Labial trauma post birth: A delphi study of classification and suturing requirements.

OBJECTIVES: Primary objectives were to establish consensus of opinion for classification of post birth labial trauma and which types of post birth labial trauma require suturing. Secondary objectives were to establish optimal method, material and anaesthetic for suturing labial trauma. DESIGN: Delphi study consisting of 3 rounds. SETTING: UK and Europe PARTICIPANTS: 8 midwives, 4 obstetricians, 7 specialist perineal midwives, 1 consultant midwife and 2 midwifery lecturers all with relevant expertise and or recent, regular clinical experience of assessing and suturing labial trauma from 2 United Kingdom (UK) universities, 12 UK healthcare trusts and 1 European healthcare organisation. METHODS: A Delphi study consisting of an initial round of 6 professional medical illustrations of labial trauma with 6 open questions attached to each sent to panel members. 2 further rounds developed from the first round with between 2 and 10 opt-in statements for the 6 questions for each illustration to 20 and 22 panel members respectively. Consensus was set at 70% opt-in for each statement. FINDINGS: Consensus was reached that unilateral or bilateral vertical skin separation with minimal trauma to underlying tissues was described as a graze and does not require suturing. Consensus was reached that unilateral or bilateral deeper vertical trauma with involvement of the underlying tissue and horizontal trauma across the labia does require suturing with interrupted technique, injected local anaesthetic and using Vicryl Rapide 3.0 or equivalent. CONCLUSION: A pilot study and definitive randomised controlled trial are required to establish in vivo whether labial tears including those which are transverse, are less painful and heal better with interrupted suturing compared to continuous or subcuticular sutures.

Are obstetric outcomes affected by female genital mutilation?

INTRODUCTION AND HYPOTHESIS: Female genital mutilation (FGM) has been associated with adverse obstetric and neonatal outcomes, such as postpartum haemorrhage (PPH), perineal trauma, genital fistulae, obstructed labour and stillbirth. The prevalence of FGM has increased in the UK over the last decade. There are currently no studies available that have explored the obstetric impact of FGM in the UK. The aim of our study was to investigate the obstetric and neonatal outcomes of women with FGM when compared with the general population. METHODS: We conducted a retrospective case-control study of consecutive pregnant women with FGM over a 5-year period between 1 January 2009 and 31 December 2013. Each woman with FGM was matched for age, ethnicity, parity and gestation with subsequent patients without FGM (control cohort) over the same 5-year period. Outcomes assessed were mode of delivery, duration of labour, estimated blood loss, analgaesia, perineal trauma and foetal outcomes. RESULTS: A total of 242 eligible women (121 FGM, 121 control) were identified for the study. There was a significant increase in the use of episiotomy in the FGM group (p = 0.009) and a significant increase in minor PPH in the control group during caesarean sections (p = 0.0001). There were no differences in all other obstetric and neonatal parameters. CONCLUSIONS: In our unit, FGM was not associated with an increased incidence of adverse obstetric and foetal morbidity or mortality.

Episiotomy preferences, indication, and classification--a survey among Nordic doctors.

INTRODUCTION: Episiotomy performance impacts perineal health and rates of obstetric anal sphincter injuries (OASIS). Our objective was to assess self-reported episiotomy practice and opinions on clinical indication for episiotomy among Nordic physicians and to investigate potential misclassification. MATERIAL AND METHODS: A survey was conducted among doctors attending the 2012 Nordic obstetrical and gynecological conference. Participants were asked to draw an episiotomy on a photo of a perineum with a crowning fetal head similarly to their clinical practice if an episiotomy was clinically indicated, and to name the technique drawn. Differences in outcome measures were compared by country of practice and seniority. RESULTS: The majority of the 297 participants (47%) drew a lateral episiotomy according to our classification by incision point and angle, but as many as 64% of these 138 doctors misclassified this as mediolateral episiotomy. Only 20% drew a mediolateral episiotomy, the great majority classifying it accurately, but 8% misclassified their mediolateral cut as a lateral episiotomy. One-third of episiotomies were nonclassifiable. In general, doctors in Finland, Sweden, and Norway more often favored lateral episiotomies compared with doctors in Denmark and Iceland. There were significant differences between Finnish and Norwegian vs. Danish and Swedish doctors in perception of clinical indications for episiotomy. CONCLUSIONS: The great variation in self-reported episiotomy performance between Nordic physicians and large misclassification rates indicate that educational programs are warranted. Use of uniform classification and appropriate techniques may be crucial to investigate the role of episiotomies in preventing OASIS.

Risk factors for birth-related perineal trauma: a cross-sectional study in a birth centre.

AIM AND OBJECTIVES: To identify maternal, newborn and obstetric factors associated with birth-related perineal trauma in one independent birth centre. BACKGROUND: Risk factors for birth-related perineal trauma include episiotomy, maternal age, ethnicity, parity and interventions during labour including use of oxytocin, maternal position at time of birth and infant birth weight. Understanding more about these factors could support the management of vaginal birth to prevent spontaneous perineal trauma, in line with initiatives to reduce routine use of episiotomy. DESIGN: Cross-sectional study. METHODS: Data were retrospectively collected from one independent birth centre in Brazil, during 2006-2009. The dependent variable (perineal trauma) was classified as: (1) intact perineum or first-degree laceration, (2) second-degree laceration and (3) episiotomy (right mediolateral or median). RESULTS: There were 1079 births during the study period. Parity, use of oxytocin during labour, position at time of giving birth and infant birth weight were associated with second-degree lacerations and episiotomies. After adjusting for parity, oxytocin, maternal position at the expulsive stage of labour and infant birth weight influenced perineal outcomes among primiparae only. CONCLUSIONS: Although the overall rate of episiotomies in this study was low compared with national data, it was observed that younger women were most vulnerable to this intervention. In this age group in particular, the use of oxytocin as well as semi-upright positions at the time of birth was associated with second-degree lacerations and episiotomies. RELEVANCE TO CLINICAL PRACTICE: The use of upright alternative positions for birth and avoidance of use of oxytocin could reduce the risk of perineal trauma from lacerations and need to perform episiotomy.

Classification of episiotomy: towards a standardisation of terminology.

Seven episiotomy incisions are described in the literature, although only midline, mediolateral or lateral episiotomies are commonly used. Recent research has demonstrated variations in both site and direction of the incision, and differences between the angle of incision at the time of crowning of the fetal head and the angle of the scar once the wound has been repaired. We review this evidence and suggest that this variation may undermine the reliability of much published work. We suggest a standardised definition of each type of episiotomy to establish uniformity going forward, so that future studies are amenable to comparison and meta-analysis.

A prospective cohort study of women after primary repair of obstetric anal sphincter laceration.

OBJECTIVE: This study was undertaken to prospectively assess subjective anorectal symptoms by questionnaire and to prospectively assess the integrity of the anal sphincter by physical and ultrasonographic examination in women with and without obstetric anal sphincter laceration. STUDY DESIGN: Fifteen subjects who sustained obstetric anal sphincter lacerations at the time of vaginal delivery were matched with 15 control subjects and followed up prospectively. Women underwent physical and ultrasonographic evaluations and answered questionnaires regarding anorectal symptoms at 6 weeks and at 4 months post partum. Data were evaluated with the Fisher exact test, the Wilcoxon exact and signed rank tests, and the McNemar test. RESULTS: On postpartum examination the subjects with lacerations had more separated sphincters and decreased anal resting and squeeze tones with respect to control subjects (P <.05). According to ultrasonographic evaluation the anal sphincters were more commonly disrupted in the laceration group than in the control group (external anal sphincter, 40% vs 20%; P =.43; and internal anal sphincter, 47% vs 7%; P =.035). Subjective rating of fecal incontinence was significantly greater in the laceration group than in the control group (P <.05). There was no correlation between fecal incontinence symptoms and the integrity of the external anal sphincter. At the 4-month visit, fecal incontinence was resolved in 36% of subjects; however, continued anorectal dysfunction was reported by 43% of subjects in the laceration group versus only 7% of the control subjects (P =.08). CONCLUSION: Reports of fecal incontinence were significantly greater among women with a history of primarily repaired obstetric anal sphincter lacerations than among control subjects. Ultrasonographic examination revealed separated anal sphincters in 40% of the women with obstetric anal sphincter lacerations, despite repair at the time of delivery.

Episiotomy vs perineal tear: which is less traumatic?

Episiotomy is a well-established procedure in obstetric care worldwide. This article examines the available research and literature on episiotomy vs perineal tear to determine whether there is any evidence that episiotomy is indeed less traumatic than allowing the perineum to tear.

Effects of heat and cold on the perineum after episiotomy/laceration.

The Redness Edema Ecchymosis Discharge Approximation (REEDA) tool, devised to evaluate postpartum healing of the perineum following an episiotomy/laceration, was used to evaluate the effects of heat and cold on the perineum during the first 24 hours after delivery. Ninety patients were randomly assigned to one of three treatment groups. Treatment consisted of 30 subjects applying a warm perineal pack, 30 applying a cold perineal pack, and 30 taking a warm sitz bath. Analysis of variance indicated no difference in the REEDA score before or two hours after treatment. A Pearson r correlation indicated the REEDA score was associated with a laceration and not with infant weight. Although these findings do not support assumptions from the literature, this study provides baseline data and trends for future study.