Implicações físicas e psicológicas da episiotomia no puerpério / Physical and psychological implications of episiotomy in the puerperium

A episiotomia é um procedimento cuja aplicação rotineira ou seletiva vem sendo discutida desde a publicação do Manual de Boas Práticas de Atenção ao Parto e Nascimento pela Organização Mundial da Saúd e (OMS) em 1996. Esta revisão de bibliografia procurou, então, investigar as informações disponíveis até o momento sobre as implicações físicas e emocionais da episiotomia no puerpério, levando em consideração o nível de conhecimento das puérperas sobre o procedimento, a dor, as limitações físicas percebidas e as repercussões na sexualidade da mulher nesse período. A análise dos dados apontou para a exclusão da mulher na tomada de decisões de seu trabalho de parto e para o impacto negativo na autoestima e na sexualidade, trazendo, também, limitações físicas ausentes nos casos de laceração. A comparação do nível de dor entre mulheres com episiotomias e lacerações foi inconclusivo, sugerindo a necessidade de maiores estudos.(AU)

Episiotomy is a procedure which's routine or selective application has been discussed since the publication of the Good Practices for Attention to Childbirth and Birth Manual by World Health Organization (WHO) in 1996. This bibliography review aims to investigate the available information regarding the physical and emotional aspects of episiotomy`s healing in the puerperium. Women's level of knowledge about the subject, pain, perceived physical limitations and the impact on sexuality during this period were the main points taken into consideration. Results pointed to the exclusion of women in the decision-making process of their labors and to a negative impact on self-esteem and sexuality, also inflicting physical limitations that were absent in cases of laceration. The comparison of pain level between women with episiotomies and lacerations was inconclusive, suggesting the need for further studies.(AU)

Hematoma espontáneo del ligamento ancho luego de un parto vaginal normal: reporte de caso / Spontaneous hematoma of the broad ligament after a normal vaginal delivery: case report / Hematoma espontâneo do ligamento largo após um parto vaginal normal: apresentação de um caso clínico

La hemorragia posparto es una de las principales causas de muerte materna con una elevada morbimortalidad. El hematoma del ligamento ancho representa una entidad inusual, de difícil diagnóstico y alta sospecha clínica. Se presenta el caso clínico de una paciente con un hematoma del ligamento ancho espontáneo luego de un parto vaginal. Se optó por una conducta activa con laparotomía y antibioticoterapia obteniendo una buena evolución con egreso hospitalario a los 30 días. Se realiza la discusión del caso luego de revisar la bibliografía disponible.

Postpartum hemorrhage is one of the main causes of maternal death with high morbidity and mortality. The broad ligament hematoma represents an unusual entity, difficult to diagnose, in which clinical suspicion is determinant. The clinical case of a patient with a spontaneous broad ligament hematoma after a vaginal delivery is presented. An active management with laparotomy and antibiotic therapy was chosen, obtaining a satisfactory evolution with hospital discharge at 30 days. The case is discussed, after reviewing the available bibliography.

A hemorragia pós-parto é uma das principais causas de morte maternal com alta morbidade e mortalidade. O hematoma do ligamento largo representa uma entidade incomum, de difícil diagnóstico e alto suspeita clínica. A presentamos o caso clínico de uma paciente com hematoma espontâneo do ligamento largo, após parto vaginal. Foi optada por conduta ativa com laparotomía e antibioticoterapia, obtendo boa evolução com alta hospitalar após 30 dias. O caso é discutido depois de revisar a bibliografia disponível.

Frequência de lesões perineais nos partos vaginais após implementação do Programa de Humanização do Parto / Perineal injuries frequency in vaginal deliveries after the implementation of Childbirth Humanization Program

Há controvérsia quanto ao uso da episiotomia por não existir consenso sobre sua realização. O objetivo foi encontrar fatores de risco envolvidos nas lesões perineais, em uma maternidade de baixo risco, bem como estudar a evolução do uso da episiotomia nos quatro primeiros anos de implementação do Programa de Humanização do Parto. Foi feita uma avaliação retrospectiva analítica, qualitativa, entre os anos de 2014 e 2017, com uma amostra de 4.303 gestantes. Percebeu-se que houve relação significativa entre a ocorrência de laceração perineal e o uso de indutores do parto. Quanto à realização da episiotomia, houve relação significativa com os fatores de risco: primiparidade, indução, posição de litotomia e uso do fórceps. Houve também aumento significativo na ocorrência de lacerações ao longo dos quatro anos, com aumento das lesões leves. A frequência da episiotomia também mostrou diferença significativa, porém, sem manter constância com o passar do tempo.(AU)

There is controversy regarding the use of episiotomy, as there is no consensus about its performance. The objective was to find risk factors involved in perineal lesions in a low-risk maternity hospital, as well as to study the evolution of the use of episiotomy in the first four years of the implementation of the Humanization of Childbirth Program. Was made a retrospective analytical evaluation, qualitative, between 2014 and 2017, with a sample of 4.303 pregnant women. It was perceived that there was a significant relationship between the occurrence of perineal laceration and the use of induction of Childbirth. Regarding the episiotomy, there was a significant relationship with risk factors: primiparity, induction, lithotomy position and use of forceps. There was also a significant increase in the occurrence of lacerations over the four years, with an increase in mild injuries. The frequency of episiotomy may also be significant, however, without keeping up with the passage of time.(AU)

Implementação de práticas assistenciais para prevenção e reparo do trauma perineal no parto / Implementación de prácticas asistenciales para la prevención y reparación de trauma perineal en el parto / Implementation of care practices to prevent and repair perineal trauma in childbirth

RESUMO Objetivos Implementar práticas assistenciais para prevenção e reparo do trauma perineal no parto normal. Métodos Estudo quase-experimental, realizado no Hospital da Mulher Mãe-Luzia, Macapá, AP. Realizaram-se 74 entrevistas com enfermeiros e médicos e 70 com puérperas, e analisaram-se dados de prontuários (n=555). O desenvolvimento da pesquisa se deu em três fases: pré-auditoria e auditoria de base (fase 1); intervenção educativa e implementação de boas práticas assistenciais (fase 2); auditoria pós-implementação (fase 3); a análise foi pela comparação das fases 1 e 3. Resultados Após a intervenção educativa, menos profissionais incentivavam puxos dirigidos, realizavam episiotomia e suturavam lacerações de primeiro grau; mais mulheres informaram que o parto foi em posição litotômica; mais registros nos prontuários indicaram o uso de Vicryl® na sutura da mucosa e pele. Conclusões A intervenção educativa melhorou os cuidados e os desfechos perineais, porém há lacunas na implementação das evidências e inadequações no manejo do cuidado perineal.

RESUMEN Objetivo Implementar prácticas asistenciales para la prevención y reparación del trauma perineal en el parto. Método Estudio casi experimental, conducido en el Hospital da Mulher Mãe-Luzia, Macapá, AP. Se realizaron 74 entrevistas con médicos y enfermeras y 70 con puérperas y se analizaron los datos de registros médicos (n=555). La investigación se desarrolló en tres fases: preauditoría y auditoría de base (fase 1); intervención educativa e implementación de buenas prácticas asistenciales (fase 2); auditoría posimplementación (fase 3); el análisis fue comparando las fases 1 y 3. Resultados Después de la intervención educativa, menos profesionales incentivaban pujo dirigido, realizaban episiotomía y suturaban desgarros de primer grado; más mujeres tuvieron el parto en posición litotomía; más registros indicaban uso de Vicryl® para suturar la mucosa y piel. Conclusión La intervención educativa ha mejorado el cuidado y los resultados perineales, pero hay lagunas en la implementación de evidencias y deficiencias en el cuidado perineal.

ABSTRACT Objective To implement care practices for perineal trauma prevention and repairing in normal birth. Method Quasi-experimental study conducted at Hospital da Mulher Mãe-Luzia, in Macapá, AP, Brazil. Seventy-four (74) nurses and obstetricians and 70 post-partum women were interviewed and the records of 555 patients were analyzed. The study was conducted in three stages: pre-audit and baseline audit (phase 1); educational intervention and implementation of best practices (phase 2); post-implementation audit (phase 3). Data was analyzed by comparison of the results of phases 1 and 3. Results Following the educational intervention, a lower number of health professionals encouraged directed pushing, performed episiotomies and repaired first-degree lacerations; more women reported lithotomy position; more patient records indicated the use of Vicryl™ to suture the perineal mucosa and skin. Conclusion The educational intervention improved birth care and perineal outcomes. Nevertheless, gaps were identified in the implementation of evidence, as well as inappropriate perineal care management

Eficácia do Epi-No® na diminuição da episiotomia e risco de lesão perineal pós-parto: revisão sistemática / Effectiveness of Epi-No® in decline episiotomy and risk of injury perineal postpartum: systematic review

A pergunta mais clássica das gestantes ou futuras mães seria qual tipo de parto escolher. Para as que pretendem ter parto normal, o desejo é ter seu períneo íntegro após o parto. Como a taxa de episiotomia aumentou consideravelmente, e atualmente é a operação cirúrgica mais frequente em mulheres no mundo, surge à necessidade de pesquisar quais métodos seriam capazes de minimizar ou evitar esse procedimento. Este estudo objetivou avaliar a eficácia de um aparelho em forma de balão que infla com ajuda de um medidor de pressão denominado Epi-No® na redução da necessidade de episiotomia e na diminuição do risco de lesão pós-parto. Foi realizada uma revisão sistemática da literatura, de estudos clínicos randomizados, que investigassem os efeitos do Epi-No® levantados no período de 24 a 30 de setembro de 2014 através das palavras-chave. Inicialmente foram encontrados 1.149 artigos, seguindo os critérios de inclusão e exclusão, o número foi reduzido, sendo analisados 6 artigos neste estudo. Conclui-se então que o uso do Epi-No® parece ser eficaz na redução de episiotomia e lesões pós-parto, no entanto são necessários mais estudos controlados randomizados com maiores números amostrais para determinar melhor a sua eficácia.(AU)

The most classic question of pregnant women or future mothers is: which type of delivery to choose? For those who intend to take normal delivery, the desire is that the perineum remain integrate after delivery. Since episiotomy rate has increased considerably and is currently the most common surgical procedure in women in the world, comes the need to know which methods would be effective to prevent it. This study aimed to evaluate the effectiveness of a balloon-like device that inflates with the help of a pressure gauge known as Epi-No® in reducing the need for episiotomy and decreased risk of postpartum injury. A systematic literature review was performed with randomized clinical trials to investigate the effects of Epi-No®, from September 24 to 30, using keywords. Initially, were found 1.149 articles, following the inclusion and exclusion criteria, the number was reduced and 6 articles wer analyzed in this study. The conclusion is that Epi-No® appears to be effective in reducing episiotomy and postpartum injuries, but we need more randomized controlled trials with larger sample numbers to better determine their effectiveness.(AU)

Perineal trauma after vaginal delivery in healthy pregnant women / Trauma perineal após parto vaginal em parturientes saudáveis

CONTEXT AND OBJECTIVE: Despite all the medical care provided during delivery labor, perineal injury is still prevalent and may lead to diverse pelvic floor disorders. The aim here was to investigate the prevalence of obstetric and anal sphincter injuries (OASIS) in healthy pregnant women after vaginal delivery. DESIGN AND SETTING: Cross-sectional study involving 3,034 patients with singletons in a secondary hospital for low-risk cases. METHODS: A standardized questionnaire was prepared and applied to medical files that had been completely filled out (classification of the Royal College of Obstetricians and Gynecologists, RCOG) in order to identify OASIS and analyze risk factors associated with mild and severe perineal lacerations. RESULTS: The women's mean age was 25 years; more than half (54.4%) were primiparae. Almost 38% of the participants had perineal lacerations; these were severe in 0.9% of the cases. Previous vaginal delivery (odds ratio, OR: 1.64 [1.33-2.04]) and forceps delivery (OR: 2.04 [1.39-2.97]) were risk factors associated with mild perineal injuries (1st and 2nd OASIS classifications). Only remaining standing for prolonged periods during professional activity (OR: 2.85 [1.34-6.09]) was associated with severe perineal injuries. CONCLUSION: The prevalence of severe perineal injuries was concordant with data in the literature. The variable of standing position was considered to be a risk factor for severe perineal injury and should be further investigated. .

CONTEXTO E OBJETIVOS: Apesar do cuidado médico executado durante o trabalho de parto, os traumas perineais ainda são prevalentes e podem levar a várias desordens do assoalho pélvico. O objetivo foi investigar a prevalência de injúrias obstétricas e do esfíncter anal em mulheres saudáveis após parto vaginal. DESENHO E LOCAL DE ESTUDO: Estudo transversal envolvendo 3.034 pacientes com recém-natos únicos de um hospital secundário de baixo risco. MÉTODOS: Um questionário padronizado foi preparado e aplicado aos prontuários completamente preenchidos (classificação do Royal College of Obstetricians and Gynecologists) para identificar as lesões obstétricas e do esfíncter anal e analisar fatores de risco associados com lacerações perineais leves e graves. RESULTADOS: A média de idade das mulheres era 25 anos; mais da metade (54,4%) era primípara. Quase 38% das participantes tiveram lacerações perineais; estas foram graves em 0,9% dos casos. A presença de parto vaginal prévio (odds ratio, OR, 1,64 [1,33-2,04]) e o parto fórceps (OR 2,04 [1,39-2,97]) foram fatores de risco associados às lesões perineais leves (primeira e segunda classificações de lesão esfíncter e anal). Somente a posição em pé prolongada durante a atividade profissional (OR 2,85 [1,34-6,09]) estava associada com lesões perineais graves. CONCLUSÃO: A prevalência de trauma perineal grave concordou com dados da literatura. A variável posição em pé foi considerada fator de risco para trauma perineal grave e necessita ser investigada. .

Nascer no Brasil: o retrato do nascimento na voz das mulheres / Born in Brazil: the birth of the picture in women's voice

Vídeo: Nascer no Brasil - O retrato do nascimento na voz das mulheres é o tema da série em DVD Nascer no Brasil. Depoimentos emocionantes de mulheres logo após o nascimento de seus filhos dão voz aos números da pesquisa Nascer no Brasil – Inquérito Nacional sobre Parto e Nascimento, estudo inédito coordenado pela Escola Nacional de Saúde Pública Sergio Arouca (Ensp/Fiocruz), que teve como objetivo conhecer os determinantes, a magnitude e os efeitos das intervenções obstétricas no parto, incluindo as cesarianas desnecessárias, assim como a motivação das mulheres pela escolha do parto. Vídeo: Parto, da violência obstétrica às boas práticas No Brasil, a chance de dar à luz sem intervenções durante o trabalho de parto é remota. Apenas 5 por cento das mulheres tiveram essa experiência, segundo a pesquisa Nascer no Brasil, coordenada pela Fiocruz. Muitos procedimentos passaram a ser usados de forma rotineira causando mais traumas do que benefícios. O vídeo de Bia Fioretti, coproduzido pela VideoSaúde Distribuidora da Fiocruz, aborda a realidade de nascer no Brasil e para qual direção caminhamos...

Mensuração e caracterização da dor após episiotomia e sua relação com a limitação de atividades / Measurement and characteristics of pain after episiotomy and its relationship with the activity limitations / Medición y características del dolor después de la episiotomía y su relación con la limitación de actividades

Trata-se de um estudo descritivo realizado com cinquenta mulheres em pós-parto vaginal com episiotomia. Objetivou-se mensurar e caracterizar a dor perineal em primíparas submetidas ao parto normal com episiotomia e verificar as atividades limitadas pela dor. Para avaliação da dor foi utilizada a Escala Numérica e o Questionário McGill, bem como um formulário para analisar as atividades que estavam limitadas. A média de dor perineal encontrada foi cinco. As categorias sensorial e avaliação subjetiva foram as mais selecionadas no Questionário McGill. A dor perineal foi caracterizada como latejante, que repuxa, que esquenta, ardida, dolorida, chata, incômoda, que prende e que deixa tensa. Sentar, deitar e deambular foram as atividades mais limitadas. Em conclusão, foi possível verificar a presença de dor perineal nas puérperas causada pela episiotomia e identificar que as atividades de sentar, deitar e deambular estavam limitadas por este sintoma.

This is a descriptive study, involving fifty women after vaginal delivery with episiotomy. The study aimed to measure and to characterize the perineal pain in primiparae who have had a natural childbirth with episiotomy and to verify the activities limited by the perineal pain. For evaluation of perineal pain, a Numeric Scale and the McGill Pain Questionnaire were used, as well as another questionnaire to analyze the activities limited. In the Numeric Scale, the median of perineal pain referred were five. The sensory and subjective evaluation categories were the most selected in the McGill questionnaire. The perineal pain was characterized as pulsing, pulling, hot, stinging, hurting, annoying, troublesome, tight and tense. The most limited activities were sitting, laying down (onto the bed), and walking. In conclusion, it was possible to verify the presence of perineal pain between women in the postpartum period caused by episiotomy and identify the activities of sitting, lying down and walking were limited for this symptom.

Se realizo un estudio descriptivo de cincuenta mujeres después del parto vaginal con episiotomía. Objetivó-se medir y caracterizar el dolor perineal en primíparas sometidas al parto normal con episiotomía y verificar las actividades limitadas por el dolor perineal. Para la evaluación del dolor se utilizo la Escala Numérica, el Cuestionario de del Dolor de McGill y un cuestionario para analizar las actividades limitadas. En la Escala Numérica, la media de dolor fue cinco. Las categorías de evaluación sensorial y subjetiva fueron los más seleccionados en el cuestionario McGill. La dolor perineal se caracterizó como palpitante, de esfuerzo, que se calienta, quema, duele, aburrido, incómodo, y deja que mantiene estrechos. Sentado, tumbado y caminar son las actividades más limitados. Finalización: fue posible verificar la presencia de dolor perineal entre primíparas causada por la episiotomia e identificar las actividades de sentado, acostado y caminando se vieron limitados por en este síntoma.

Fístula rectovaginal posobstétrica: tratamiento quirúrgico mediante avance de colgajo endorrectal / Postobstetric rectovaginal fistula: surgical treatment using endorectal advancement flap

Introducción: Las fístulas rectovaginales ocurren con una frecuencia menor a 5 % respecto a otros tipos de fístulas de la región anorrectal; el trauma obstétrico es la causa más común de este tipo de fístulas. Existen diversos procedimientos quirúrgicos para la reparación de las mismas. Material y métodos: Se realizó un estudio de 16 pacientes con diagnóstico de fístula rectovaginal posobtétrica, atendidas en el Hospital Juárez de México entre enero de 1992 y diciembre de 2006. Se analizó edad de las pacientes, tipo de trauma obstétrico, tiempo de inicio de la sintomatología después del parto, localización y tamaño de la fístula, índice de éxito y recidivas mediante el tratamiento con avance de colgajo endorrectal, y necesidad de esfinteroplastia complementaria. Resultados: La edad promedio fue de 25.6 años. En todas las pacientes, la sintomatología inició después de un parto vaginal durante el cual se realizó episiotomía o hubo desgarro perineal. Todas las fístulas fueron menores de 2.5 cm de diámetro y de localización baja. Con el colon preparado, en todas las pacientes se reparó la fístula rectovaginal mediante avance de colgajo endorrectal. En dos pacientes se llevó acabo, además, esfinteroplastia del esfínter anal. Los resultados fueron satisfactorios en 15 pacientes (93.7 %); no hubo mortalidad operatoria y no fueron utilizados estomas de protección. Conclusiones: El colgajo endorrectal es un procedimiento seguro para la reparación de fístulas rectovaginales de origen posobstétrico, algunos casos pueden requerir esfinteroplastia del esfínter anal.

BACKGROUND: Rectovaginal fistulas account for <5% of all rectal fistulas. Obstetrical injuries are the most common cause of these types of fistulas. There have been a multitude of surgical approaches developed for operative repair. METHODS: Between January 1992 and December 2006, 16 patients with postobstetric rectovaginal fistula were treated at the Hospital Juárez of México. Age, type of obstetric trauma, time elapsed between delivery and beginning of symptoms, location, and size of the fistulas, rate of success and recurrence with the use of endorectal flap, and need for complementary sphincteroplasty were all evaluated. RESULTS: Median age of the patients was 25.6 years. All women reported that their symptoms began after a vaginal delivery that included an episiotomy or 4th degree laceration. All fistulas were low and small (<2.5 cm in diameter). Patients received bowel preparation and underwent rectovaginal repair using endorectal advancement flap. In two cases, additional overlap repair of the anal sphincter was performed. Result of repair was good to excellent in 15 patients (93.7%). There were no operative mortalities, and no covering stomas were used. CONCLUSIONS: Endorectal flap repair provides successful postobstetric rectovaginal fistula closure. Concomitant sphincteroplasty may be necessary in some cases.

Sintomas urinários irritativos após parto vaginal ou cesárea / Irritative bladder symptoms after vaginal delivery or c-section

OBJETIVO: Avaliar a frequência de Sintomas Urinários Irritativos (SUI) três anos após o parto em mulheres previamente entrevistadas no terceiro trimestre da gestação e sua associação com a via de parto exclusiva, a paridade, a idade materna, o peso do RN, a realização da episiotomia e o uso de fórcipe. MÉTODOS: Das 340 mulheres, originalmente avaliadas no terceiro trimestre da gestação, 120 foram localizadas e entrevistadas por telefone, três anos após o parto, entre junho e outubro de 2006. Foi analisada a associação entre SUI e via exclusiva de parto (vaginalou cesáreo), paridade,idade materna, peso do recém-nascido, realização da episiotomia e uso de fórcipe. Os resultados foram avaliados por meio de estatística descritiva, teste Qui quadrado e cálculo da razão de prevalência (p< 0,05). RESULTADOS: O grupo de mulheres estudadas consistiu de primíparas (37,5 por cento) e multíparas (62,5 por cento). As 95 que tiveram via exclusiva de parto foram categorizadas em vaginal (53) e cesáreas (42). Não houve associação significativa entre a presença de SUI após o parto e a via de parto exclusiva e a paridade. Também não encontramos associação entre a presença de SUI e a idade materna (> 35) peso do recém-nascido (> 4000g), realização da episiotomia e uso de fórcipe. CONCLUSÃO: A via de parto e a paridade não foram fatores determinantes para a disfunção do trato urinário inferior após o parto, representada pelos sintomas urinários irritativos, tampouco, a idade materna, o peso do RN, a realização da episiotomia e o uso de fórcipe.

OBJECTIVE: This study intended to investigate the frequency of irritative bladder symptoms three years after delivery in women previously interviewed in the third trimester of pregnancy and its correlation to mode of delivery, parity, maternal age, birth weight, episiotomy and forceps. METHODS: From 340 women previously evaluated at the third trimester of pregnancy, 120 were interviewed three years after delivery, between June and October 2006. Correlation of postpartum irritative bladder symptoms and mode of delivery (exclusively vaginal or c-section), parity, maternal age, birth weight, episiotomy and forceps was analyzed. Associations between irritative bladder symptoms and obstetric parameters were assessed by the Fisher's exact test and Chi-square (p< 0.05). RESULTS: The study group consisted of 37.5 percent primiparous and 62.5 percent multiparous women. Mode of delivery was exclusively vaginal in 53 women and exclusively c-section in 42. No statistical difference was found between irritative bladder symptoms and mode of delivery and parity. No statistical difference was found between irritative symptoms and maternal age (> 35), birth weight (> 4000g), episiotomy and forceps. CONCLUSION: After childbirth, dysfunction of the lower urinary tract, characterized by irritative bladder symptoms, was not associated with mode of delivery, parity, maternal age, birth weight, episiotomy and forceps.

Lesão esfincteriana e continência anal em pós-parto vaginal / Sphincter injury and anal continence after vaginal

Incontinência anal (IA) é definida pela perda involuntária de gases, fezes líquidas ou sólidas. Entre várias causas de IA, o trauma obstétrico é causas primária de lesão esfincteriana anal (LEA) e tem sido foco de pesquisa, tratamento e prevenção. Este trabalho tem por objetivo revisar incidência , fatores de risco e medidas que previnam e/ ou reduzam o trauma obstétrico sobre a continência anal.

Relieving perineal pain after perineorrhaphy by diclofenac rectal suppositories: a randomized double-blinded placebo controlled trial.

BACKGROUND: Perineal pain after episiotomy is a common problem following vaginal birth. The pain affects either physical or mental function negatively. There are many methods in perineal pain relief such as local ice pack and a bath, ultrasound, oral anesthesia, and intravenous anesthesia. Analgesic rectal suppository is one of various methods in pain relief especially in drowsy patients, or when oral preparation causes gastric discomfort, nausea or vomiting. OBJECTIVE: To assess the effectiveness of diclofenac rectal suppositories for relief perineal pain after perineorrhaphy. DESIGN: A randomized double-blinded placebo controlled trial. MATERIAL AND METHOD: Seventy-two term, singleton, pregnant women who gave vaginal birth with second to third degree episiotomy tears were randomized with envelop concealment to either diclofenac or placebo rectal suppositories group. Each group received two tablets of 50 mg diclofenac or two tablets of look-alike placebo rectal suppositories. Visual analogue scale was used for scaling pain score before administration of the medications, and at 30 minutes, 1, 2, 12, and 24 hours after administration. RESULTS: No differences were found in the median pain scores before administration of medications and at 30 min, 1 hour and 2 hour after administration (p > 0.05), while the median pain scores were significantly reduced in the diclofenac group at 12 and 24 hours after administration compared to the control group (4.5 vs. 0.0; p < 0.001 and 2.0 vs. 0.0; p = 0.02 for 12 hours and 24 hours, consecutively). CONCLUSION: The present study suggested that diclofenac suppository was effective on reducing perineal pain after episiotomy, especially at 12 and 24 hours after administration.

Ibuprofen versus acetaminophen for the relief of perineal pain after childbirth: a randomized controlled trial.

OBJECTIVES: To evaluate efficacy of ibuprofen compared with acetaminophen for relief of perineal pain after childbirth, side effects of ibuprofen compared with acetaminophen and patient satisfaction in treatment between the 2 groups. MATERIAL AND METHOD: A total of 210 women who gave birth by spontaneous vaginal delivery with mediolateral episiotomy between June 2006 and November 2006 were randomly assigned to receive either ibuprofen (400 mg) (n = 106) or acetaminophen (1000 mg) (n = 104), both given orally when suturing was completed. Pain ratings were recorded before the treatment and at 1, 2, 3 and 4 hours after the treatment on a 10-cm visual analogue scale. Side effects and patient satisfaction were assessed at 24 hours. RESULTS: Pain in the ibuprofen group was considerably more reduced than the acetaminophen group at 1 hour of treatment (mean pain rating 2.18 vs. 2.88, respectively; p < 0.003). Even though, at 2, 3 and 4 hours of treatment ibuprofen seemed to give more reliefof pain than acetaminophen, they did not reach statistically significant differences (mean pain rating; at 2 hour: 1.59 vs. 1.97, p = 0.093; at 3 hour: 1.08 vs. 1.31, p = 0.183; and at 4 hour: 0.69 vs. 0.85, p = 0.169; respectively). There were no side effects and no significant differences in overall patient satisfaction between the two groups. CONCLUSION: Ibuprofen was consistently better than acetaminophen at 1 hour after treatment for relief of perineal pain after childbirth without any side effects. After 2 hours, ibuprofen and acetaminophen had similar analgesic properties.

Dispareunia en mujeres después del parto: estudio de casos y controles en un hospital de Acapulco, México / Women’s dyspareunia after childbirth: a case study in a hospital in Acapulco, Mexico

OBJETIVO: Identificar los factores asociados con la dispareunia entre 60 y 180 días después del parto en mujeres con antecedentes de uno o dos partos. MÉTODOS: Estudio de casos y controles, pareados por la edad y la paridad en 304 mujeres que acudieron al servicio de planificación familiar de un hospital de Acapulco, Guerrero, México, entre los 60 y 180 días después del parto. Se aplicó un cuestionario con preguntas sobre su situación socioeconómica (edad, escolaridad propia y de su pareja, estado civil, situación laboral, de seguridad social y de tenencia de su casa) y sus antecedentes obstétricos (características del parto, paridad, lugar de atención, desgarros, episiotomía y complicaciones) y ginecológicos (sensación de estrechez del introito, presencia de cicatriz queloide de la episiorrafia, síntomas de vaginitis, resequedad vaginal, métodos anticonceptivos empleados y tipo y duración de la lactancia). Se consideraron como casos a las mujeres que refirieron dolor, ardor o sangrado al tener relaciones sexuales con penetración vaginal después del parto. Se aplicó un modelo de regresión logística no condicionada y se calcularon las razones de posibilidades (odds ratios, OR) y los intervalos de confianza de 95 por ciento (IC95 por ciento). RESULTADOS: De 368 mujeres que habían reiniciado relaciones sexuales, 152 (41,3 por ciento) refirieron dispareunia. Los factores asociados con dispareunia fueron haber tenido infección con o sin dehiscencia de la episiorrafia (OR = 34,09; IC95 por ciento: 10,59 a 109,78), presentar síntomas de vaginitis (OR = 7,43; IC95 por ciento: 3,68 a 14,99), tener sensación de estrechez del introito vaginal (OR = 6,38; IC95 por ciento: 2,92 a 13,94) y practicar la lactancia exclusiva (OR = 4,86; IC95 por ciento: 2,44 a 9,69). CONCLUSIONES: La dispareunia estuvo relacionada con las complicaciones de la episiotomía y sus posibles secuelas, como la infección, la dehiscencia de la episiorrafia y la estrechez del introito...

OBJECTIVE: To identify the factors associated with dyspareunia, during the 60-180 days following childbirth, in women with a history of one or two childbirths. METHODS: A case study of 304 women, matched by age and parity who visited family planning services in a hospital in Acapulco, State of Guerrero, Mexico, 60-180 days after giving birth. A questionnaire was administered to assess socioeconomic status (age, level of education, partner’s level of education, marital status, employment, social security, and homeownership), obstetric history (type of birth, parity, location of the birth, tearing, episiotomy, and complications), and gynecological status (constricted introitus, scar tissue at the episiotomy site, symptoms of vaginitis, vaginal dryness, contraceptive use, and breast feeding duration). Cases were defined as those women who related pain, burning, or bleeding following vaginal intercourse after childbirth. An unconditional logistic regression model was applied and odd ratios (OR) and 95 percent confidence interval were calculated. RESULTS: Of the 368 women who had reinitiated sexual relations, 152 (41.3 percent) mentioned dyspareunia. The factors associated with dyspareunia were: an infection with or without episiorrhaphy dehiscence (OR = 34.09; CI95 percent: 10.59-109.78); symptoms of vaginitis (OR = 7.43; CI95 percent: 3.68-14.99); tightness in the introitus of the vagina (OR = 6.38; CI95 percent: 2.92-13.94), and breast feeding exclusively (OR = 4.86; CI95 percent: 2.44- 9.69). CONCLUSIONS: Dyspareunia was related to complications with episiotomy and its possible sequelae, such as infection, episiorrhaphy dehiscence, and constricted introitus. More attention should be given to the episiotomy site during the postpartum period and greater selectivity is needed when deciding which women require an episiotomy.

Cloaca traumática: revisión de la técnica de reparación quirúrgica / Traumatic cloaca: revision of the surgical repair technique

La cloaca traumática es la dehiscencia del cuerpo perineal, parte inferior del septo recto-vaginal y sector anterior del aparato esfinteriano debida, lo más frecuentemente, a injuria obstétrica. Se presenta bajo la forma de incontinencia fecal y su diagnóstico es clínico. El tratamiento es quirúrgico e incluye la realización de una esfinteroplastía asociada a una técnica de reconstrucción perineal. Presentamos el caso de una mujer de 37 años en la que se realizó corrección quirúrgica y revisamos la literatura con relación a los aspectos técnicos, recomendaciones y resultados del manejo de esta condición.

The disruption of the perineal body, division of the anal sphincters anteriorly, and loss of the distal rectovaginal septum is known as traumatic cloaca, resulting usually from obstetric injury. Fecal incontinence is the main complain and clinical diagnosis is definitive. Surgical treatment includes the sphincteroplasty and perineal body reconstruction. We present a 37 year-old female who underwent surgical repair, and a review of the literature on the technical aspects, recommendations, and outcome of the management of this condition.

Randomised controlled trial of perineal shaving versus hair cutting in parturients on admission in labor.

OBJECTIVES: To compare the maternal and neonatal outcomes between perineal shaving and hair cutting in parturients on admission in labor MATERIAL AND METHOD: Five hundred pregnant women with labor pain and no medical or obstetric complications were selected at random on admission to be assigned into two groups at Rajavithi Hospital from 1st November 2001 to 28th February 2002. Forty two women were excluded because of cesarean section. Two hundred and twenty-seven cases received perineal hair cutting and 231 cases received perineal shaving. RESULTS: The gestational age at delivery was statistically significant difference between those receiving perineal hair cutting (39.4 week) comparing with those receiving perineal shaving (39.1 week) (p < 0.05). There was no statistically significant difference in 2 groups for puerperal morbidity, perineal wound infection and dehiscence. There were no neonatal infection and puerperal infection in both groups, where as both accoucheurs and perineorrhaphy operators were more satisfied the perineal shaving group than the cutting group (p < 0.001). CONCLUSION: Perineal shaving or hair cutting on admission in labor had no statistical significant difference effect on the perineal wound infection and dehiscence, neonatal infection, puerperal morbidity and infection.

Perineal pain after vaginal delivery

The objective of this study was to assess pain morbidity after vaginal delivery and effect of episiotomy on it. Fifty women delivering vaginally at Liaquat University Hospital and Aga Khan Maternal and Child Care Center Hyderabad were followed through a pre-developed questionnaire at 24-48 hours after delivery, 10th post partum day and 10th post partum week for assessment of pain All women with episiotomy [n-25] required oral analgesia following delivery, 2 required parenteral analgesia for 24 hours compared to no analgesia for perineal pain in control group. At day 10, 4 [16%] among episiotomy group had inflamed and gaping wound requiring local treatment and removal of stitches. Two [8%] required admission for restitching Dyspareunia was more common among episiotomy group, Two required medical / surgical intervention for it. Episiotomy adversely affect the pain morbidity after vaginal delivery