Anal incontinence and fecal urgency following vaginal delivery with episiotomy among primiparous patients.

OBJECTIVE: To investigate anal incontinence following mediolateral or lateral episiotomy during a first vaginal delivery. METHODS: The present prospective follow-up study enrolled primiparous patients who underwent vaginal delivery including mediolateral or lateral episiotomy between April 1, 2010 and March 31, 2012. Participants completed interviews before delivery, and were given anal-incontinence questionnaires to be returned for analysis at 3 months and 6 months postpartum. Anal incontinence was defined as a St Mark's incontinence score above four and individual anal-incontinence components were analyzed separately; results were compared between the two episiotomy techniques. RESULTS: Questionnaires were returned by 300 and 366 patients who underwent mediolateral and lateral episiotomies, respectively; baseline characteristics were similar. Anal incontinence at 3 months and 6 months was recorded among 21 (7.0%) and 9 (3.0%) patients who underwent mediolateral and 27 (7.4%) and 20 (5.5%) who underwent lateral episiotomy, respectively. The study was underpowered to confirm equivalence between the groups; however, no statistically significant differences were observed in the rates of anal incontinence, flatus, solid or liquid incontinence, and de novo incontinence. Fecal urgency (P=0.017) and de novo fecal urgency (P=0.008) were more prevalent among patients who underwent lateral episiotomies at 6 months. CONCLUSION: Anal incontinence was comparable between primiparous patients who underwent mediolateral or lateral episiotomy. The association between lateral episiotomy and fecal urgency merits further scientific interest.

Mediolateral versus lateral episiotomy and their effect on postpartum coital activity and dyspareunia rate 3 and 6 months postpartum.

OBJECTIVES: Comparison of the effects of two episiotomy types on sexual activity, dyspareunia and overall satisfaction after childbirth. STUDY DESIGN: A prospective follow-up study of a randomized comparative trial evaluating peripartum outcome of a vaginal delivery after mediolateral (MLE) or lateral (LE) episiotomy. MAIN OUTCOME MEASURES: The participants completed questionnaires regarding sexual activity, dyspareunia, perineal pain, aesthetic appearance and overall satisfaction 3 (3M) and 6 months (6M) postpartum. RESULTS: A total of 648 women were available for the analyses (306 MLE, 342 LE). The groups showed no difference regarding resumption and regularity of sex, timing of resumption, frequency and intensity of dyspareunia, perineal pain, aesthetic appearance or overall satisfaction 3M or 6M postpartum. 98.0% of women after MLE and 97.7% after LE resumed sexual intercourse within 6M after delivery (p = 0.74). In the same period 15.6% of women after MLE and 16.1% after LE suffered from considerable dyspareunia (p = 0.86). CONCLUSIONS: Quality of sexual life and perception of perineal pain after MLE is equivalent to LE.

Timing of episiotomy and outcome of a non-instrumental vaginal delivery.

INTRODUCTION: The aim of this study was to compare to compare immediate delivery outcome as well as healing, pain, anal incontinence and sexuality in a short-term and a long-term follow up after episiotomy performed before or at crowning in nulliparous women. MATERIAL AND METHODS: This cohort study is a comparison of prospectively collected data evaluating the importance of the timing of episiotomy. Patients with episiotomy performed before crowning (n = 86) and at crowning (n = 404) were compared. Obstetric anal sphincter injuries rate, additional perineal or vaginal trauma, neonatal outcome, episiotomy length, 2nd stage of labor duration, blood loss, infection, hematoma, dehiscence, need for resuturing, pain, painful defecation, resumption of sexual intercourse, dyspareunia, anal incontinence and constipation were assessed immediately after delivery or from responses to questionnaires 24 and 72 h, 10 days, 3 and 6 months postpartum. RESULTS: The groups did not differ in age, body mass index, birthweight, occipito-posterior presentation, shoulder dystocia, or episiotomy type. Significant differences between before crowning and at crowning groups were observed in additional vaginal trauma [26 (30.2%) vs. 66 (16.3%), respectively, p < 0.001], mean episiotomy length (42 mm vs. 36 mm, p < 0.001), and mean estimated blood loss (367 mL vs. 344 mL, p < 0.001). Difference in obstetric anal sphincter injuries rate did not reach statistical significance [0 (0.0%) vs. 7 (1.7%), p = 0.61]. The groups did not differ in additional perineal trauma, pain (Visual Analogue Scale, Verbal Rating Scale and Activities of Daily Living scales), healing complications, sexual functions or anal incontinence in short-term or long-term follow up. CONCLUSIONS: Our results suggest that episiotomy performed at crowning is not associated with worse anatomical or functional delivery outcome, and support a restrictive approach to episiotomy. The effect of episiotomy timing on pelvic organ prolapse development remains to be determined.

Clinical evaluation of early postpartum pain and healing outcomes after mediolateral versus lateral episiotomy.

OBJECTIVE: To evaluate short-term perineal pain among primiparous women after mediolateral episiotomy (MLE) and lateral episiotomy (LE). METHODS: The prospective randomized study was conducted in the Czech Republic during 2010-2012. Consecutive primiparous women who gave birth at or after 37 weeks of pregnancy and had indications for an episiotomy were enrolled and randomly assigned to undergo MLE or LE. Patients were unaware of the episiotomy type performed. The primary outcomes were pain at 24 hours, 72 hours, and 10 days post partum, measured by a visual analog scale, verbal rating scale, interference with activities of daily living, and amount of analgesic use. RESULTS: The analysis included 266 women who underwent MLE and 297 women who underwent LE. Complete relief of pain was observed in 6 (2.3%) of 266 women after 24 hours, 21 (8.0%) of 264 after 72 hours, and 77 (29.1%) of 265 after 10 days in the MLE group, and in 11 (3.9%) of 285, 23 (7.7%) of 297, and 78 (26.4%) of 295 in the LE group, respectively (P=0.36). There were no significant differences in overall pain scores from any rating system or in the amount of analgesics used. CONCLUSION: Incidence and extent of pain in the first 10 days after LE correspond to those after adequately performed MLE.

The role of thumb and index finger placement in manual perineal protection.

INTRODUCTION AND HYPOTHESIS: Comparison of the modifications of the Viennese method of manual perineal protection (VMPP) and hands-off delivery techniques by applying basic principles of mechanics with assessments of tensions within perineal structures using a novel biomechanical model of the perineum. Evaluation of the role of the precise placements of the accoucheur's posterior (dominant) thumb and index finger in perineal tissue tension when performing a modified Viennese method of MPP. METHODS: We carried out an experimental study on a biomechanical model of the perineum at NTIS (New Technologies for Information Society, Pilsen, Czech Republic). Hands-off and 38 variations of VMPP were simulated during vaginal delivery with the finite element model imitating a clinical lithotomy position. RESULTS: The main outcome measures were quantity and extent of strain/tension throughout the perineal body during vaginal delivery. Stress distribution between modifications of VMPP showed a wide variation in peak perineal tension from 72 to 102 % compared with 100 % for the "hands-off" technique. Extent of reduction depended on the extent of finger movement across a horizontal, transverse x-axis, and on final finger position on a vertical, antero-posterior y-axis. The most effective modification of VMPP was initial position of fingers 12 cm apart (x = ±6) on the x-axis, 2 cm anteriorly from the posterior fourchette (y = +2) on the y-axis with 1cm movement of both finger and thumb toward the midline on the x-axis (Δx = 1) with no movement on the y-axis (Δy = 0). CONCLUSIONS: In a biomechanical assessment with simulation of vaginal delivery, exact placement of fingertips on the perineal skin, together with their co-ordinated movement, plays an important role in the extent of reduction of perineal tension.

Clinical evaluation of peripartum outcomes of mediolateral versus lateral episiotomy.

OBJECTIVE: To evaluate the incidence and extent of vaginal and perineal trauma among primiparous women after mediolateral and lateral episiotomy. METHODS: In a prospective randomized study at University Hospital Pilsen, Czech Republic, 790 consecutive primiparous women were enrolled between April 2010 and April 2012. Mediolateral episiotomy (MLE) followed an angle of at least 60° from the midline. Lateral episiotomy (LE) started 1-2 cm laterally from the midline and was directed toward the ischial tuberosity. A rectal examination was performed before episiotomy repair. RESULTS: MLE was performed for 390 women, and LE for 400. The groups did not differ in maternal or neonatal characteristics. No difference was found in incidence or extent of vaginal and perineal trauma; or in additional perineal (1.8% vs 1.5%, P=0.6) or vaginal (8.5% vs 10.6%, P=0.2) trauma continuing along the episiotomy incision. The incidence of anal sphincter injury did not differ between MLE and LE (1.5% vs 1.3%, P=0.7). MLE was associated with shorter repair times (P<0.05), less suturing material (P<0.05), and shorter distances from the anus (P<0.001). CONCLUSION: Risk of additional vaginal and perineal trauma, and anal sphincter injury after adequately performed mediolateral episiotomy is relatively low and corresponds to that of lateral episiotomy.

Stereophotogrammetry of the perineum during vaginal delivery.

OBJECTIVE: To analyze deformation of the perineum during normal vaginal delivery in order to identify clinical steps that might be beneficial when executing manual perineal protection. METHODS: The present prospective study at Charles University Hospital, Pilsen, Czech Republic, enrolled 10 primiparous women at term undergoing non-instrumental vaginal delivery assisted by the same obstetrician between September 2009 and September 2010. A modified hands-poised technique performed concurrently with stereophotogrammetry was used to analyze and quantify perineal deformation and strain at the final stage of delivery. RESULTS: The highest tissue strain (mean, 177%; 95% confidence interval [CI], 106.3-248.5) was in a transverse direction and occurred at the level of the fourchette (i.e. 1cm was transversely stretched and deformed to 2.77 cm during the final stage of vaginal delivery). This strain was more than 4 times higher than the maximum anteroposterior strain (mean, 43%; 95% CI, 28.6-57.4). CONCLUSION: On the basis of these stereophotogrammetry data, a technique of perineal protection executed by fingers of the posterior (right) hand can be proposed. Further experimental and clinical studies are needed to evaluate whether this technique might assist in reducing obstetric perineal trauma.

Importancia del ángulo de la episiotomía / Significance of the angle of episiotomy

La metodología de los estudios que evalúan el papel de la episiotomía mediolateral carece de la calidad necesaria y no puede extraerse actualmente de ellos conclusión alguna acerca del traumatismo perineal grave y la incontinencia anal. Se identificaron cuatro problemas: la definición y la ejecución práctica de la episiotomía mediolateral, y el diagnóstico y clasificación del traumatismo perineal. La definición y ejecución de la episiotomía mediolateral difieren ampliamente entre las distintas instituciones y los distintos individuos. El problema principal es la precisión de la dirección elegida. Se introdujeron tres términos: ángulo de incisión, de sutura y de cicatrización de episiotomía. Anteriormente, la episiotomía mediolateral se definía por un ángulo de incisión mínimo de 40°. Sin embargo,cuando se incide a 40°, el ángulo mediano luego de la reparación era de 20°, mientras que el ángulo de cicatrización era de 30° en los casos de desgarros de tercer grado frente a 38° en los controles. Al usar un ángulo de incisión de 60°, el ángulo mediano de sutura fue de 45° y el de cicatrización de 48°. Actualmente se propone que la episiotomía mediolateral se defina como “una incisión en el perineo durante la última parte de la segunda etapa del trabajo de parto, que comienza en el perineo medial pero se dirige lateralmente en un ángulo de al menos 60° en dirección de la tuberosidad isquial”. Se requieren más investigaciones para evaluar la seguridad de este ángulo de incisión.

Evaluation of the incision angle of mediolateral episiotomy at 60 degrees.

OBJECTIVE: To study the angle of mediolateral episiotomy at the time of cut, after primary repair, and 6 months postpartum; and the incidence and severity of perineal pain and anal incontinence 6 months after delivery. METHODS: The study group comprised 60 consecutively recruited primiparous women who required episiotomy during delivery assisted by 2 obstetricians. The incision angle of episiotomy (defined as 60°) was measured before cutting, after primary repair, and after 6 months. At follow-up, perineal pain was evaluated by a verbal rating score; anal incontinence was assessed by St Mark's score. RESULTS: The angles differed significantly among the incision (60°), repair (45°), and 6-month (48°) measurements (P < 0.001). There was a poor correlation between the suture angle and the angle measured at 6 months postpartum. No severe perineal tear was diagnosed in the cohort. At 6 months postpartum, only 1 woman reported mild symptoms of de novo anal incontinence, whereas 7 women reported perineal pain related to episiotomy. CONCLUSION: An incision angle of mediolateral episiotomy of 60° resulted in a low incidence of anal sphincter tearing, anal incontinence and perineal pain. A randomized controlled trial is needed to assess the outcome when different angles of episiotomy are used.

Anal dilation during labor.

OBJECTIVE: To determine the incidence and range of anal dilation during the final phase of the second stage of labor and shortly after delivery; determine whether parity affects anal dilation; and obtain anthropometric data for future projects. METHODS: The anal diameter was measured on admission, when the fetal head crowned, and after suturing perineal injury in 142 women delivered between August 2008 and May 2009 at University Hospital Pilsen and District Hospital Klatovy, in the Czech Republic. RESULTS: The anus was dilated during the second stage of labor in all women, and differences between primiparas and multiparas were not significant. The medians for both the anteroposterior and transverse diameters were 25 mm. No measured variable was statistically associated with anal sphincter dilation. CONCLUSION: Anal dilation during the second stage of labor causes anthropometric changes to the perineum. This ought to be considered when designing anthropometric studies and in studies aiming at minimizing anal sphincter trauma during delivery.

The incision angle of mediolateral episiotomy before delivery and after repair.

OBJECTIVE: To assess the relevance of the suture angle when evaluating mediolateral episiotomy, and the safety of the accepted lower limit of 40 degrees for the incision angle. METHOD: The angles formed by the incision and suture lines with the midline were measured, and any perineal tear noted, in 50 consecutive women undergoing their first vaginal delivery. RESULTS: The angles were significantly different (40 degrees and 22.5 degrees , respectively; P<0.001). The only variable significantly linked to the difference was the timing of the episiotomy. CONCLUSION: The suture angle cannot currently be used to assess the adequacy of the incision angle; moreover, an incision angle of 40 degrees is probably too acute to prevent potential sphincter damage.