Timing of operative vaginal delivery and associated perinatal outcomes in nulliparous women

Objective.?To compare perinatal outcomes in nulliparous women who had operative vaginal delivery early during second stage (1–3?h) to those who delivered vaginally with a prolonged second stage (>3?h).

Methods.?This is a retrospective cohort study of nulliparas with term, singleton, vaginal deliveries beyond the first hour of second stage. Women who underwent operative vaginal deliveries (OVD) during 1–3?h of the second stage were compared to women who delivered vaginally but with a second stage duration of >3?h. Perinatal outcomes were examined using chi-square test, and potential confounders were controlled for using multivariable logistic regression analysis.

Results.?Nulliparas delivered vaginally beyond 3?h of second stage had lower odds of third or fourth degree perineal lacerations (aOR?=?0.63, 95% CI 0.51–0.77), neonatal cephalohematoma (aOR?=?0.48, 95% CI 0.28–0.83) and admissions to intensive care nursery (aOR?=?0.70, 95% CI 0.49–0.99) compared to operative vaginal deliveries during 1–3?h of second stage.

Conclusion.?Compared to nulliparas who had operative vaginal deliveries performed early (1–3?h) in the second stage, women who delivered later (>3?h duration of second stage), either by spontaneous or operative vaginal delivery, had lower risk of third or fourth degree perineal lacerations without incurring risk of increased adverse neonatal outcomes.     

Use of lubricant gel to shorten the second stage of labor during vaginal delivery

Abstract

Background: Vaginal application of lubricant during labor has been studied to shorten the length of the second stage of labor.

Objective: To evaluate whether vaginal application of lubricant shortens the second stage of labor.

Data sources: Electronic databases were searched from their inception until February 2018. No restrictions for language or geographic location were applied.

Study eligibility criteria: Randomized controlled trials (RCTs) comparing the use of lubricant of the vaginal canal (i.e. intervention group) with a control group (i.e. no lubricant) in pregnant women with singleton gestation and cephalic presentation undergoing spontaneous vaginal delivery at term. Trials on other interventions that might impact second stage of labor (pushing methods, perineal massage, Ritgen’s maneuver, etc.) were not included.

Study appraisal and synthesis methods: All analyses were done using an intention-to-treat approach. The primary outcome was the length of the second stage of labor. Pooled analysis was performed using the random-effects model of DerSimonian and Laird to produce summary treatment effects in terms of mean difference (MD) with 95% confidence interval (CI).

Tabulation, integration, and results: Three RCTs including 512 women evaluating the effect of lubricant application during labor were included in the meta-analysis. All trials included pregnant women with singleton gestations in cephalic presentation at term undergoing spontaneous vaginal delivery. One trial included only nulliparous women, while the other two included both nulliparous and multiparous women. Lubricant application started in the first stage before the active phase of labor, and was done intermittently by the midwife or the physician. A sterile gel was applied into the vaginal canal manually or with an applicator. All trials used water-soluble gel. The quantity of gel used was about 2–5?ml for each vaginal examination. There were no statistically significant differences, comparing women who received lubricant gel during labor with those who did not, in the lengths of second stage of labor (MD ?7.11?min, 95% CI ?15.60 to 1.38), of the first stage of labor, or of the active phase of the first stage of labor. No between-group differences were noticed in the risk of perineal lacerations, mode of delivery, and in the neonatal outcomes.

Conclusion: Vaginal application of lubricant during labor does not reduce the length of the second stage of labor in pregnant women with singleton gestations undergoing an attempt at spontaneous vaginal delivery at term.     

经阴道头位分娩中倡导限制会阴切开

介绍国内外头位分娩中会阴切开的现状及研究概况,说明限制会阴切开在产科临床推行的意义。通过限制会阴切开在头位分娩的临床实施,客观分析其关键技术环节及难点。     

Incidence and risk factors for severe perineal laceration after vaginal delivery in Japanese patients

Objective: The aim of this study was to assess the frequency of severe perineal lacerations defined as either third- or fourth-degree lacerations during normal spontaneous vaginal delivery and to evaluate potential risk factors in Japanese patients. Materials and methods: An electronic audit of the perinatal database at the Tama-Nagayama Hospital of Nippon Medical School and Yamaguchi Hospital from 1997 through 2004 was completed. Singleton vaginal vertex deliveries were analyzed for potential risk factors using univariate and multivariate logistic regression analysis. Results: From the database, 7,946 deliveries were identified, with 135 deliveries resulting in severe lacerations (1.7%). In the multivariate logistic regression analysis, severe lacerations were associated significantly with primiparous (odds ratio, 4.36; 95% CI, 2.17–9.57), oxytocin use (odds ratio, 2.19; 95% CI, 1.27–3.73), midline episiotomy (odds ratio, 4.68; 95% CI, 2.09–11.55), forceps-assisted delivery (odds ratio, 7.11; 95% CI, 1.95–20.59), vacuum-assisted delivery (odds ratio, 5.93; 95% CI, 3.38–10.36), and shorter attendant experience (odds ratio, 2.88; 95% CI, 1.12–9.81). Conclusions: The present study demonstrated that operator factors, such as midline episiotomy, oxytocin use, assisted delivery and attendant experience, are independent risk for severe perineal lacerations after vaginal delivery in Japanese patients. The results suggest that midline episiotomy and assisted vaginal delivery, especially forceps-assisted delivery should be avoided in patients who are being delivered of a first child whenever possible.     

Incidence, severity, and determinants of perineal pain after vaginal delivery: a prospective cohort study

OBJECTIVES: The purpose of this study was to determine the frequency of perineal pain in the 6 weeks after vaginal delivery and to assess the association between perineal trauma and perineal pain.Study design This was a prospective cohort study of parturients at 1 day, 7 days,' and 6 weeks' post partum in an academic tertiary obstetric unit in Toronto, Canada. Four hundred forty-four women were followed up, including women with an intact perineum (n=84), first-/second-degree tears (n=220), episiotomies (n=97), or third-/fourth-degree tears (n=46). Primary outcome was the incidence of perineal pain on day of interview; secondary outcomes were pain score measurements and interference with daily activities. RESULTS: Perineal trauma was more common among primiparous women, those with operative vaginal deliveries, and those with epidural analgesia during the second stage of labor. The incidence of perineal pain among the groups during the first week was intact perineum 75% (day 1) and 38% (day 7); first-/second-degree tears 95% and 60%; episiotomies 97% and 71%; and third-/fourth-degree tears 100% and 91%. By 6 weeks, the frequency of perineal pain was not statistically different between trauma groups. CONCLUSION: Acute postpartum perineal pain is common among all women. However, perineal pain was more frequent and severe for women with increased perineal trauma.     

Racial/ethnic differences in perineal, vaginal and cervical lacerations

OBJECTIVE: To determine if variation exists between ethnicities for risk of perineal, vaginal, and cervical laceration at vaginal delivery. STUDY DESIGN: Retrospective cohort study of nulliparous women who underwent vaginal delivery of a vertex presentation. Predictor variable was ethnicity with outcome variables cervical, vaginal, and second-, third-, or fourth-degree perineal laceration. Logistic regression analysis was conducted to control for confounders. RESULTS: Of the 17,216 who met criteria, Filipino (OR = 1.92, 95% CI 1.64-2.25) and Chinese (OR = 1.60, 95% CI 1.33-1.92) women were at greatest risk for third- and fourth-degree laceration. Only Filipino (OR = 1.32, 95% CI 1.10-1.57) and other Asian (OR = 1.23, 95% CI 1.08-1.41) women were at slightly increased risk of vaginal laceration. No differences were seen for cervical laceration. CONCLUSION: Different ethnicities are at widely varying risk of perineal laceration, but little difference exists for vaginal or cervical lacerations. Research into the mechanisms behind this should investigate differences in perineal anatomy.     

Randomized controlled trial of glove perforation in single- and double-gloving in episiotomy repair after vaginal delivery

OBJECTIVE: The aims of the study presented here were to compare the rate of glove perforation between single-gloving and double-gloving methods, and the time of operation and level of surgeon in episiotomy repair after vaginal delivery. METHOD: A prospective randomized controlled trial was performed from the beginning of May to the end of December, 2002 at Ramathibodi Hospital. A comparison of glove perforation between single-gloving and double-gloving methods was performed. Glove perforations were tested by filling each glove with water. Glove perforation rate, position of perforation, time of operation and surgeon level of experience were analyzed. RESULTS: One hundred and fifty sets of double-gloving method and 150 sets of single-gloving method were evaluated. The glove perforation rates were 4.6 and 18% in double-inner gloves and single-gloves, respectively, with statistical difference (P < 0.05). There was no significant difference between glove perforation rates in double-outer gloves (22.6%) and single-gloves (18%). There was matched perforation of the same finger of both outer and inner gloves in 2% of all double-inner gloves. The frequency of glove perforation was classified by the surgeon's level of experience and time of operation was no difference in each level. CONCLUSION: The double-gloving method significantly reduced the risk of exposure of the surgeon's hand to the patient's blood, when compared with the single-gloving method in episiotomy repair. There were no differences in the rate of glove perforations compared to the time of operation and level of surgeon.     

Long-term impacts of vaginal birth with mediolateral episiotomy on sexual and pelvic dysfunction and perineal pain

Objective: To investigate whether spontaneous vaginal birth with mediolateral episiotomy has any long-term impact on urinary and/or fecal incontinence, sexual dysfunction and perineal pain in primiparous women.

Methods: This matched case-control study included 150 women between 25 and 35 years old who had a singleton childbirth at least five years previously. Patients were grouped as; women who had a spontaneous vaginal delivery with mediolateral episiotomy (Group 1), an elective cesarean delivery (Group 2), and who had no delivery (Group 3). Controls were matched for age and delivery time. Urinary/fecal incontinence were questioned and Female Sexual Function Index (FSFI) questionnaire was completed. Total FSFI and domain scores were compared. Statistical evaluation was performed using One-way ANOVA test or χ² test. Statistical significance was defined as p?Results: No women had urinary/fecal incontinence nor sexual dysfunction. Mean total FSFI points in Group 1 were significantly lower than in Groups 2 and 3 (p?=?0.001). There were significant differences in sexual desire between groups 1 and 3 (p?=?0.005), in arousal and in orgasm between both groups 1 and 2 (p?=?0.001 and p?=?0.038, respectively) and groups 1 and 3 (p?=?0.001 and p?=?0.001, respectively). There was no significant difference between groups 2 and 3 in any parameters or total points.

Conclusions: Vaginal delivery with mediolateral episiotomy is not associated with urinary and/or fecal incontinence and sexual dysfunction but associated with a decreased sexual functioning as well as sexual desire, arousal and orgasm within postpartum five years.     

Risk factors for acute postpartum urinary retention after vaginal delivery: focus on episiotomy direction

Objective: This study aimed to investigate the independent factors for acute postpartum urinary retention (APUR) after vaginal delivery.

Methods: From January 2008 to December 2013, 98 patients with APUR after vaginal delivery without instrument use were compared with 108 control patients matched by age and medical history. Multivariate logistic regression analysis was performed to identify independent risk factors for APUR. Predictive accuracy for the multivariate model was assessed using the derived area under a receiver operating characteristics curve.

Results: Among maternal previous partial history, mean live birth history was lower in the APUR group (0.12 versus 0.31, p?=?0.017). Regional anesthesia use (76.5% versus 60.2%, p?=?0.036), mediolateral episiotomy (63.3% versus 31.5%, p?<?0.001) and labor time were significantly higher in the APUR group. Multivariate logistic regression analysis showed that mediolateral episiotomy, labor time and the presence of regional anesthesia were independent contributing factors for the development of APUR. This model’s predictive accuracy for APUR was 73.1%.

Conclusion: Prolonged labor time, regional anesthesia and mediolateral episiotomy were independent factors for APUR. Therefore, we considered median episiotomy to be the best approach during vaginal delivery avoiding APUR.     

Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States

OBJECTIVE: The purpose of this study was to estimate the incidence of urinary and bowel incontinence in relation to anal sphincter laceration in primiparous women and to identify factors that are associated with anal sphincter laceration in a unit that uses primarily midline episiotomy. STUDY DESIGN: From January 1, 1997, to March 30, 2000, 2941 questionnaires concerning pelvic floor function 6 months after delivery were mailed to primiparous women who were delivered vaginally at the University of Michigan Medical Center. Charts were reviewed for 2858 deliveries to assess the use of episiotomy and the degree of perineal trauma, along with demographic and pertinent delivery variables. There were 943 women who completed the urinary function questionnaire and 831 women who completed the bowel function questionnaire. Univariate analysis was performed on all covariates. Multiple logistic regression was used for the analysis of the presence of third- or fourth-degree lacerations as the outcome. RESULTS: Nineteen percent of the women who completed the survey had sustained third- or fourth-degree lacerations during childbirth. The women in the sphincter laceration group were more likely (23.0%) to have bowel incontinence than the women in the control group (13.4%) (P<.05). The incidence of worse bowel control was nearly 10 times higher in women with fourth-degree lacerations (30.8%) compared with women with third-degree lacerations (3.6%, P<.001). Macrosomia (odds ratio, 2.19; 95% CI, 1.61, 2.99), forceps-assisted delivery (odds ratio, 4.75; 95% CI, 3.43, 6.57), and vacuum-assisted delivery (odds ratio, 3.51; 95% CI, 2.64, 4.66) were associated with higher risks of third- and fourth-degree lacerations. Midline episiotomy (odds ratio, 2.24; 95% CI, 1.81, 2.77), but not mediolateral (odds ratio, 0.66; 95% CI, 0.375, 1.19), episiotomy was associated with anal sphincter lacerations. More than one half of the women had new onset of urinary incontinence after delivery and reported several lifestyle modifications to prevent leakage. CONCLUSION: Women with third- and fourth-degree lacerations were more likely to have bowel incontinence than women without anal sphincter lacerations. Fourth-degree lacerations appear to affect anal continence greater than third-degree lacerations.     

Minimizing genital tract trauma and related pain following spontaneous vaginal birth

Genital tract trauma is common following vaginal childbirth, and perineal pain is a frequent symptom reported by new mothers. The following techniques and care measures are associated with lower rates of obstetric lacerations and related pain following spontaneous vaginal birth: antenatal perineal massage for nulliparous women, upright or lateral positions for birth, avoidance of Valsalva pushing, delayed pushing with epidural analgesia, avoidance of episiotomy, controlled delivery of the baby's head, use of Dexon (U.S. Surgical; Norwalk, CT) or Vicryl (Ethicon, Inc., Somerville, NJ) suture material, the "Fleming method" for suturing lacerations, and oral or rectal ibuprofen for perineal pain relief after delivery. Further research is warranted to determine the role of prenatal pelvic floor (Kegel) exercises, general exercise, and body mass index in reducing obstetric trauma, and also the role of pelvic floor and general exercise in pelvic floor recovery after childbirth.     

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

ObjectiveThe 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).MethodsA 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.ResultsA 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).ConclusionAlthough 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.     

Factors predictive of failed operative vaginal delivery

OBJECTIVE: The purpose of this study was to determine what factors are independently associated with an increased likelihood of failed operative vaginal delivery. STUDY DESIGN: We conducted a population-based case-control study evaluating maternal, pregnancy, provider, care setting, and fetal factors associated with failed operative vaginal delivery. Subjects were identified using Washington state birth certificates for infants born between 1992 and 2001. Cases (n = 1750) were live-born singletons with both labored cesarean delivery and an operative vaginal delivery ("failure") coded on the birth certificate. Controls (n = 3500), frequency matched by delivery year to the cases, were randomly selected from among singletons undergoing a successful operative vaginal delivery. Odds ratios (OR) and associated 95% CI, estimated with Mantel-Haenszel methods, measured the association between case status and potential risk factors. RESULTS: Failed operative vaginal delivery was associated with increased maternal age, African American race, higher body mass index (BMI), diabetes, polyhydramnios, induction of labor, dysfunctional labor, and prolonged labor. Case compared with control mothers were more likely to deliver a low-birth weight or macrosomic infant. CONCLUSION: Identification of maternal and fetal factors associated with failed operative vaginal delivery may enable providers to better counsel patients, and allow improved planning and allocation of surgical resources.