Decision-to-delivery interval for emergency caesareans in the Aurore perinatal network

Objectives

To determine the interval between decision and delivery (DDI) for urgent and very urgent caesarean deliveries within a perinatal network, to compare the results according to maternity ward level and organisation, and to assess the impact of DDI on neonatal outcome.

Study design

Prospective observational study in the 31 maternity units of the Aurore perinatal network (17 Level I, 12 Level II, and two Level III). The obstetric team defined the degree of urgency for the caesareans, measured the DDI, and reported neonatal outcome.

Results

The study includes 666 unplanned caesarean sections. The median DDI for emergency caesareans (n = 365) was 48 min for Level I units, 40 min for Level II, and 22 min for Level III (P < 0.05). For the very urgent caesareans (n = 82), the median DDI was respectively 35, 24, and 13 min (P < 0.05) and the percentage with a DDI ≤ 30 min were 45%, 62%, and 100% (P < 0.05). The proportion of DDI ≤ 30 min was 0% in maternity units where obstetricians and anaesthetists were not always onsite, 67% when only the anaesthetist was always present (P < 0.05) and 88% for units where both were always present. The neonate's condition did not differ significantly according to DDI.

Conclusions

DDI varies very substantially according to the level and organisation of the maternity units in the Aurore network. It was not significantly correlated with neonatal outcome in our population.     

Susceptibility of red blood cell lipids to in vitro oxidation and antioxidant status in preeclampsia

Objective

To investigate susceptibility of red blood cell (RBC) lipids to oxidation and antioxidant status in preeclampsia.

Study design

Twenty-one women with mild preeclampsia, 21 women with severe preeclampsia, and 20 healthy pregnant women were included in this cross-sectional study. Susceptibility of RBC to oxidative stress was determined by measuring RBC-malondialdehyde levels after incubation with hydrogen peroxide. Vitamins E and C, total carotenoids and erythrocyte superoxide dismutase and glutathione peroxidase (GPx) activities and serum total antioxidant capacity (TAC) were determined spectrophotometrically. One-way analysis of variance and correlation analysis were used for statistical analyses.

Results

Compared with the normal pregnant women, susceptibility of RBC to oxidation was enhanced in the mild (p < 0.05) and severe (p < 0.01) preeclampsia groups, TAC was lower in the mild (p < 0.01) and severe (p < 0.001) preeclampsia groups. Vitamin C level was decreased in severe preeclampsia and total carotene level was decreased in mild and severe preeclampsia groups (p < 0.05). GPx activity was also decreased in the mild (p < 0.01) and severe (p < 0.05) preeclampsia groups.

Conclusion

The results of the present study supported the oxidative stress hypothesis of preeclampsia and it is possible that RBC play a role in the pathophysiology of the disease.     

Comparative evaluation of the Joel-Cohen cesarean section versus the transrectal incision

Objective

The aim of this study was to compare the Joel-Cohen method for cesarean section to the traditional transrectal incision.

Method

Fifty-two patients requiring a caesarean section were enrolled in this prospective study. Overall morbidity and post-operative pain was assessed. Four surgeons participated to this study, each included 13 patients. The main judgement criterion was post-operative pain on the first day.

Results

Post-operative pain on the first day was less important (50 vs 23% p = 0.04) in Joel-Cohen's. This method was shorter compared to the transrectal incision (33,6 + 6,4 min vs 51,2 + 8 min p < 0.0001). There was no difference in overall morbidity between the two groups.

Conclusion

Joel-Cohen's method decrease post-operative pain and is a shorter procedure compared to the transrectal incision.     

Acute antepartum pyelonephritis in pregnancy: a critical analysis of risk factors and outcomes

Objective

To test the incidence and sonographic parameters of pyelonephritis during pregnancy, and to examine risk factors and pregnancy outcomes of women with acute antepartum pyelonephritis.

Study design

A retrospective population-based study comparing all singleton pregnancies of patients with and without acute antepartum pyelonephritis was performed. Patients lacking prenatal care as well as multiple gestations were excluded from the study. Multiple logistic regression models were used to control for confounders.

Results

Out of 219,612 singleton deliveries in 1988–2010, 165 women (0.07%) suffered from acute antepartum pyelonephritis. Abnormal sonographic findings were found in 85.7% of the patients with pyelonephritis. Pyelonephritis was significantly associated with nulliparity (46.1% vs. 24.4%, p < 0.001), younger maternal age (26.3 ± 6.0 vs. 28.6 ± 5.8 years, p < 0.001), intrauterine growth restriction (IUGR) (6.7% vs. 2.1%, p < 0.001), placental abruption (3.6% vs. 0.7%, p < 0.001), low 1 min Apgar scores (10.3% vs. 6.0%, p < 0.05), urinary tract infection (UTI) (4.2% vs. 0.4%, p < 0.001) and preterm delivery (less than 37 weeks gestation; 20.0% vs. 7.8%; p < 0.001). Using a multivariable analysis, independent risk factors for acute antepartum pyelonephritis were nulliparity (OR 2.0; 95% C.I 1.4–2.9; p < 0.001), UTI (OR 10.3; 95% C.I 4.8–22.1; p < 0.001) and younger maternal age (OR 0.96; 95% C.I 0.93–0.99; p = 0.009). Using another multivariable analysis, with preterm delivery as the outcome variable, acute antepartum pyelonephritis was found as an independent risk factor for preterm delivery (OR 2.6; 95% C.I 1.7–3.9; p < 0.001).

Conclusion

Acute antepartum pyelonephritis is associated with adverse perinatal outcomes and specifically is an independent risk factor for preterm delivery.     

Pregnancy outcomes in women with severe needle phobia

Objectives

Needle phobia in pregnancy poses a problem as women may refuse medical care because of their fear. The present study investigates the impact of needle phobia on the antenatal and intrapartum care of needle phobic women and reports on the pregnancy and neonatal outcomes.

Study design

A retrospective cohort of 112 cases, divided into severe and mild cases of needle phobia, was collected from the anaesthetic referral database. The data were collected manually as well as by using the computerised hospital database, and were analysed using SPSS version 19. Chi-square analysis and unpaired t-test were used to analyse categorical and continuous variables, respectively. The overall departmental statistics for 2009 and 2010 were used as a comparator.

Results

Women with severe needle phobia, compared to those with mild needle phobia, registered late with the antenatal services (17 weeks vs 14 weeks, p < 0.05), had a significant delay in obtaining their first antenatal blood tests (25 weeks vs 15 weeks, p < 0.0001), consented less often to the booking blood tests (62.8% vs 98.6%, p < 0.0001) and antenatal tests (30.2% vs 76.8%, p < 0.0001), had low use of pethidine (4.7% vs 24.6%, p < 0.01) and a higher demand for general anaesthesia (11.6% vs 0%, p < 0.01) and had an increased number of physiological deliveries of the placenta (37.2% vs 8.7%, p < 0.0001). The incidence of maternal and neonatal adverse outcomes in both groups was low.

Conclusion

Despite the differences in choice of analgesia and acceptance of routine blood tests, pregnancy outcomes in women with severe needle phobia were good. The study highlighted the importance of adequate risk assessment of all women disclosing their needle phobic status, and of provision of high-standard multidisciplinary care involving primary and secondary healthcare professionals.     

Comparison of active and expectant management on the duration of the third stage of labour and the amount of blood loss during the third and fourth stages of labour: a randomised controlled trial

Background

Postpartum haemorrhage is one of the most important causes of maternal death.

Objectives

To evaluate the effect of active management of the third stage of labour on the amount of blood loss in the third and fourth stages of labour, and the duration of the third stage of labour.

Methods

A randomised controlled trial was completed on 200 women who gave birth at a maternity unit in Iran. In the intervention group (n=100), 10 IU of oxytocin was injected intramuscularly into the mother following birth of the anterior shoulder of the baby. After clamping and cutting the umbilical cord, the uterus was pushed upwards and posterior, while the cord was pulled down with constant and intermittent traction until the placenta was delivered. In the control group (n=100), on observing signs of placental separation, the placenta was expulsed by maternal force. In both groups of women, blood loss was measured at birth using collecting devices, and drapes and sheets were weighed to estimate blood loss.

Findings

Mean blood loss during the third stage of labour was 216.93±165.16 ml and 232.12±150.35 ml in the intervention and control groups, respectively; the difference was not significant (p=0.49). In contrast, mean blood loss during the fourth stage of labour differed significantly (422.62±324.7 ml and 327.27±255.99 ml in the intervention and control groups, respectively; p=0.02). The mean duration of the third stage of labour was less in the intervention group than in the control group (4.69±5.51 mins and 6.34±5.03 mins; p=0.028).

Conclusions

Active management did not decrease blood loss during the third stage of labour, but did decrease the duration of this stage. Active management was associated with increased blood loss during the fourth stage of labour. Due to conflicting results between studies, further research should be undertaken to determine the optimal method by which to manage the third stage of labour.     

L-arginine pathway in neonates with meconium-stained amniotic fluid

Objective

To study the arginase, nitric oxide synthase and nitric oxide pathways associated with passage of meconium.

Study design

Cord blood samples were collected from 20 newborns with meconium-stained amniotic fluid (MSAF) and from 23 newborns with clear amniotic fluid. Cord blood pH, arginase, nitric oxide synthase and nitric oxide levels were compared between the groups.

Result

The differences between the arginase and nitric oxide measurements of the newborns with MSAF and those with clear amniotic fluid were significant. In the MSAF group arginase levels were significantly lower (p = 0.007) and nitric oxide levels were significantly higher (p = 0.032) than the clear amniotic fluid group.

Conclusion

Hypoxia may be involved in the pathogenesis of meconium passage due to decreased arginase and increased nitric oxide levels.     

The impact of plasma fibrinogen levels on patients with vulvar cancer

Objective

To investigate the association between plasma fibrinogen levels and clinico-pathological parameters of patients with vulvar cancer and to determine their value as prognostic parameters.

Study design

In this retrospective study, we evaluated pretreatment plasma fibrinogen levels in 120 patients with invasive squamous cell vulvar cancer and correlated them with clinico-pathological parameters and patients’ survival.

Results

Pretreatment plasma fibrinogen levels were directly associated with tumor stage (pT1a vs. pT1b vs. pT2 vs. pT3-4, p = 0.001), lymph node involvement (pN0 vs. pN1, p = 0.04), and histological grade (G1 vs. G2 vs. G3, p = 0.03), but not with patients’ age (≤70 years vs. >70 years, p = 0.6). In a multivariate survival analysis, tumor stage (p = 0.006/p = 0.02) and lymph node involvement (p < 0.001/p < 0.001), but neither histological grade (p = 0.2/p = 0.9) nor plasma fibrinogen levels (p = 0.6/p = 0.6) were associated with disease-free and overall survival, respectively. In a multivariate analysis, patient's age (≤70 years vs. >70 years) was associated with overall survival (p = 0.03) but not with disease-free survival (p = 0.1).

Conclusion

Pretreatment plasma fibrinogen levels were directly associated with tumor stage, lymph node involvement and histological grade. Although we could demonstrate a prognostic value of pretreatment plasma fibrinogen levels on survival, we were unable to establish fibrinogen as an independent prognostic parameter in patients with vulvar cancer.     

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

Objective

to evaluate the effects of low-level laser therapy for perineal pain and healing after episiotomy.

Design

a double-blind, randomised, controlled clinical trial comparing perineal pain scores and episiotomy healing in women treated with low-level laser therapy (LLLT) and with the simulation of the treatment.

Setting

the study was conducted in the Birth Centre and rooming-in units of Amparo Maternal, a maternity service located in the city of São Paulo, Brazil.

Participants

fifty-two postpartum women who had had mediolateral episiotomies during their first normal delivery were randomly divided into two groups of 26: an experimental group and a control group.

Intervention

in the experimental group, the women were treated with LLLT. Irradiation was applied at three points directly on the episiotomy after the suture and in three postpartum sessions: up to 2 hrs postpartum, between 20 and 24 hrs postpartum and between 40 and 48 hrs postpartum. The LLLT was performed with diode laser, with a wavelength of 660 nm (red light), spot size of 0.04 cm², energy density of 3.8 J/cm², radiant power of 15 mW and 10 s per point, which resulted in an energy of 0.15 J per point and a total energy of 0.45 J per session. The control group participants also underwent three treatment sessions, but without the emission of radiation (simulation group), to assess the possible effects of placebo treatment.

Main outcomes

perineal pain scores, rated on a scale from 0 to 10, were evaluated before and immediately after the irradiation in the three sessions. The healing process was assessed using the REEDA scale (Redness, Edema, Echymosis, Discharge Aproximation) before each laser therapy session and 15 and 20 days after the women's discharge.

Findings

comparing the pain scores before and after the LLLT sessions, the experimental group presented a significant within-group reduction in mean pain scores after the second and third sessions (p=0.003 and p<0.001, respectively), and the control group showed a significant reduction after the first treatment simulation (p=0.043). However, the comparison of the perineal pain scores between the experimental and control groups indicated no statistical difference at any of the evaluated time points. There was no significant difference in perineal healing scores between the groups. All postpartum women approved of the low-level laser therapy.

Conclusions

this pilot study showed that LLLT did not accelerate episiotomy healing. Although there was a reduction in perineal pain mean scores in the experimental group, we cannot conclude that the laser relieved perineal pain. This study led to the suggestion of a new research proposal involving another irradiation protocol to evaluate LLLT's effect on perineal pain relief.     

Red, orange and green Caesarean sections: a new communication tool for on-call obstetricians

Objective

To evaluate the effect of a novel communication tool, related to the degree of urgency for Caesarean sections (CSs), on the decision-to-delivery interval for emergency CS.

Study design

Red CS are very urgent cases corresponding to life-threatening maternal or foetal situations, orange CS are urgent cases and green CS are non-urgent intrapartum CS. We carried out this cohort study in a French maternity hospital. The study included all emergency Caesarean sections during two 6-month periods, before and after introduction of the code. We compared the decision-to-delivery interval of the two study periods.

Results

Our study included 174 emergency CS. The mean decision-to-delivery interval after introduction of the code was 31.7 min, significantly shorter (p = 0.02) than the 39.6 min interval before introduction of the colour code. Except for the preparation time, each time interval decreased. This included transporting the patient into the operating theatre, and the incision-to-delivery time interval.

Conclusion

This study suggests that the use of the three-colour code could significantly shorten the decision-to-delivery interval in emergency CS. Further prospective studies are needed to confirm this result.     

First-trimester maternal serum metastin, placental growth factor and chitotriosidase levels in pre-eclampsia

Objective

To investigate whether the serum levels of metastin and PIGF and chitotriosidase activity early in pregnancy differ in women who develop pre-eclampsia from those who remain normotensive.

Study design

A retrospective case–control study of prospectively collected data. Thirty healthy pregnant women and 31 women with pre-eclampsia were included in the study. Serum samples were collected at 11–14 weeks and stored at −70 °C. Levels of metastin, PIGF and chitotriosidase activity were measured in serum from pregnant women with subsequent development of pre-eclampsia and matched controls.

Results

Mean maternal serum metastin (1554 ± 385 pmol/L vs 1995 ± 375 pmol/L, p < 0.001) and PIGF (111.9 ± 7.0 pg/mL vs 124.9 ± 13.5 pg/mL, p < 0.001) levels were significantly lower and chitotriosidase activity was significantly higher (681.6 ± 248.3 nmol/mL/h vs 527.7 ± 223.1 nmol/mL/h, p < 0.01) in women who subsequently developed pre-eclampsia than in those who remained normotensive. The areas under the curve equal to 0.797, 0.831 and 0.681 (p < 0.001, p < 0.001 and p < 0.01) for metastin, PIGF, and chitotriosidase respectively were determined for the prediction of pre-eclampsia.

Conclusions

Metastin and PIGF levels and chitotriosidase activity are altered in the first trimester serum of women destined to become pre-eclamptic, reflecting placental dysfunction. Metastin, like PIGF, may have a potential to be used as a first-trimester biomarker of pre-eclampsia.     

Is there any relation between IL-6 gene −174 G>C polymorphism and postmenopausal osteoporosis?

Objective

IL-6 gene single nucleotide polymorphisms (SNPs) have been reported to have a protective effect against bone resorption. We aimed to investigate the association between bone mineral density and IL-6 promoter region −174 G>C SNP.

Study design

This study included 356 postmenopausal Turkish women, of whom 201 were osteoporotic (lumbar spine T score < −2.5 SD) and 155 non-osteoporotic (lumbar spine T score > −1.5 SD). Bone mineral density (BMD) measures were obtained using dual-energy X-ray absorptiometry. SNP of the IL-6 gene (−174 G>C) was examined by polymerase chain reaction-restriction fragment length polymorphism.

Results

The frequencies of the variant C allele (24% vs. 30%, p = 0.074) and mutant CC genotype (12% vs. 20%, p = 0.094) were higher in non-osteoporotic women. Lumbar spine and total hip BMD values were lowest among women with the G/G genotype, intermediate in the heterozygotes, and highest in women with the C/C genotype. The GG (p = 0.022) and GC (p = 0.037) genotypes were covariates which approached statistical significance in the regression model fitting of BMD.

Conclusion

IL-6 promoter region SNP showed an association with BMD in this postmenopausal Turkish population and these data suggest that the wild GG genotype influences the phenotype.     

Modes of delivery of first and second twins as a function of their presentation. Study of 614 consecutive patients from 1992 to 2000

Objectives

To study modes of delivery and neonatal morbidity of twins as a function of their presentation.

Study design

The study related to 614 consecutive patients who gave birth to twins in the maternity ward of the Hôpital Robert Debré from 1992 to 2000. Group A (n = 529) included patients who gave birth after 33 weeks of gestation and group B (n = 85) before 33 weeks. The parameters studied were the mode of delivery, the need for intubation at birth, 5-min Apgar score <9, transfer to intensive care, death in the neonatal period. The chi-square test was used for statistical analysis.

Results

In group A, significantly more cesarean sections were performed for breech–breech (22.6%) and breech–vertex (16%) presentations than for vertex–vertex (10.3%) and vertex–breech (4.6%) presentations. In group B, there was no significant difference in the rate of vaginal delivery. Second vertex twins of group A had significantly higher frequencies of intubation (3%) at birth and transfer to intensive care (3%) than the vertex first twins born by vaginal delivery (p = 0.01). These percentages were not significantly different from those observed for the second twins born by planned Cesarean section before the start of labor (2.8 and 5.6%, respectively). In group B, neonatal parameters did not differ significantly with the type of presentation at delivery.

Conclusions

The type of presentation should not influence the choice of mode of delivery of twin pregnancies, whatever the gestational age.     

Assessment of preoperative serum prolidase activity in epithelial ovarian cancer

Objective

Prolidase is a cytosolic exopeptidase that cleaves iminodipeptides with C-terminal proline and hydroxyproline and plays a major role in collagen turnover. The aim of this study was to evaluate preoperative serum prolidase activity, total oxidant status (TOS), and total antioxidant capacity (TAC) in patients with newly diagnosed epithelial ovarian cancer (EOC).

Study design

Serum prolidase activity, TOS, and TAC were measured spectrophotometrically in both EOC cases (n = 28) and controls (n = 28).

Results

Preoperative serum prolidase activity and TOS were significantly higher in patients with EOC compared to controls (p = 0.009 and 0.008, respectively), whereas TAC was significantly lower in cases (p < 0.001). A significant positive correlation was found between the stage, grade, and CA-125 level of EOC and serum prolidase activity (rho = 0.466, p = 0.012; rho = 0.501, p = 0.007; and rho = 0.447, p = 0.017, respectively) and TOS (rho = 0.588, p = 0.001; rho = 0.412, p = 0.029; and rho = 0.568, p = 0.002, respectively). In contrast, there was a negative correlation between TAC and the stage, grade, and CA-125 level of EOC (rho = −0.555, p = 0.002; rho = −0.566, p = 0.002; and rho = −0.581, p = 0.001, respectively).

Conclusion

Findings of the present study demonstrate that serum prolidase activity is significantly associated with the stage, tumor grade, and preoperative CA-125 level of EOC.     

Does 45,X/46,XX mosaicism with 6–28% of aneuploidy affect the outcomes of IVF or ICSI?

Objective

Several studies have shown an increased frequency of chromosomal aberrations in female partners of couples examined prior to intracytoplasmic sperm injection (ICSI). A retrospective cohort study was performed to determine whether 45,X/46,XX mosaicism affects the outcomes of in vitro fertilization (IVF) or ICSI.

Study design

Forty-six women with a 45,X/46,XX karyotype with 6–28% of aneuploidy were compared with 59 control women (46,XX), matched for age, from the female population who underwent IVF or ICSI between 1 January 1996 and 31 December 2006 at the Reproductive Medicine Unit at Brest University Hospital. The outcomes of 254 treatment cycles were compared according to patient karyotype.

Results

No difference was found in the number of retrieved oocytes (8.9 ± 5.5 vs 8.5 ± 4.7; p = 0.56) or the number of mature oocytes (7.4 ± 4.7 vs 6.9 ± 4.2; p = 0.49) between the 45,X/46,XX group and the 46,XX group, respectively. Fertilization rates did not differ between the groups for either IVF or ICSI. In addition, no difference was found in the pregnancy rate by cycle (17.4% vs 18.7%, respectively; p = 0.87). The percentage of first-trimester miscarriages was similar in both groups (13.6% vs 12.5%, respectively; p = 0.51).

Conclusion

45,X/46,XX mosaicism with 6–28% of aneuploidy has no adverse effect on the outcomes of IVF or ICSI among women referred to assisted reproductive technologies.     

Clinical estimation of fetal weight and the Hawthorne effect

Objective

The Hawthorne effect refers to improvement in performance solely due to the subject's knowledge that he or she is being studied. We sought to determine if an obstetrician's clinical estimation of fetal weight (EFW) is influenced by the Hawthorne effect seen in some clinical trials.

Study design

We compared obstetricians’ clinical EFW's obtained during a study period to those obtained prior to the study period in one institution. We included any patient presenting at ≥37 weeks gestation. We excluded multiple pregnancies and patients with a recent sonographic EFW.

Results

There was no difference in regards to the proportion of EFW's within 10% of the birthweight (67.9% vs. 68.5%, p = .91), the mean absolute difference of EFW-birthweight (282 ± 227 g vs. 285 ± 232 g, p = .88), or the mean absolute percent error (8.5 ± 7.4% vs. 8.6 ± 7.2%, p = .96). We also could not find any Hawthorne effect when we excluded resident physicians’ EFW's and when we analyzed the subgroup of newborns with a birth weight ≥4000 g.

Conclusion

An obstetrician's knowledge that he or she is being studied is unlikely to improve clinical EFW accuracy. Published clinical EFW accuracies are likely to be similar to those obtained in clinical practice.     

Treatment of uterine myoma with 5 or 10mg mifepristone daily during 6 months, post-treatment evolution over 12 months: double-blind randomised clinical trial

Objectives

To evaluate the efficacy and safety of 5 and 10 mg doses of mifepristone for 6 months for the treatment of uterine fibroids and to check those results at 1 year post-treatment.

Study design

Randomised double-blind clinical study carried out at the “Eusebio Hernández” Hospital, Havana, Cuba. One hundred and seventy-six women with symptomatic uterine fibroids received one daily capsule of 10 mg mifepristone orally or one daily capsule of 5 mg mifepristone orally, over 6 months. Up to two endometrial biopsies were performed. Reduction in fibroid volume was used to evaluate efficacy.

Results

The 5 and 10 mg dose had a similar efficacy in reducing the fibroid volume, 48.1% and 39.1%, p = 0.07, and that of the uterus, 30.3% and 27.2%, p = 0.63, respectively. Twelve months after treatment the majority of the subjects were asymptomatic with symptom prevalence similar to that at the end of treatment, except for hypermenorrhea and metrorrhagia, although the intensity of hypermenorrhea was much less, p < 0.01.

Conclusions

(1) Both doses obtain similar results in reducing fibroid size. (2) Administering 6 months’ treatment achieves symptomatic improvement lasting 1 year in a high percentage of cases. (3) More studies need to be carried out with longer treatment and follow-up periods.     

Effect of tamoxifen on extracellular signal-regulated kinases in the urethra of castrated female rats

Objective

To explore the role of primary physicians in the diagnostic delay of lower urinary tract and pelvic organ prolapse symptoms in parous women.

Study design

Prospective cohort study of women referred to the Urogynecology Outpatient Clinic of a major medical center by primary physicians in the community for initial assessment of lower urinary tract and pelvic organ prolapse symptoms.

Results

Most of the women blamed themselves for the delay. However, the primary physicians were considered responsible for 33.5% of the delays. There was no between-group differences in self-blame (p = 0.438). Women with pelvic organ prolapse blamed the gynecologist significantly more often than women with lower urinary tract symptoms (p = 0.043); 38.6% of the physicians considered the symptoms not sufficiently severe or a natural part of aging.

Conclusion

Patients need to receive more information on the availability of specific evaluations and treatments for pelvic floor dysfunction.     

Effectiveness of local anaesthetics with and without vasoconstrictors for perineal repair during spontaneous delivery: double-blind randomised controlled trial

Objective

to investigate the use of local anaesthetics, in the presence or absence of vasoconstrictors, for perineal repair during spontaneous delivery.

Design

double-blind, randomised-controlled trial.

Setting

a birth centre, in the city of Sao Paulo, Brazil.

Participants

from June to December 2004, a total of 96 women were allocated into three groups (first-degree perineal lacerations, second-degree perineal lacerations or episiotomy), and treated with local anaesthesia (1% lidocaine or 1% lidocaine with epinephrine) (n=16 per treatment per group).

Interventions

an initial local infiltration of the anaesthetic solution was given so that episiotomy could be carried out (5 ml) and to suture spontaneous lacerations (1 ml), followed by repeated doses (1 ml) until pain was completely inhibited.

Measurements and findings

the main outcome measurement was the volume of anaesthetic used during episiotomy and perineal suture. Our data suggest that the concomitant use of the vasoconstrictor resulted in a significantly lower average volume used in the treatment of first-degree (1 ml, 95% confidence interval (CI) 0.4–1.6) and second-degree (3.7 ml, 95% CI 1.6–5.8) lacerations (p=0.002 and 0.001, respectively). A 0.3 ml (95% CI 1.5–2.1) average decrease in anaesthetic volume was observed with episiotomy (p=0.724). The maximum volume of anaesthetic used with and without vasoconstrictor was 1–2 ml in 95% and 3–4 ml in 50% of first-degree lacerations, respectively, and 1–6 ml in 88% and 7–15 ml in 81% of second-degree lacerations, respectively. For episiotomy, the maximum dose was 15 ml, regardless of anaesthetic solution used.

Key conclusions

our data confirm the hypothesis that the use of anaesthetics in conjunction with vasoconstrictors is more effective than anaesthetics alone in the repair of perineal lacerations, but not for episiotomy.