Evaluation of postpartum perineal pain and dyspareunia--a prospective study

Objective

Postpartum perineal pain and dyspareunia have been reported to affect 42% of women within the first 2 weeks after their first vaginal delivery. We aimed to determine the prevalence of dyspareunia and perineal pain using validated pain scores following accurate classification of perineal trauma according to the guidelines of the Royal College of Obstetricians and Gynaecologists.

Study design

Prospective study of women having their first vaginal delivery. All women had a perineal and rectal examination. Pain was assessed with a 4-point Verbal Rating Score and an 11-point visual analogue scale on day 1, day 5 and 2 months after delivery.

Results

Two hundred and fifty-four women were invited and 95% participated. Ninety-two percent experienced perineal pain on day one, resolving in 88% (p < 0.001) at 2 months. Compared to an intact perineum or first degree tear significantly more women experienced perineal pain after a second, third or fourth degree tear. Forty percent resumed coitus within 2 months regardless of whether perineal trauma occurred or not. Five days after delivery, uncomplicated episiotomies resulted in more perineal pain than second degree tears.

Conclusions

Although perineal pain affected 92% of mothers, it resolved in the majority within 2 months of delivery. Obstetric anal sphincter injury is associated with more perineal pain than other perineal trauma. Spontaneous second degree tears cause less perineal pain than episiotomies. The 11-point visual analogue scale may be more sensitive than the 4-point Verbal Rating Score.     

Techniques to reduce perineal pain during spontaneous vaginal delivery and perineal suturing: a UK survey of midwifery practice

OBJECTIVE: To investigate use of pharmacological and non-pharmacological methods of perineal analgesia used by midwives during the second stage of labour and perineal repair in the UK. DESIGN: Postal survey. METHODS: Self-complete questionnaires were sent to Heads of Midwifery in all 219 maternity units in the UK. Information was requested on the number and type of deliveries undertaken in the previous year and on the midwifery procedures used to provide pain relief immediately before delivery and for perineal repair. Details were also sought on local anaesthetics given before episiotomy or perineal repair. FINDINGS: 207 completed questionnaires were returned providing information on 210 maternity units. Midwives reported using a variety of non-pharmacological analgesic methods to control pain at the end of the second stage of labour. Hot packs were used in 70 (33%) maternity units, cold packs in 44 (21%) and perineal massage in 109 (52%). Midwives in 131 (62%) maternity units used injectable local anaesthetics to control perineal pain. All units advocated use of local anaesthetic before episiotomy or perineal repair, but the reported doses used varied widely. CONCLUSIONS: The literature on levels of pain experienced immediately before spontaneous vaginal delivery and during perineal repair is sparse, but what evidence exists suggests that, for some women, these occasions are accompanied by severe pain. Findings from this survey show that there is considerable variation in what midwives provide to control pain. Formal evaluation of the perineal analgesia offered to women during the second stage of labour is urgently required.     

Enhancing postnatal perineal care

Maternal physical and psychological wellbeing during the postnatal period can be significantly impaired by perineal trauma sustained during childbirth. Current literature emphasises preventative measures, yet there is a lack of a systematic, evidence based approach to postnatal perineal care. This is concerning as the eighth 'Saving mothers' lives' report (CMACE 2011) identifies genital tract sepsis for the first time as the leading cause of maternal deaths. The aim of this article is therefore to develop a systematic approach to improve postnatal perineal care with a focus on assessment and treatment of perineal pain as well as recovery of pelvic floor function.     

Experience with an obstetric perineal clinic

Objective: To review the characteristics of patients attending a dedicated perineal clinic in a maternity hospital. Methods: Case-note review of all new referrals over 2 years 1998 and 1999. Results: A total of 399 women were referred with mean age of 34 years (range 18–77), parity of 1.7 (range 1–13) and duration of symptoms of 14 (range 1–156) months. A total of 213 (53%) women were assessed following a recognized third degree perineal tear, 78 (20%) because of fecal incontinence, 45 (11%) for determination of future mode of delivery following a previous perineal injury, 37 (9%) women for treatment of perineal pain and 26 (7%) for other miscellaneous complaints. A total of 83 (21%) required physiotherapy, 42 (11%) received dietetic manipulation, 29 (7%) were treated for perineal pain and 12 (3%) underwent vaginal surgery. A total of 24 (6%) women were referred for consideration of secondary anal sphincter repair and 11 (3%) for specialist gastroenterological investigation. Conclusions: The perineal clinic provides a valuable resource for investigation and treatment of postpartum perineal injury.     

Naproxen suppository for perineal pain after vaginal delivery.

OBJECTIVE: To assess the effectiveness of rectal naproxen for reducing perineal pain after vaginal delivery. METHODS: A double-blind randomized controlled trial of 142 post partum women randomly allocated to receive either naproxen (71 patients) or placebo (71 patients) suppositories. The first dose was given immediately after complete perineal suturing, while the second dose was given 6 hours post partum. The validated Thai short-form McGill pain questionnaire was used to evaluate perineal pain at 0, 6, and 24 hours post partum. Pain scores were analyzed using the unpaired t test. RESULTS: Pain scores at 6 and 24 hours for women in the naproxen group were significantly lower compared with women in the placebo group (6.4 and 2.3 vs 18.4 and 5.5; P<0.001). No side effects with naproxen were found. CONCLUSIONS: Rectal naproxen is effective and safe for reducing perineal pain after vaginal delivery.     

The prevalence of enduring postnatal perineal morbidity and its relationship to perineal trauma

OBJECTIVE: to investigate the prevalence of enduring postnatal perineal morbidity and its relationship to perineal trauma. DESIGN: a retrospective cross-sectional community survey of postnatal women. PARTICIPANTS AND SETTING: a total population sample of 2100 women were surveyed from two maternity units within Birmingham. Women were identified from the Trust's computerised Maternity Information System (MIS). METHODS: Women were surveyed using a self-administered postal questionnaire 12 months after birth. The questionnaire included self-assessment of perineal pain, perineal healing, urinary incontinence, flatus incontinence, faecal incontinence, sexual morbidity and dyspareunia. FINDINGS: a response rate of 23.3% was achieved (n=482). A high level of perineal morbidity was reported (53.8% stress urinary incontinence, 36.6% urge urinary incontinence, 9.9% liquid faecal incontinence, 54.5% with at least one index of sexual morbidity). Women with perineal trauma reported significantly more morbidity (sexual morbidity, dyspareunia, stress and urge urinary incontinence) than women with an intact perineum. Women with perineal trauma also resumed sexual intercourse later than women with an intact perineum. Women with a first- or second-degree tear reported significantly more perineal morbidity (stress incontinence, sexual morbidity) than women with an intact perineum, and resumed sexual intercourse later. However, a high percentage of women with an intact perineum also reported new-onset perineal morbidity: stress urinary incontinence (34.8%); urge urinary incontinence (19.5%); flatus incontinence (13.8%); and dyspareunia (25.3%), highlighting that enduring perineal morbidity can occur irrespective of perineal trauma. CONCLUSION: enduring postnatal perineal morbidity is common in women with all types and grades of perineal trauma and intact perineum after childbirth. This highlights the need for further debate and research into the prevalence and experience of postnatal morbidity.     

Spontaneous pushing during birth. Relationship to perineal outcomes

Vaginal birth is a recognized factor in perineal tissue damage and postpartum perineal pain. This study examined outcomes of 39 primiparous women who had spontaneous vaginal births. In a retrospective survey, women were asked to describe the type of pushing used to give birth and what the level of pain had been in the perineal (or vaginal) area during the first week postpartum. Labor and delivery chart data documented extent of episiotomy and/or laceration sustained. Eleven (28%) women reported using spontaneous bearing down efforts, and the remaining 28 (72%) were directed. Women who used spontaneous pushing were more likely to have intact perineums postpartum and less likely to have episiotomies, and second or third degree lacerations (chi 2 [3, N = 39] = 8.1, P = .043). Other variables, such as maternal age, infant birth weight, length of second stage, provider type, and use of epidural, did not demonstrate a significant difference in perineal outcome. Further analysis showed a significant relationship between the extent of perineal disruption and pain (F [3,30] = 5.08, P = .005).     

Enhancing postnatal perineal care: Part 2

Maternal physical and psychological wellbeing during the postnatal period can be significantly impaired by perineal trauma sustained during childbirth. Current literature emphasises preventative measures, yet there is a lack of a systematic, evidence based approach to postnatal perineal care. This is concerning as the eighth 'Saving mothers' lives' report (CMACE 2011) identifies genital tract sepsis for the first time as the leading cause of maternal deaths. The aim of this article is therefore to develop a systematic approach to improve postnatal perineal care with a focus on assessment and treatment of perineal pain as well as recovery of pelvic floor function.     

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.     

Women's experiences of perineal pain during the immediate postnatal period: a cross-sectional study in Brazil

Objective

to identify the severity and prevalence of perineal pain during the post partum in-patient period and associated obstetric, maternal and newborn baby factors following birth.

Design

cross-sectional study.

Setting

a postnatal ward of a hospital in São Paulo, Brazil.

Participants

303 postnatal women.

Measurements

interviews and perineal assessment were conducted to evaluate the perineal outcomes (trauma and pain). Data on maternal characteristics and infant anthropometric variables were collected.

Results

among all women, 80.5% had perineal trauma (60.7% had episiotomy) and 18.5% reported perineal pain. The mean pain intensity score was 4.8±1.9 on the visual analogue scale. Only maternal age (ORa=1.08) and performance of episiotomy (ORa=3.80) remained as independent predictors of perineal pain in the final logistic regression model.

Key conclusions

perineal pain in the immediate postnatal period was highly associated with older maternal age and use of episiotomy, although the overall reporting of perineal pain was low.

Implications for practice

perineal pain following vaginal birth is associated with interventions during labour as well as with maternal characteristics. Despite the negative impact on a woman's daily activities, perineal pain following birth is neglected by care givers and usually not reported by women who may consider it to be a normal outcome of giving birth. Care providers need to ensure all interventions during labour and birth are informed by evidence of benefit and that barriers to implementation of evidence are addressed. Further work is needed to obtain the views of women in Brazil on their health and well-being following birth.     

The effects of cryotherapy on perineal pain after childbirth: A systematic review and meta-analysis

BackgroundMost women experience perineal pain after childbirth. Sustained perineal pain affects mother's daily living. Various methods have been used to relieve postpartum perineal pain, such as cold or warm therapy, but the pain-control effects of cryotherapy are still controversial.AimsThe purpose of this study was to verify the effectiveness of cryotherapy in relieving perineal pain in women after childbirth.MethodsThe researchers searched the CINAHL, Cochrane, EMBASE, PubMed, Korea Education and Research Information Service, NDSL, KoreaMed, LILACS and SciELO databases for studies to include in this review, and selected studies using PICO criteria. Methodological quality was assessed based on Cochrane's risk of bias 2 for randomized controlled trials. Data were analyzed with the Comprehensive Meta-Analysis program.FindingsEleven published studies encompassing 1,492 participants were included. Cryotherapy significantly reduced pain two days postpartum. Ice packs and gel packs had similar pain-relieving effects. Cryotherapy did not differ significantly from Epifoam therapy (hydrocortisone-pramoxine) in its effects on perineal pain one day or five days after childbirth.ConclusionsCryotherapy can be an effective non-pharmacological nursing intervention to reduce pain after childbirth.     

Risk factors and management of obstetric perineal injury

Perineal injury sustained during childbirth is a major aetiological factor in the development of perineal pain, sexual dysfunction, prolapse and disturbance in bowel and bladder function. Preferential use of the vacuum extractor, restricting the use of episiotomy, repair of anal sphincter rupture by a trained doctor and selective caesarean section in these women can be beneficial in preventing complications. More focused training of midwives and doctors in perineal and anal sphincter anatomy and repair is needed to minimize the morbidity associated with inadequate repair and missed tears. Future research must address ways to predict and minimize severe perineal injury, and the management of subsequent pregnancies following anal sphincter injury.     

Episiotomy and perineal tears presumed to be imminent: randomized controlled trial

BACKGROUND: The indication of the restricted use of episiotomy at tears presumed to be imminent is not clear. METHODS: Randomized controlled trial with two perineal management policies. Use of episiotomy: (a). only for fetal indications and (b). in addition at a tear presumed to be imminent. Participants: 146 primiparous women with an uncomplicated singleton pregnancy at >34 weeks of gestation. For the intention-to-treat analysis those 109 women were included who vaginally delivered a live full-term baby between January 1999 and September 2000: 49 women in group a, 60 in group b. OUTCOME MEASURES: Reduction of episiotomies, increase of intact perinea or only minor perineal trauma (intact perineum and first-degree tears), third-degree tears, anterior perineal trauma, perineal pain in the postpartum period, pH of the umbilical artery, Apgar scores, maternal blood loss. RESULTS: Episiotomy rates were 41% in group a and 77% in group b (p < 0.001). Women in the restrictive policy group had a greater chance of an intact perineum (29% vs. 10%; p = 0.023) or only minor perineal trauma (39% vs. 13%; p = 0.003) and had significant lower pain scores postpartum at different activities. There were no statistically significant differences with regard to third-degree tears, anterior trauma, pre- and postpartum hemoglobin concentrations, Apgar scores and pH of the umbilical artery. CONCLUSIONS: Avoiding episiotomy at tears presumed to be imminent increases the rate of intact perinea and the rate of only minor perineal trauma, reduces postpartum perineal pain and does not have any adverse effects on maternal or fetal morbidity.     

Association of spontaneous perineal stretching during delivery with perineal lacerations

OBJECTIVE: To evaluate the effect of perineal stretching on perineal damage during vaginal delivery. STUDY DESIGN: Patients at term in active labor were included. Perineal length was measured during the active phase, second stage and 24 hours postpartum. Perineal damage was assessed before repair and 24 hours postpartum. RESULTS: Three hundred women were included. Mean perineal length during the active phase was 4.02 +/- 1.07 cm, and mean stretching was 2.25 +/- 1.2 cm. Of the parturients who had stretched the perineum > 150%, 40.7% required perineal repair as compared with 19.5% of parturients with less perineal stretching (p < 0.005). Significant risk factors included: age and parity, ethnicity, use of epidural, second-stage length, and perineal stretching. Stretching of > 150% remained significant in a multivariate mode (OR 2.11, p < 0.01). CONCLUSION: Second-stage perineal stretching > 150% was predictive of perineal damage. In trying to avoid unnecessary episiotomies, this method may prove helpful.     

The effect of regular antenatal perineal massage on postnatal pain and anal sphincter injury: a prospective observational study.

OBJECTIVE: Antenatal perineal massage has been shown to reduce the incidence of perineal tears in primiparous women. The aim of this study was to determine whether perineal massage impacts on primary prevention of symptomatic disruption of the fecal continence mechanism. METHODS: An observational study recruited two cohorts of women. The first, massage group (MG) chose to perform daily perineal massage from 34 weeks gestation, and the second, control group (CG) was asked to avoid massage. Perineal injury and postnatal pain were documented and all women were invited to attend at three months postpartum for continence assessment, anal manometry, and endoanal ultrasound. RESULTS: Of 179 women recruited, 100 were in the MG while 79 women were controls. Mode of delivery was not influenced by perineal massage. Although the impact did not reach statistical significance, women aged over 30 years in the MG were more likely to be delivered with an intact perineum than controls. Postnatal perineal pain was much reduced in the MG compared with the CG (p = 0.029). Of the women recruited, 136 (75.9%) returned for a postnatal continence assessment. Manometry pressures, continence scores, and endoanal ultrasound findings were similar in both groups. CONCLUSION: Antenatal perineal massage was found to significantly affect postnatal perineal pain scores although it did not impact on the incidence of intact perineum at delivery, postnatal continence scores, anal manometry pressures, or endoanal ultrasound findings.     

Randomized comparison of chromic versus fast-absorbing polyglactin 910 for postpartum perineal repair

OBJECTIVE: We conducted a randomized trial to evaluate the healing characteristics of chromic versus fast-absorbing polyglactin 910. METHODS: Laboring women were randomly assigned to chromic or fast-absorbing polyglactin for perineal repairs. Subjects were evaluated at 24-48 hours, 10-14 days, and 6-8 weeks to assess perineal and uterine pain, analgesic use, presence of residual suture, and wound dehiscence. RESULTS: Between April 2002 and January 2003, 1,361 subjects were randomly assigned. Two thirds of women in each group (459 fast-absorbing polyglactin and 449 chromic) required sutures for perineal repairs. Women were evaluated according to randomization assignment. Overall, 794 (87%) of subjects received the appropriate allocated suture to repair a perineal laceration (399 of 459, 86.9% fast-absorbing polyglactin 910; 395 of 449, 88% chromic catgut). At 24-48 hours, there was a statistically significant reduction in uterine cramping pain (25% versus 34%; P =.006) in subjects randomly assigned to fast-absorbing polyglactin. At 10-14 days, there were no statistically significant differences between the groups. At 6-8 weeks there was, again, a statistically significant reduction in uterine cramping pain (1% versus 4%; P =.017) and a statistically significant decrease in analgesic use (5% versus 10%; P =.048) in subjects randomly assigned to fast-absorbing polyglactin. Finally, at 6-8 weeks postpartum there was no difference in residual suture (2 of 175 versus 2 of 134; P =.802) or wound breakdowns (4 of 175 versus 3 of 134; P =.959) for fast-absorbing polyglactin 910 and chromic catgut, respectively. CONCLUSION: Our data suggest that fast-absorbing polyglactin 910 and chromic elicit similar postpartum perineal discomfort. In contrast to previous studies evaluating standard polyglactin, our trial demonstrated that fast-absorbing polyglactin rarely requires late removal and has a similar wound breakdown profile as compared with chromic. LEVEL OF EVIDENCE: I     

Dolor pélvico en mujeres con episiotomía versus mujeres con desgarro perineal de segundo grado

IntroductionPelvic pain is one of the most common pelvic floor dysfunctions in the postpartum period, depending on the degree of injury and the time at which it is assessed. The degree of involvement of a mediolateral episiotomy is similar to that of a second degree perineal tear, therefore it was decided to conduct a study to collect the degree of pain reported using the McGill Pain Questionnaire.Material and methodsAn observational, prospective longitudinal epidemiological study of dynamic cohorts was conducted among 384 women, of whom 255 had a second-degree tear and 129 had undergone an episiotomy. An assessment of the pelvic floor was carried out, together with data collection (performance or not of perineal massage, pelvic floor muscle exercises, presence of Kristeller, type of suture) as well as the degree and type of pain using the McGill Questionnaire, in the immediate puerperium, at six weeks, and six months of postpartum.ResultsIn the immediate puerperium more than 50% of women reported some type of painful sensation, without finding significant differences between both cohorts. However, as the study evolved, there was a progressive decrease in pain in both cohorts. By six weeks postpartum, less than 33% of women reported a painful sensation, considered as absence of pain according to the criteria of the McGill questionnaire.ConclusionThe presence of episiotomy or second degree perineal tear was not related to perineal pain.     

A randomized comparison of glycerol-impregnated chromic catgut with untreated chromic catgut for the repair of perineal trauma

Summary. Glycerol-impregnated chromic catgut and untreated chromic catgut were compared in a randomized controlled trial involving 737 consecutive women who required repair of perineal trauma following spontaneous vaginal delivery. Medical staff preference was equally divided between the two materials. More untreated chromic catgut sutures required removal both by 10 days and by 3 months postpartum. Women whose perineal trauma was repaired with glycerol-impregnated chromic catgut were 10% more likely to have perineal pain at 10 days and 33% more likely to suffer from dyspareunia in the 3 months following delivery. The high rates of maternal morbidity associated with glycerol-impregnated chromic catgut appear to preclude its use for perineal repair.