Mirjam Lukasse

Perineal techniques during the second stage of labour for reducing perineal trauma.

BACKGROUNDnMost vaginal births are associated with trauma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including perineal massage, warm or cold compresses, and perineal management techniques have been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011.nnnOBJECTIVESnTo assess the effect of perineal techniques during the second stage of labour on the incidence and morbidity associated with perineal trauma.nnnSEARCH METHODSnWe searched Cochrane Pregnancy and Childbirths Trials Register (26 September 2016) and reference lists of retrieved studies.nnnSELECTION CRITERIAnPublished and unpublished randomised and quasi-randomised controlled trials evaluating perineal techniques during the second stage of labour. Cross-over trials were not eligible for inclusion.nnnDATA COLLECTION AND ANALYSISnThree review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. We checked data for accuracy.nnnMAIN RESULTSnTwenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Overall, trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques.Most studies did not report data on our secondary outcomes. We downgraded evidence for risk of bias, inconsistency, and imprecision for all comparisons. Hands off (or poised) compared to hands onHands on or hands off the perineum made no clear difference in incidence of intact perineum (average risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.12, two studies, Tau² 0.00, I² 37%, 6547 women; moderate-quality evidence), first-degree perineal tears (average RR 1.32, 95% CI 0.99 to 1.77, two studies, 700 women; low-quality evidence), second-degree tears (average RR 0.77, 95% CI 0.47 to 1.28, two studies, 700 women; low-quality evidence), or third- or fourth-degree tears (average RR 0.68, 95% CI 0.21 to 2.26, five studies, Tau² 0.92, I² 72%, 7317 women; very low-quality evidence). Substantial heterogeneity for third- or fourth-degree tears means these data should be interpreted with caution. Episiotomy was more frequent in the hands-on group (average RR 0.58, 95% CI 0.43 to 0.79, Tau² 0.07, I² 74%, four studies, 7247 women; low-quality evidence), but there was considerable heterogeneity between the four included studies.There were no data for perineal trauma requiring suturing. Warm compresses versus control (hands off or no warm compress)A warm compress did not have any clear effect on the incidence of intact perineum (average RR 1.02, 95% CI 0.85 to 1.21; 1799 women; four studies; moderate-quality evidence), perineal trauma requiring suturing (average RR 1.14, 95% CI 0.79 to 1.66; 76 women; one study; very low-quality evidence), second-degree tears (average RR 0.95, 95% CI 0.58 to 1.56; 274 women; two studies; very low-quality evidence), or episiotomy (average RR 0.86, 95% CI 0.60 to 1.23; 1799 women; four studies; low-quality evidence). It is uncertain whether warm compress increases or reduces the incidence of first-degree tears (average RR 1.19, 95% CI 0.38 to 3.79; 274 women; two studies; I² 88%; very low-quality evidence).Fewer third- or fourth-degree perineal tears were reported in the warm-compress group (average RR 0.46, 95% CI 0.27 to 0.79; 1799 women; four studies; moderate-quality evidence). Massage versus control (hands off or routine care)The incidence of intact perineum was increased in the perineal-massage group (average RR 1.74, 95% CI 1.11 to 2.73, six studies, 2618 women; I² 83% low-quality evidence) but there was substantial heterogeneity between studies). This group experienced fewer third- or fourth-degree tears (average RR 0.49, 95% CI 0.25 to 0.94, five studies, 2477 women; moderate-quality evidence).There were no clear differences between groups for perineal trauma requiring suturing (average RR 1.10, 95% CI 0.75 to 1.61, one study, 76 women; very low-quality evidence), first-degree tears (average RR 1.55, 95% CI 0.79 to 3.05, five studies, Tau² 0.47, I² 85%, 537 women; very low-quality evidence), or second-degree tears (average RR 1.08, 95% CI 0.55 to 2.12, five studies, Tau² 0.32, I² 62%, 537 women; very low-quality evidence). Perineal massage may reduce episiotomy although there was considerable uncertainty around the effect estimate (average RR 0.55, 95% CI 0.29 to 1.03, seven studies, Tau² 0.43, I² 92%, 2684 women; very low-quality evidence). Heterogeneity was high for first-degree tear, second-degree tear and for episiotomy - these data should be interpreted with caution. Ritgens manoeuvre versus standard careOne study (66 women) found that women receiving Ritgens manoeuvre were less likely to have a first-degree tear (RR 0.32, 95% CI 0.14 to 0.69; very low-quality evidence), more likely to have a second-degree tear (RR 3.25, 95% CI 1.73 to 6.09; very low-quality evidence), and neither more nor less likely to have an intact perineum (RR 0.17, 95% CI 0.02 to 1.31; very low-quality evidence). One larger study reported that Ritgens manoeuvre did not have an effect on incidence of third- or fourth-degree tears (RR 1.24, 95% CI 0.78 to 1.96,1423 women; low-quality evidence). Episiotomy was not clearly different between groups (RR 0.81, 95% CI 0.63 to 1.03, two studies, 1489 women; low-quality evidence). Other comparisonsThe delivery of posterior versus anterior shoulder first, use of a perineal protection device, different oils/wax, and cold compresses did not show any effects on perineal outcomes. Only one study contributed to each of these comparisons, so data were insufficient to draw conclusions.nnnAUTHORS CONCLUSIONSnModerate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent. Poor-quality evidence suggests hands-off techniques may reduce episiotomy, but this technique had no clear impact on other outcomes. There were insufficient data to show whether other perineal techniques result in improved outcomes.Further research could be performed evaluating perineal techniques, warm compresses and massage, and how different types of oil used during massage affect women and their babies. It is important for any future research to collect information on womens views.

Childhood abuse and fear of childbirth - a population-based study

BACKGROUNDnChildhood abuse affects adult health. The objective of this study was to examine the association between a self-reported history of childhood abuse and fear of childbirth.nnnMETHODSnA population-based, cross-sectional study was conducted of 2,365 pregnant women at five obstetrical departments in Norway. We measured childhood abuse using the Norvold Abuse Questionnaire and fear of childbirth using the Wijma Delivery Expectancy Questionnaire. Severe fear of childbirth was defined as a Wijma Delivery Expectancy Questionnaire score of ≥ 85.nnnRESULTSnOf all women, 566 (23.9%) had experienced any childhood abuse, 257 (10.9%) had experienced emotional abuse, 260 (11%) physical abuse, and 290 (12.3%) sexual abuse. Women with a history of childhood abuse reported severe fear of childbirth significantly more often than those without a history of childhood abuse, 18 percent versus 10 percent (p = 0.001). The association between a history of childhood abuse and severe fear of childbirth remained significant after adjustment for confounding factors for primiparas (adjusted OR: 2.00; 95% CI: 1.30-3.08) but lost its significance for multiparas (adjusted OR: 1.17; 95% CI: 0.76-1.80). The factor with the strongest association with severe fear of childbirth among multiparas was a negative birth experience (adjusted OR: 5.50; 95% CI: 3.77-8.01).nnnCONCLUSIONSnA history of childhood abuse significantly increased the risk of experiencing severe fear of childbirth among primiparas. Fear of childbirth among multiparas was most strongly associated with a negative birth experience.

Fear of childbirth and risk of cesarean delivery: a cohort study in six European countries.

BACKGROUNDnFew studies have examined the mode of birth among women with fear of childbirth, and the results are conflicting. The objective of this study was to assess the association between fear of childbirth and cesarean delivery in North European women.nnnMETHODSnA longitudinal cohort study was conducted among 6,422 pregnant women from Belgium, Iceland, Denmark, Estonia, Norway, and Sweden. Fear of childbirth was measured by the Wijma Delivery Expectancy Questionnaire during pregnancy and linked to obstetric information from hospital records.nnnRESULTSnAmong 3,189 primiparous women, those reporting severe fear of childbirth were more likely to give birth by elective cesarean, (OR, 1.66 [95% CI 1.05-2.61]). Among 3,233 multiparous women, severe fear of childbirth increased the risk of elective cesarean (OR 1.87 [95% CI 1.30-2.69]). Reporting lack of positive anticipation, one of six dimensions of fear of childbirth, was most strongly associated with elective cesarean (OR 2.02 [95% CI 1.52-2.68]). A dose-effect pattern was observed between level of fear and risk of emergency cesarean in both primiparous and multiparous women. Indications for cesarean were more likely to be reported as nonmedical among those with severe fear of childbirth; 16.7 versus 4.6 percent in primiparous women, and 31.7 versus 17.5 percent in multiparous women.nnnCONCLUSIONnHaving severe fear of childbirth increases the risk of elective cesarean, especially among multiparous women. Lack of positive anticipation of the upcoming childbirth seems to be an important dimension of fear associated with cesarean delivery. Counseling for women who do not look forward to vaginal birth should be further evaluated.

Prevalence and associated factors of fear of childbirth in six European countries

OBJECTIVESnThis study set out to compare the prevalence, content and associated factors of fear of childbirth in six European countries.nnnMETHODnA cross-sectional study of 6870 pregnant women attending routine antenatal care in Belgium, Iceland, Denmark, Estonia, Norway and Sweden (Bidens).nnnMAIN OUTCOME MEASUREnSevere fear of childbirth, defined as a Wijma Delivery Expectancy Questionnaire score of ≥85.nnnRESULTSnEleven percent of all women reported severe fear of childbirth, 11.4% among primiparous and 11.0% among multiparous women. There were significant differences between the countries for prevalence of severe fear of childbirth, varying from 4.5% in Belgium to 15.6% in Estonia for primiparous women and from 7.6% in Iceland to 15.2% in Sweden for multiparous women. After adjusting for age, education and gestational age, only primiparous women from Belgium had significantly less fear of childbirth, AOR 0.35 (0.19-0.52) compared to Norway (largest participating group). Exploratory factor analyses revealed significant differences between the countries for the six factors extracted.nnnCONCLUSIONnFOC appears to be an international phenomenon, existing with similar proportions in the participating European countries, except for primiparous women in Belgium who in our study reported significantly less severe fear of childbirth. Our study suggests that the content of fear of childbirth may differ between countries.

Childhood abuse and common complaints in pregnancy.

BACKGROUNDnChildhood abuse affects adult health. The objective of this study was to examine the prevalence of emotional, physical, and sexual childhood abuse within a large Norwegian cohort of pregnant women and its association with common complaints in pregnancy.nnnMETHODSnThis study is based on the Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health. Regression analyses were used to examine associations of childhood abuse and 16 common complaints in pregnancy.nnnRESULTSnEighteen percent (10,363/55,776) of the women reported some type of childhood abuse. Of all women, 3,870 (6.9%) reported sexual abuse, 3,075 (5.5%) physical abuse, and 7,619 (13.6%) emotional abuse as a child. Of those reporting childhood abuse, 31 percent reported two or more types of abuse. All 16 common complaints in pregnancy were associated with reported childhood abuse. Women reporting three types of childhood abuse reported 5.4 common complaints in pregnancy (mean) compared with 3.7 for women without childhood abuse (p < 0.001). Women reporting childhood abuse are more likely to report seven or more common complaints in pregnancy: adjusted odds ratio (AOR) 1.7 (95% CI 1.6-1.9) for emotional abuse; AOR 2.5 (95% CI 2.0-3.1) for combined physical and sexual abuse; and AOR 3.5 (95% CI 3.0-4.0) for all three kinds of abuse. Sociodemographic characteristics and other risk factors did not explain this graded association.nnnCONCLUSIONSnAbuse in childhood is associated with increased reporting of common complaints of pregnancy. Clinicians should consider the possible role of childhood abuse when treating women with many common complaints in pregnancy.

Fear of childbirth, women's preference for cesarean section and childhood abuse: a longitudinal study

Objective. To examine the association between childhood abuse and fear of childbirth and the wish for cesarean section during second pregnancy. Design. A longitudinal cohort study using data from the Norwegian Mother and Child Cohort Study (MoBa) conducted by the Norwegian Institute of Public Health. Setting. Fifty maternity units in Norway, 1999–2006. Sample. We included 4,876 women who participated in the MoBa study during their first and second pregnancy. Methods. Postal questionnaires at 18 and 30 weeks gestation and 6 months postpartum linked to the Medical Birth Registry of Norway. Main Outcome Measures. Associations between childhood abuse and womens fear of childbirth and preference for cesarean section during second pregnancy were assessed using regression analyses, adjusting for confounding factors such as mode of delivery and birth experience of first pregnancy. Results. Of 4,876 women, 1,023 (21%) reported some form of childhood abuse. Compared to women without a history of childhood abuse, childhood‐abused women more frequently reported fear of childbirth (23% vs. 15%, p < 0.001) and the wish for cesarean section (6.4% vs. 4.0%, p < 0.002) during second pregnancy. The association between childhood abuse and fear of childbirth and preference for cesarean section remained significant after adjusting for mode of first delivery and experience of first birth (adjusted odds ratio [OR] 1.53, 95%CI 1.24–1.90 and 1.57, 1.09–2.27, respectively). Conclusion. Childhood abuse is associated with fear of childbirth and preference for cesarean section during second pregnancy. Mode of delivery and postpartum self‐reported birth experience of the first pregnancy did not alter this association significantly.

Prevalence of sexual, physical and emotional abuse in the Norwegian mother and child cohort study

BackgroundAbuse of women occurs in every society of the world. Increased information about the prevalence in industrialized countries, like Norway, is required to make strategies to prevent abuse. Our aim was to investigate the prevalence of self-reported sexual, physical and emotional abuse in a large obstetric population in Norway, and the associations between exposure to adult abuse, socio-demographics and other characteristics.MethodsOur study is based on the Norwegian Mother and Child (MoBa) Cohort study, conducted by the Norwegian Institute of Public Health. The current study included 65,393 women who responded to two extensive postal questionnaires during pregnancy. Any adult abuse is defined as being exposed to one or more types of adult abuse, any child abuse is defined as being exposed to one or more types of child abuse, and any lifetime abuse is defined as being exposed to abuse either as a child and/or as an adult. Perpetrators were categorized as known or stranger.ResultsOverall, 32% of the women reported any lifetime abuse, 20% reported any adult abuse, 19% reported any child abuse and 6% reported abuse both as adults and as children. Emotional abuse was the most frequently reported type of abuse both as adults (16%) and children (14%). Adult sexual abuse was reported by 5% and child sexual abuse by 7%. Physical abuse was reported by 6% as adults and by 6% as children. Approximately 30% of those reporting adult or child abuse reported exposure to two or three types of abuse. Five percent of the women reported exposure to any abuse during the last 12u2009months. For all types of abuse, a known perpetrator was more commonly reported. Logistic regression showed that being exposed to child abuse, smoking and drinking alcohol in the first trimester of pregnancy, living alone, and belonging to the eldest age group were significantly associated with being exposed to any adult abuse.ConclusionThe reported prevalence of any lifetime abuse was substantial in our low-risk pregnant population. Antenatal care is an opportunity for clinicians to ask about experiences of abuse and identify those at risk.

A History of Abuse and Operative Delivery – Results from a European Multi-Country Cohort Study

Objective The main aim of this study was to assess whether a history of abuse, reported during pregnancy, was associated with an operative delivery. Secondly, we assessed if the association varied according to the type of abuse and if the reported abuse had been experienced as a child or an adult. Design The Bidens study, a cohort study in six European countries (Belgium, Iceland, Denmark, Estonia, Norway, and Sweden) recruited 6724 pregnant women attending routine antenatal care. History of abuse was assessed through questionnaire and linked to obstetric information from hospital records. The main outcome measure was operative delivery as a dichotomous variable, and categorized as an elective caesarean section (CS), or an operative vaginal birth, or an emergency CS. Non-obstetrically indicated were CSs performed on request or for psychological reasons without another medical reason. Binary and multinomial regression analysis were used to assess the associations. Results Among 3308 primiparous women, sexual abuse as an adult (≥18 years) increased the risk of an elective CS, Adjusted Odds Ratio 2.12 (1.28–3.49), and the likelihood for a non-obstetrically indicated CS, OR 3.74 (1.24–11.24). Women expressing current suffering from the reported adult sexual abuse had the highest risk for an elective CS, AOR 4.07 (1.46–11.3). Neither physical abuse (in adulthood or childhood <18 years), nor sexual abuse in childhood increased the risk of any operative delivery among primiparous women. Among 3416 multiparous women, neither sexual, nor emotional abuse was significantly associated with any kind of operative delivery, while physical abuse had an increased AOR for emergency CS of 1.51 (1.05–2.19). Conclusion Sexual abuse as an adult increases the risk of an elective CS among women with no prior birth experience, in particular for non-obstetrical reasons. Among multiparous women, a history of physical abuse increases the risk of an emergency CS.

Prevalence of emotional, physical and sexual abuse among pregnant women in six European countries

The primary objective was to investigate the prevalence of a history of abuse among women attending routine antenatal care in six northern European countries. Second, we explored current suffering from reported abuse.

Sexual violence and pregnancy-related physical symptoms

BackgroundFew studies have investigated the impact of sexual violence on health during pregnancy. We examined the association between sexual violence and the reporting of physical symptoms during pregnancy.MethodsA population-based national cohort study conducted by The Norwegian Mother and Child Cohort study (MoBa) collected data from pregnant women through postal questionnaires at 17 and 32u2009weeks gestation. Three levels of sexual violence were measured: 1) mild (pressured into sexual relations), 2) moderate (forced with violence into sexual relation) and 3) severe (rape). Differences between women reporting and not reporting sexual violence were assessed using Pearson’s X2 test and multiple logistic regression analyses.ResultsOf 78 660 women, 12.0% (9 444) reported mild, 2.8% (2 219) moderate and 3.6% (2 805) severe sexual violence. Sexual violence was significantly associated with increased reporting of pregnancy-related physical symptoms, both measured in number of symptoms and duration/degree of suffering. Compared to women not reporting sexual violence, the probability of suffering from ≥8 pregnancy-related symptoms estimated by Adjusted Odds Ratio (AOR) was 1.49 (1.41–1.58) for mild sexual violence, 1.66(1.50–1.84) for moderate and 1.78 (1.62–1.95) for severe. Severe sexual violence both previously and recently had the strongest association with suffering from ≥8 pregnancy-related symptoms, AOR 6.70 (2.34–19.14).ConclusionA history of sexual violence is associated with increased reporting of pregnancy-related physical symptoms. Clinicians should consider the possible role of a history of sexual violence when treating women who suffer extensively from pregnancy-related symptoms.