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.     

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.     

Topical lidocaine-prilocaine cream versus lidocaine infiltration for pain relief during repair of perineal tears after vaginal delivery: randomized clinical trial

Objective: The current study aims to compare the analgesic effect of lidocaine-prilocaine (LP) cream with lidocaine infiltration during repair of perineal tears after vaginal delivery.

Materials and methods: A single center open-labeled randomized clinical trial was carried out in a tertiary University Hospital between October 2016 and May 2017 (Clinical Trials.Gov: NCT02883179). We included parous women, who delivered at gestational age >37 weeks with first- or second-degree perineal tears. The participants were randomized in a 1:1 ratio to either lidocaine infiltration (Group I); or application of LP cream (Group II) for pain relief during perineal repair. The primary outcome was the difference in mean pain score during perineal repair. Secondary outcomes included the participants’ satisfaction, the need for additional anesthesia, the duration of perineal repair, and the rate of adverse effects of both medications.

Results: The study included 144 participants randomized to both groups. The mean pain score during perineal repair was significantly lower in the LP cream group (3.86?±?1.59) than the lidocaine infiltration group (5.99?±?1.47) [p?=?.001]. The duration of repair was significantly shorter in the LP group than the lidocaine infiltration group (6.37?±?3.68 versus 8.17?±?2.75?min, respectively, p?=?.001). The need for additional anesthesia was quite similar in both groups (p?=?.371). More women in the LP cream group were satisfied than the other group with statistical significant difference (76.4 versus 30.6%, p?=?.000). No difference between side effects in both groups (p?=?.171)

Conclusions: Topical application of lidocaine-prilocaine cream is an effective analgesic during repair of perineal tears with no harmful side effects.     

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.     

Effect of far-infrared radiation on perineal wound pain and sexual function in primiparous women undergoing an episiotomy

Objective

To evaluate the effect of far-infrared radiation on postpartum perineal pain and sexual function in primiparous women undergoing an episiotomy and 2nd degree perineal laceration.

Racial differences in severe perineal lacerations after vaginal delivery

OBJECTIVE: The purpose of this study was to determine the relationship between maternal race and rates of third- and fourth-degree laceration after vaginal delivery. STUDY DESIGN: An electronic audit of the medical procedures database at Thomas Jefferson University Hospital from 1983 through 2000 was completed. Univariate and multivariable models were computed with the use of logistic regression models. RESULTS: From the database, 34,048 vaginal deliveries were identified, with 3487 deliveries resulting in third- or fourth-degree laceration (10.2%). Overall severe laceration rates by race with all vaginal deliveries for patients without and with episiotomy were as follows: white, 4.3% and 15.1%; black, 2.0% and 19.3%; Asian 9.1% and 32.3%; Hispanic, 3.4% and 17.0%, respectively. After being controled for other variables with multivariable logistic regression in all vaginal deliveries, Asian race (odds ratio, 2.04; 95% CI, 1.43-2.92), forceps (odds ratio, 3.71; 95% CI, 3.39-4.05), vacuum-assisted delivery (odds ratio, 1.86; 95% CI, 1.64-2.10), large size for gestational age (odds ratio, 1.94; 95% CI, 1.21-3.09), and episiotomy (odds ratio, 3.09; 95% CI, 2.66-3.59) were associated significantly with severe lacerations. CONCLUSION: Race is an independent risk factor for severe perineal lacerations after vaginal delivery, with Asian women at highest risk. Asian women who undergo episiotomy and operative vaginal delivery are especially at high risk for rectal sphincter injury.     

Manometric evaluation of anal sphincter function after vaginal and cesarean delivery

Objective

To compare anal sphincter function following spontaneous vaginal delivery and cesarean delivery, and assess the association of perineal length and sphincter injury with each delivery mode.

Method

Perineal length was measured and anal manometric measurements were performed in 120 primigravidas before and after delivery.

Results

Mean values for maximum anal resting and squeeze pressures were significantly lower after delivery irrespective of the mode of delivery, but there was a positive correlation between postpartum maximum anal resting pressure and perineal length (r = 0.24, P < 0.01).

Conclusion

Anal sphincter function was disturbed after both vaginal and cesarean delivery, a finding weakened by the fact that almost half of the cesareans were performed for cephalopelvic disproportion identified during labor.     

Transcutaneous electrical nerve stimulation (TENS) for pain control after vaginal delivery and cesarean section

Abstract

Objective: The present study aims to determine the efficiency and reliability of transcutaneous electrical nerve stimulation (TENS) in the management of pain related with uterine contractions after vaginal delivery and the pain related with both abdominal incision uterine contractions after cesarean section.

Methods: A hundred healthy women who underwent cesarean section under general anesthesia were randomly assigned to the placebo group (Group 1) or the TENS group (Group 2), while 100 women who delivered by vaginal route without episiotomy were randomized into the placebo group (Group 3) or the TENS group (Group 4).

Results: The patients in Group 2 had statistically lower visual analog scale (VAS) and verbal numerical scale (VNS) scores than the patients in Group 1 (p?<?0.001 for both). The patients in Group 4 had statistically lower VAS and VNS scores than the patients in Group 3 (p?=?0.022 and p?=?0.005, respectively). The analgesic requirement at the eighth hour of cesarean section was significantly lower in the patients who were treated with TENS (p?=?0.006). The need for analgesics at the eighth hour of vaginal delivery was statistically similar in the patients who were treated with TENS and the patients who received placebo (p?=?0.830).

Conclusion: TENS is an effective, reliable, practical and easily available modality of treatment for postpartum pain.     

Risk factors for severe perineal lacerations during childbirth

Background

Severe perineal lacerations represent a significant complication of normal labor with a strong impact on quality of life.

Objectives

To identify factors that lead to the occurrence of severe perineal lacerations.

Search strategy

We searched MEDLINE, Scopus, ClinicalTrials.gov, the Cochrane Central Register of Controlled Trials, Google Scholar and reference lists from all included studies.

Selection criteria

We included prospective and retrospective observational studies.

Data collection and analysis

Predetermined data were collected and analyzed with the Mantel–Haenszel fixed-effects model or the DerSimonian–Laird random-effects model.

Main results

The meta-analysis included 22 studies (n = 651 934). Women with severe perineal tears were more likely to have had heavier infants (mean difference 192.88 g [95% CI, 139.80–245.96 g]), an episiotomy (OR 3.82 [95% CI, 1.96–7.42]), or an operative vaginal delivery (OR 5.10 [95% CI, 3.33–7.83]). Epidural anesthesia (OR 1.95 [95% CI, 1.63–2.32]), labor induction (OR 1.08 [95% CI, 1.02–1.14]), and labor augmentation (OR 1.95 [95% CI, 1.56–2.44]) were also more common among women with perineal lacerations.

Conclusions

Various factors contribute to the occurrence of perineal lacerations. Future studies should consistently evaluate all examined parameters to determine their possible interrelation.     

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.     

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.     

Postpartum pain after vaginal delivery. A review of comparative analgesic trials

Perineal tissue injury and uterine cramping within the first 24-48 hours after vaginal delivery are established models for studying pain relief. In this study, information was gathered from prospective, randomized investigations comparing the safety and efficacy of several oral analgesics. Nonsteroidal antiinflammatory drugs (NSAIDs) have been found consistently to be more useful than a placebo or acetaminophen. As compared with aspirin, the newer NSAIDs had a more delayed onset of action but required fewer doses. Mild analgesics were usually all that was necessary, and a combination with codeine was usually unnecessary. Side effects and breast milk concentrations of the drugs were negligible for this short-term therapy. Although no drug was found to be preferable to the others, aspirin and ibuprofen were the least expensive.     

Effect of epidural anaesthesia on clinician-applied force during vaginal delivery

OBJECTIVE: Epidural anesthesia (EA) is used in 80% of vaginal deliveries and is linked to neonatal and maternal trauma. Our objectives were to determine (1) whether EA affected clinician-applied force on the fetus and (2) whether this force influenced perineal trauma. STUDY DESIGN: After informed consent, multiparas with term, cephalic, singletons were delivered by 1 physician wearing a sensor-equipped glove to record force exerted on the fetal head. Those with EA were compared with those without for delivery force parameters. Regression analysis was used to identify predictors of vaginal laceration. RESULTS: The force required for delivery was greater in patients with EA (n = 27) than without (n = 5) (P < .01). Clinical parameters, including birth weight (P = .31) were similar between the groups. Clinician force was similar in those with no versus first- versus second-degree laceration (P = .5). Only birth weight was predictive of laceration (P = .02). CONCLUSION: Epidural use resulted in greater clinician force required for vaginal delivery of the fetus in multiparas, but this force was not associated with perineal trauma.     

Factors predicting severe perineal trauma during childbirth: role of forceps delivery routinely combined with mediolateral episiotomy

OBJECTIVE: Anal sphincter injury and its sequelae are a recognized complication of vaginal childbirth. The aim of the present study was to identify risk factors for third- and fourth-degree perineal tears in patients undergoing either spontaneous or vaginal-assisted delivery by forceps routinely combined with mediolateral episiotomy. STUDY DESIGN: We retrospectively reviewed 5377 vaginal deliveries based on the analysis of the obstetric database and patient records of our department during a 5-year period from 1999 to 2003. Cases and control subjects were chosen randomly and patients' records were reviewed for the following variables: maternal age, parity, gestational age, tobacco use, gestational diabetes or pregnancy-induced hypertension, use of peridural anesthesia, duration of first and second stages of labor, use of mediolateral episiotomy, forceps combined with mediolateral episiotomy, induction of labor, infant head diameter, shoulder circumference, and birth weight. RESULTS: Of 5044 spontaneous vaginal deliveries 32 (0.6%) and of 333 assisted vaginal deliveries 14 (4.2%) patients sustained a perineal defect involving the external sphincter. An univariate analysis of these 46 cases and 155 randomly selected control subjects showed that low parity (P = .003; Mann-Whitney U test), prolonged first and second stages of labor (P = .001, P = .001), high birth weight (P = .031), episiotomy (P = .004; Fisher exact test), and forceps delivery (P = .002) increased the risk for sphincter damage. In multivariate regression models, only high birth weight (P = .004; odds ratio [OR] 1.68, 1.18-2.41, 95% confidence interval [CI]), and forceps delivery combined with mediolateral episiotomies (P < .001; OR 5.62, 2.16-14.62, 95% CI) proved to be independent risk factors. There was a statistical significant interaction of birth weight and head circumference (P = .012; OR 0.99, 0.98-0.99, 95% CI). Although the use of episiotomy conferred an increased risk toward a higher likelihood of severe perineal trauma, it did not reach statistical significance (P = .06; OR 2.15, 0.97-4.76, 95% CI). CONCLUSIONS: In consistence with previous reports, women who are vaginally delivered of a large infant are at a high risk for sphincter damage. Although the rate of these complications was surprisingly low in vaginally assisted childbirth, the use of forceps, even if routinely combined with mediolateral episiotomy, should be minimized whenever possible.     

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.