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American Journal of Obstetrics &... Mar 2022Several interventions during the second stage of labor have been identified and investigated. Prophylactic intrapartum betamimetics should be avoided, as their usage is... (Review)
Review
Several interventions during the second stage of labor have been identified and investigated. Prophylactic intrapartum betamimetics should be avoided, as their usage is associated with an increase in operative vaginal deliveries. Women without epidural anesthesia are recommended to give birth in any upright or lateral position. The best position for giving birth in women with epidural anesthesia is insufficiently studied, and neither recumbent nor upright positions can therefore be recommended. The routine use of maternal stirrups in the second stage of labor is not recommended. Consider avoiding water immersion during the second stage of labor, as the risks have not been adequately assessed. In nulliparous women at term with epidural analgesia, delayed pushing is not recommended. Pushing via a woman's own urge to push (open glottis) or pushing using the Valsalva maneuver (closed glottis) can both be considered. Both traditional coaching during pushing and ultrasound-assisted coaching may be considered. The use of a dental support device can be considered. All forms of fundal pressure are not recommended in the second stage of labor. Perineal massage and stretching of the perineum with a water-soluble lubricant in the second stage of labor is recommended. Perineal hyaluronidase injection as a method to reduce perineal trauma is not recommended. The use of perineal gel in the second stage of labor is not recommended. The use of perineal warm packs and heating pads are recommended. A perineal protection device can be considered. In fetuses with persistent occiput posterior position, manual rotation can be considered. Routine use of the Ritgen's maneuver does not seem to be associated with any benefits and is not recommended. The "Hands-poised" position is recommended over the "hands-on" method for delivery of the fetus. Routine episiotomy is not recommended. The routine use of ultrasound in the second stage of labor is not recommended. Waiting 1 additional hour (4 hours) for nulliparous women with epidural anesthesia before the diagnosis of a prolonged second stage of labor is recommended. A mandatory second opinion before cesarean delivery in the second stage of labor is recommended.
Topics: Delivery, Obstetric; Episiotomy; Female; Humans; Labor Stage, Second; Perineum; Pregnancy; Water
PubMed: 34871779
DOI: 10.1016/j.ajogmf.2021.100548 -
The New England Journal of Medicine Mar 2017
Topics: Diabetes Mellitus, Type 2; Fournier Gangrene; Humans; Liver Diseases, Alcoholic; Male; Middle Aged; Perineum; Scrotum; Tomography, X-Ray Computed
PubMed: 28328332
DOI: 10.1056/NEJMicm1609306 -
Journal of Gynecology Obstetrics and... Sep 2019The objective of these clinical practice guidelines was to analyse all of the interventions during pregnancy and childbirth that might prevent obstetric anal sphincter...
INTRODUCTION
The objective of these clinical practice guidelines was to analyse all of the interventions during pregnancy and childbirth that might prevent obstetric anal sphincter injuries (OASIS) and postnatal pelvic floor symptoms.
MATERIAL AND METHODS
These guidelines were developed in accordance with the methods prescribed by the French Health Authority (HAS).
RESULTS
A prenatal clinical examination of the perineum is recommended for women with a history of Crohn's disease, OASIS, genital mutilation, or perianal lesions (professional consensus). Just after delivery, a perineal examination is recommended to check for OASIS (Grade B); if there is doubt about the diagnosis, a second opinion should be requested (Grade C). In case of OASIS, the injuries (including their severity) and the technique for their repair should be described in detail (Grade C). Perineal massage during pregnancy must be encouraged among women who want it (Grade B). No intervention conducted before the start of the active phase of the second stage of labour has been shown to be effective in reducing the risk of perineal injury. The crowning of the baby's head should be manually controlled and the posterior perineum manually supported to reduce the risk of OASIS (Grade C). The performance of an episiotomy during normal deliveries is not recommended to reduce the risk of OASIS (Grade A). In instrumental deliveries, episiotomy may be indicated to avoid OASIS (Grade C). When an episiotomy is performed, a mediolateral incision is recommended (Grade B). The indication for episiotomy should be explained to the woman, and she should consent before its performance. Advising women to have a caesarean delivery for primary prevention of postnatal urinary or anal incontinence is not recommended (Grade B). During pregnancy and again in the labour room, obstetrics professionals should focus on the woman's expectations and inform her about the modes of delivery.
Topics: Anal Canal; Delivery, Obstetric; Episiotomy; Female; Gynecology; Humans; Infant, Newborn; Lacerations; Obstetrics; Parturition; Perineum; Pregnancy; Risk Factors; Societies, Medical
PubMed: 30553051
DOI: 10.1016/j.jogoh.2018.12.002 -
Gaceta Sanitaria 2021The purpose of this study will be to review several studies regarding the repair or treatment of perineal tears after vaginal delivery. This is expected to be an update... (Review)
Review
OBJECTIVE
The purpose of this study will be to review several studies regarding the repair or treatment of perineal tears after vaginal delivery. This is expected to be an update for a midwife in daily caring.
METHODS
Two electronic databases (PubMed and Sciencedirect) were searched to locate relevant literature about perineal tears/wound/laceration/trauma that is published in 2016-2021. 124 Pubmed articles and 452 ScienceDirect articles filtered successfully. The articles that have been obtained will be evaluated based on the inclusion criteria in this study. We summarize place and date, objective, design, samples, the measurement used, and research results.
RESULTS
9 articles were found that matched the inclusion criteria. Three articles examined the effect of the type of suture on perineal pain, and another 6 discussed therapy to reduce the adverse effects of perineal tears. The therapies used are far-infrared radiation therapy, capacitive-resistive radiofrequency therapy, pelvic floor muscle training in early postpartum, cold therapy, and treatment with TheresienOl (natural oil).
CONCLUSION
Sutures and technique/suturing second-degree perineal tears or a postpartum episiotomy can affect perineal pain. Cold gel pad therapy and treatment with natural oil on perineal wounds can affect perineal pain and wound healing.
Topics: Delivery, Obstetric; Episiotomy; Female; Humans; Lacerations; Midwifery; Obstetric Labor Complications; Perineum; Pregnancy
PubMed: 34929815
DOI: 10.1016/j.gaceta.2021.10.024 -
Journal of the American Animal Hospital... 2018Perineal hernia refers to the failure of the muscular pelvic diaphragm to support the rectal wall, resulting in herniation of pelvic and, occasionally, abdominal viscera... (Review)
Review
Perineal hernia refers to the failure of the muscular pelvic diaphragm to support the rectal wall, resulting in herniation of pelvic and, occasionally, abdominal viscera into the subcutaneous perineal region. The proposed causes of pelvic diaphragm weakness include tenesmus associated with chronic prostatic disease or constipation, myopathy, rectal abnormalities, and gonadal hormonal imbalances. The most common presentation of perineal hernia in dogs is a unilateral or bilateral nonpainful swelling of the perineum. Clinical signs do occur, but not always. Clinical signs may include constipation, obstipation, dyschezia, tenesmus, rectal prolapse, stranguria, or anuria. The definitive diagnosis of perineal hernia is based on clinical signs and findings of weak pelvic diaphragm musculature during a digital rectal examination. In dogs, perineal hernias are mostly treated by surgical intervention. Appositional herniorrhaphy is sometimes difficult to perform as the levator ani and coccygeus muscles are atrophied and unsuitable for use. Internal obturator muscle transposition is the most commonly used technique. Additional techniques include superficial gluteal and semitendinosus muscle transposition, in addition to the use of synthetic implants and biomaterials. Pexy techniques may be used to prevent rectal prolapse and bladder and prostate gland displacement. Postoperative care involves analgesics, antibiotics, a low-residue diet, and stool softeners.
Topics: Animals; Dog Diseases; Dogs; Hernia; Herniorrhaphy; Perineum
PubMed: 29757662
DOI: 10.5326/JAAHA-MS-6490 -
Midwifery Sep 2023The aim of this study is to evaluate the effect of perineal massage and warm compresses technique on the perineum integrity during second stage of labor. (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
The aim of this study is to evaluate the effect of perineal massage and warm compresses technique on the perineum integrity during second stage of labor.
DESIGN AND SETTING
A single-center, prospective, randomized controlled trial was conducted between March 1st, 2019, and December 31st, 2020, at Hospital of Braga.
PARTICIPANTS
Women with 18 years or older, between 37 weeks and 41 weeks pregnant, in whom a vaginal birth of a fetus in the cephalic presentation was planned were recruited. Eight hundred forty-eight women were randomly assigned (Perineal massage and warm compresses group, n = 424 and control group, n = 424), and 800 women, both perineal massage and warm compresses group (n = 400) and control group (n = 400) were included in the strict per protocol analysis.
INTERVENTION
In the perineal massage and warm compresses group, women received perineal massage and warm compresses and in the control group, women received hands-on technique.
RESULTS
The incidence of intact perineum was significantly higher in the perineal massage and warm compresses group [perineal massage and warm compresses group: 47% vs control group: 26.3%; OR 2.53, 95% CI 1.86-3.45, p<0.001], whereas second-degree tears and episiotomy rate were significantly lower in this group [perineal massage and warm compresses group: 7.2% vs control group: 12.3%; OR 1.96, 95% CI 1.17-3.29, p = 0.010 and perineal massage and warm compresses group: 9.5% vs control group: 28.5%; OR 3.478, 95% CI 2.236-5.409, p<0.001, respectively]. Also, obstetric anal sphincter injury with and without episiotomy and second-degree tears with episiotomy were significantly lower in the perineal massage and warm compresses group [perineal massage and warm compresses group: 0.5% vs control group: 2.3%; OR 5.404, 95% CI 1.077-27.126, p = 0.040 and perineal massage and warm compresses group: 0.3% vs control group: 1.8%; OR 9.253, 95% CI 1.083-79.015, p = 0.042, respectively].
CONCLUSIONS
The perineal massage and warm compresses technique increased the incidence of intact perineum and reduced the incidence of second-degree tear, episiotomy and obstetric anal sphincter injury.
IMPLICATIONS FOR PRACTICE
Perineal massage and warm compresses technique is feasible, inexpensive and reproductible. Therefore, this technique should be taught and trained to midwives students and midwives team. Thus, women should have this information and have the option to decide whether they want to receive the perineal massage and warm compresses technique in the second stage of labor.
Topics: Pregnancy; Female; Humans; Perineum; Prospective Studies; Obstetric Labor Complications; Episiotomy; Massage
PubMed: 37385009
DOI: 10.1016/j.midw.2023.103763 -
European Journal of Obstetrics,... Sep 2019Perineal trauma may have a negative impact on women's lives as it has been associated with perineal pain, urinary incontinence and sexual dysfunction. The aim of this... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Perineal trauma may have a negative impact on women's lives as it has been associated with perineal pain, urinary incontinence and sexual dysfunction. The aim of this systematic review and meta-analysis of randomized controlled trials was to evaluate the effectiveness of warm compresses during the second stage of labor in reducing perineal trauma.
METHODS
Electronic databases were searched from inception of each database to May 2019. Inclusion criteria were randomized trials comparing warm compresses (i.e. intervention group) with no warm compresses (i.e. control group) during the second stage of labor. Types of participants included pregnant women planning to have a spontaneous vaginal birth at term with a singleton in a cephalic presentation. The primary outcome was the incidence of intact perineum. Meta-analysis was performed using the Cochrane Collaboration methodology with results being reported as relative risk (RR) with 95% confidence interval (CI).
RESULTS
Seven trials, including 2103 participants, were included in this meta-analysis. Women assigned to the intervention group received warm compresses made from clean washcloths or perineal pads immersed in warm tap water. These were held against the woman's perineum during and in between pushes in second stage. Warm compresses usually started when the baby's head began to distend the perineum or when there was active fetal descent in the second stage of labor. We found a higher rate of intact perineum in the intervention group compared to the control group (22.4% vs 15.4%; RR 1.46, 95% CI 1.22 to 1.74); a lower rate of third degree tears (1.9% vs 5.0%; RR 0.38, 95% CI 0.22 to 0.64), fourth degree tears (0.0% vs 0.9%; RR 0.11, 95% CI 0.01 to 0.86) third and fourth degree tears combined (1.9% vs 5.8%; RR 0.34, 95% CI 0.20 to 0.56) and episiotomy (10.4% vs 17.1%; RR 0.61, 95% CI 0.51 to 0.74).
CONCLUSION
Warm compresses applied during the second stage of labor increase the incidence of intact perineum and lower the risk of episiotomy and severe perineal trauma.
Topics: Adult; Female; Hot Temperature; Humans; Labor Stage, Second; Obstetric Labor Complications; Perineum; Pregnancy
PubMed: 31238205
DOI: 10.1016/j.ejogrb.2019.06.011 -
Midwifery Jul 2017perineal injury is common after birth and may be caused by tears or episiotomy or both. Perineal massage has been shown to prevent episiotomies in primiparous women. On... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
perineal injury is common after birth and may be caused by tears or episiotomy or both. Perineal massage has been shown to prevent episiotomies in primiparous women. On the other hand, pelvic floor exercises might have an influence by shortening the first and second stages of labour in the primigravida.
AIM
the aim of this study was to investigate the effects of a pelvic floor training following a birth programme on perineal trauma.
DESIGN
a single-blind quasi-randomized controlled trial with two groups: standard care and intervention.
SETTING
a tertiary, metropolitan hospital in Seville, Spain.
PARTICIPANTS
women (n=466) who were 32 weeks pregnant, having a singleton pregnancy and anticipating a normal birth were randomised. Women in the experimental groups were asked to perform a pelvic floor training programme that included: daily perineal massage and pelvic floor exercises from 32 weeks of pregnancy until birth. They were allocated to an intervention group by clusters (antenatal education groups) randomized 1:1. The control group had standard care that did not involve a perineal/pelvic floor intervention. These women were collected in a labour ward at admission 1:3 by midwives.
RESULTS
outcomes were analysed by intention-to-treat. Women assigned to the perineal/pelvic floor intervention showed a 31.63% reduction in episiotomy (50.56% versus 82.19%, p<0.001) and a higher likelihood of having an intact perineum (17.61% versus 6.85%, p<0.003). There were also fewer third (5.18% versus 13.12%, p<0.001) and fourth degree-tears (0.52% versus 2.5%, p<0.001). Women allocated to the intervention group also had less postpartum perineal pain (24.57% versus 36.30%, p<0.001) and required less analgesia in the postnatal period (21.14% versus 30.82%, p<0.001).
CONCLUSIONS
a training programme composed of pelvic floor exercises and perineal massage may prevent episiotomies and tears in primiparous women. This programme can be recommended to primiparous women in order to prevent perineal trauma.
KEY CONCLUSION
the pelvic floor programme was associated with significantly lower rates of episiotomies and severe perineal trauma; and higher intact perineum when compared with women who received standard care only.
IMPLICATIONS FOR PRACTICE
the programme is an effective intervention that we recommend to all women at 32nd week of pregnancy to prevent perineal trauma.
Topics: Adult; Episiotomy; Exercise; Female; Humans; Parturition; Pelvic Floor; Perineum; Pregnancy; Prenatal Care; Single-Blind Method; Spain; Tertiary Care Centers; Urban Population
PubMed: 28391147
DOI: 10.1016/j.midw.2017.03.015 -
The New Zealand Medical Journal Aug 2020Fistula-in-ano is a very common surgical condition, caused by anal cryptoglandular inflammation. Most cases are idiopathic. Other causes such as Crohn's disease, trauma...
Fistula-in-ano is a very common surgical condition, caused by anal cryptoglandular inflammation. Most cases are idiopathic. Other causes such as Crohn's disease, trauma and malignancy are well known. Management of fistula-in-ano is largely surgical, especially if the patient is symptomatic. The goal of surgical therapy is sepsis drainage, delineate anatomy and eradicate the fistula while preserving faecal continence. Establishing the aetiology is also crucial as often a combination of specialist medical therapy is required, for example, in Crohn's disease. We report an extremely unusual case of fistula-in-ano on an elderly man with chronic lymphocytic leukaemia (CLL). Histology from the fistula track demonstrated CLL infiltration. This case, not previously reported on PubMed search, illustrates a good example of joint specialist medical (a haematologist) and surgical effort in successfully treating this symptomatic fistula-in-ano.
Topics: Abscess; Aged; Drainage; Humans; Leukemia, Lymphocytic, Chronic, B-Cell; Magnetic Resonance Imaging; Male; Perineum; Rectal Fistula; Watchful Waiting
PubMed: 32994604
DOI: No ID Found -
Neurourology and Urodynamics Aug 2022The vaginal introitus is the entrance to the vagina, encompassing the anterior and posterior vestibules and the perineum. The surgical anatomy of the vaginal introitus,... (Review)
Review
AIM
The vaginal introitus is the entrance to the vagina, encompassing the anterior and posterior vestibules and the perineum. The surgical anatomy of the vaginal introitus, the lowest level of the vagina, has not been subject to a recent comprehensive examination and description. Vaginal introital surgery (perineorrhaphy) should be a key part of surgery for a majority of pelvic organ prolapse.
METHODS
Cadaver studies were performed on the anterior and posterior vestibules and the perineum. Histological studies were performed on the excised perineal specimens of a cohort of 50 women undergoing perineorrhaphy. Included are pre- and postoperative studies which were performed on 50 women to determine the anatomical and histological changes achieved with a simple (anterior) perineorrhaphy.
RESULTS
The vaginal introitus is equivalent to the Level III section of the vagina, measured posteriorly from the clitoris to the anterior perineum then down the perineum to the anal verge. The anterior and posterior vestibules, with nonkeratinizing epithelium, extend laterally to the keratinized epithelium of the labia minora (Hart's line). The anterior vestibule has six anatomical layers while the posterior vestibule has three. The perineum has an inverse trapezoid shape. Perineorrhaphy specimens were a mean 2.9 cm wide and 1.6 cm deep. They show squamous epithelium with loose underlying connective tissue. There were no important structures seen histologically, for example, ligaments or muscles. Microscopically, only 6 (12%) were completely normal with 44 (88%) showing minor changes including inflammation and scarring. Considerable anatomical benefits were achieved with such a perineorrhaphy including a 27.6% increase in the perineal length and a 30.8% reduction in the genital hiatus.
CONCLUSION
An understanding of the anatomy and histology of the vaginal introitus can assist with performing a simple and effective perineorrhaphy, the main surgical intervention at the vaginal introitus.
Topics: Anal Canal; Clitoris; Female; Humans; Pelvic Organ Prolapse; Perineum; Vagina
PubMed: 35592994
DOI: 10.1002/nau.24961