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Journal of Advanced Nursing May 2018To explore the quantitative/qualitative literature on women's experiences of perineal trauma sustained during childbirth and the impact it may have on... (Review)
Review
AIM
To explore the quantitative/qualitative literature on women's experiences of perineal trauma sustained during childbirth and the impact it may have on psychological/emotional wellbeing BACKGROUND: Obstetric complications during childbirth can be a risk factor for postpartum psychological distress. Perineal trauma is one of the most frequent obstetric complications and it is important to understand any impact on psychological/emotional wellbeing.
DESIGN
A convergent qualitative design using a hybrid deductive-inductive thematic synthesis approach to data transformation was used.
DATA SOURCES
Web of knowledge, CINAHL, MEDLINE, AMED, PsyArticles, PsycInfo until May 2017.
REVIEW METHODS
Stage 1: transforming findings from the qualitative, quantitative and mixed methods studies into themes using thematic synthesis. Stage 2: integrating themes from the quantitative studies into those derived from the qualitative studies RESULTS: Records (N=2152) found of which 11 qualitative 22 quantitative and 1 mixed methods were included in this review. Five themes were derived from thematic synthesis of qualitative studies 'The mystery of perineal trauma', 'The misery of perineal suturing', 'The postnatal perineum', 'Normalisation and feeling dismissed' and 'Adjusting to a new normal - Coping and compromise' and five themes identified from the quantitative studies, experience of birth (N=4), Sexual functioning (N=12), Social functioning (N=2), Psychological health (N=8) and Quality of Life (N=5).
CONCLUSION
Perineal trauma can have a negative impact on psychological/emotional wellbeing, however the literature is conflicted and in need of clarification. Future research should clearly describe the perineal status of the women in the sample, use validated measures and consider the timing of such measures. This article is protected by copyright. All rights reserved.
PubMed: 29791012
DOI: 10.1111/jan.13724 -
The Cochrane Database of Systematic... Sep 2015Postpartum constipation, with symptoms such as pain or discomfort, straining, and hard stool, is a common condition affecting mothers. Haemorrhoids, pain at the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Postpartum constipation, with symptoms such as pain or discomfort, straining, and hard stool, is a common condition affecting mothers. Haemorrhoids, pain at the episiotomy site, effects of pregnancy hormones and haematinics used in pregnancy can increase the risk of postpartum constipation. Eating a high-fibre diet and increasing fluid intake is usually encouraged, although laxatives are commonly used in relieving constipation. The effectiveness and safety of available interventions for preventing postpartum constipation needs to be ascertained.
OBJECTIVES
To evaluate the effectiveness and safety of interventions for preventing postpartum constipation.
SEARCH METHODS
We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 April 2015), Stellenbosch University database, ProQuest Dissertation and Theses database, World Health Organization International Clinical Trials Registry Platform (ICTRP), ClinicalTrials.gov (30 April 2015) and reference lists of included studies.
SELECTION CRITERIA
All randomised controlled trials (RCTs) comparing any intervention for preventing postpartum constipation versus another intervention, placebo or no intervention. Interventions could include pharmacological (e.g. laxatives) and non-pharmacological interventions (e.g. acupuncture, educational and behavioural interventions).We included quasi-randomised trials. Cluster-RCTs were eligible for inclusion but none were identified. Studies using a cross-over design were not eligible for inclusion in this review.
DATA COLLECTION AND ANALYSIS
Two review authors independently screened the results of the search to select potentially relevant studies, extracted data and assessed risk of bias. Results were pooled in a meta-analysis only where there was no substantial statistical heterogeneity.
MAIN RESULTS
We included five trials (1208 postpartum mothers); four compared a laxative with placebo and one compared a laxative alone versus the same laxative plus a bulking agent in women who underwent surgical repair of third degree perineal tears. Trials were poorly reported and risk of bias was unclear for most domains. Overall, there was a high risk of selection and attrition bias. Laxative versus placeboNone of the four trials included in this comparison assessed any of our pre-specified primary outcomes (pain or straining on defecation, incidence of postpartum constipation or changes in quality of life).All four trials reported time to first bowel movement (not pre-specified in our protocol). In one trial, more women in the laxative group had their first bowel movement less than 24 hours after delivery compared to women in the placebo group (risk ratio (RR) 2.90, 95% confidence interval (CI) 2.24 to 3.75, 471 women). Individual trials also reported inconsistent results for days one, two and three after delivery. Pooled results of two trials showed that fewer women in the laxative group were having their first bowel movement at day four compared with controls (average RR 0.36, 95% CI 0.21 to 0.61, 671 women).Regarding secondary outcomes, no trials reported on stool consistency using the Bristol stool form scale orrelief of abdominal pain/discomfort . One trial reported the number of women having loose or watery stools and there were more women who experienced this in the laxative group compared to the placebo group (RR 26.96, 95% CI 3.81 to 191.03, 106 women). One trial found no clear difference in the number of enemas between groups (RR 0.63, 95% CI 0.38 to 1.05, 244 women). One trial reported more women having more than two bowel movements per day in the laxative compared to the placebo group (RR 26.02, 95% CI 1.59 to 426.73, 106 women). Adverse effects were poorly reported; two trials reported the number of women having abdominal cramps, but their results could not be pooled in a meta-analysis due to substantial statistical heterogeneity. In one trial, more women in the laxative group had abdominal cramps compared to the placebo group (RR 4.23, 95% CI 1.75 to 10.19, 471 women), while the other trial showed no difference between groups (RR 0.25, 95% CI 0.03 to 2.20, 200 women). With regards to adverse effects of the intervention on the baby , one trial found no difference in the incidence of loose stools (RR 0.62, 95% CI 0.16 to 2.41, 281 women) or diarrhoea (RR 2.46, 95% CI 0.23 to 26.82, 281 women) between the two groups. Laxative versus laxative plus bulking agentOnly one trial was included in this comparison and reported on pain or straining on defecation in women who underwent surgical repair of third degree perineal tears; there was no reported difference between groups (median (range) data only). No difference was reported in the incidence of postpartum constipation (data not reported) and the outcome changes in quality of life was not mentioned.Time to first bowel movement was reported as a median (range) with no difference between the two groups. In terms of adverse effects , women in the laxative plus stool-bulking group were reported to be at a greater risk of faecal incontinence during the immediate postpartum period (median (range) data only). However the number of women having any episode of faecal incontinence during first 10 days postpartum was reported with no clear difference between the two groups (14/77 (18.2%) versus 23/70 (32.9%), RR 0.55, 95% CI 0.31 to 0.99, 147 women). The trial did not report on adverse effects of the intervention on the babies.The trial reported none of the following pre-specified secondary outcomes: stool consistency using Bristol stool form scale , use of alternative products , laxative agents , enemas , relief of abdominal pain/discomfort and stool frequency .
AUTHORS' CONCLUSIONS
We did not identify any trials assessing educational or behavioural interventions. We identified four trials that examined laxatives versus placebo and one that examined laxatives versus laxatives plus stool bulking agents. Results from trials were inconsistent and there is insufficient evidence to make general conclusions about the effectiveness and safety of laxatives.Further rigorous trials are needed to assess the effectiveness and safety of laxatives during the postpartum period for preventing constipation. Trials assessing educational and behavioural interventions and positions that enhance defecation are also needed. Future trials should report on the following important outcomes: pain or straining on defecation; incidence of postpartum constipation, quality of life, time to first bowel movement after delivery, and adverse effects caused by the intervention such as: nausea or vomiting, pain and flatus.
Topics: Adult; Constipation; Dietary Fiber; Female; Humans; Laxatives; Perineum; Postpartum Period; Randomized Controlled Trials as Topic
PubMed: 26387487
DOI: 10.1002/14651858.CD011625.pub2 -
BMJ Open Sep 2015A rise in obstetric anal sphincter injuries (OASIS) has been observed and a preventive approach, originating in Finland, has been introduced in several European... (Review)
Review
OBJECTIVES
A rise in obstetric anal sphincter injuries (OASIS) has been observed and a preventive approach, originating in Finland, has been introduced in several European hospitals. The aim of this paper was to systematically evaluate the evidence behind the 'Finnish intervention'.
DESIGN
A systematic review of the literature conducted according to the Preferred Reporting for Systematic Reviews and Meta-analyses (PRISMA) guidelines.
OUTCOME MEASURES
The primary outcome was OASIS. Secondary outcomes were (perinatal): Apgar scores, pH and standard base excess in the umbilical cord, and (maternal): episiotomy, intact perineum, first and second-degree perineal lacerations, duration of second stage, birth position and women's perceptions/birth experiences.
METHODS
Multiple databases (Cochrane, Embase, Pubmed and SveMed) were systematically searched for studies published up to December 2014. Both randomised controlled trials and observational studies were eligible for inclusion. Studies were excluded if a full-text article was not available. Studies were evaluated by use of international reporting guidelines (eg, STROBE).
RESULTS
Overall, 1042 articles were screened and 65 retrieved for full-text evaluation. Seven studies, all observational and with a level of evidence at 2c or lower, were included and consistently reported a significant reduction in OASIS. All evaluated episiotomy and found a significant increase. Three studies evaluated perinatal outcomes and reported conflicting results. No study reported on other perineal outcomes, duration of the second stage, birth positions or women's perceptions.
CONCLUSIONS
A reduction in OASIS has been contributed to the Finnish intervention in seven observational studies, all with a low level of evidence. Knowledge about the potential perinatal and maternal side effects and women's perceptions of the intervention is extremely limited and the biological mechanisms underlying the Finnish intervention are not well documented. Studies with a high level of evidence are needed to assess the effects of the intervention before implementation in clinical settings can be recommended.
Topics: Adult; Anal Canal; Episiotomy; Fecal Incontinence; Female; Finland; Humans; Infant, Newborn; Lacerations; Obstetric Labor Complications; Perineum; Pregnancy; Treatment Outcome
PubMed: 26369797
DOI: 10.1136/bmjopen-2015-008346 -
Journal of Clinical Nursing May 2023To investigate the effect of tissue adhesives on perineal wound healing and pain relief in women with perineal trauma during childbirth. (Meta-Analysis)
Meta-Analysis Review
AIMS AND OBJECTIVES
To investigate the effect of tissue adhesives on perineal wound healing and pain relief in women with perineal trauma during childbirth.
BACKGROUND
Due to the high incidence and severe consequences of perineal trauma during childbirth, tissue adhesives are recommended as an alternative to conventional sutures to repair perineal trauma. Although many original studies have explored the effect of tissue adhesives on perineal wound healing and pain relief in women with perineal trauma during childbirth, these studies have differed in participants, interventions and outcomes. Therefore, the effect of tissue adhesives on wound healing and pain relief in perineal trauma during childbirth is inconclusive.
DESIGN
A systematic review and meta-analysis based on PRISMA 2020.
METHODS
A systematic and comprehensive literature search was conducted. Eight electronic databases, three clinical trial registers, and grey literature were searched from inception to 28th April 2021 and reference lists were also retrieved. Randomised controlled trials (RCTs) involving women with first- or second-degree perineal lacerations or women who underwent episiotomy were included. The intervention was the use of tissue adhesives alone or in combination with sutures. For the outcome indicators of perineal wound healing and pain relief, subgroup analyses based on the extent of perineal trauma and measurement time points were conducted, respectively.
RESULTS
A total of 14 RCTs involving 2264 participants were included in this research. The results indicated that for first-degree lacerations, the incidence of wound complications was significantly higher in the tissue adhesives group. In contrast, for episiotomy, the effect of the combination of tissue adhesives and sutures was comparable to that of sutures exclusively. The pooled results revealed that tissue adhesives exerted a positive effect on relieving immediate and short-term perineal pain, but no significant difference was found in the effect of long-term pain relief. Moreover, this review also supported the effect of tissue adhesives in shortening intraoperative repair time and improving clinician-maternal satisfaction.
CONCLUSIONS
The existing evidence illustrates that tissue adhesives effectively promote perineal wound healing and relieve immediate and short-term pain. However, for first-degree lacerations, the increased occurrence of wound complications must be prudently considered when applying tissue adhesives alone, whereas, for episiotomy, the combination of tissue adhesives and sutures may be a promising repair alternative. Future studies are encouraged to adopt long-term effect, adverse effect, and cost-effect analysis as important outcome indicators to comprehensively validate the applicability and generalisability of tissue adhesives.
RELEVANCE TO CLINICAL PRACTICE
For first-degree perineal lacerations, we do not recommend using tissue adhesives alone to repair the wound, given the increased wound complications. While for episiotomy, the combination of tissue adhesives and sutures may be a promising alternative to the use of sutures exclusively. Additionally, the adverse effect and long-term effect of using tissue adhesives alone to repair perineal trauma should be further clarified.
Topics: Pregnancy; Female; Humans; Tissue Adhesives; Lacerations; Perineum; Parturition; Delivery, Obstetric; Episiotomy; Pain; Obstetric Labor Complications
PubMed: 34672033
DOI: 10.1111/jocn.16086 -
International Journal of Gynaecology... Jul 2022Women with previous obstetric anal sphincter injuries (OASIs) are at a higher risk of recurrence in the subsequent pregnancy, which may lead to the development or... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Women with previous obstetric anal sphincter injuries (OASIs) are at a higher risk of recurrence in the subsequent pregnancy, which may lead to the development or worsening of anal incontinence. Due to a lack of evidence, few recommendations can be made about the factors that may affect the risk of OASI recurrence.
OBJECTIVE
We sought to conduct a systematic review and meta-analysis to investigate potential risk factors for recurrent OASIs.
SEARCH STRATEGY
Studies up to May 2019 were identified from PubMed, Scopus, Cochrane Library, and ISI Web of Science.
SELECTION CRITERIA
Studies assessing the impact of risk factors on OASI recurrence in subsequent pregnancies were included. Reviews, letters to the editor, conference abstracts, book chapters, guidelines, Cochrane reviews, and expert opinions were excluded.
DATA COLLECTION AND ANALYSIS
Data were extracted by two independent reviewers. Odds ratio and standardized mean difference were chosen as effect measures. Pooled estimates were calculated using the random-effects model.
MAIN RESULTS
The meta-analysis showed that maternal age, gestational age, occiput posterior presentation, oxytocin augmentation, operative delivery, and shoulder dystocia were associated with the risk of recurrent OASIs in the subsequent delivery.
CONCLUSION
Prenatal and intrapartum risk factors are associated with recurrence of OASI. PROSPERO registration no. CRD42020178125.
Topics: Anal Canal; Delivery, Obstetric; Fecal Incontinence; Female; Humans; Obstetric Labor Complications; Perineum; Pregnancy; Risk Factors
PubMed: 34559892
DOI: 10.1002/ijgo.13950 -
American Journal of Surgery Sep 2016The aim of this study was to compare the short-term morbidity and long-term oncologic benefits of extralevator abdominoperineal excision (ELAPE) with conventional... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The aim of this study was to compare the short-term morbidity and long-term oncologic benefits of extralevator abdominoperineal excision (ELAPE) with conventional abdominoperineal resection (CAPR) for patients with rectal cancer.
METHODS
Electronic search of the Cochrane Library, MEDLINE, EMBASE, Korean Journal, and J-EAST database from 2007 until August 2015 was carried out. We considered randomized controlled trials and nonrandomized comparative studies comparing ELAPE with CAPR to be eligible, if they included patients with rectal cancers.
RESULTS
A total of 1 randomized controlled trials and 10 nonrandomized comparative studies met the inclusion criteria, involving 1,736 patients in the ELAPE group and 1,320 in the CAPR group. The ELAPE was associated with a significantly lower intraoperative perforation rate. There were no differences regarding the circumferential margin involvement, R0 resections, and local recurrence rate. There was less blood loss in ELAPE patients.
CONCLUSIONS
The ELAPE significantly lowered the intraoperative perforation rate, with no benefits regarding circumferential resection margin involvement and local recurrence rate.
Topics: Abdomen; Digestive System Surgical Procedures; Humans; Perineum; Rectal Neoplasms; Treatment Outcome
PubMed: 27317475
DOI: 10.1016/j.amjsurg.2016.02.022 -
American Journal of Obstetrics and... Jul 2023This study aimed to compare the prognostic accuracy of intrapartum transperineal ultrasound measures of fetal descent before operative vaginal birth in predicting... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
This study aimed to compare the prognostic accuracy of intrapartum transperineal ultrasound measures of fetal descent before operative vaginal birth in predicting complicated or failed procedures.
DATA SOURCES
We performed a predefined systematic search in Medline, Embase, CINAHL, and Scopus from inception to June 10, 2022.
STUDY ELIGIBILITY CRITERIA
We included studies assessing the following intrapartum transperineal ultrasound measures before operative vaginal birth to predict procedure outcome: angle of progression, head direction, head-perineum distance, head-symphysis distance, midline angle, and/or progression distance.
METHODS
Study quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Bivariate meta-analysis was used to pool sensitivities and specificities into summary receiver operating characteristic curves for each intrapartum transperineal ultrasound measure. Subgroup analyses were performed for measures taken at rest vs with pushing and prediction of failed vs complicated operative vaginal birth.
RESULTS
Overall, 16 studies involving 2848 women undergoing attempted operative vaginal birth were included. The prognostic accuracy of intrapartum transperineal ultrasound measures taken at rest to predict failed or complicated operative vaginal birth was high for angle of progression (area under the receiver operating characteristic curve, 0.891; 9 studies) and progression distance (area under the receiver operating characteristic curve, 0.901; 3 studies), moderate for head direction (area under the receiver operating characteristic curve, 0.791; 6 studies) and head-perineum distance (area under the receiver operating characteristic curve, 0.747; 8 studies), and fair for midline angle (area under the receiver operating characteristic curve, 0.642; 4 studies). There was no study with sufficient data to assess head-symphysis distance. Subgroup analysis showed that measures taken with pushing tended to have a higher area under the receiver operating characteristic curve for angle of progression (0.927; 4 studies), progression distance (0.930; 2 studies), and midline angle (0.903; 3 studies), with a similar area under the receiver operating characteristic curve for head direction (0.802; 4 studies). The prediction of failed vs complicated operative vaginal birth tended to be less accurate for angle of progression (0.837 [4 studies] vs 0.907 [6 studies]) and head direction (0.745 [3 studies] vs 0.810 [5 studies]), predominantly because of lower specificity, and was more accurate for head-perineum distance (0.812 [6 studies] vs 0.687 [2 studies]).
CONCLUSION
Angle of progression, progression distance, and midline angle measured with pushing demonstrated the highest prognostic accuracy in predicting complicated or failed operative vaginal birth. Overall, the measurements seem to perform better with pushing than at rest.
Topics: Pregnancy; Female; Humans; Prognosis; Labor Presentation; Ultrasonography, Prenatal; Prospective Studies; Ultrasonography; Head
PubMed: 36427598
DOI: 10.1016/j.ajog.2022.11.1294 -
The Cochrane Database of Systematic... Aug 2020Postpartum constipation, with symptoms, such as pain or discomfort, straining, and hard stool, is a common condition affecting mothers. Haemorrhoids, pain at the...
BACKGROUND
Postpartum constipation, with symptoms, such as pain or discomfort, straining, and hard stool, is a common condition affecting mothers. Haemorrhoids, pain at the episiotomy site, effects of pregnancy hormones, and haematinics used in pregnancy can increase the risk of postpartum constipation. Eating a high-fibre diet and increasing fluid intake are usually encouraged. Although laxatives are commonly used in relieving constipation, the effectiveness and safety of available interventions for preventing postpartum constipation should be ascertained. This is an update of a review first published in 2015.
OBJECTIVES
To evaluate the effectiveness and safety of interventions for preventing postpartum constipation.
SEARCH METHODS
We searched Cochrane Pregnancy and Childbirth's Trials Register, and two trials registers ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (7 October 2019), and screened reference lists of retrieved trials.
SELECTION CRITERIA
We considered all randomised controlled trials (RCTs) comparing any intervention for preventing postpartum constipation versus another intervention, placebo, or no intervention in postpartum women. Interventions could include pharmacological (e.g. laxatives) and non-pharmacological interventions (e.g. acupuncture, educational and behavioural interventions). Quasi-randomised trials and cluster-RCTs were eligible for inclusion; none were identified. Trials using a cross-over design were not eligible.
DATA COLLECTION AND ANALYSIS
Two review authors independently screened the results of the search to select potentially relevant trials, extracted data, assessed risk of bias, and the certainty of the evidence, using the GRADE approach. We did not pool results in a meta-analysis, but reported them per study.
MAIN RESULTS
We included five trials (1208 postpartum mothers); three RCTs and two quasi-RCTs. Four trials compared a laxative with placebo; one compared a laxative plus a bulking agent versus the same laxative alone, in women who underwent surgical repair of third degree perineal tears. Trials were poorly reported, and four of the five trials were published over 40 years ago. We judged the risk of bias to be unclear for most domains. Overall, we found a high risk of selection and attrition bias. Laxative versus placebo We included four trials in this comparison. Two of the trials examined the effects of laxatives that are no longer used; one has been found to have carcinogenic properties (Danthron), and the other is not recommended for lactating women (Bisoxatin acetate); therefore, we did not include their results in our main findings. None of the trials included in this comparison assessed our primary outcomes: pain or straining on defecation, incidence of postpartum constipation, or quality of life; or many of our secondary outcomes. A laxative (senna) may increase the number of women having their first bowel movement within 24 hours after delivery (risk ratio (RR) 2.90, 95% confidence interval (CI) 2.24 to 3.75; 1 trial, 471 women; low-certainty evidence); may have little or no effect on the number of women having their first bowel movement on day one after delivery (RR 0.94, 95% CI 0.72 to 1.22; 1 trial, 471 women; very low-certainty evidence); may reduce the number of women having their first bowel movement on day two (RR 0.23, 95% CI 0.11 to 0.45; 1 trial, 471 women; low-certainty evidence); and day three (RR 0.05, 95% CI 0.00 to 0.89; 1 trial, 471 women; low-certainty evidence); and may have little or no effect on the number of women having their first bowel movement on day four after delivery (RR 0.22, 95% CI 0.03 to 1.87; 1 trial, 471 women; very low-certainty evidence), but some of the evidence is very uncertain. Adverse effects were poorly reported. Low-certainty evidence suggests that the laxative (senna) may increase the number of women experiencing abdominal cramps (RR 4.23, 95% CI 1.75 to 10.19; 1 trial, 471 women). Very low-certainty evidence suggests that laxatives taken by the mother may have little or no effect on loose stools in the baby (RR 0.62, 95% CI 0.16 to 2.41; 1 trial, 281 babies); or diarrhoea (RR 2.46, 95% CI 0.23 to 26.82; 1 trial, 281 babies). Laxative plus bulking agent versus laxative only Very low-certainty evidence from one trial (147 women) suggests no evidence of a difference between these two groups of women who underwent surgical repair of third degree perineal tears; only median and range data were reported. The trial also reported no evidence of a difference in the incidence of postpartum constipation (data not reported), but did not report on quality of life. Time to first bowel movement was reported as a median (range); very low-certainty evidence suggests little or no difference between the two groups. A laxative plus bulking agent may increase the number of women having any episode of faecal incontinence during the first 10 days postpartum (RR 1.81, 95% CI 1.01 to 3.23; 1 trial, 147 women; very low-certainty evidence). The trial did not report on adverse effects of the intervention on babies, or many of our secondary outcomes.
AUTHORS' CONCLUSIONS
There is insufficient evidence to make general conclusions about the effectiveness and safety of laxatives for preventing postpartum constipation. The evidence in this review was assessed as low to very low-certainty evidence, with downgrading decisions based on limitations in study design, indirectness and imprecision. We did not identify any trials assessing educational or behavioural interventions. We identified four trials that examined laxatives versus placebo, and one that examined laxatives versus laxatives plus stool bulking agents. Further, rigorous trials are needed to assess the effectiveness and safety of laxatives during the postpartum period for preventing constipation. Trials should assess educational and behavioural interventions, and positions that enhance defecation. They should report on the primary outcomes from this review: pain or straining on defecation, incidence of postpartum constipation, quality of life, time to first bowel movement after delivery, and adverse effects caused by the intervention, such as: nausea or vomiting, pain, and flatus.
Topics: Adult; Constipation; Defecation; Dietary Fiber; Female; Humans; Laxatives; Perineum; Postpartum Period; Puerperal Disorders; Randomized Controlled Trials as Topic; Time Factors
PubMed: 32761813
DOI: 10.1002/14651858.CD011625.pub3 -
Midwifery Aug 2020Negative maternal outcomes such as perineal trauma and related perineal pain may cause both long-and short- term morbidities. Hands on and hands off/poised technique are... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Negative maternal outcomes such as perineal trauma and related perineal pain may cause both long-and short- term morbidities. Hands on and hands off/poised technique are two kinds of techniques to protect perineum during the second-stage of labor. Hands on technique has been the routine midwifery practice for a long time; nevertheless, the effects of hands on technique on protecting perineum has been doubted. Hands off/poised as a promising technique seems prevalent in clinical practice. However, there is no consensus on use of hands off/poised technique and hands on technique. The effects of these techniques on maternal outcomes have not been fully investigated.
OBJECTIVE
To evaluate the effects of hands on hands off/poised technique on maternal outcomes during the second-stage of labor.
DESIGN
Systematic review and meta-analysis of relevant quantitative studies.
DATA SOURCES
Seven databases: PubMed, EMBASE, The Cochrane Library, CINAHL, WanFang Data, China National Knowledge Infrastructure (CKNI), SinoMed were systematically searched from inception to July 23,2018 for relevant quantitative studies comparing the effects of hands on and hands off/poised technique on maternal outcomes.
REVIEW METHODS
Quantitative studies were retrieved for relevant studies. Two reviewers independently screened the studies, evaluated the methodological quality using JBI appraisal checklist tools and extracted the data. The included studies were divided into two groups for analysis according to study types.
RESULTS
Nine RCTs with a total of 7112 participants and eight non-RCTs with 37,786 participants were included for meta-analysis. Based on the results from RCTs, this study did not find difference between hands on and hands off/poised technique regarding the risk of 2nd perineal tears, 3rd /4th degree perineal tears, duration of second-stage labor and incidence of postpartum hemorrhage (PPH>500 ml). The results from 9 non-RCTs were similar with that of RCTs, except for showing less 2nd degree perineal tears in hands off/poised technique than in hands on technique.
CONCLUSION
Evidence in the present study indicated that hands off/poised technique may be a promising delivery technique to maintain intact perineum, and reduce perineal pain and episiotomy use among women with low-risk pregnancy undergoing vaginal delivery. In addition, hands off/poised technique might be safe to use as it did not increase the risk of severe perineal trauma, postpartum hemorrhage, and longer duration of second-stage labor when compared with hands on technique. More studies with stringent study design, especially large randomized controlled trial, should be conducted before strong recommendation of the hands off/poised technique.
Topics: Female; Humans; Midwifery; Obstetric Labor Complications; Outcome Assessment, Health Care; Pregnancy; Procedures and Techniques Utilization; Time Factors
PubMed: 32422467
DOI: 10.1016/j.midw.2020.102712 -
The Cochrane Database of Systematic... Mar 2020Vacuum and forceps assisted vaginal deliveries are reported to increase the incidence of postpartum infections and maternal readmission to hospital compared to... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Vacuum and forceps assisted vaginal deliveries are reported to increase the incidence of postpartum infections and maternal readmission to hospital compared to spontaneous vaginal delivery. Prophylactic antibiotics may be prescribed to prevent these infections. However, the benefit of antibiotic prophylaxis for operative vaginal deliveries is still unclear. This is an update of a review last published in 2017.
OBJECTIVES
To assess the effectiveness and safety of antibiotic prophylaxis in reducing infectious puerperal morbidities in women undergoing operative vaginal deliveries including vacuum or forceps delivery, or both.
SEARCH METHODS
For this update, we searched Cochrane Pregnancy and Childbirth's Trials Register, ClinicalTrials.gov, the WHO International Clinical Trials Registry Platform (ICTRP) (5 July 2019), and reference lists of retrieved studies.
SELECTION CRITERIA
All randomised controlled trials comparing any prophylactic antibiotic regimens with placebo or no treatment in women undergoing vacuum or forceps deliveries were eligible. Participants were all pregnant women without evidence of infections or other indications for antibiotics of any gestational age. Interventions were any antibiotic prophylaxis (any dosage regimen, any route of administration or at any time during delivery or the puerperium).
DATA COLLECTION AND ANALYSIS
Two review authors assessed trial eligibility and risk of bias. Two review authors extracted the data independently using prepared data extraction forms. Any discrepancies were resolved by discussion and a consensus reached through discussion with all review authors. We assessed methodological quality of the two included studies using the GRADE approach.
MAIN RESULTS
Two studies, involving 3813 women undergoing either vacuum or forceps deliveries, were included. One study involving 393 women compared the antibiotic intravenous cefotetan after cord clamping compared with no treatment. The other study involving 3420 women compared a single dose of intravenous amoxicillin and clavulanic acid with placebo using 20 mL of intravenous sterile 0.9% saline. The evidence suggests that prophylactic antibiotics reduce superficial perineal wound infection (risk ratio (RR) 0.53, 95% confidence interval (CI) 0.40 to 0.69; women = 3420; 1 study; high-certainty evidence), deep perineal wound infection (RR 0.46, 95% CI 0.31 to 0.69; women = 3420; 1 study; high-certainty evidence) and probably reduce wound breakdown (RR 0.52, 95% CI 0.43 to 0.63; women = 2593; 1 study; moderate-certainty evidence). We are unclear about the effect on organ or space perineal wound infection (RR 0.11, 95% CI 0.01 to 2.05; women = 3420; 1 study) and endometritis (average RR 0.32, 95% CI 0.04 to 2.64; 15/1907 versus 30/1906; women = 3813; 2 studies) based on low-certainty evidence with wide CIs that include no effect. Prophylactic antibiotics probably lower serious infectious complications (RR 0.44, 95% CI 0.22 to 0.89; women = 3420; 1 study; high-certainty evidence). They also have an important effect on reduction of confirmed or suspected maternal infection. The two included studies did not report on fever or urinary tract infection. It is unclear, based on low-certainty evidence, whether prophylactic antibiotics have any impact on maternal adverse reactions (RR 2.00, 95% CI 0.18 to 22.05; women = 2593; 1 study) and maternal length of stay (MD 0.09 days, 95% CI -0.23 to 0.41; women = 393; 1 study) as the CIs were wide and included no effect. Prophylactic antibiotics slightly improve perineal pain and health consequences of perineal pain and probably reduce costs. Prophylactic antibiotics did not have an important effect on dyspareunia (difficult or painful sexual intercourse) or breastfeeding at six weeks. Antibiotic prophylaxis may slightly improve maternal hospital re-admission and maternal health-related quality of life. Neonatal adverse reactions were not reported in any included trials.
AUTHORS' CONCLUSIONS
Prophylactic intravenous antibiotics are effective in reducing infectious puerperal morbidities in terms of superficial and deep perineal wound infection or serious infectious complications in women undergoing operative vaginal deliveries without clinical indications for antibiotic administration after delivery. Prophylactic antibiotics slightly improve perineal pain and health consequences of perineal pain, probably reduce the costs, and may slightly reduce the maternal hospital re-admission and health-related quality of life. However, the effect on reduction of endometritis, organ or space perineal wound infection, maternal adverse reactions and maternal length of stay is unclear due to low-certainty evidence. As the evidence was mainly derived from a single multi-centre study conducted in a high-income setting, future well-designed randomised trials in other settings, particularly in low- and middle-income settings, are required to confirm the effect of antibiotic prophylaxis for operative vaginal delivery.
Topics: Amoxicillin-Potassium Clavulanate Combination; Anti-Bacterial Agents; Antibiotic Prophylaxis; Cefotetan; Endometritis; Episiotomy; Extraction, Obstetrical; Female; Humans; Length of Stay; Obstetrical Forceps; Perineum; Pregnancy; Puerperal Infection; Randomized Controlled Trials as Topic; Surgical Wound Infection; Vacuum Extraction, Obstetrical; Vaginal Diseases
PubMed: 32215906
DOI: 10.1002/14651858.CD004455.pub5