Ethel Burns

Incidence of and risk factors for perineal trauma: a prospective observational study

BackgroundOur aim was to describe the range of perineal trauma in women with a singleton vaginal birth and estimate the effect of maternal and obstetric characteristics on the incidence of perineal tears.MethodsWe conducted a prospective observational study on all women with a planned singleton vaginal delivery between May and September 2006 in one obstetric unit, three freestanding midwifery-led units and home settings in South East England. Data on maternal and obstetric characteristics were collected prospectively and analysed using univariable and multivariable logistic regression. The outcome measures were incidence of perineal trauma, type of perineal trauma and whether it was sutured or not.ResultsThe proportion of women with an intact perineum at delivery was 9.6% (125/1,302) in nulliparae, and 31.2% (453/1,452) in multiparae, with a higher incidence in the community (freestanding midwifery-led units and home settings). Multivariable analysis showed multiparity (OR 0.52; 95% CI: 0.30–0.90) was associated with reduced odds of obstetric anal sphincter injuries (OASIS), whilst forceps (OR 4.43; 95% CI: 2.02–9.71), longer duration of second stage of labour (OR 1.49; 95% CI: 1.13–1.98), and heavier birthweight (OR 1.001; 95% CI: 1.001–1.001), were associated with increased odds. Adjusted ORs for spontaneous perineal truama were: multiparity (OR 0.42; 95% CI: 0.32–0.56); hospital delivery (OR 1.48; 95% CI: 1.01–2.17); forceps delivery (OR 2.61; 95% CI: 1.22–5.56); longer duration of second stage labour (OR 1.45; 95% CI: 1.28–1.63); and heavier birthweight (OR 1.001; 95% CI: 1.000–1.001).ConclusionsThis large prospective study found no evidence for an association between many factors related to midwifery practice such as use of a birthing pool, digital perineal stretching in the second stage, hands off delivery technique, or maternal birth position with incidence of OASIS or spontaneous perineal trauma. We also found a low overall incidence of OASIS, and fewer second degree tears were sutured in the community than in the hospital settings. This study confirms previous findings of overall high incidence of perineal trauma following vaginal delivery, and a strong association between forceps delivery and perineal trauma.

Managing Obstetric Emergencies and Trauma (MOET) structured skills training in Armenia, utilising models and reality based scenarios

BackgroundMortality rates in Western Europe have fallen significantly over the last 50 years. Maternal mortality now averages 10 maternal deaths per 100,000 live births but in some of the Newly Independent States of the former Soviet Union, the ratio is nearly 4 times higher. The availability of skilled attendants to prevent, detect and manage major obstetric complications may be the single most important factor in preventing maternal deaths. A modern, multidisciplinary, scenario and model based training programme has been established in the UK (Managing Obstetric Emergencies and Trauma (MOET)) and allows specialist obstetricians to learn or revise the undertaking of procedures using models, and to have their skills tested in scenarios.MethodsGiven the success of the MOET course in the UK, the organisers were keen to evaluate it in another setting (Armenia). Pre-course knowledge and practice questionnaires were administered. In an exploratory analysis, post-course results were compared to pre-course answers obtained by the same interviewer.ResultsAll candidates showed an improvement in post-course scores. The range was far narrower afterwards (167–188) than before (85–129.5). In the individual score analysis only two scenarios showed a non-significant change (cord prolapse and breech delivery).ConclusionThis paper demonstrates the reliability of the model based scenarios, with a highly significant improvement in obstetric emergency management. However, clinical audit will be required to measure the full impact of training by longer term follow up. Audit of delays, specific obstetric complications, referrals and near misses may all be amenable to review.

Characteristics, Interventions, and Outcomes of Women Who Used a Birthing Pool: A Prospective Observational Study

BACKGROUND Birthing pools are integrated into maternity care in the United Kingdom and are a popular care option for women in midwifery-led units and at home. The objective of this study was to describe and compare maternal characteristics, intrapartum events, interventions, and maternal and neonatal outcomes by planned place of birth for women who used a birthing pool. METHODS A total of 8,924 women at low risk of childbirth complications were recruited from care settings in England, Scotland, and Northern Ireland. Descriptive analysis was performed. RESULTS Overall, 7,915 (88.9%) women had a spontaneous birth (5,192, 58.3% water births), of whom 4,953 (55.5%) were nulliparas. Fewer nulliparas whose planned place of birth was the community (freestanding midwifery unit or home) had labor augmentation by artificial membrane rupture (149, 11.3% [95% CI: 9.6-13.1]), compared with an alongside midwifery unit (271, 22.7% [95% CI: 20.3-25.2]), or obstetric unit (639, 26.3% [95% CI: 24.5-28.1]). Results were similar for epidural analgesia and episiotomy. More community nulliparas had spontaneous birth (1,172, 88.9% [95% CI: 87.1-90.6]), compared with birth in an alongside midwifery unit (942, 79% [95% CI: 76.6-81.3]) and obstetric unit (1,923, 79.2% [95% CI: 77.5-80.8]); and fewer required hospital transfer (265, 20% [95% CI: 17-22.2]) compared with those in an alongside midwifery unit (370, 31% [95% CI: 28.3-33.7]). Results for multiparas and newborns were similar across care settings. Twenty babies had an umbilical cord snap, 18 (90%) of which occurred during water birth. CONCLUSIONS Birthing pool use was associated with a high frequency of spontaneous birth, particularly among nulliparas. Findings revealed differences in midwifery practice between obstetric units, alongside midwifery units, and the community, which may affect outcomes, particularly for nulliparas. No evidence was found for a difference across care settings in interventions or outcomes in multiparas or in outcomes for newborns. During water birth, it is important to prevent undue traction on the cord as the baby is guided to the surface.

Labouring women who used a birthing pool in obsteric units in Italy: prospective observational study

BackgroundFor women at low risk of childbirth complications, water immersion during labour is a care option in many high income countries. Our aims were (a) to describe maternal characteristics, intrapartum events, interventions, maternal and neonatal outcomes for all women who used a birthing pool during labour who either had a waterbirth or left the pool and had a landbirth, and for the subgroup of women who had a waterbirth in 19 obstetric units, and (b) to compare maternal characteristics, intrapartum events, interventions, and maternal and neonatal outcomes for women who used a birthing pool with a control group of women who did not use a birthing pool for whom we prospectively collected data in a single centre.MethodsProspective observational study in 19 Italian obstetric units 2002-2005. Participants were: (a) 2,505 women in labour using a birthing pool in 19 obstetric units; and (b) 114 women in labour using a birthing pool and 459 women who did not use a birthing pool in one obstetric unit. Descriptive statistics were calculated for the sample as a whole and, separately, for those women who gave birth in water. Categorical data were compared using Chi square statistics and continuous data by T-tests.ResultsOverall, 95.6% of women using a birthing pool had a spontaneous vertex delivery, 63.9% of which occurred in water. Half of nulliparas and three quarters of multiparas delivered in water. Adverse maternal and neonatal outcomes were rare. There were two cases of umbilical cord snap with waterbirth. Compared with controls, significantly more women who used a birthing pool adopted an upright birth position, had hands off delivery technique, and a physiological third stage. Significantly fewer nulliparas had an episiotomy, and more had a second degree perineal tear, with no evidence of a difference for extensive perineal tears.ConclusionsBirthing pool use was associated with spontaneous vaginal birth. The increase in second degree tears was balanced by fewer episiotomies. Undue umbilical cord traction should be avoided during waterbirth.