PERINEAL OUTCOMES AND NURSE-MIDWIFERY MANAGEMENT

This article describes the association among perineal outcomes, selected risk factors, and alternative intrapartum approaches used by nurse-midwives. This nonrandomized concurrent (cohort) study analyzed all spontaneous vaginal births (N = 1211) attended by nurse-midwives at a university hospital over a 2-year period. Univariate analysis was used to calculate relative risks for the associations between two perineal outcomes and selected variables. Study results indicated that parity, ethnicity, birth weight, and use of two techniques (hot compresses and lubrication) were associated with lacerations. The same factors that increase the risk of perineal lacerations also made the performance of an episiotomy more likely; however, for episiotomy, an inverse relationship with perineal hot compresses was noted, and perineal lubrication had no effect. Lack of perineal support was associated with a 66% rise in the risk of episiotomy. Use of birthing positions other than lithotomy significantly reduced the likelihood of episiotomy. The authors concluded that selected care measures to protect the perineum may reduce maternal morbidity and simplify intrapartum care. The risks and benefits of alternative strategies commonly used by nurse-midwives while caring for diverse populations during birth should be further evaluated in large multiethnic populations.     

Risk factors for birth canal lacerations in primiparous women

Lacerations of the birth canal are common side effects of vaginal birth. They are potentially preventable. Although serious long-term consequences have been identified for severe perineal lacerations, less attention has been paid to lacerations in other locations and how the risk factors vary for different lacerations. We analyzed a dataset including 1009 primiparous women with singleton pregnancies and vaginal deliveries, and we examined risk factors for third- and fourth-degree perineal lacerations and periurethral, vaginal, and labial lacerations using logistic regression analysis. Large fetal size (> or = 3500 g) substantially increased the risk of perineal (odd ratio [OR], 3.8; 95% confidence interval [CI], 1.8 to 7.9) and periurethral (OR, 2.3; 95% CI, 1.0 to 5.0) lacerations but not other types of lacerations. Episiotomy had no impact on perineal lacerations (OR 0.9) but had very strong protective effects for other lacerations (OR 0.1). Prolonged second stage of labor (> 120 minutes) increased the risk of perineal and vaginal lacerations but reduced the risk for periurethral lacerations. Instrumental deliveries were significant risk factors for third- and fourth-degree perineal lacerations, with by far the strongest effect for low forceps (OR 25.0 versus < 3 for outlet forceps, outlet vacuum, and low vacuum). We concluded that separating different birth canal lacerations is critical in identifying risk factors and potential preventive strategies.     

Perineal Outcomes and Maternal Comfort Related to the Application of Perineal Warm Packs in the Second Stage of Labor: A Randomized Controlled Trial

ABSTRACT: Background: Perineal warm packs are widely used during childbirth in the belief that they reduce perineal trauma and increase comfort during late second stage of labor. The aim of this study was to determine the effects of applying warm packs to the perineum on perineal trauma and maternal comfort during the late second stage of labor. Methods: A randomized controlled trial was undertaken. In the late second stage of labor, nulliparous women (n = 717) giving birth were randomly allocated to have warm packs (n = 360) applied to their perineum or to receive standard care (n = 357). Standard care was defined as any second‐stage practice carried out by midwives that did not include the application of warm packs to the perineum. Analysis was on an intention‐to‐treat basis, and the primary outcome measures were requirement for perineal suturing and maternal comfort. Results: The difference in the number of women who required suturing after birth was not significant. Women in the warm pack group had significantly fewer third‐ and fourth‐degree tears and they had significantly lower perineal pain scores when giving birth and on “day 1” and “day 2” after the birth compared with the standard care group. At 3 months, they were significantly less likely to have urinary incontinence compared with women in the standard care group. Conclusions: The application of perineal warm packs in late second stage does not reduce the likelihood of nulliparous women requiring perineal suturing but significantly reduces third‐ and fourth‐degree lacerations, pain during the birth and on days 1 and 2, and urinary incontinence. This simple, inexpensive practice should be incorporated into second stage labor care. (BIRTH 34:4 December 2007)     

Management of persistent occiput posterior position: a substantial role of instrumental rotation in the setting of failed manual rotation

Introduction: To compare the maternal and neonatal outcomes associated with Instrumental Rotation (IR) to operative vaginal delivery in occiput posterior (OP) position with Thierry’s spatulas (TS), in the setting of failed manual rotation (MR).

Study design: We led a prospective observational cohort study in a tertiary referral hospital in Toulouse, France. All women presenting in labor with persistent OP position at full cervical dilatation and who delivered vaginally after failed MR and with IR or OP assisted delivery were included from January 2014 to December 2015.

The main outcomes measured were maternal morbidity parameters including episiotomy rate, incidence and severity of perineal lacerations, perineal hematomas and postpartum hemorrhage. Severe perineal tears corresponded to third and fourth degree lacerations. Fetal morbidity outcomes comprised neonatal Apgar scores, acidemia, fetal injuries, birth trauma and neonatal intensive care unit admissions.

Results: Among 9762 women, 910 (9.3%) presented with persistent OP position at full cervical dilatation and 222 deliveries were enrolled. Of 111 attempted IR, 97 were successful (87.4%). The incidence of anal sphincter injuries was significantly reduced after IR attempt (1.8% vs. 12.6%; p?Conclusion: Our results support the use of IR in order to reduce perineal morbidity associated with OP assisted delivery, in the setting of a failed manual rotation.     

Maternal Position at Midwife‐Attended Birth and Perineal Trauma: Is There an Association?

ABSTRACT: Background: Most women will sustain some degree of trauma to the genital tract after vaginal birth. This study aimed to examine the association between maternal position at birth and perineal outcome in women who had a midwife‐attended, spontaneous vaginal birth and an uncomplicated pregnancy at term. Methods: Data from 3,756 births in a major public tertiary teaching hospital were eligible for analysis. The need for sutures in perineal trauma was evaluated and compared for each major factor studied (maternal age, first vaginal delivery, induction of labor, not occipitoanterior, use of regional anesthesia, deflexed head and newborn birthweight >3,500 g). Birth positions were compared against each other. Subgroup analysis determined whether birth positions mattered more or less in each of the major factors studied. The chi‐square test was used to compare categorical variables. Results: Most women (65.9%) gave birth in the semi‐recumbent position. Of the 1,679 women (44.5%) who required perineal suturing, semi‐recumbent position was associated with the need for perineal sutures, whereas all‐fours was associated with reduced need for sutures; these associations were more marked in first vaginal births and newborn birth weight over 3,500 g. When regional anesthesia was used, semi‐recumbent position was associated with a need for suturing, and lateral position associated with a reduced need for suturing. The four major factors significantly related to perineal trauma included first vaginal birth, use of regional anesthesia, deflexed head, and newborn weight more than 3,500 g. Conclusions: Women should be given the choice to give birth in whatever position they find comfortable. Maternity practitioners have a responsibility to inform women of the likelihood of perineal trauma in the preferred birth position. Ongoing audit of all clinicians attending births is encouraged to further determine effects of maternal birth position and perineal trauma, to investigate women's perception of comfortable positioning at birth, and to measure changes to midwifery practice resulting from this study.     

Minimizing genital tract trauma and related pain following spontaneous vaginal birth

Genital tract trauma is common following vaginal childbirth, and perineal pain is a frequent symptom reported by new mothers. The following techniques and care measures are associated with lower rates of obstetric lacerations and related pain following spontaneous vaginal birth: antenatal perineal massage for nulliparous women, upright or lateral positions for birth, avoidance of Valsalva pushing, delayed pushing with epidural analgesia, avoidance of episiotomy, controlled delivery of the baby's head, use of Dexon (U.S. Surgical; Norwalk, CT) or Vicryl (Ethicon, Inc., Somerville, NJ) suture material, the "Fleming method" for suturing lacerations, and oral or rectal ibuprofen for perineal pain relief after delivery. Further research is warranted to determine the role of prenatal pelvic floor (Kegel) exercises, general exercise, and body mass index in reducing obstetric trauma, and also the role of pelvic floor and general exercise in pelvic floor recovery after childbirth.     

OUTCOMES OF MACROSOMIC INFANTS IN A NURSE-MIDWIFERY SERVICE

The purpose of this study was to compare outcomes of term infants of average birth weight with outcomes of large infants in a nurse-midwifery service. A retrospective study design was used. Data were retrieved from a computer data base that contained information from a data form routinely completed for all births. Subjects were women cared for by the nurse-midwives including those for whom the birth was conducted by a physician. The final n study population was 2,228; 322 (14.5%) of the infants weighed 4,000 g or more. Women who delivered large infants had a significantly higher prepregnant body mass index and pregnancy weight gain. Shoulder dystocia occurred more often in large infants; however, newborn intensive care unit admission rates did not differ between the average birth weight and the large infants. Apgar scores at 1 and 5 minutes were significantly lower for infants weighing ≥ 4,500 g compared to those with birth weights of 2,500-3,999 g and those 4,000-4,449 g; however, these differences were not clinically significant. A trend for fewer occurrences of shoulder dystocia in the side-lying birth position was observed. Logistic regression predicting poor Apgar scores (< 7) showed parity as a protective factor and increased gestational age and higher maternal body mass index as predictive of low Apgar scores. Large infants had birth outcomes comparable to those reported by others in the medical literature, suggesting that nurse-midwifery management, including consultation with physician colleagues, can be appropriate and safe. © 1998 by the American College of Nurse-Midwives.     

Severe perineal lacerations in nulliparous women and episiotomy type

OBJECTIVE: To determine the patient-related factors associated with severe perineal lacerations in nulliparous women and to evaluate the effect of episiotomy type on the risk of severe perineal tears. STUDY DESIGN: In all, 400 nulliparous women admitted in labor between June and December 2001 were prospectively enrolled. Maternal height, perineal length, fetal birth weight, fetal head circumference, and severe perineal lacerations (third and fourth degrees) were recorded. RESULTS: The rate of severe perineal lacerations was 2% (8/400); 3% with midline, 1% with mediolateral groups. In patients with severe lacerations, perineal length was significantly (p < 0.001) shorter and the head circumference of their babies in the midline significantly (p < 0.05) greater than normal, and birth weights were also significantly (p < 0.05) greater in the mediolateral group. A cut-off value for perineal length of 3.05 cm was found for severe lacerations in the midline group. CONCLUSION: If episiotomy is to be performed, it must be borne in mind that patients with a perineal length of < or = 3 cm have an elevated risk of severe perineal lacerations, and if clinical or ultrasound examination suggests that the fetal head is large, mediolateral episiotomy may be preferred. Otherwise, midline episiotomy must be considered.     

Outcomes of macrosomic infants in a nurse-midwifery serivce

The purpose of this study was to compare outcomes of term infants of average birth weight with outcomes of large infants in a nurse-midwifery service. A retrospective study design was used. Data were retrieved from a computer data base that contained information from a data form routinely completed for all births. Subjects were women cared for by the nurse-midwives including those for whom the birth was conducted by a physician. The final n study population was 2,228; 322 (14.5%) of the infants weighed 4,000 g or more. Women who delivered large infants had a significantly higher prepregnant body mass index and pregnancy weight gain. Shoulder dystocia occurred more often in large infants; however, newborn intensive care unit admission rates did not differ between the average birth weight and the large infants. Apgar scores at 1 and 5 minutes were significantly lower for infants weighing ≥ 4,500 g compared to those with birth weights of 2,500–3,999 g and those 4,000–4,449 g; however, these differences were not clinically significant. A trend for fewer occurrences of shoulder dystocia in the side-lying birth position was observed. Logistic regression predicting poor Apgar scores (< 7) showed parity as a protective factor and increased gestational age and higher maternal body mass index as predictive of low Apgar scores. Large infants had birth outcomes comparable to those reported by others in the medical literature, suggesting that nurse-midwifery management, including consultation with physician colleagues, can be appropriate and safe.     

Are Asian American women at higher risk of severe perineal lacerations?

Objective: To evaluate whether Asian race is an independent risk factor for severe perineal lacerations.

Methods: We performed a nationwide population-based retrospective cohort study examining the relationship between Asian race and severe perineal lacerations (third and fourth degree). The data were collected from the 2012 Healthcare Cost and Utilization Project National Inpatient Sample (HCUP-NIS). Characteristics of Asian American women were compared with those of non-Asian women. The primary outcome of interest was severe perineal lacerations. Multivariable logistic regression was used to refine the associations between Asian race and severe perineal lacerations while adjusting for confounding effects. Results were compared with previously published data using a pooled odds ratio.

Results: 2,270,044 Women with singleton vaginal deliveries were identified, and 120,452 (5.3%) were Asian. After adjusting for confounders, Asian women were more likely to experience severe perineal lacerations than any other racial group (3.5% versus 6.3%, adjusted odds ratio [aOR] 1.50, 99% CI 1.29–1.74, p?p?Conclusion: Asian race is an independent risk factor for severe perineal lacerations in the United States.     

NURSE-MIDWIFERY SERVICE IN A RURAL SETTING

This article describes the structure and development of a successful, rural nurse-midwifery service consisting of nine certified nurse-midwives and four obstetricians. The model has shown that the addition of a nurse-midwifery service and the adoption of a collaborative care model can improve obstetric outcomes. The outcomes of this model include an increase in the number of women served each year, a decrease in the cesarean section rate, an increase in the number of twin gestations delivered vaginally, an increase in the number of breech presentations delivered vaginally, an increase in the success rate of vaginal birth after cesarean section, and decreased numbers of episiotomies, with a resulting decrease in the number of third- and fourth-degree lacerations.     

Birthing postures and birth canal lacerations

Objective: This study was performed to assess the differences in the birth canal lacerations following the lateral and fours posture deliveries compared with those following the supine posture deliveries.

Methods: We examined the birth canal lacerations of our “low risk” pregnant women under the midwife-led delivery care at Japanese Red Cross Katsushika Maternity Hospital between April 2006 and March 2015.

Results: There were 3826, 1754 and 719 women who delivered with supine, lateral and fours postures. The rate of no laceration in the women who delivered with lateral posture was significant lower than that in the women who delivered with supine posture (OR 0.630, 95% CI 0.56–0.71, p?p?p?Conclusion: The current results may be to help for self-determination of birthing postures in prenatal women.     

A Comparison of Outcomes Between Joint and Physician-Only Obstetric Practices

ABSTRACT: Since 1981, the cesarean birth rate of a joint practice has been consistently lower than that of physician-only practices at a private community hospital in Yolo County, California. This study sought to determine whether differences in perinatal outcomes were influenced by women's use of a joint versus a physician-only practice or were associated with parity, maternal age, or newborn birthweight. Data from the hospital's 1634 consecutive singleton births in 1990 were examined, using a prospective concurrent analytic cohort study design. Chi square statistics and stepwise logistic regressions were used for data analysis. The joint practice had a significantly lower rate of total cesarean births (9.3%) compared with the physician-only practices (17.7%); the frequencies of severe lacerations were 1.0 percent and 6.4 percent, respectively. No significant differences were found in parity, birthweight, or newborn outcomes in the two types of practice. Type of practice was the major determinant of cesarean birth (p > 0.0001). All variables studied, including type of practice, were significant determinants of primary cesarean birth. Parity and practice type were significant determinants of third- and fourth-degree lacerations (p > 0.0001). The type of practice from which women receive care is significantly associated with both method of birth and possibility of severe perineal trauma.     

Multivariable evaluation of term birth weight: a comparison between ultrasound biometry and symphysis-fundal height

Abstract

Objective: To determine whether perineal massage during the second stage of labor using oil enriched with vitamins, increases the chances of delivering with an intact perineum as compared to perineal massage using pure liquid wax.

Method: A prospective, randomized, double-blind study was conducted. Women were assigned to liquid wax (jojoba oil) versus purified formula of almond and olive oil, enriched with vitamin B1, B2, B6, E and fatty acids. The caregivers used the oils during the second stage of labor.

Results: A total of 164 women undergoing vaginal delivery were recruited. No significant differences regarding perineal lacerations, number of sutures and length of suturing were noted between the two groups. Likewise, while analyzing separately nulliparous and multiparous women, no significant differences were noted. Controlling for birth weight >4000?g, using the Mantel–Haenszel technique, no association was noted between perineal lacerations and the type of oil used (weighted OR?=?0.9, 95% CI 0.3–2.4; p?=?0.818).

Conclusion: The type of the oil used during the second stage of labor for prevention of perineal tears has no effect on the integrity of the perineum. Accordingly, it seems that there is no perfect oil.     

Body mass index, midwifery intrapartum care, and childbirth lacerations

Weight status is an important determinant of many health indices. Data from a clinical trial on measures to lower genital tract trauma in vaginal birth were used for a secondary analysis. The goal was to describe the relationship of body mass index and pregnancy weight gain to clinical intrapartum care, infant birthweight, and genital tract trauma with vaginal birth. Intrapartum care measures and labor events did not vary by maternal weight status. Overweight and obese women were more likely to be parous, and Hispanic or American Indian. Total pregnancy weight gain decreased, and infant birthweight increased as body mass index category increased. Obese women who gained 40 or more pounds during pregnancy had elevated rates of macrosomia and genital tract lacerations.     

Factors Related to Genital Tract Trauma in Normal Spontaneous Vaginal Births

Abstract: Objective: Episiotomy rates are declining in the United States. In settings with very low rates, evidence remains sparse on how best to facilitate birth without lacerations. The purpose of this investigation was to identify maternal and clinical factors related to genital tract trauma in normal, spontaneous vaginal births. Methods: Data from a randomized clinical trial of perineal management techniques were used to address the study objective. Healthy women had spontaneous births with certified nurse‐midwives in a medical center setting. Proportions of maternal characteristics and intrapartum variables were compared in women who did and did not sustain sufficient trauma to warrant suturing, according to parity (first vaginal births versus others). Logistic regression using a backward elimination strategy was used to identify predictors of obstetric trauma. Results : In women who had a first vaginal birth, risk factors for trauma were maternal education of high school or beyond, Valsalva pushing, and infant birthweight. Risk factors in women having a second or higher vaginal birth were prior sutured trauma and infant birthweight. For all mothers, delivery of the infant's head between contractions was associated with reduced trauma to the genital tract. Conclusions: Delivery technique that is unrushed and controlled may help reduce obstetric trauma in normal, spontaneous vaginal births. (BIRTH 33:2 June 2006)