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1.
BJOG ; 128(3): 584-592, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-33426798

RESUMO

OBJECTIVE: To evaluate the impact of a care bundle (antenatal information to women, manual perineal protection and mediolateral episiotomy when indicated) on obstetric anal sphincter injury (OASI) rates. DESIGN: Multicentre stepped-wedge cluster design. SETTING: Sixteen maternity units located in four regions across England, Scotland and Wales. POPULATION: Women with singleton live births between October 2016 and March 2018. METHODS: Stepwise region by region roll-out every 3 months starting January 2017. The four maternity units in a region started at the same time. Multi-level logistic regression was used to estimate the impact of the care bundle, adjusting for time trend and case-mix factors (age, ethnicity, body mass index, parity, birthweight and mode of birth). MAIN OUTCOME MEASURES: Obstetric anal sphincter injury in singleton live vaginal births. RESULTS: A total of 55 060 singleton live vaginal births were included (79% spontaneous and 21% operative). Median maternal age was 30 years (interquartile range 26-34 years) and 46% of women were primiparous. The OASI rate decreased from 3.3% before to 3.0% after care bundle implementation (adjusted odds ratio 0.80, 95% CI 0.65-0.98, P = 0.03). There was no evidence that the effect of the care bundle differed according to parity (P = 0.77) or mode of birth (P = 0.31). There were no significant changes in caesarean section (P = 0.19) or episiotomy rates (P = 0.16) during the study period. CONCLUSIONS: The implementation of this care bundle reduced OASI rates without affecting caesarean section rates or episiotomy use. These findings demonstrate its potential for reducing perineal trauma during childbirth. TWEETABLE ABSTRACT: OASI Care Bundle reduced severe perineal tear rates without affecting caesarean section rates or episiotomy use.


Assuntos
Parto Obstétrico/normas , Lacerações/epidemiologia , Complicações do Trabalho de Parto/epidemiologia , Melhoria de Qualidade/estatística & dados numéricos , Adulto , Canal Anal/lesões , Cesárea/efeitos adversos , Cesárea/normas , Cesárea/estatística & dados numéricos , Análise por Conglomerados , Parto Obstétrico/efeitos adversos , Parto Obstétrico/estatística & dados numéricos , Inglaterra/epidemiologia , Episiotomia/efeitos adversos , Episiotomia/normas , Episiotomia/estatística & dados numéricos , Feminino , Humanos , Lacerações/prevenção & controle , Modelos Logísticos , Complicações do Trabalho de Parto/prevenção & controle , Períneo/lesões , Gravidez , Projetos de Pesquisa , Fatores de Risco , Escócia/epidemiologia , País de Gales/epidemiologia
2.
Pan Afr Med J ; 37: 48, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33209175

RESUMO

In the COVID-19's crisis, elective surgery and non-emergent cases were postponed; all other procedures have to be minimized. A 17-year male patient with severe crush and degloving injury over the thigh, gluteal, sacral, and perineum areas was admitted to our Department on the 16th of March 2020. The patient presented soft tissue skin and muscle loss. A double Latissimus Dorsi and Anterolateral Thigh free flaps were indicated. However, due to the particular circumstance of the COVID-19 crisis, we applied domestic negative wound therapy (NPWT) using gauzes and wall suction. We obtained suitable granulation tissue after 17 consecutive days with this treatment. The raw area was then covered with an expanded split-thickness skin graft. The wound healed at 95%, and the patient was discharged on 25th of April 2020. He was followed up in an outpatient setting with wound care and physiotherapy. This case showed that in a limited-resource setting, with available wall suction, the domestic NPWT is a versatile tool to promote granulation tissue.


Assuntos
Betacoronavirus , Infecções por Coronavirus/epidemiologia , Lesões por Esmagamento/cirurgia , Desenluvamentos Cutâneos/cirurgia , Tratamento de Ferimentos com Pressão Negativa/métodos , Pneumonia Viral/epidemiologia , Retalhos Cirúrgicos/transplante , Acidentes de Trânsito , Adolescente , Bandagens , Nádegas/lesões , Desbridamento , Humanos , Masculino , Músculo Esquelético/lesões , Pandemias , Períneo/lesões , Coxa da Perna/lesões , Cicatrização , Infecção dos Ferimentos/tratamento farmacológico , Infecção dos Ferimentos/microbiologia
3.
Cochrane Database Syst Rev ; 10: CD006304, 2020 10 09.
Artigo em Inglês | MEDLINE | ID: mdl-33034900

RESUMO

BACKGROUND: Perineal trauma is common during childbirth and may be painful. Contemporary maternity practice includes offering women numerous forms of pain relief, including the local application of cooling treatments. This Cochrane Review is an update of a review last updated in 2012. OBJECTIVES: To evaluate the effectiveness of localised cooling treatments compared with no treatment, placebo, or other cooling treatments applied to the perineum for pain relief following perineal trauma sustained during childbirth. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (7 October 2019) and reference lists of retrieved studies. SELECTION CRITERIA: Published and unpublished randomised and quasi-randomised trials (RCTs) that compared a localised cooling treatment applied to the perineum with no treatment, placebo, or another cooling treatment applied to relieve pain related to perineal trauma sustained during childbirth. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed study eligibility, extracted data and assessed the risk of bias of included studies. Data were double checked for accuracy. The certainty of the evidence was assessed using the GRADE approach. MAIN RESULTS: We included 10 RCTs that enrolled 1233 women randomised to the use of one cooling treatment (ice, cold gel pad, cooling plus compression, cooling plus compression plus (being) horizontal) compared with another cooling treatment, no treatment, or placebo (water pack, compression). The included trials were at low or uncertain risk of bias overall, with the exception that the inability to blind participants and personnel to group allocation meant that we rated all trials at unclear or high risk for this domain. We undertook a number of comparisons to evaluate the different treatments. Cooling treatment (ice pack or cold gel pad) versus no treatment There was limited very low-certainty evidence that cooling treatment may reduce women's self-reported perineal pain within four to six hours (mean difference (MD) -4.46, 95% confidence interval (CI) -5.07 to -3.85 on a 10-point scale; 1 study, 100 participants) or between 24 and 48 hours of giving birth (risk ratio (RR) 0.73, 95% CI 0.57 to 0.94; 1 study, 316 participants). The evidence is very uncertain about the various measures of wound healing, for example, wound edges gaping when inspected five days after giving birth (RR 2.56, 95% CI 0.58 to 11.33; 1 study, 315 participants). Women generally rated their satisfaction with perineal care similarly following cooling or no treatment. The potential exception was that there may be a trivially lower mean difference of -0.1 on a five-point scale of psychospiritual comfort with cooling treatment, that is unlikely to be of clinical importance. Cooling treatment (cold gel pad) + compression versus placebo (gel pad + compression) There was limited low-certainty evidence that there may be a trivial MD of -0.43 in pain on a 10-point scale at 24 to 48 hours after giving birth (95% CI -0.73 to -0.13; 1 study, 250 participants) when a cooling treatment plus compression from a well-secured perineal pad was compared with the placebo. Levels of perineal oedema may be similar for the two groups (low-certainty evidence) and perineal bruising was not observed. There was low-certainty evidence that women may rate their satisfaction as being slightly higher with perineal care in the cold gel pad and compression group (MD 0.88, 95% CI 0.38 to 1.38; 1 trial, 250 participants). Cooling treatment (ice pack) versus placebo (water pack) One study reported that no women reported pain after using an ice pack or a water pack when asked within 24 hours of giving birth. There was low-certainty evidence that oedema may be similar for the two groups when assessed at four to six hours (RR 0.96, 95% CI 0.50 to 1.86; 1 study, 63 participants) or within 24 hours of giving birth (RR 0.36, 95% CI 0.08 to 1.59). No women were observed to have perineal bruising at these times. The trialists reported that no women in either group experienced any adverse effects on wound healing. There was very low-certainty evidence that women may rate their views and experiences with the treatments similarly (for example, satisfied with treatment: RR 0.91, 95% CI 0.77 to 1.08; 63 participants). Cooling treatment (ice pack) versus cooling treatment (cold gel pad) The evidence is very uncertain about the effects of using ice packs or cold gel pads on women's self-rated perineal pain, on perineal bruising, or on perineal oedema at four to six hours or within 24 hours of giving birth. Perineal oedema may persist 24 to 48 hours after giving birth in women using the ice packs (RR 1.69, 95% CI 1.03 to 2.7; 2 trials, 264 participants; very low-certainty). The risk of gaping wound edges five days after giving birth may be decreased in women who had used ice packs (RR 0.22, 95% CI 0.05 to 1.01; 215 participants; very low-certainty). However, this did not appear to persist to day 10 (RR 3.06, 95% CI 0.63 to 14.81; 214 participants). Women may rate their opinion of treatment less favourably following the use of ice packs five days after giving birth (RR 0.33, 95% CI 0.17 to 0.68; 1 study, 49 participants) and when assessed on day 10 (RR 0.82, 95% CI 0.73 to 0.92; 1 study, 208 participants), both very low-certainty. AUTHORS' CONCLUSIONS: There is limited very low-certainty evidence that may support the use of cooling treatments, in the form or ice packs or cold gel pads, for the relief of perineal pain in the first two days following childbirth. It is likely that concurrent use of several treatments is required to adequately address this issue, including prescription and non-prescription analgesia. Studies included in this review involved the use of cooling treatments for 10 to 20 minutes, and although no adverse effects were noted, these findings came from studies of relatively small numbers of women, or were not reported at all. The continued lack of high-certainty evidence of the benefits of cooling treatments should be viewed with caution, and further well-designed trials should be conducted.


Assuntos
Hipotermia Induzida/métodos , Manejo da Dor/métodos , Períneo/lesões , Terapia Combinada/métodos , Episiotomia/efeitos adversos , Feminino , Humanos , Hipotermia Induzida/efeitos adversos , Manejo da Dor/efeitos adversos , Parto , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto
4.
Am J Obstet Gynecol ; 223(5): 709-714, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32888923

RESUMO

Obstetrical perineal and anal sphincter lacerations can be associated with considerable sequelae. The diagnosis of short-term bowel, bladder, and healing problems can be delayed if patients are not seen until the traditional postpartum visit at 4 to 6 weeks. Specialized peripartum clinics create a unique opportunity to collaborate with obstetrical specialists to provide early, individualized care for patients experiencing a variety of pelvic floor issues during pregnancy and in the postpartum period. Although implementation of these clinics requires thoughtful planning and partnering with care providers at all levels in the obstetrics care system, many of the necessary resources are available in routine gynecologic practice. Using a multidisciplinary approach with pelvic floor physical therapists, nurses, advanced practice providers, and other specialists is important for the success of this service line and enhances the level of care provided. Overall, these clinics provide a structured means by which pregnant and postpartum women with pelvic floor symptoms can receive specialized counseling and treatment.


Assuntos
Canal Anal/lesões , Lacerações/terapia , Obstetrícia , Distúrbios do Assoalho Pélvico/terapia , Modalidades de Fisioterapia , Cuidado Pós-Natal/organização & administração , Cuidado Pré-Natal/organização & administração , Parto Obstétrico/efeitos adversos , Dispareunia/terapia , Incontinência Fecal/terapia , Feminino , Humanos , Lacerações/etiologia , Equipe de Assistência ao Paciente , Diafragma da Pelve/lesões , Distúrbios do Assoalho Pélvico/etiologia , Prolapso de Órgão Pélvico/terapia , Dor Pélvica/terapia , Períneo/lesões , Período Periparto , Gravidez , Encaminhamento e Consulta , Incontinência Urinária/terapia
5.
Obstet Gynecol ; 136(4): 707-715, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32925614

RESUMO

OBJECTIVE: To compare neonatal intensive care unit (NICU) or special care nursery admission for deliveries with water immersion compared with deliveries in the matched control group without water immersion. Secondary outcomes included adverse neonatal diagnoses, maternal infections, and perineal lacerations. METHODS: We conducted a retrospective study using electronic health record data (2014-2018) from two health systems (eight hospitals), with similar clinical eligibility, associated with low risks of intrapartum complications, and implementation policies for waterbirth. The water immersion group included women intending waterbirth. Water immersion was recorded prospectively during delivery. The comparison population were women who met the clinical eligibility criteria for waterbirth but did not experience water immersion during labor. Comparison cases were matched (1:1) using propensity scores. Outcomes were compared using Fischer's exact tests and logistic regression with stratification by stage of water immersion. RESULTS: Of the 583 women with water immersion, 34.1% (199) experienced first-stage water immersion only, 65.9% (384) experienced second-stage immersion, of whom 12.0% (70) exited during second stage, and 53.9% (314) completed delivery in the water. Neonatal intensive care unit or special care nursery admissions were lower for second-stage water immersion deliveries than deliveries in the control group (odds ratio [OR] 0.3, 95% CI 0.2-0.7). Lacerations were lower in the second-stage immersion group (OR 0.5, 95% CI 0.4-0.7). Neonatal intensive care unit or special care nursery admissions and lacerations were not different between the first-stage immersion group and their matched comparisons. Cord avulsions occurred for 0.8% of second-stage water immersion deliveries compared with none in the control groups. Five-minute Apgar score (less than 7), maternal infections, and other adverse outcomes were not significantly different between either the first- or second-stage water immersion groups and their control group. CONCLUSION: Hospital-based deliveries with second-stage water immersion had lower risk of NICU or special care nursery admission and perineal lacerations than matched deliveries in the control group without water immersion.


Assuntos
Parto Obstétrico , Registros Eletrônicos de Saúde/estatística & dados numéricos , Doenças do Recém-Nascido , Lacerações , Parto Normal , Complicações do Trabalho de Parto , Adulto , Índice de Apgar , Parto Obstétrico/efeitos adversos , Parto Obstétrico/métodos , Parto Obstétrico/estatística & dados numéricos , Feminino , Humanos , Recém-Nascido , Doenças do Recém-Nascido/diagnóstico , Doenças do Recém-Nascido/prevenção & controle , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Segunda Fase do Trabalho de Parto , Lacerações/diagnóstico , Lacerações/etiologia , Lacerações/prevenção & controle , Masculino , Minnesota/epidemiologia , Parto Normal/efeitos adversos , Parto Normal/métodos , Parto Normal/estatística & dados numéricos , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/etiologia , Complicações do Trabalho de Parto/prevenção & controle , Períneo/lesões , Gravidez , Resultado da Gravidez/epidemiologia , Estudos Retrospectivos
6.
Cochrane Database Syst Rev ; 8: CD011625, 2020 08 05.
Artigo em Inglês | MEDLINE | ID: mdl-32761813

RESUMO

BACKGROUND: Postpartum constipation, with symptoms, such as pain or discomfort, straining, and hard stool, is a common condition affecting mothers. Haemorrhoids, pain at the episiotomy site, effects of pregnancy hormones, and haematinics used in pregnancy can increase the risk of postpartum constipation. Eating a high-fibre diet and increasing fluid intake are usually encouraged. Although laxatives are commonly used in relieving constipation, the effectiveness and safety of available interventions for preventing postpartum constipation should be ascertained. This is an update of a review first published in 2015. OBJECTIVES: To evaluate the effectiveness and safety of interventions for preventing postpartum constipation. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register, and two trials registers ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (7 October 2019), and screened reference lists of retrieved trials. SELECTION CRITERIA: We considered all randomised controlled trials (RCTs) comparing any intervention for preventing postpartum constipation versus another intervention, placebo, or no intervention in postpartum women. Interventions could include pharmacological (e.g. laxatives) and non-pharmacological interventions (e.g. acupuncture, educational and behavioural interventions). Quasi-randomised trials and cluster-RCTs were eligible for inclusion; none were identified. Trials using a cross-over design were not eligible. DATA COLLECTION AND ANALYSIS: Two review authors independently screened the results of the search to select potentially relevant trials, extracted data, assessed risk of bias, and the certainty of the evidence, using the GRADE approach. We did not pool results in a meta-analysis, but reported them per study. MAIN RESULTS: We included five trials (1208 postpartum mothers); three RCTs and two quasi-RCTs. Four trials compared a laxative with placebo; one compared a laxative plus a bulking agent versus the same laxative alone, in women who underwent surgical repair of third degree perineal tears. Trials were poorly reported, and four of the five trials were published over 40 years ago. We judged the risk of bias to be unclear for most domains. Overall, we found a high risk of selection and attrition bias. Laxative versus placebo We included four trials in this comparison. Two of the trials examined the effects of laxatives that are no longer used; one has been found to have carcinogenic properties (Danthron), and the other is not recommended for lactating women (Bisoxatin acetate); therefore, we did not include their results in our main findings. None of the trials included in this comparison assessed our primary outcomes: pain or straining on defecation, incidence of postpartum constipation, or quality of life; or many of our secondary outcomes. A laxative (senna) may increase the number of women having their first bowel movement within 24 hours after delivery (risk ratio (RR) 2.90, 95% confidence interval (CI) 2.24 to 3.75; 1 trial, 471 women; low-certainty evidence); may have little or no effect on the number of women having their first bowel movement on day one after delivery (RR 0.94, 95% CI 0.72 to 1.22; 1 trial, 471 women; very low-certainty evidence); may reduce the number of women having their first bowel movement on day two (RR 0.23, 95% CI 0.11 to 0.45; 1 trial, 471 women; low-certainty evidence); and day three (RR 0.05, 95% CI 0.00 to 0.89; 1 trial, 471 women; low-certainty evidence); and may have little or no effect on the number of women having their first bowel movement on day four after delivery (RR 0.22, 95% CI 0.03 to 1.87; 1 trial, 471 women; very low-certainty evidence), but some of the evidence is very uncertain. Adverse effects were poorly reported. Low-certainty evidence suggests that the laxative (senna) may increase the number of women experiencing abdominal cramps (RR 4.23, 95% CI 1.75 to 10.19; 1 trial, 471 women). Very low-certainty evidence suggests that laxatives taken by the mother may have little or no effect on loose stools in the baby (RR 0.62, 95% CI 0.16 to 2.41; 1 trial, 281 babies); or diarrhoea (RR 2.46, 95% CI 0.23 to 26.82; 1 trial, 281 babies). Laxative plus bulking agent versus laxative only Very low-certainty evidence from one trial (147 women) suggests no evidence of a difference between these two groups of women who underwent surgical repair of third degree perineal tears; only median and range data were reported. The trial also reported no evidence of a difference in the incidence of postpartum constipation (data not reported), but did not report on quality of life. Time to first bowel movement was reported as a median (range); very low-certainty evidence suggests little or no difference between the two groups. A laxative plus bulking agent may increase the number of women having any episode of faecal incontinence during the first 10 days postpartum (RR 1.81, 95% CI 1.01 to 3.23; 1 trial, 147 women; very low-certainty evidence). The trial did not report on adverse effects of the intervention on babies, or many of our secondary outcomes. AUTHORS' CONCLUSIONS: There is insufficient evidence to make general conclusions about the effectiveness and safety of laxatives for preventing postpartum constipation. The evidence in this review was assessed as low to very low-certainty evidence, with downgrading decisions based on limitations in study design, indirectness and imprecision. We did not identify any trials assessing educational or behavioural interventions. We identified four trials that examined laxatives versus placebo, and one that examined laxatives versus laxatives plus stool bulking agents. Further, rigorous trials are needed to assess the effectiveness and safety of laxatives during the postpartum period for preventing constipation. Trials should assess educational and behavioural interventions, and positions that enhance defecation. They should report on the primary outcomes from this review: pain or straining on defecation, incidence of postpartum constipation, quality of life, time to first bowel movement after delivery, and adverse effects caused by the intervention, such as: nausea or vomiting, pain, and flatus.


Assuntos
Constipação Intestinal/prevenção & controle , Fibras na Dieta/uso terapêutico , Laxantes/uso terapêutico , Transtornos Puerperais/prevenção & controle , Adulto , Defecação , Fibras na Dieta/efeitos adversos , Feminino , Humanos , Laxantes/efeitos adversos , Períneo/lesões , Período Pós-Parto , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Tempo
7.
BMC Womens Health ; 20(1): 131, 2020 06 22.
Artigo em Inglês | MEDLINE | ID: mdl-32571291

RESUMO

BACKGROUND: Aim of the study was to estimate the prevalence of postpartum anal incontinence among women who delivered vaginally, and to assess the extent to which obstetric injuries to the anal sphincters are missed. METHODS: All women (both primiparous and multiparous) who delivered vaginally and received any kind of sutures in the perineal area at Innlandet Hospital Trust Elverum in Norway between January 1, 2015 and June 30, 2016 were invited to answer a questionnaire on St. Mark's incontinence score and to participate in a clinical examination of the pelvic floor including endoanal sonography. RESULTS: In total 52,3% (n = 207) of the 396 invited women participated in the study. Mean St. Mark's score was 1.8 points (95% CI 1.4 to 2.1) at examination 14 months (mean) postpartum, and none of the participants suffered from weekly fecal leakage. Fecal urgency affected 11.7% (95% CI 7.1 to 16.3) of the participants, and 8.7% (95%CI 5.1 to 12.8) had weekly involuntary leakage of flatus. Nine women (9.3%, 95% CI 4.1 to 15.5) had a previously undetected third degree obstetric anal sphincter injury. CONCLUSION: The prevalence of anal incontinence among women who have delivered vaginally and received sutures due to 1st and 2nd degree perineal lacerations is low. Some obstetric anal sphincter injuries remain unrecognized at the time of delivery, but the symptoms of anal incontinence due to these injuries are in the lower half of the St. Mark's incontinence score. Women with persistent symptoms like fecal urgency or leakage of gas and/or feces should be referred to evaluation by a colorectal surgeon in order to achieve optimal treatment.


Assuntos
Canal Anal/lesões , Parto Obstétrico/estatística & dados numéricos , Episiotomia/efeitos adversos , Incontinência Fecal/epidemiologia , Lacerações/epidemiologia , Períneo/lesões , Adulto , Canal Anal/fisiopatologia , Estudos Transversais , Parto Obstétrico/métodos , Episiotomia/estatística & dados numéricos , Incontinência Fecal/etiologia , Feminino , Humanos , Noruega/epidemiologia , Complicações do Trabalho de Parto/epidemiologia , Períneo/fisiopatologia , Gravidez , Prevalência , Qualidade de Vida
8.
Arch Gynecol Obstet ; 302(2): 321-328, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32564129

RESUMO

PURPOSE: Antibiotic treatment during surgical repair of obstetric anal sphincter injuries (OASIS) had been a matter of debate. We aimed to review the available literature regarding the efficacy of metronidazole administration in women undergoing perineal repair following obstetric OASIS. STUDY DESIGN: To identify potentially eligible studies, we searched PubMed, Scopus, Embase and the Cochrane Library from inception to January 13th, 2019.Reference lists of identified studies were searched. No language restrictions were applied. We used a combination of keywords and text words represented by "Metronidazole", "obstetrics", "obstetric anal sphincter injury", "OASIS", "third degree tear", "fourth degree tear", "third degree laceration", "fourth degree laceration", "antibiotic therapy", "perineal damage" and "perineal trauma". Two reviewers independently screened the titles and abstracts of records retrieved from the database searches. Both reviewers recommended studies for the full-text review. Thescreen of full-text articles recommended by at least one reviewer was done independently by the same two reviewers and assessedfor inclusion in the systematic review. Disagreements between reviewers were resolved by consensus. RESULTS: The electronic database search yielded a total of 54,356 results (Fig. 1). After duplicate exclusion 28,154 references remained. Of them, 26 were relevant to the review based on title and abstract screening. None of these articles dealt with the use of metronidazole for the prevention of infections complicating anal sphincter repair in women with OASIS. A Cochrane review addressing antibiotic prophylaxis for patients following OASIS, compared prophylactic antibiotics against placebo or no antibiotics, included only one randomized controlled trial of 147 participants. This study showed that prophylactic antibiotics (not metronidazole) may be helpful to prevent perineal wound complications following OASIS. Fig. 1 Study seection process CONCLUSION: Anaerobic infections potentially complicate wound repair after OASIS. Although scientific societies recommend the use of antibiotics for the prevention of infectious morbidity after OASIS, no study has specifically assessed the role of metronidazole.


Assuntos
Canal Anal/lesões , Antibacterianos/uso terapêutico , Lacerações/etiologia , Metronidazol/uso terapêutico , Períneo/lesões , Infecção dos Ferimentos/prevenção & controle , Ferimentos e Lesões/prevenção & controle , Adulto , Canal Anal/microbiologia , Antibioticoprofilaxia/efeitos adversos , Parto Obstétrico/métodos , Feminino , Humanos , Complicações do Trabalho de Parto/cirurgia , Obstetrícia/métodos , Gravidez , Ferimentos e Lesões/complicações , Ferimentos e Lesões/tratamento farmacológico
9.
Arch Gynecol Obstet ; 302(1): 77-83, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32388778

RESUMO

PURPOSE: To evaluate the impact of a selective use of episiotomy combined with Couder's maneuver on the incidence of perineal tears in spontaneous term deliveries. METHODS: A comparative, retrospective, mono-centric study in a university maternity unit was designed and included all primiparous women who delivered spontaneously after 37 weeks of gestation in cephalic presentation. Two cohorts were studied, before and after the practice of Couder's maneuver. In the first cohort, the ''OSE cohort'' only selective episiotomies were performed from January 2009 to December 2010. In the second cohort, from January 2016 to December 2017, the ''SEC cohort'' selective episiotomies combined with Couder's maneuver were performed by midwives and obstetricians. The primary outcome was the type of perineal tears, according to the Royal College of Obstetricians and Gynaecologists (RCOG) classification. RESULTS: A total of 2081 patients were included: 909 patients in the OSE cohort and 1172 patients in the SEC cohort. Couder's maneuver was performed in 59% of the SEC cohort. In the SEC cohort, there were an increase in the number of intact perinea (55% versus 63%, p < 0.001), a decrease in second-degree perineal tears (18% versus 11%, p < 0.001) and a decrease in labia minora tears (48% versus 37%, p < 0.001). The rate of obstetrical anal sphincter injuries was less than 1% in both cohorts (0.3% versus 0.5%, p = 0.7). CONCLUSION: A selective use of episiotomy combined with Couder's maneuver could reduce the incidence of perineal tears, particularly second-degree perineal tears, without increasing the rate of obstetrical anal sphincter injuries.


Assuntos
Canal Anal/lesões , Parto Obstétrico/efeitos adversos , Episiotomia/estatística & dados numéricos , Lacerações/epidemiologia , Complicações do Trabalho de Parto/cirurgia , Períneo/lesões , Adulto , Parto Obstétrico/métodos , Episiotomia/efeitos adversos , Feminino , Humanos , Incidência , Tocologia , Complicações do Trabalho de Parto/epidemiologia , Avaliação de Processos e Resultados em Cuidados de Saúde , Paridade , Períneo/cirurgia , Médicos , Gravidez , Resultado da Gravidez , Estudos Retrospectivos
12.
BJOG ; 127(8): 951-956, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32285571

RESUMO

OBJECTIVE: The assessment of risk factors, including mediolateral episiotomy (MLE), for the recurrence of obstetric anal sphincter injury (rOASI). DESIGN: Population-based cohort study. SETTING: Data from the nationwide database of the Dutch Perinatal Registry (Perined). POPULATION: A cohort of 391 026 women at term, of whom 9943 had an OASI in their first delivery and had a second vaginal delivery of a liveborn infant in cephalic position. METHODS: Possible risk factors were tested for statistical significance using univariate and multivariate logistic regression analysis. MAIN OUTCOME MEASURES: Rate of rOASI. RESULTS: The rate of rOASI was 5.8%. Multivariate analysis identified a birthweight of ≥4000 g (adjusted OR, aOR, 2.1, 95% CI 1.6-2.6) and a duration of second stage of ≥30 minutes (aOR 1.8, 95% CI 1.4-2.3) as statistically significant risk factors for rOASI. Mediolateral episiotomy was associated with a statistically significant lower rate of rOASI in spontaneous vaginal delivery (SVD) (aOR 0.4, 95% CI 0.3-0.5) and in operative vaginal delivery (OVD) (aOR 0.2, 95% CI 0.1-0.5). CONCLUSIONS: Women with a history of OASI have a higher rate of OASI in their next delivery. Duration of the second stage of ≥30 minutes and a birthweight of ≥4000 g are significantly associated with an increased rate of rOASI. Mediolateral episiotomy is associated with a significantly lower rate of rOASI in both SVD and OVD. TWEETABLE ABSTRACT: Mediolateral episiotomy is associated with a significant lower recurrence rate of OASI in women with an OASI in their first delivery.


Assuntos
Canal Anal/lesões , Episiotomia/estatística & dados numéricos , Lacerações/epidemiologia , Complicações do Trabalho de Parto/epidemiologia , Períneo/lesões , Vácuo-Extração/efeitos adversos , Adulto , Feminino , Humanos , Apresentação no Trabalho de Parto , Lacerações/prevenção & controle , Estudos Longitudinais , Países Baixos/epidemiologia , Complicações do Trabalho de Parto/prevenção & controle , Gravidez , Recidiva , Medição de Risco , Fatores de Risco , Prevenção Secundária
13.
Arch Gynecol Obstet ; 301(6): 1405-1410, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32328711

RESUMO

PURPOSE: To study the association between the number of vaginal examinations (VEs) performed during labor and subsequent severe perineal trauma. METHODS: This is a retrospective cohort study. We included all women admitted to the delivery ward between 2008 and 2017, in active labor. Exclusion criteria included preterm deliveries (< 37 weeks), Cesarean deliveries and episiotomy during delivery. The primary outcome, severe perineal trauma, was defined as perineal tears grades 3-4. The cohort was divided into 4 groups, based on the number of VEs performed during labor: Group 1-up to two VEs (n = 4588), Group 2-three to four VEs (n = 5815), Group 3-five to six VEs (n = 4687), and Group 4-seven or more VEs (n = 7297). RESULTS: Overall, 22,387 women were included in the study. The rate of severe perineal trauma in groups 1, 2, 3 and 4 was 0.4%, 0.1%, 0.8%, and 0.4%, respectively (p < 0.001). Performing five or more VEs during labor was associated with a higher risk of severe perineal trauma (0.26% vs. 0.53%, p < 0.01), as compared to four VEs or less. Using a logistic regression model, we found that performing five or more VEs during labor (aOR = 1.72 CI 95% (1.21-2.47), p < 0.001) or performing an instrumental delivery (aOR = 2.65 CI 95% (1.72-4.07), p < 0.001) were directly associated with the risk for severe perineal trauma. Applying epidural anesthesia showed an inverse association with severe perineal trauma (aOR = 0.54 CI 95% (0.38-0.77), p < 0.001). CONCLUSION: Performing five or more VEs during active labor is associated with an increased risk for severe perineal trauma.


Assuntos
Exame Ginecológico/efeitos adversos , Complicações do Trabalho de Parto/etiologia , Períneo/lesões , Adulto , Estudos de Coortes , Feminino , Humanos , Gravidez , Estudos Retrospectivos
14.
BJOG ; 127(11): 1382-1390, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32339378

RESUMO

OBJECTIVE: Women's levels of resilience and attitudes towards perineal lacerations vary greatly. Some women see them as part of the birthing process, while others react with anger, depressed mood or even thoughts of self-harm. A previous study has reported increased risk of postpartum depressive (PPD) symptoms in women with severe perineal lacerations. The aim of this study was to assess the association between severe obstetric perineal lacerations and PPD. A secondary objective was to assess this association among women with low resilience. DESIGN: Nested cohort study. SETTING: Uppsala, Sweden. SAMPLE: Vaginally delivered women with singleton pregnancies (n = 2990). METHODS: The main exposure was obstetric perineal lacerations. Resilience was assessed in gestational week 32 using the Swedish version of the Sense of Coherence Scale. A digital acyclic graph was used to identify possible confounders and mediators. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI). A sub-analysis was run after excluding women with normal or high resilience. MAIN OUTCOME MEASURES: Postpartum depression, assessed with the Depression Self-Reporting Scale, completed at 6 weeks postpartum. RESULTS: There was no significant association between severe obstetric perineal lacerations and PPD at 6 weeks postpartum. However, a significant association was found between severe lacerations and PPD in women with low resilience (OR = 4.8, 95% CI 1.2-20), persisting even after adjusting for confounding factors. CONCLUSION: Healthcare professionals might need to identify women with low resilience, as they are at increased risk for PPD after a severe perineal laceration. TWEETABLE ABSTRACT: Severe perineal lacerations associated with postpartum depression in women with low resilience in a Swedish cohort.


Assuntos
Parto Obstétrico/psicologia , Depressão Pós-Parto/psicologia , Lacerações/psicologia , Complicações do Trabalho de Parto/psicologia , Períneo/lesões , Resiliência Psicológica , Adulto , Parto Obstétrico/efeitos adversos , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Lacerações/etiologia , Modelos Logísticos , Gravidez , Fatores de Risco , Suécia
15.
Rev. argent. coloproctología ; 31(1): 28-30, mar. 2020. ilus
Artigo em Espanhol | LILACS | ID: biblio-1102177

RESUMO

Introducción: El término ''síndrome antifosfolipídico'' (SAF) describe la asociación de los anticuerpos antifosfolipídicos (AAF) con un cuadro clínico de hipercoagulabilidad caracterizado por trombosis a repetición y abortos recurrentes. Objetivo: Presentar un caso de celulitis severa de periné en paciente con SAF y tratamiento con hidroxicloroquina. Caso clínico: Paciente de 39 años con embarazo de término con SAF tratado con hidroxicloroquina y anticoagulación que desarrolló una infección severa de partes blandas del periné que fue tratado con interrupción del embarazo, drenaje agresivo del periné y tratamiento antibiótico extenso con buena evolución. Conclusión: La asociación del tratamiento con hidroxicloroquina, embarazo y una complicación séptica es incierta. El tratamiento con inmunosupresión no es estándar y podría haber favorecido el mal pronóstico del cuadro clínico. (AU)


Objetive: To present a case of severe perineal cellulitis in a pregnant patient with Antiphospholipid syndrome treated wiht hidroxicloroquine. Case report: A 39 years old female pregnant patient with AFS treated with hidroxicloroquine and heparin developed severe perineal infection with systemic impairment. Final treatment included aggressive perineal drainage in multiple sessions, pregnancy delivered and systemic treatment with wide spectrum antibiotics and general measures. Discusion and Conclusion: Treatment with hidroxicloroquine, pregnancy and septic complication is infrequent. This approach is not standard and it could favored worst prognostic of the general syndrome. (AU)


Assuntos
Humanos , Feminino , Gravidez , Adulto , Complicações Infecciosas na Gravidez , Celulite (Flegmão)/cirurgia , Celulite (Flegmão)/tratamento farmacológico , Síndrome Antifosfolipídica/tratamento farmacológico , Gangrena de Fournier/cirurgia , Gangrena de Fournier/tratamento farmacológico , Períneo/cirurgia , Períneo/lesões , Clindamicina/uso terapêutico , Vancomicina/uso terapêutico , Meropeném/uso terapêutico , Hidroxicloroquina/efeitos adversos , Hidroxicloroquina/uso terapêutico , Antibacterianos/uso terapêutico
16.
Am J Obstet Gynecol ; 222(6): 580.e1-580.e5, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32142829

RESUMO

Obstetric anal sphincter injuries represent the minority of obstetric lacerations, but can have a significant long-term impact on urinary and fecal continence, as well as pelvic organ support. Accurate diagnosis of lacerations, appropriate repair, and close follow-up are essential to healthy healing and to improve outcomes for women. The infrequency of these injuries has resulted in a lack of familiarity with laceration repair and postpartum care of this population at all levels of practice. As such, continuing education strategies aimed at simulation, increased clinical exposure to anal sphincter injuries, and evidence-based repair techniques are important for mitigating the deficits in the current obstetric environment. Ensuring that patients have access to timely multidisciplinary postpartum care and education on the laceration incurred is essential to promote healthy healing and to optimize pelvic floor outcomes.


Assuntos
Canal Anal/lesões , Competência Clínica , Lacerações/diagnóstico , Lacerações/cirurgia , Complicações do Trabalho de Parto/diagnóstico , Complicações do Trabalho de Parto/cirurgia , Obstetrícia/educação , Parto Obstétrico/métodos , Episiotomia , Incontinência Fecal , Feminino , Humanos , Diafragma da Pelve/lesões , Períneo/lesões , Cuidado Pós-Natal , Gravidez , Fístula Retovaginal , Treinamento por Simulação
17.
Cochrane Database Syst Rev ; 3: CD004455, 2020 03 26.
Artigo em Inglês | MEDLINE | ID: mdl-32215906

RESUMO

BACKGROUND: Vacuum and forceps assisted vaginal deliveries are reported to increase the incidence of postpartum infections and maternal readmission to hospital compared to spontaneous vaginal delivery. Prophylactic antibiotics may be prescribed to prevent these infections. However, the benefit of antibiotic prophylaxis for operative vaginal deliveries is still unclear. This is an update of a review last published in 2017. OBJECTIVES: To assess the effectiveness and safety of antibiotic prophylaxis in reducing infectious puerperal morbidities in women undergoing operative vaginal deliveries including vacuum or forceps delivery, or both. SEARCH METHODS: For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (5 July 2019), and reference lists of retrieved studies. SELECTION CRITERIA: All randomised controlled trials comparing any prophylactic antibiotic regimens with placebo or no treatment in women undergoing vacuum or forceps deliveries were eligible. Participants were all pregnant women without evidence of infections or other indications for antibiotics of any gestational age. Interventions were any antibiotic prophylaxis (any dosage regimen, any route of administration or at any time during delivery or the puerperium). DATA COLLECTION AND ANALYSIS: Two review authors assessed trial eligibility and risk of bias. Two review authors extracted the data independently using prepared data extraction forms. Any discrepancies were resolved by discussion and a consensus reached through discussion with all review authors. We assessed methodological quality of the two included studies using the GRADE approach. MAIN RESULTS: Two studies, involving 3813 women undergoing either vacuum or forceps deliveries, were included. One study involving 393 women compared the antibiotic intravenous cefotetan after cord clamping compared with no treatment. The other study involving 3420 women compared a single dose of intravenous amoxicillin and clavulanic acid with placebo using 20 mL of intravenous sterile 0.9% saline. The evidence suggests that prophylactic antibiotics reduce superficial perineal wound infection (risk ratio (RR) 0.53, 95% confidence interval (CI) 0.40 to 0.69; women = 3420; 1 study; high-certainty evidence), deep perineal wound infection (RR 0.46, 95% CI 0.31 to 0.69; women = 3420; 1 study; high-certainty evidence) and probably reduce wound breakdown (RR 0.52, 95% CI 0.43 to 0.63; women = 2593; 1 study; moderate-certainty evidence). We are unclear about the effect on organ or space perineal wound infection (RR 0.11, 95% CI 0.01 to 2.05; women = 3420; 1 study) and endometritis (average RR 0.32, 95% CI 0.04 to 2.64; 15/1907 versus 30/1906; women = 3813; 2 studies) based on low-certainty evidence with wide CIs that include no effect. Prophylactic antibiotics probably lower serious infectious complications (RR 0.44, 95% CI 0.22 to 0.89; women = 3420; 1 study; high-certainty evidence). They also have an important effect on reduction of confirmed or suspected maternal infection. The two included studies did not report on fever or urinary tract infection. It is unclear, based on low-certainty evidence, whether prophylactic antibiotics have any impact on maternal adverse reactions (RR 2.00, 95% CI 0.18 to 22.05; women = 2593; 1 study) and maternal length of stay (MD 0.09 days, 95% CI -0.23 to 0.41; women = 393; 1 study) as the CIs were wide and included no effect. Prophylactic antibiotics slightly improve perineal pain and health consequences of perineal pain and probably reduce costs. Prophylactic antibiotics did not have an important effect on dyspareunia (difficult or painful sexual intercourse) or breastfeeding at six weeks. Antibiotic prophylaxis may slightly improve maternal hospital re-admission and maternal health-related quality of life. Neonatal adverse reactions were not reported in any included trials. AUTHORS' CONCLUSIONS: Prophylactic intravenous antibiotics are effective in reducing infectious puerperal morbidities in terms of superficial and deep perineal wound infection or serious infectious complications in women undergoing operative vaginal deliveries without clinical indications for antibiotic administration after delivery. Prophylactic antibiotics slightly improve perineal pain and health consequences of perineal pain, probably reduce the costs, and may slightly reduce the maternal hospital re-admission and health-related quality of life. However, the effect on reduction of endometritis, organ or space perineal wound infection, maternal adverse reactions and maternal length of stay is unclear due to low-certainty evidence. As the evidence was mainly derived from a single multi-centre study conducted in a high-income setting, future well-designed randomised trials in other settings, particularly in low- and middle-income settings, are required to confirm the effect of antibiotic prophylaxis for operative vaginal delivery.


Assuntos
Antibioticoprofilaxia , Extração Obstétrica/efeitos adversos , Infecção Puerperal/prevenção & controle , Doenças Vaginais/prevenção & controle , Combinação Amoxicilina e Clavulanato de Potássio/uso terapêutico , Antibacterianos/uso terapêutico , Antibioticoprofilaxia/efeitos adversos , Cefotetan/uso terapêutico , Endometrite/prevenção & controle , Episiotomia/efeitos adversos , Feminino , Humanos , Tempo de Internação , Forceps Obstétrico , Períneo/lesões , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto , Infecção da Ferida Cirúrgica/prevenção & controle , Vácuo-Extração/efeitos adversos
18.
Eur J Obstet Gynecol Reprod Biol ; 247: 94-100, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32087423

RESUMO

Several studies have investigated the importance of maternal, fetal factors and intrapartum characteristics in predicting severe perineal lacerations. The purpose of the present systematic review is to accumulate current evidence and provide estimated effect sizes for the various risk factors described. We reviewed Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar for published studies in the field for observational studies as well as randomized controlled trials. Two researchers independently assessed the included studies and documented outcomes. Data extraction was performed using a modified data form that was based in Cochrane`s data collection form for intervention reviews for RCTs and non-RCTs. Forty-three articles were selected for inclusion in the present systematic review. The analyzed population reached 716,031 parturient of whom 22,280 (3,1%) sustained third- and fourth-degree perineal lacerations. Several risk factors were identified. Instrumental delivery [RR 3.38 (2.21, 5.18)], midline episiotomy [RR 2.88 (1.79, 4.65)] and a persistent occiput posterior position [RR 2.73 (2.08, 3.58)] were associated with the higher risk of developing severe perineal lacerations. Mediolateral episiotomy did not increase, but was also not protective against perineal lacerations [RR 1.55 (0.95, 2.53)]. Several factors contribute to the development of severe perineal lacerations. The present meta-analysis presents accumulated data that may help physicians estimate risks and provide appropriate patient counseling.


Assuntos
Episiotomia/estatística & dados numéricos , Extração Obstétrica/estatística & dados numéricos , Lacerações/epidemiologia , Períneo/lesões , Peso ao Nascer , Episiotomia/efeitos adversos , Extração Obstétrica/efeitos adversos , Feminino , Humanos , Lacerações/classificação , Complicações do Trabalho de Parto/etiologia , Gravidez , Fatores de Risco
19.
Aust N Z J Obstet Gynaecol ; 60(2): 175-182, 2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32065386

RESUMO

BACKGROUND: Third- and fourth-degree tears are associated with significant pain, discomfort and impact on quality of life and intimate relationships. Australian women experience comparatively higher rates of third- and fourth-degree tears relative to countries of similar economic development. AIMS: We aimed to conduct a comprehensive review of the literature, published over the past five years, to identify the best ways to prevent and manage third- and fourth-degree perineal tears in Australian maternity centres. MATERIALS AND METHODS: We searched the literature using the Cochrane Database of Systematic Reviews, EMBASE, MEDLINE, Maternity and Infant Care Database and Google Scholar for articles published since 2013 using key search terms. A review of reviews was undertaken given the extensive amount of literature on this topic. RESULTS: Twenty-six systematic reviews were identified. The most common risk factors reported in the literature for third- and fourth-degree tears included primiparity, mother's ethnicity, large for gestational age infants and certain interventions used in labour and birth, such as instrumental deliveries. Preventive practices with varying degrees of effectiveness and often dependant on parity included: antenatal perineal massage, different maternal birthing positions, water births, warm compresses, protection of the perineum and episiotomy for instrumental births. CONCLUSIONS: Third- and fourth-degree perineal tears are associated with immediate and long-term implications for women and health systems. Evidence-based approaches can reduce the number of women who sustain a severe perineal tear and alleviate the associated disease burden for those who do.


Assuntos
Lacerações/prevenção & controle , Complicações do Trabalho de Parto/prevenção & controle , Períneo/lesões , Canal Anal/lesões , Austrália , Parto Obstétrico/efeitos adversos , Episiotomia , Feminino , Humanos , Lacerações/terapia , Complicações do Trabalho de Parto/terapia , Gravidez , Qualidade de Vida , Fatores de Risco
20.
Eur J Obstet Gynecol Reprod Biol ; 247: 66-72, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32070848

RESUMO

Pelvic floor trauma during childbirth is highly prevalent and is associated with long term risks of incontinence and pelvic organ prolapse. Societies and organizations have published clinical guidelines in order to standardise and improve the management of perineal care. The aim of this study was to systematically evaluate the quality of clinical guidelines on obstetric perineal trauma and care using the AGREE II instrument. We searched Medline, PubMed, Web of Science and ScienceDirect databases from inception until the 15th of December 2018 using the terms "guideline" OR "guidelines", OR "guidance", OR "recommendation" AND "obstetric anal sphincter injury", OR "perineal laceration" OR "perineal tear" OR "perineal trauma" OR "vaginal tear". Twelve guidelines were included, in English and Spanish.The assessment of the guidelines was performed using AGREE II by 5 appraisers.Ten guidelines scored more than 50 %, and 3 of them scored higher than 70 %. Two guidelines scored <50 % and were considered as low quality. Level of evidence and grade of recommendations were used by 7 guidelines of the 12 guidelines. Although some guidelines received high scores, there is space for improvement of the standards of guidelines.


Assuntos
Canal Anal/lesões , Lacerações/terapia , Diafragma da Pelve/lesões , Períneo/lesões , Guias de Prática Clínica como Assunto/normas , Parto Obstétrico/efeitos adversos , Episiotomia/efeitos adversos , Episiotomia/métodos , Feminino , Humanos , Lacerações/prevenção & controle , Gravidez
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