Prediction of Perineal Trauma During Childbirth by Assessment of Striae Gravidarum Score

ObjectiveTo explore the association between striae gravidarum (SG) and the risk for perineal trauma (PT) in childbirth.DesignA cross-sectional study.SettingMaternity ward in 5 university medical centers.ParticipantsThree hundred and eighty-five women (28.9±5.3 years old) who delivered vaginally.MethodsStriae gravidarum score was assessed using the Atwal numerical scoring system. The association was examined between PT as the outcome measure, defined by tears or laceration, and the total striae scores (TSS) obtained at the abdomen, hips, buttocks, and breast.ResultsSignificantly higher TSS scores were found in women with PT compared with women without PT (3.60±0.39 vs. 2.31±0.23, p=.003). Specifically, striae scores at the breast and hips were significantly higher among women who had PT. Logistic regression analysis revealed that TSS (OR=0.079; 95% CI 1.012, 1.151; p=.021), as well as a rise in body mass index (BMI) during pregnancy (OR=1.025; 95% CI 1.001, 1.049; p=.043) are significant predictors of PT.ConclusionsThis study demonstrates a significant relation between SG and PT. The findings suggest that SG assessment may be used in the clinical setting by midwives and nurses as a simple and noninvasive tool to better define women at risk for PT.     

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.     

Prevalence and Predictors of Women's Experience of Psychological Trauma During Childbirth

ABSTRACT: Background: The increased acceptance of the prevalence of trauma in human experience as well as its psychological consequences has led to revisions of diagnostic criteria for the disorder. The three purposes of this study were to examine the rates at which women experienced psychological trauma in childbirth, to explore possible causal factors, and to examine possible factors in the development of the disorder. Methods: One hundred and three women from childbirth education classes in the Atlanta metropolitan area completed a survey in late pregnancy and a follow‐up interview approximately 4 weeks after the birth. Results: The childbirth experience was reported as traumatic by 34 percent of participants. Two women (1.9%) developed all the symptoms needed to diagnose posttraumatic stress disorder, and 31 women (30.1%) were partially symptomatic. Regression analysis showed that antecedent factors (e.g., history of sexual trauma and social support) and event characteristics (e.g., pain in first stage of labor, feelings of powerlessness, expectations, medical intervention, and interaction with medical personnel) were significant predictors of perceptions of the childbirth as traumatic. The pain experienced during the birth, levels of social support, self‐efficacy, internal locus of control, trait anxiety, and coping were significant predictors of the development of posttraumatic stress disorder symptoms after the birth. Conclusions: These findings suggest several intervention points for health care practitioners, including careful prenatal screening of past trauma history, social support, and expectations about the birth; improved communication and pain management during the birth; and opportunities to discuss the birth postpartum. (BIRTH 30:1 March 2003)     

Postpartum Perineal Pain in a Low Episiotomy Setting: Association with Severity of Genital Trauma,Labor Care,and Birth Variables

Background: Perineal pain is common after childbirth. We studied the effect of genital tract trauma, labor care, and birth variables on the incidence of pain in a population of healthy women exposed to low rates of episiotomy and operative vaginal delivery. Methods: A prospective study of genital trauma at birth and assessment of postpartum perineal pain and analgesic use was conducted in 565 midwifery patients. Perineal pain was assessed using the present pain intensity (PPI) and visual analog scale (VAS) components of the validated short‐form McGill pain scale. Multivariate logistic regression examined which patient characteristics or labor care measures were significant determinants of perineal pain and use of analgesic medicines. Results: At hospital discharge, women with major trauma reported higher VAS pain scores (2.16 ± 1.61 vs 1.48 ± 1.40; p < 0.001) and were more likely to use analgesic medicines (76.3 vs 23.7%, p = 0.002) than women with minor or no trauma. By 3 months, average VAS scores were low in each group and not significantly different. Perineal pain at the time of discharge was associated in univariate analysis with higher education level, ethnicity (non‐Hispanic white), nulliparity, and longer length of active maternal pushing efforts. In a multivariate model, only trauma group and length of active pushing predicted the pain at hospital discharge. In women with minor or no trauma, only length of the active part of second stage labor had a positive relationship with pain. In women with major trauma, the length of active second stage labor had no independent effect on the level of pain at discharge beyond its effect on the incidence of major trauma. Conclusions: Women with spontaneous perineal trauma reported very low rates of postpartum perineal pain. Women with major trauma reported increased perineal pain compared with women who had no or minor trauma; however, by 3 months postpartum this difference was no longer present. In women with minor or no perineal trauma, a longer period of active pushing was associated with increased perineal pain.     

限制会阴切开及会阴切口选择的临床探讨

目的:探讨限制会阴切开在头位自然分娩中的应用,比较会阴侧切与会阴正中切开两种术式母儿的结局。方法:收集2012年3～6月重庆医科大学附属第一医院产科自然分娩的586例足月单胎头位孕妇的临床资料进行回顾性分析,其中未行会阴切开196例(未行会阴切开组),行会阴侧切270例(会阴侧切组),行会阴正中切开120例(会阴正中切开组)。比较3种方式对母儿的影响。结果:在产后出血、产后住院时间、产后恢复性交时间、产后性生活满意度及产后会阴疼痛评分方面,未行会阴切开组均优于会阴切开两组,差异均有统计学意义(P<0.05),而会阴正中切开组与会阴侧切组以上指标比较,差异无统计学意义(P>0.05);3组间产褥感染、预防性使用抗生素、产后尿失禁、盆腔脏器脱垂、新生儿Apgar评分和脐血pH值两两比较,差异均无统计学意义(P>0.05)。而会阴正中切开组会阴Ⅰ～Ⅱ度裂伤率(6.67%)与会阴侧切组(1.48%)比较,有显著性升高(P<0.05)。结论:头位自然分娩过程中,在无绝对会阴切开指征时,尽量保持会阴的完整性,对母儿预后无不良影响。在有严格的会阴切开指征时,优先选择会阴侧切,降低会阴裂伤的发生。     

Perineal Trauma and Postpartum Perineal Morbidity in Asian and Non-Asian Primiparous Women Giving Birth in Australia

Objectives: To describe the postpartum perineal morbidity of primiparous women who had a vaginal birth and compare outcomes between Asian and non-Asian women in the first 2 days following the birth and at 6 and 12 weeks postpartum.
Design: Data from a randomized clinical trial of a perineal management technique (perineal warm packs) were used to address the study objective.
Setting: Two maternity hospitals in Sydney, Australia.
Participants: Primiparous women who had a vaginal birth in the trial were included ( n =697). One third of the women were identified as "Asian."
Results: Compared with non-Asian women, Asian women were significantly more likely to have an episiotomy; require perineal suturing; sustain a third- or fourth-degree perineal tear; and report their perineal pain as being moderate to severe on day 1 following the birth. Asian women were less likely to give birth in an upright position or to resume sexual intercourse by 6 or 12 weeks following the birth.
Conclusion: More research is needed into methods that could reduce the high rates of perineal trauma experienced by Asian women, and midwives need to be able to offer appropriate support for Asian women.     

Use of Hyaluronidase to Prevent Perineal Trauma During Spontaneous Births: A Randomized,Placebo‐Controlled,Double‐blind,Clinical Trial

Introduction: The purpose of this study was to compare the frequency and severity of perineal trauma during spontaneous birth with or without perineal injections of hyaluronidase (HAase). Methods: A randomized, placebo‐controlled, double‐blind clinical trial was conducted in a midwife‐led, in‐hospital birth center in São Paulo, Brazil. Primiparous women (N = 160) were randomly assigned to an experimental (n = 80) or control (n = 80) group. During the second stage of labor, women in the experimental group received an injection of 20.000 turbidity‐reducing units of HAase in the posterior region of the perineum, and those in the control group received a placebo injection. The assessment of perineal outcome was performed by 2 independent nurse‐midwives. A 1‐tailed Fisher exact test was performed, and a P value < .025 was considered statistically significant. Results: Perineal integrity occurred in 34.2% of the experimental group and in 32.5% of the control group, which was not a statistically significant difference (P= .477). First‐degree laceration was the most common trauma in the posterior region of the perineum in women in both groups (experimental = 56%, control = 42.6%). Severe perineal trauma occurred in 28.9% of the experimental group and 38.8% of the control group, which also was not a statistically significant difference (P= .131). The depth of second‐degree perineal lacerations in the experimental and control groups, measured by the Peri‐Rule, was 1.9 cm and 2.3 cm, respectively. An episiotomy was performed in 11 women (experimental group = 3, control group = 8), and 4 (all in control group) had third‐degree lacerations. Discussion: The use of injectable HAase did not increase the proportion of intact perineum and did not reduce the proportion of severe perineal trauma in our sample.     

Childbirth and the Development of Acute Trauma Symptoms: Incidence and Contributing Factors

Background: Little is known about the relationship between women's birthing experiences and the development of trauma symptoms. This study aimed to determine the incidence of acute trauma symptoms and posttraumatic stress disorder in women as a result of their labor and birth experiences, and to identify factors that contributed to the women's psychological distress. Method: Using a prospective, longitudinal design, women in their last trimester of pregnancy were recruited from four public hospital antenatal clinics. Telephone interviews with 499 participants were conducted at 4 to 6 weeks postpartum to explore the medical and midwifery management of the birth, perceptions of intrapartum care, and the presence of trauma symptoms. Results: One in three women (33%) identified a traumatic birthing event and reported the presence of at least three trauma symptoms. Twenty‐eight women (5.6%) met DSM‐IV criteria for acute posttraumatic stress disorder. Antenatal variables did not contribute to the development of acute or chronic trauma symptoms. The level of obstetric intervention experienced during childbirth (β= 0.351, p < 0.0001)and the perception of inadequate intrapartum care (β= 0.319, p < 0.0001) during labor were consistently associated with the development of acute trauma symptoms. Conclusions: Posttraumatic stress disorder after childbirth is a poorly recognized phenomenon. Women who experienced both a high level of obstetric intervention and dissatisfaction with their intrapartum care were more likely to develop trauma symptoms than women who received a high level of obstetric intervention or women who perceived their care to be inadequate. These findings should prompt a serious review of intrusive obstetric intervention during labor and delivery, and the care provided to birthing women.     

The Role of the Support Individual in Active Caring During Childbirth

In most modem delivery units, evidence-based care of the parturient is focused on the physical health of the mother and fetus. Increasingly, the patient’s social, cultural, and psychological needs are recognized as important elements influencing the emotional and physical health of both the mother and newborn. The quantity and quality of support provided to the mother during labour may address some of these needs and result in improved health care outcomes. In this article we review the effects of labour support as provided by the father, nurse, midwife, monitrice, and doula. Directions for further research, including the need for a prospective evaluation of active support during childbirth, are discussed.