women included, 7803 (63.2%) had an episiotomy and 4543 (36.8%) did not have an episiotomy; the rate of OASIS was similar in both groups (0.7%). After stratification on use of instrument, an association between episiotomy and OASIS was shown in the case of instrumental delivery (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.26-0.80) but not if the delivery was spontaneous (OR 0.76, 95% CI 0.29-1.98). The result was similar after matching on propensity score (in the case of operative vaginal delivery: OR 0.20, 95% CI 0.10-0.75). CONCLUSION: Episiotomy seems to be a protective factor for OASIS in nulliparous woman at term only in the case of operative vaginal delivery.

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

BACKGROUND: Numerous interventions to reduce perineal trauma during childbirth have been studied in recent years, including perineal massage. OBJECTIVE: To determine the efficacy of perineal massage during the second stage of labor to prevent perineal damage. SEARCH STRATEGY: Systematic search in PubMed, Pedro, Scopus, Web of Science, ScienceDirect, BioMed, SpringerLink, EBSCOhost, CINAHL, and MEDLINE with the terms Massage, Second labor stage, Obstetric delivery, and Parturition. SELECTION CRITERIA: The articles must have been published in the last 10 years; the perineal massage was administered to the study sample; and the experimental design consisted of randomized controlled trial. DATA COLLECTION AND ANALYSIS: Tables were used to describe both the studies' characteristics and the extracted data. The PEDro and Jadad scales were used to assess the quality of studies. MAIN RESULTS: Of the 1172 total results identified, nine were selected. Seven studies were included in the meta-analysis and indicated a statistically significant decreased number of episiotomies in perineal massage. CONCLUSIONS: Massage during the second stage of labor appears to be effective in preventing episiotomies and reducing the duration of the second stage of labor. However, it does not appear to be effective in reducing the incidence and severity of perineal tears.

The effectiveness of interventions in the prevention of perineal trauma in parturients: A systematic review with meta-analysis.

AIM: To investigate the effectiveness of interventions to prevent the occurrence of perineal trauma in parturients. METHODS: A bibliographic search was carried out in Cochrane Library, MEDLINE via PUBMED, LILACS via Virtual Health Library (VHL), Embase, Scopus, CINAHL, Scielo, Web of Science, and PEDro databases. Randomized clinical trials evaluating the effects of any intervention to prevent perineal trauma during pregnancy and/or childbirth were included. There were no temporal or language restrictions. The risk of bias assessment was performed using the Revised Cochrane Risk-of-bias Tool for Randomized Trials. RESULTS: Fifty studies, with a total of 17,221 participants, were included in this meta-analysis. No intervention during childbirth was effective for the prevention of perineal trauma (RR = 1.07, 95% CI [0.98.1.18], p < 0.01, I2 = 83%) when compared to no intervention. However, a lower risk of perineal laceration was verified with techniques performed during pregnancy, when compared to no intervention (RR = 0.81, 95% CI [0.71, 0.93], p = 0.05, I2 = 47%). Among them, highlight the effects of perineal massage in preventing lacerations (RR = 0.69, 95% CI [0.54, 0.87], p < 0.01) when compared to no intervention. CONCLUSIONS: The techniques performed during pregnancy, especially perineal massage, are associated with a lower risk of perineal laceration.

Regional and clinical guidelines for prevention and care of obstetric anal sphincter injuries - A critical frame analysis.

OBJECTIVE: Policy documents govern how the prevention and care of obstetric anal sphincter injuries (OASIS) are implemented. Thus, in the absence of Swedish national guidelines on OASIS, differing views may be visible in the regional and local policy documents. Therefore, we aimed to analyse regional and local policies, guidelines, and care programs on the prevention of OASIS and care for OASIS-affected women in a Swedish context by applying a critical frame analysis inspired by Verloo. DESIGN AND SETTING: A cross-sectional study of existing policy documents from Swedish healthcare regions was performed. The documents were analysed using Verloo's critical frame analysis. FINDINGS: We found that OASIS was framed as a preventable problem addressed by skilled protective manoeuvres of the healthcare staff. Education, communication, and teamwork were three frames of crucial solutions to minimise the prevalence of OASIS. However, complicating power dimensions between professional groups and between professionals and birthing women were identified. Furthermore, several discursive struggles were found, predominantly regarding the scientific evidence for the suggested prevention and care. CONCLUSION: The policy documents emphasised that OASIS is preventable, and improved education, communication, and teamwork could diminish the OASIS prevalence. Nevertheless, power dimensions and discursive struggles may challenge the preventive efforts. Furthermore, each Swedish region has the sovereignty to develop its policies, which was reflected in our findings and may imply inequities in care provision. Thus, there is an urgent need to develop comprehensive national high-quality guidelines of high quality for OASIS prevention and care so that all women giving birth have access to equal care and treatment in Sweden.

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

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

Perineal Massage during Pregnancy for the Prevention of Postpartum Urinary Incontinence: Controlled Clinical Trial.

Background and objectives: Urinary incontinence is any involuntary loss of urine. It may result in anxiety, depression, low self-esteem and social isolation. Perineal massage has spread as a prophylactic technique for treating complications during labor. Acknowledged effects of perineal massage are reduction of incidence and severity of perineal tear and use of equipment directly related to the intrapartum perineal trauma. The aim of this study was to determine the effectiveness of massage in urinary incontinence prevention and identification of possible differences in its form of application (self-massage or by a physiotherapist), with the previous assumption that it is effective and that there are differences between the different forms of application. Materials and Methods: A controlled clinical trial with a sample of 81 pregnant women was conducted. The participants were divided into three groups: a group that received the massage applied by a specialized physiotherapist, another group that applied the massage to themselves, and a control group that only received ordinary obstetric care. Results: No differences were identified in the incidence or severity of urinary incontinence among the three groups. The severity of the incontinence was only affected by the body mass index and the weight of the baby at the time of delivery. Conclusions: A relationship between perineal massage interventions and development of urinary incontinence has not been observed.

Birth preparedness and complication readiness practice and associated factors among pregnant women in Central Ethiopia, 2021: A cross-sectional study.

BACKGROUND: Birth preparedness and complication readiness (BP/CR) is an intervention designated by the World Health Organization (WHO) as an essential element of the antenatal (ANC) package with a concept of a global strategy to reduce maternal mortality. In Ethiopia, the proportion of pregnant women preparing for birth and related complications has remained low. Whereas, the need for additional study is indicated to add more evidence to the country's efforts to end preventable maternal death. METHODS: A facility-based cross-sectional study was conducted from March 01 to May 01, 2021. A systematic random sampling technique was applied to recruit 422 pregnant women. Bivariable and multivariable binary logistic regression was fitted to identify factors associated with BP/CR practice. Variables with a p-value ≤ 0.25 on the bivariable analysis were included in multivariable analysis. Adjusted odds ratios (AOR) with the respective 95% confidence interval (CI) and a p-value <0.05 was used to set statistically significant variables in the multivariable analysis. RESULTS: A total of 414 pregnant women have participated in the study. The overall BP/CR practice level was 44.9% (95% CI: 40.1, 49.7). Preconception care utilization (PCC) (AOR = 2.31; 95% CI:1.38-3.86), urban residents (AOR = 2.00; 95% CI:1.21-3.31), knowledge of BP/CR (AOR = 2.29; 95% CI:1.27-3.47), knowledge of danger signs during pregnancy (AOR = 2.05; 95% CI:1.21-3.47), knowledge of danger signs in newborns (AOR = 2.06; 95% CI:1.21-3.47), starting ANC visits in the 1st and 2nd trimester (AOR = 2.52; 95% CI:1.40-4.52), number of ANC visit ≥ three (AOR = 1.66; 95% CI;1.01-2.74), knowing Expected Date of Delivery (EDD) (AOR = 3.71; 95% CI:2.01-6.82), and joint decision-making on obstetric services (AOR = 3.51; 95% CI;1.99-6.20) were factors significantly associated with BP/CR practice. CONCLUSION: Based on the WHO standard, this study revealed a low level of BP/CR practice among pregnant women, with only less than half of women adequately prepared for childbirth and its complications. Moreover, it has been shown that BP/CR practice is influenced by socio-economic, maternal knowledge, and health service-related factors. Therefore, improving the status of BP/CR practice by expanding awareness creation opportunities, strengthening PCC and early ANC initiation by improving pregnant women's understanding, and promoting joint decision-making on obstetric services are recommended.