Kathy Waghorn

Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation

OBJECTIVE Our purpose was to compare consequences for women of receiving versus not receiving median episiotomy early and 3 months post partum on the outcomes perineal pain, urinary and pelvic floor functioning by electromyography, and sexual functioning and to analyze the relationship between episiotomy and third- and fourth-degree tears. STUDY DESIGN A secondary cohort analysis was performed of participants within a randomized clinical trial, analyzed by type of perineal trauma and pain, pelvic floor, and sexual consequences of such trauma, while controlling for trial arm. The study was conducted in three university or community hospitals; 356 primiparous and 341 multiparous women were studied. RESULTS Early and 3-month-postpartum perineal pain was least for women who gave birth with an intact perineum. Spontaneous perineal tears were less painful than episiotomy. Sexual functioning was best for women with an intact perineum or perineal tears. Postpartum urinary and pelvic floor symptoms were similar in all perineal groups. At 3 months post partum those delivered with an intact perineum had the strongest pelvic floor musculature, those with episiotomy the weakest. Among primiparous women third- and fourth-degree tears were associated with median episiotomy (46/47). After forceps births were removed and 21 other variables potentially associated within such tears were controlled for, episiotomy was strongly associated with third- and fourth-degree tears (odds ratio +22.08, 95% confidence interval 2.84 to 171.53). Physicians using episiotomy at high rates also used other procedures, including cesarean section, more frequently. CONCLUSION Perineal and pelvic floor morbidity was greatest among women receiving median episiotomy versus those remaining intact or sustaining spontaneous perineal tears. Median episiotomy was causally related to third- and fourth-degree tears. Those using episiotomy at the highest rates were more likely use other interventions as well. Episiotomy use should be restricted to specified fetal-maternal indications.

In-Hospital Formula Supplementation of Healthy Breastfeeding Newborns:

The UNICEF/WHO Baby-Friendly Hospital Initiative suggests that breastfeeding activities in hospital are important to later breastfeeding. Understanding reasons for in-hospital supplementation may help to optimize the successful implementation of this initiative. The objective was to identify predictors of in-hospital initial formula supplementation of healthy, breastfeeding newborns. The authors analyzed 564 Canadian mother-infant pairs and interviewed nurses. Half of the study infants (47.9%) received formula in hospital; the median age at first supplementation was 8.4 hours. Risk for supplementation was affected by birth occurring between 7 PM and 9 AM (hazard ratio [HR] varied with time) and high maternal trait anxiety (HR = 1.61, 95% confidence interval [CI] = 1.01, 2.59). The following variables were protective against supplementation: planning to exclusively breastfeed (HR = 0.46, 95% CI = 0.33, 0.64), planning to breastfeed for ≥ 3 months (HR = 0.56, 95% CI = 0.37-0.86), childbirth education (HR = 0.61, 95% CI = 0.43, 0.86), mother born in Canada (HR = 0.68, 95% CI = 0.53, 0.87), completion of community college (HR = 0.76, 95% CI = 0.59, 0.98), male infant (HR = 0.78, 95% CI = 0.61, 0.99), and breastfeeding at delivery (HR varied with time). Nurses reported breastfeeding problems, infant behavior, and maternal fatigue as reasons for supplementing. Reassessing patterns of night feeds and encouraging breastfeeding at delivery may decrease supplementation. Trait anxiety reduction and the role of infant gender in supplementation merit further study.

One-to-one nurse labor support of nulliparous women stimulated with oxytocin.

Obiective: To compare the benefits of one-to-one nurse labor support with the benefits of usual intrapartum nursing care in women stimulated with oxytoc in. Design: A secondary analysis of a randomized controlled trial. Setting: A 637-bed university hospital. Participants: One hundred nulliparous women 37 weeks or more gestation, carrying singletons, in labor with vertex presentation, stimulated with oxytocin, less than 5 cm dilated at baseline, and not scheduled for cesarean delivery or induction nor having paid labor support present. Interventions: One-to-one care consisted of the presence of a nurse during labor and birth who provided emotional support, physical comfort, and instruction on relaxation and coping techniques. Usual care consisted of care for 2–3 laboring women with supportive activities varying by nurse. Main Outcome Measure: Cesarean delivery. Results: A beneficial trend because of one-to-one nurse support, with a 56% reduction in risk of total cesarean deliveries [RR of experimental vs. control = 0.44 (95% confidence interval = 0.19 to 1.01)]. Conclusion: The beneficial trend in reducing cesarean deliveries attributed to one-to-one nursing in women stimulated with oxytocin suggests that continuous support by intrapartum nursing staff may benefit women stimulated with oxytocin during labor.

Does Episiotomy Prevent Perineal Trauma and Pelvic Floor Relaxation

Objective To compare the outcomes of the current practice of liberally or routinely employing episiotomy to prevent perineal tears and pelvic floor relaxation (control group) to a policy of restricting episiotomy use to specific fetal and maternal indications (experimental group). Design A randomized controlled trial (RCT). Setting Three university hospitals in Montreal. Subjects Seven hundred three low-risk women enrolled at 30 to 34 weeks of gestation were randomized late in labor to the designated trial arm, by parity, and followed up to 3 months postpartum. Main outcome measures Antepartum and postpartum information on perineal trauma and pain, pelvic floor symptoms (urinary incontinence), and sexual activity was collected through the use of standard questionnaires; pelvic floor function was measured by electromyographic (EMG) perineometry. Results Restricting episiotomy use in primiparous women was associated with similar sutured perineal trauma to the liberal or routine approach. Multiparous women in the restricted episiotomy group more often gave birth with an intact perineum (31% compared with 19%, odds ratio (OR) = 1.85, 95% confidence interval (CI) = 1.09 to 3.16). All but one 3rd/4th-degree perineal tear was associated with median episiotomy (46 of 47 in primiparous women and 6 of 6 among multiparous women). No difference between trial groups was found in postpartum perineal pain, antepartum and 3-month postpartum EMG perineometry, and urinary and pelvic floor symptoms. Conclusions We found no evidence that liberal or routine use of episiotomy prevents perineal trauma or pelvic floor relaxation. Virtually all severe perineal trauma was associated with median episiotomy. Restriction of episiotomy use among multiparous women resulted in significantly more intact perineums and less perineal suturing.

CLINICAL STUDIESOne-to-One Nurse Labor Support of Nulliparous Women Stimulated With Oxytocin

Obiective: To compare the benefits of one-to-one nurse labor support with the benefits of usual intrapartum nursing care in women stimulated with oxytoc in. Design: A secondary analysis of a randomized controlled trial. Setting: A 637-bed university hospital. Participants: One hundred nulliparous women 37 weeks or more gestation, carrying singletons, in labor with vertex presentation, stimulated with oxytocin, less than 5 cm dilated at baseline, and not scheduled for cesarean delivery or induction nor having paid labor support present. Interventions: One-to-one care consisted of the presence of a nurse during labor and birth who provided emotional support, physical comfort, and instruction on relaxation and coping techniques. Usual care consisted of care for 2–3 laboring women with supportive activities varying by nurse. Main Outcome Measure: Cesarean delivery. Results: A beneficial trend because of one-to-one nurse support, with a 56% reduction in risk of total cesarean deliveries [RR of experimental vs. control = 0.44 (95% confidence interval = 0.19 to 1.01)]. Conclusion: The beneficial trend in reducing cesarean deliveries attributed to one-to-one nursing in women stimulated with oxytocin suggests that continuous support by intrapartum nursing staff may benefit women stimulated with oxytocin during labor.