Functional evaluation of the perineum in pregnancy. Hypertonia of the levator ani muscles

In this study, the role of "levator ani muscles hypertonia" among pathogenetic factors of perineal obstetric injuries is analysed. For this purpose, clinical data of 142 pregnant women, who underwent functional evaluation of perineum during pregnancy and 30 days after delivery were examined. Data here reported are not sufficient to confirm the importance of this factor within the pathogenesis of postpartum perineal deficiency. Levator ani hypertonia on one hand seems to be able to obstruct fetal progression, on the other hand it presumably constitutes, as an expression of a good voluntary control of perineal muscles, a favourable prognostic factor.     

Postpartum perineal evaluation. Role of the Q-tip test

Data reported in this study concern 56 women who were subjected, 1 and 6 months after delivery, to a perineal examination including, in addition to the functional evaluation of the levator ani muscles, the "Q-tip test". A positive Q-tip test is associated with a greater incidence of stress urinary incontinence, especially when, at the same time, the score for the functional evaluation of the levator ani muscles ("Perineal Testing") is inferior to 3. The results of this study seem to indicate a greater gravity and ventral extension of obstetric perineal injuries.     

A comparison of "hands off" versus "hands on" techniques for decreasing perineal lacerations during birth

Our goal was to determine the frequency, degree, and location of perineal lacerations and the neonatal outcomes associated with the use of two techniques of perineal protection--expectant ("hands off") and interventionist ("hands on")--during childbirth. We conducted a randomized controlled trial to compare the effectiveness of two techniques for perineum protection during spontaneous delivery. Study participants included 70 nulliparous expectant mothers, who were divided equally between the "hands off" and "hands on" groups (n = 35 per group). Perineal laceration occurred in 81.4% of the women. Among these, first-degree lacerations were predominant (82.5%). Lacerations in the anterior and posterior regions of the perineum occurred with similar frequencies. Laceration rates did not differ between the "hands off" and "hands on" groups (P > .05). Neonatal outcomes were similar in both groups. The use of "hands off" technique of perineal protection does not alter the frequency or degree of perineal lacerations in childbirth, relative to a "hands on" technique.     

Effectiveness of nitrous oxide for postpartum perineal repair: a randomised controlled trial

Objective

To compare the effectiveness of self-administered 50% nitrous oxide and conventional infiltrative anaesthesia with 1% prilocaine hydrochloride in postpartum perineal repair.

Study design

A total of 100 women were prospectively enrolled and randomised to receive either infiltrative anaesthesia or a self-administered nitrous oxide mixture (Livopan^©) for pain relief during postpartum perineal suturing. Besides data concerning anaesthesia, characteristics of patients and labour were documented for statistical analysis. Pain experienced during perineal repair was assessed using the short form of the McGill Pain Questionnaire (SF-MPQ).

Results

Forty-eight women received nitrous oxide and 52 underwent perineal suturing after infiltrative anaesthesia. There were no statistically significant differences regarding maternal age, body mass index (BMI), duration of pregnancy and suturing time between the groups. The most frequent birth injury was second-degree perineal laceration in the study group [22/48; 46%] and episiotomy in the control group [18/52; 35%]. Pain experienced during genital tract suturing and patients’ satisfaction showed no statistically significant differences between the groups. Thirty-seven women in the study group and 47 in the control group were satisfied with the anaesthesia during perineal repair and would recommend it to other parturients [37/48, 77% vs. 47/52, 90%; p = 0.0699).

Conclusion

Nitrous oxide self-administration during genital tract suturing after vaginal childbirth is a satisfactory and effective alternative to infiltrative anaesthesia.     

Subclinical autoimmunity in recurrent aborters

Thirty-four women with habitual abortion (HA) were evaluated for the presence of lupus-associated autoantibodies, antisperm antibodies, and evidence of complement abnormalities. A control group of women who had only successful pregnancy outcomes also was studied. Fourteen HA women had anatomic, genetic, or hormonal causes for their pregnancy losses ("explained losses"), and 20 had no apparent causative factors ("unexplained losses"). Fifty percent of HA women with unexplained losses and 34% of women with explained losses had at least one abnormal result, but multiple autoimmune abnormalities were found only in women with unexplained losses. Anticardiolipin antibodies were found most commonly (30% of all HA women and 8% of controls). Two clinically normal HA women had multiple autoantibodies detected. This study suggests that recurrent pregnancy loss may be a marker for subclinical autoimmune disease.     

The use of graft materials in vaginal pelvic floor surgery.

OBJECTIVE: To review recent literature on graft materials used in vaginal pelvic floor surgery. METHODS: A Pubmed-search ("anterior vaginal wall" or "cystocele"), ("posterior vaginal wall" or "rectocele") and ("vaginal vault" or "pelvic prolapse") and ("mesh" or "erosion" or "graft" or "synthetic") from 1995 to 2005 was performed; recent reviews [Birch C. The use of prosthetics in pelvic reconstructive surgery. Best Pract Res Clin Obstet Gynaecol 2005;19:979-91 [1]; Maher C, Baessler K. Surgical management of anterior vaginal wall prolapse: an evidence-based literature review. Int Urogynecol J Pelvic Floor Dysfunct 2005 (May 25) [Electronic Publication] [2]; Maher C, Baessler K. Surgical management of posterior vaginal wall prolapse: an evidence-based literature review. Int Urogynecol J Pelvic Floor Dysfunct 2006;17:84-8 [3]; Altman D, Mellgren A, Zetterstrom J. Rectocele repair using biomaterial augmentation: current documentation and clinical experience. Obstet Gynecol Surv 2005;60:753-60 [4] were added. RESULT: There are few prospective randomized trials that prove the benefit of implanting grafts in vaginal pelvic floor surgery. Many articles are retrospective case series with small sample sizes or incomplete outcome variables. Serious complications such as erosions are often not mentioned. Inconsistent or unclear criteria for anatomic cure make it difficult to compare outcomes. Quality of life issues such as dyspareunia, urinary or bowel symptoms are often ignored. CONCLUSION: Due to a lack of well-designed prospective randomized trials, recommendations for using graft materials in vaginal reconstructive surgery cannot be made. At this time, grafts should have limited use in a carefully selected patient population.     

Risk factors for third degree perineal ruptures during delivery

Objective To determine risk factors for the occurrence of third degree perineal tears during vaginal delivery.
Design A population-based observational study.
Population All 284,783 vaginal deliveries in 1994 and 1995 recorded in the Dutch National Obstetric Database were included in the study.
Methods Third degree perineal rupture was defined as any rupture involving the anal sphincter muscles. Logistic regression analysis was used to assess risk factors.
Main outcome measures An overall rate of third degree perineal ruptures of 1.94% was found. High fetal birthweight, long duration of the second stage of delivery and primiparity were associated with an elevated risk of anal sphincter damage. Mediolateral episiotomy appeared to protect strongly against damage to the anal sphincter complex during delivery (OR: 0.21, 95% CI: 0.20–0.23). All types of assisted vaginal delivery were associated with third degree perineal ruptures, with forceps delivery (OR: 3.33, 95%-CI: 2.97–3.74) carrying the largest risk of all assisted vaginal deliveries. Use of forceps combined with other types of assisted vaginal delivery appeared to increase the risk even further.
Conclusions Mediolateral episiotomy protects strongly against the occurrence of third degree perineal ruptures and may thus serve as a primary method of prevention of faecal incontinence. Forceps delivery is a stronger risk factor for third degree perineal tears than vacuum extraction. If the obstetric situation permits use of either instrument, the vacuum extractor should be the instrument of choice with respect to the prevention of faecal incontinence.     

Perineal modification in pregnancy and puerperium, risk of urinary incontinence]

Pregnancy and delivery are important etiopathological factors in the alteration of pelvic equilibrium; in particular and the first delivery is the decisive factor in terms of perineal sequelae affecting pelvic equilibrium and urinary continence. Epidemiological studies have identified a number of pathogenic risk factors related to pregnancy (abnormal increase in maternal weight, diabetes in pregnancy and macrosoma) and the newborn (cranial circumference, newborn weight). Mechanical stress caused by the passage of the fetus may lead to the overstretching of the pelvic floor and the failure to recognise muscular damage even in the absence of macroscopic lesions. In the immediate postpartum or after a number of years these may damage the function of the musculo-aponeurotic structures of the perineum and foster the onset of alterations to pelvic equilibrium and urinary incontinence. In this study the authors have evaluated the modifications to the perineum and continence during pregnancy and puerperium. METHODS: Clinical data were analysed for 40 puerperae all of whom underwent a through perineal examination to assess the function of perineal muscles, both on discharge and 6 months after delivery. RESULTS: The authors tried to identify the main risk factors which predisposed the onset of changes to pelvic equilibrium and urinary continence. On the basis of the contemporary outcome of the Q-TIP test and TP, all women were divided into 4 groups: Group A (TP < 3 and positive Q-TIP test) (22.5%). CONCLUSIONS: In the light of these results, the authors affirm that during gestation it is important to concentrate preventive action on these risk factors.     

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.     

Prevention of Perineal Trauma by Perineal Massage During Pregnancy: A Pilot Study

ABSTRACT: Although the performance of perineal massage by a woman or her partner during the last weeks of pregnancy may help to prevent perineal trauma at delivery, the technique has never been evaluated rigorously. This study examined the feasibility of a randomized, controlled trial, and more specifically assessed the participation rate, the acceptability of the intervention, and whether or not an attending physician could remain blind to participants' groups. The pilot study was a single-blinded, randomized, controlled trial. Nulliparous women, 32 to 34 weeks pregnant, were recruited from June 8 to July 31, 1992, at the offices of family physicians and obstetricians who practice at the Hôpital du Saint-Sacrement in Quebec City. Women assigned to the intervention group practiced daily 10-minute perineal massage and completed a diary, and those in the control group had standard care. Women and attending physicians completed a questionnaire about the aspect of blindness. Among the 174 women who delivered during the study period, 104 (59.8%) were approached by a midwife and 46 (26.4%) were randomized. Twenty (91.0%) of the 22 women in the massage group returned their perineal massage diaries. Based on the postpartum questionnaire, 20 women practiced the technique at least four times a week for three weeks or longer. No woman in the control group practiced massage. The attending physician was aware of the woman's group in only three instances (6.7%). Based on the results of this pilot study, a randomized, controlled trial to evaluate the efficacy of perineal massage in preventing perineal trauma at birth appears feasible.     

Use of hyaluronidase to prevent perineal trauma during spontaneous delivery: a pilot study

Our objective was to compare the frequency, degree, and location of perineal trauma during spontaneous delivery with or without perineal injections of hyaluronidase (HAase). This was a randomized, controlled pilot study, conducted in a midwife‐led hospital birth center in São Paulo, Brazil. Primiparous women (N = 139) were randomly assigned to an intervention group (HAase injection, n = 71) or to a control group (no injection, n = 68). Significant differences were noted between the two groups in frequency of perineal trauma (intervention, 39.4%; control, 76.5%), degree of spontaneous laceration (intervention, 0.0%; control, 82.4%), and laceration located in the posterior region of the perineum (intervention, 54.2%; control, 84.3%). When episiotomy and second‐degree lacerations were considered together and women with intact perineum were excluded from the analysis, the difference between the groups was no longer significant. With the use of the HAase enzyme, the relative risk was 0.5 for perineal trauma and 0.0 for second‐degree lacerations. The present findings suggest that perineal injection of HAase prevented perineal trauma. These findings provide strong rationale for a larger follow‐up study.     

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.     

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.     

Milk fever

Infectious complications following delivery were, in the past, attributed to "milk fever": these were milk congestion, milk deposits, rancid milk, etc., that were held responsible. The milk was reabsorbed into the blood of the patient and settled in the peritoneum ("milk peritonitis"), in the broad ligaments (pelvic abscess), in the thighs (phlebitis) and also in the breasts (breast abscess). This belief, originated by Aristotle, was accepted by excellent authors like Andre Levret (1703-1780), one of the most famous French obstetricians and Nicolas Puzos, at the same time. More recently, authors alluded to it and blamed "milk fever" for being at the origin of dramatic pictures which they described in their novels, like Victor Hugo and Guy de Maupassant, for instance.     

'Soothing the ring of fire': Australian women's and midwives' experiences of using perineal warm packs in the second stage of labour

Objective

to determine women's and midwives’ experiences of using perineal warm packs in the second stage of labour.

Design

as part of a randomised controlled trial (Warm Pack Trial), women and midwives were asked to complete questionnaires about the effects of the warm packs on pain, perineal trauma, comfort, feelings of control, satisfaction and intentions for use during future births.

Setting

two hospitals in Sydney, Australia.

Participants

a randomised controlled trial was undertaken. In the late second stage of labour, nulliparous women (n=717) giving birth were randomly allocated to having warm packs (n=360) applied to their perineum or standard care (n=357). Standard care was defined as any second stage practice carried out by midwives that did not include the application of warm packs to the perineum. Three hundred and two nulliparous women randomised to receive warm packs (84%) received the treatment. Questionnaires were completed by 266 (88%) women who received warm packs, and 270 (89%) midwives who applied warm packs to these women.

Intervention

warm, moist packs were applied to the perineum in the late second stage of labour.

Findings

warm packs were highly acceptable to both women and midwives as a means of relieving pain during the late second stage of labour. Almost the same number of women (79.7%) and midwives (80.4%) felt that the warm packs reduced perineal pain during the birth. Both midwives and women were positive about using warm packs in the future. The majority of women (85.7%) said that they would like to use perineal warm packs again for their next birth and would recommend them to friends (86.1%). Likewise, 91% of midwives were positive about using the warm packs, with 92.6% considering using them in the future as part of routine care in the second stage of labour.

Key conclusions

responses to questionnaires, eliciting experiences of women and midwives involved in the Warm Pack Trial, demonstrated that the practice of applying perineal warm packs in the late second stage of labour was highly acceptable and effective in helping to relieve perineal pain and increase comfort.

Implications for practice

perineal warm packs should be incorporated into second stage pain relief options available to women during childbirth.     

Multiparity causes uncoordinated activity of pelvic- and perineal-striated muscles and urodynamic changes in rabbits

Temporal and coordinated activation of pelvic- (pubococcygeous) and perineal- (bulbospongiosus and ischiocavernosus) striated muscles occurs during micturition in female rabbits. We have hypothesized that the coordinated activation of pelvic and perineal muscles is modified during the micturition of young multiparous rabbits. Young virgin and multiparous female chinchilla rabbits were used to simultaneously record cystometrograms and electromyograms of the pubococcygeous, ischocavernosus, and bulbospongiosus muscles. Bladder function was assessed using standard urodynamic variables. The temporal coordination of pelvic- and perineal-striated muscle activity was changed in multiparous rabbits. The cystometrogram recordings were different than those obtained from virgin rabbits, as seen in alterations of the threshold volume, the residual volume, the voiding duration, and the maximum pressure. In rabbits, we find that multiparity causes uncoordinated activity of pubococcygeous, ischiocavernosus, and bulbospongiosus muscles and modifies the urodynamics.     

The hazards of surgical glove dusting powders

Surgical contaminants of many kinds, including glove powder, constitute a source of formation of granulomas. This is particularly well-documented in the peritoneal cavity ("starch peritonitis"), but has been documented in most anatomic sites. The production of starch-free gloves should remove this hazard, but the surgeon should remain aware that most particulate substances introduced into the body inevitably set up an inflammatory response.     

Effectiveness of an educational programme in perineal repair for midwives

Objective

to evaluate the effectiveness of a work-based module and in-service educational programme in perineal repair for midwives on their perceived level of competency undertaking this skill in clinical practice.

Design

a quasi-experimental pre–post intervention case study combining a non-equivalent comparison group and evaluation action research.

Setting

six NHS consultant/midwifery led Trusts in South East England between December 2002 and 2006.

Participants

145 midwives from six NHS Trusts.

Interventions

a post-registration work-based module in perineal repair for midwives and alternative two hour in-service perineal repair workshops across five intervention Trusts.

Main outcome measures

midwives' perceived level of competency and confidence undertaking perineal repair.

Main findings

significantly greater numbers of midwives were able to practice perineal repair at higher levels of competency following an educational intervention in five intervention Trusts (P<.006). There was a non-significant difference in the comparison Trust (P<.535). In addition, an educational programme for midwives increased the numbers of senior student midwives who were able to participate in perineal repair confidently under the direct supervision of their mentor when they perceived that their mentor was confident and competent undertaking the procedure.

Key conclusions

an educational programme in perineal repair can make a significant difference to the midwives' perceived level of competency and confidence when assessing and managing perineal trauma and repair.

Implications for practice

competency and expertise are complex phenomena and the data has provided greater insight into the complex nature of workplace learning alongside the multiple factors influencing clinical decision-making such as staff shortage, time constraints and inadequate numbers of midwives who are able to instruct, supervise and assess competency in perineal repair. Funding for training is fundamental for the sustainability of future practice development.     

Warm tub bath during delivery

In a prospective study, 88 women bathed in a warm tub bath for 1/2-2 hours during first stage labor after a strictly normal pregnancy, ending with spontaneous onset of labor at term. A control group consisted of 72 women fulfilling the same criteria of normality during pregnancy and labor, but who did not want to take a warm tub bath during labor. Apart from the bath, the two groups followed the usual obstetric procedures of the Department. The cervical dilatation in the "bath group" was 2 1/2 cm/h compared with 1 1/4 cm/h in the "control group". Mean pain score in the bath group was higher at the start of the study, before the bath, and they experienced a pain relief during bath which was not observed in the control group. This difference may be due to bias. The use of morfica and the need for stimulation of labor contractions were both twice as high in the control group, but this difference was not significant. No differences were observed with regard to operative delivery, vaginal or perineal laceration or in bleeding during labor or postpartum. The total duration of labor was the same in the two groups and no differences in neonatal condition were observed. The bacterial contamination of the bath water was insignificant and there were no significant febrile episodes post partum.