Minimizing Genital Tract Trauma and Related Pain

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  Minimizing Genital Tract Trauma and Related PainFollowing Spontaneous Vaginal Birth Leah L. Albers, CNM, DrPH, and Noelle Borders, CNM, MSN  Genital tract trauma is common following vaginal childbirth, and perineal pain is a frequent symptomreported 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 fornulliparous women, upright or lateral positions for birth, avoidance of Valsalva pushing, delayed pushingwith 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” forsuturing lacerations, and oral or rectal ibuprofen for perineal pain relief after delivery. Further research iswarranted to determine the role of prenatal pelvic floor (Kegel) exercises, general exercise, and body massindex in reducing obstetric trauma, and also the role of pelvic floor and general exercise in pelvic floorrecovery after childbirth. J Midwifery Womens Health 2007;52:246–253 © 2007 by the American Collegeof Nurse-Midwives. keywords:  episiotomy, genital tract trauma, labor management, midwifery care, perineal pain,perineal trauma INTRODUCTION Approximately three million women give birth vaginallyeach year in the United States. 1 Perineal pain fromchildbirth lacerations is a common symptom reported bynew mothers, and if protracted, the pain may interf erewith activities of daily living and family functioning. 2,3 Because the well-being of newborn infants is so depen-dent on the health and functional abilities of theirmothers, the overall health status of new mothers is apriority concern for all who work in maternity care.Women who have spontaneous vaginal births and mini-mal or no genital tract trauma have the best healthpostpartum. Such women have the fewest hospital read-missions for postdelivery morbidity, less perineal pain,stronger pelvic floors, better sexual f unction, less depres-sion, and optimum functional status. 4–6 Genital tract trauma can be caused by episiotomy,spontaneous lacerations, or both. Episiotomy rates in theUnited States have steadily declined over the past 25years, 7 but in 2003, were performed in approximately25% of all vaginal births. 8 Conversely, spontaneouslacerations requiring suturing have gradually risen asepisiotomies have declined, and in 2003, 41% of thewomen who had vaginal births in the United Statesexperienced spontaneous lacerations. 8 Because some lac-erations are not sutured, this proportion is an undercount.A direct relationship exists between the extent andcomplexity of genital tract trauma sustained with vaginalbirth and subsequent pain and functional impairment. 9,10 More genital tract trauma equals greater postpartum mor-bidity, and vice versa. While delivery over an intact peri-neum may require additional time in second stage andgreater patience from the birth attendant, it is associatedwith fewer maternal health problems in the short run (bloodloss, pain, and need for suturing) and in the long run(continued pain, pelvic floor weakness, sexual problems,and bowel and urinary incontinence). 11 Therefore, clinicalcare that enables women to give birth without genital tractlacerations will improve the health of new mothers.This article reviews the available research on thereduction of genital tract trauma and related postdeliverypain. Key concepts for practicing clinicians will besummarized for the periods before, during, and afterbirth, and areas for future research will be highlighted. LATE PREGNANCY: PERINEAL MASSAGE Two randomized trials have been published on theeffects of perineal massage in the latter weeks of preg-nancy, to assess whether regular massage leads to re-duced perineal trauma at birth. Shipman et al. 12 in theUnited Kingdom asked 681 nulliparas to perform dailypelvic floor (Kegel) exercises during the last 6 weeks of pregnancy, and half of the women were randomly as-signed to perineal massage for 4 minutes, three to fourtimes per week. Labrecque et al. 13 in Canada randomlyassigned 1034 nulliparas and 493 multiparas to eitherperineal massage or usual care for the last 6 weeks of pregnancy. Perineal massage was to be done daily for 10minutes. Both studies assessed intervention fidelity byreviewing women’s entries in daily diaries, and one-thirdof the women in each study complied fully with therespective study protocol. Both studies defined an intactperineum as no trauma, or minor and unsutured trauma,and both conducted intent-to-treat analyses.Shipman et al. 12 found a 6% reduction in trauma(second degree or more) in women who did antenatalmassage, with the largest benefit found in women aged30 or older. Labrecque et al. 13 found a 9% reduction in Address correspondence to Leah L. Albers, CNM, DrPH, FACNM, FAAN,University of New Mexico College of Nursing, Nursing/Pharmacy Build-ing, Room 216, Albuquerque, NM 87131-5688. E-mail: lalbers@salud.unm.edu 246 Volume 52, No. 3, May/June 2007 © 2007 by the American College of Nurse-Midwives 1526-9523/07/$32.00  ã  doi:10.1016/j.jmwh.2006.12.008Issued by Elsevier Inc.  sutured trauma in first-time mothers in the massagegroup, but no significant differences in multiparouswomen. The greatest benefit was seen in those womenwho fully complied with the prescribed frequency of perineal massage, suggesting that regular massage isbetter. Labrecque et al. also assessed women’s views andfound that perineal massage was highly acceptable;women would use it again in a future pregnancy, andwould recommend it to other women. No harmful effectsof perineal massage in late pregnancy were found ineither study.Together, these studies indicate that perineal massagein the later weeks of pregnancy may help some first-timemothers avoid sutured obstetric trauma. Daily massageappears of greater benefit than occasional or intermittentmassage. These techniques may help women recognizeand tolerate the stretching and pressure sensations theymay feel when giving birth. A patient education handouton antenatal perineal massage was distributed in a recentissue of this  Journal 14 and explains how to performperineal massage. CARE AT BIRTH Care measures at birth can be separated into those thatare directly or indirectly linked with perineal outcomes.Care measures that could indirectly influence perinealoutcomes include the style of pushing women are en-couraged to do in the second stage of labor and maternalposition for birth. Episiotomy and other manual tech-niques for perineal management may directly affect thedegree of obstetric trauma sustained. SECOND STAGE PUSHING: COACHED VERSUS SPONTANEOUS Most of the research on pushing method has compareddirected, coached, or Valsalva pushing (forceful bearingdown, closed glottis, and sustained breath holding) withspontaneous or self-paced pushing (non-directed, multi-ple short pushes, with no sustained breath holding).Studies comparing these two techniques have been pri-marily concerned with the effect of pushing style onneonatal acid–base status and/or the length of secondstage. 15 Some studies have directly addressed the rela-tionship between pushing method and perineal or pelvicfloor injury, or have included it in their analyses. 16,17 Sampselle and Hines 16 reported survey data from 39first-time mothers who gave birth within the previousyear. Eleven women recalled pushing spontaneously and28 recalled using Valsalva pushing. An intact perineumresulted in 5 of the 11 women who pushed spontaneouslyand 2 of the 28 women who pushed forcefully ( P  .05).Simpson and James 17 randomized 45 nulliparas withepidurals to either coached pushing at complete cervicaldilatation, or to a 2-hour rest period at the beginning of second stage, followed by non-Valsalva pushing. Imme-diate pushing was associated with lower fetal oxygensaturation and 13 of 22 women in this group had perineallacerations compared with 5 of 23 in the delayed pushinggroup ( P  .01).Schaffer et al. 18 randomized 128 nulliparas to eithercoached (Valsalva) or non-coached pushing for second-stage labor to assess the effect on pelvic floor function at3 months after birth. Only two women per group usedepidural analgesia. Three months after birth, all womenhad pelvic floor and urodynamic studies, including vag-inal squeeze tests and coughing against a full bladder.Women who had used Valsalva pushing had less favor-able urodynamic indices, indicating potential pelvic floordysfunction from forceful pushing to effect delivery.Finally, a secondary analysis from the perineal man-agement trial by Albers et al. 19 assessed risk factors forsutured genital tract trauma in first-time versus othermothers. All women (N    1176) had spontaneousvaginal births without an episiotomy. Women with su-tured obstetric lacerations were more likely to have usedValsalva pushing than women without lacerations (37%vs. 24% of first-time mothers and 26% vs. 15% of othermothers). In first births, where mothers tend to pushlonger, regression analysis showed that Valsalva pushingin second stage was an independent predictor of child-birth lacerations (RR  1.65; 95% CI, 1.05–2.59).These studies indicate that the only apparent advan-tage of Valsalva pushing is a shorter second stage, which,on occasion, may be desirable. However, expeditingdelivery by forceful, directed pushing is achieved at theexpense of three negative outcomes: reduced oxygen-ation of the fetus, more frequent trauma to the birth canal,and potential injury to future pelvic floor function. SECOND STAGE PUSHING WITH EPIDURAL: EARLY VERSUSDELAYED PUSHING Epidural analgesia has become a prevalent method of pain management in labor. Epidurals give most womenexcellent pain relief, but are associated with numerousuntoward events, including a higher risk of an instrumen-tal vaginal birth, which is associated with more perinealinjury. 20 During the 1990s, several research groupsassessed whether delaying pushing until fetal descentwould lower the rate of instrumental birth and perinealtrauma in women using epidurals, compared with theusual policy of encouraging the woman to begin pushingat complete cervical dilatation. Leah L. Albers, CNM, DrPH, FACNM, FAAN, is a Professor at theCollege of Nursing and in the Department of Obstetrics and Gynecology,School of Medicine at the University of New Mexico Health SciencesCenter in Albuquerque, NM.Noelle Borders, CNM, MSN, is a staff nurse-midwife with UniversityMidwifery Associates, Department of Obstetrics and Gynecology, Schoolof Medicine at the University of New Mexico Health Sciences Center inAlbuquerque, NM. Journal of Midwifery & Women’s Health  ã  www.jmwh.org 247  A recent review summarized the studies that assessedthe effect of immediate versus delayed pushing inwomen using epidurals on the likelihood of an instru-mental delivery. 21 Nine studies of 2953 healthy, child-bearing women were pooled in a meta-analysis. Delayedpushing was associated with a longer second stage but ashorter phase of active pushing. The incidence of instru-mental births was lower in women who delayed pushing(RR    0.92; 95% CI, 0.84–1.01), as were rotational ormid-pelvic instrumental deliveries (RR  0.69; 95% CI,0.55–0.87). No statistically significant differences werenoted in episiotomies or spontaneous lacerations; how-ever, in this meta-analysis, only 4 of the 9 includedstudies reported on episiotomy as a key outcome, andonly 5 reported on spontaneous lacerations. Because eachof these are common covariates with instrumental births,this can be viewed as a limitation of the meta-analysis.Any reduction in instrumental deliveries would be clin-ically significant in reducing the incidence of genital tracttrauma and subsequent postdelivery pain. POSITIONING FOR BIRTH Most women in the United States push and give birthwhile lying flat on their backs. The first Listening toMothers Survey 22 estimated that 74% of women whodelivered vaginally in 2002 did so while in a recumbentor lithotomy position. But upright or lateral positions forbirth are associated with greater maternal comfort andless perineal injury. 23 A Cochrane review on this topiccombined data from 20 clinical trials that included 6135women. Compared with women who gave birth in supineor lithotomy positions, women who were upright orside-lying reported greater comfort, had fewer episioto-mies (RR  0.83; 95% CI, 0.75–0.92), and had a slightlyshorter second stage (mean    4.3 min; 95% CI, 2.9–5.6). 22 Some of the included studies suggested thatupright positions for birth are associated with greaterblood loss, but this could be because blood loss may bemore visually apparent to the clinician when the womanis upright. Given the variability in quality of the includedstudies, the review concluded that no clear indication of harm is associated with upright or lateral positions forbirth, and therefore, women should be encouraged tochoose their own position according to individual pref-erence.Two recent studies from Australia have examined therelationship between birth position and perineal out-comes in retrospective analyses of large datasets. 24,25 These studies are from teaching hospitals where mostbirths were attended by midwives. In both settings, an“intact perineum” was defined as no tears or minor butunsutured trauma, and in both, the baseline rate of “intact” was 55%. Shorten et al. 24 used multivariableregression techniques to analyze data from 2891 womenwho had normal vaginal births. An intact perineum wasmost likely with delivery in a side-lying position. Ap-proximately 12% of all women used a lateral position forbirth, and of these, 67% experienced no lacerations thatrequired suturing. Soong and Barnes 25 analyzed datafrom 3756 women who had spontaneous vaginal births.Women who gave birth on all fours were the least likelyto experience any genital tract trauma that requiredsuturing. Approximately 10% of women gave birth on allfours, and of these, 61% were judged as having intactperineums. Also, 22% of women in this analysis usedepidurals, and these women were more likely to havesutured obstetric lacerations, especially if bed-confinedand immobile (OR, 1.5; 95% CI, 1.1–2.1). Together,these studies argue for alternatives to supine or lithotomypositions for birth and maternal choice in the matter.Upright or lateral positions for birth are more comfort-able and may increase the woman’s sense of control. Thismay facilitate her ability to work with her clinician tocontrol the expulsion of her infant. In addition, somepositions make performance of episiotomies more diffi-cult and, therefore, may indirectly encourage clinicianpatience. PERINEAL MANAGEMENT TECHNIQUES Hand maneuvers for perineal management with secondstage pushing and for expulsion of the infant have beenstudied to determine whether any is preferable in terms of reduced childbirth lacerations and subsequent pain. Thelargest midwifery clinical trial to date was the HOOPtrial from the United Kingdom. 26 In this study, 5471healthy women in the care of English midwives wererandomized to either “hands on” (one hand flexing thebaby’s head and the other hand guarding the perineum)or “hands poised” (both hands off, but ready to applylight pressure to the emerging baby in the case of too-rapid expulsion) for the actual birth of the baby. Theprimary outcome was perineal pain at the tenth postpar-tum day. This was the first study to systematically collectcomplete data on all types of genital tract trauma (peri-neum and other sites) sustained after normal vaginalbirths. The genital tract trauma profiles of women in thetwo groups were virtually identical. Nearly 16% had notrauma at all and 11% had episiotomies. Spontaneouslacerations of the perineum occurred in 68% of studyparticipants, the vagina in 61%, and the labia in 35%.However, women in the “hands on” group reportedslightly less perineal pain at the 10th postpartum day(31% vs. 34% of women in “hands poised”). At 3 monthspostpartum, no differences were observed in perinealpain or other functional outcomes (sexual, bowel, orurinary function or risk of depression).More recently, Brazilian midwives compared “handson” versus “hands off” in 70 nulliparous women toexamine the relationship between these hand maneuversand perineal trauma. 27 With 35 women per group, genital 248 Volume 52, No. 3, May/June 2007  tract trauma distributions were equal, indicating noadvantage for one delivery method. A lack of statisticallysignificant differences in small samples may indicate thattoo few women were studied to ascertain a true difference.Perineal massage during second-stage labor has beentested in a randomized trial by Australian midwives todetermine the effect on perineal trauma. 28 Women wererandomized (n    1340) to either perineal massage withlubricant or “usual care,” which included a variety of perineal management approaches but excluded perinealmassage during the second stage of labor. No differencesbetween groups were found in episiotomies (26% over-all), or first- or second-degree perineal tears (43%).Third- or fourth-degree lacerations, while infrequent,occurred in 12 women who received massage, and 24women in the usual care group. Because this is a rareoutcome (2.7% in the study), this difference was notstatistically significant; however, it is clinically impor-tant. Assessments at 3 months postpartum showed nogroup differences in perineal pain, sexual difficulties, orbowel or urinary symptoms. Perineal massage conferredno clear benefit, but caused no harm.Finally, 1211 women in New Mexico were random-ized to one of three methods of perineal management inthe second stage of labor: warm compresses to theperineum, perineal massage with lubricant, or keepingthe hands completely off the perineum until the infant’shead was crowning. 29 The purpose was to identify if anyof these methods decreased the incidence of spontaneouslacerations of the birth canal. Data collection recorded allsites of genital tract trauma, as first done in the HOOPstudy. Verification of midwife compliance with the studyprotocol and their accuracy in assessing childbirth lacer-ations was built into the study. Verification of midwifecompliance with the study protocol and their accuracy inassessing childbirth lacerations was built into the study.In each of the three study groups, 23% of the women hadno trauma whatsoever, 40% had a first- or second-degreeperineal laceration, and 40% had a vaginal laceration.Only 1% of study participants had an episiotomy.Women in this study sustained less genital tract traumaoverall than did women in the other perineal manage-ment studies. No differences in protracted pain or faultyhealing were observed at the 6-week office visit accord-ing to the assigned perineal management method. Thisstudy used multivariate analysis to examine the role of factors beyond the hand techniques. Two elements of delivery technique were associated with reduced genitaltract trauma: a sitting position for birth (RR  0.68; 95%CI, 0.50–0.91) and controlled delivery of the infant’shead between uterine contractions (RR  0.82; 95% CI,0.67–0.99).These studies indicate that specific perineal manage-ment techniques in the second stage of labor, such aswarm compresses or massage with lubricant, hands on orhands off, are not helpful in lowering overall rates of genital tract trauma with birth. Because none cause harm,they may have a role in provision of comfort or relax-ation in selected situations and with particular women.What appears important in reducing genital tract traumais having a reasonably comfortable mother, a slow andcontrolled expulsion of the infant, and shared responsi-bility for the outcome. EPISIOTOMY During the past 20 years, many observational studies,randomized trials, and systematic reviews have appearedin the literature concerning outcomes of liberal versusrestricted use of episiotomy. The Cochrane Databasecontains a meta-analysis of 4850 women in 6 clinicaltrials from 5 different countries. 30 This review has beenavailable since 1997, thus, the information has beenwidely disseminated and is already well-known to manyclinicians. In 2005, Hartmann et al. 31 updated this reviewbut added only one clinical trial of 146 women, thereforethe two reviews are in complete agreement. The assem-bled evidence indicates that episiotomies are to beavoided except in rare situations, such as extreme fetal jeopardy. No benefits accompany the routine use of episiotomies, and women who receive them have moregenital tract trauma, require more suturing, and havemore persistent perineal pain after childbirth. Further, nolong-term benefits follow episiotomy, such as improvedsexual function, fewer bowel or urinary symptoms, or astronger pelvic floor. As such, routine episiotomy causesmore harm than benefit.While episiotomy rates have declined in the UnitedStates, approximately 25% of  all vaginal births still areaccompanied by this procedure. 8 Rates vary according togeographic location. 7 Rates also vary by the birth atten-dant, with the lowest rates found in midwifery prac-tices. 15 Clinicians in academic centers have been shownto have lower rates than those in private practice set-tings. 32 Rates below 15% have been advocated as imme-diately possible. 31 Currently, some academic centershave extremely low rates (  1% for all clinicians, includ-ing midwives, obstetricians, and family physicians),demonstrating that episiotomies are almost never trulyindicated. 29 CARE AFTER CHILDBIRTH The extent and complexity of genital tract trauma isdirectly related to the amount of suturing required and tosubsequent perineal pain. Thus, more trauma equalsgreater morbidity after birth. 9–11 Although some clini-cians have adopted the practice of not suturing lacera-tions that exclude the anal sphincter and rectum, thisapproach has not been systematically evaluated in studiesof adequate size and with sufficient long-term follow-up. 33 The existing clinical standard favors the suturing of lacerations, other than those that are small and shallow, Journal of Midwifery & Women’s Health  ã  www.jmwh.org 249
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