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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 -
Perspectives on the Therapeutic Effects of Pelvic Floor Electrical Stimulation: A Systematic Review.International Journal of Environmental... Oct 2022Pelvic, perineal, and nervous lesions, which derive principally from pregnancy and childbirth, may lead to pelvic floor dysfunctions, such as organ prolapses and lesions...
Pelvic, perineal, and nervous lesions, which derive principally from pregnancy and childbirth, may lead to pelvic floor dysfunctions, such as organ prolapses and lesions in the nerves and muscles due to muscle expansion and physiology. It is estimated that 70% of women affected by this clinical picture have symptoms that do not respond to the classical treatments with antimuscarinic and anticholinergic drugs. Therefore, resorting to efficient alternatives and less invasive methods is necessary to assist this public health problem that predominantly affects the female population, which is more susceptible to the risk factors. This study aimed to perform an updated and comprehensive literature review focused on the effects of pelvic floor electrical stimulation, considering new perspectives such as a correlation between electric current and site of intervention and other molecular aspects, different from the present reviews that predominantly evaluate urodynamic aspects. For that purpose, PubMed and ScienceDirect databases were used to perform the search, and the method was applied. With well-researched therapeutic effects, electrical stimulation induced promising results in histological, nervous, and molecular evaluations and spinal processes, which showed beneficial results and revealed new perspectives on ways to evoke responses in the lower urinary tract in a non-invasive way. Thus, it is possible to conclude that this type of intervention may be a non-invasive alternative to treat pelvic and perineal dysfunctions.
Topics: Pregnancy; Female; Humans; Pelvic Floor; Electric Stimulation; Urodynamics; Electric Stimulation Therapy; Perineum; Exercise Therapy
PubMed: 36360918
DOI: 10.3390/ijerph192114035 -
The Journal of Obstetrics and... Nov 2022To assess the effect of lubricants on reducing perineal trauma during vaginal delivery. (Meta-Analysis)
Meta-Analysis
AIM
To assess the effect of lubricants on reducing perineal trauma during vaginal delivery.
METHODS
PubMed, Embase, the Cochrane Library, CINAHL, China National Knowledge Infrastructure, China Biology Medicine disc, WanFang databases, and ClinicalTrials.gov, were searched for literature up to 25 June 2021. Randomized controlled trials published in English or Chinese that compared the vaginal application of lubricant with standard care for women were included. Two reviewers independently performed study screening, data extraction, risk of bias assessment, and certainty of evidence assessment. Pooled effect sizes and corresponding 95% confidence intervals (CI) were calculated using meta-analysis.
RESULTS
Nineteen trials enrolling 5445 pregnant women were included. Compared with standard care, women using lubricants had a lower incidence of perineal trauma (risk ratio [RR] 0.84, 95% CI 0.76-0.93; low certainty evidence), second-degree perineal laceration (RR 0.72, 95% CI 0.64-0.82; moderate certainty evidence) and episiotomy (RR 0.77, 95% CI 0.62-0.96; very low certainty evidence), and had a shorter duration of the second-stage labor (MD -13.72 min, 95% CI -22.68 to -4.77; very low certainty evidence).
CONCLUSION
Lubricants might reduce the incidence of perineal trauma, especially second-degree perineal laceration, and shorten the duration of the second-stage labor. More well-designed studies will continue developing high-quality evidence in this field.
Topics: Female; Pregnancy; Humans; Lacerations; Perineum; Lubricants; Randomized Controlled Trials as Topic; Episiotomy
PubMed: 36319196
DOI: 10.1111/jog.15399 -
Journal of Personalized Medicine Oct 2022Fournier's gangrene (FG) is a Necrotizing Soft Tissue Infection (NSTI) of the perineal region characterized by high morbidity and mortality even if appropriately... (Review)
Review
Fournier's gangrene (FG) is a Necrotizing Soft Tissue Infection (NSTI) of the perineal region characterized by high morbidity and mortality even if appropriately treated. The main treatment strategies are surgical debridement, broad-spectrum antibiotics, hyperbaric oxygen therapy, NPWT (Negative Pressure Wound Therapy), and plastic surgery reconstruction. We present the case of a 50-year-old woman with an NSTI of the abdomen, pelvis, and perineal region associated with a rectal fistula referred to our department. After surgical debridement and a diverting blow-out colostomy, an NPWT system composed of two sponges connected by a bridge through a rectal fistula was performed. Our target was to obtain healing in a lateral-to-medial direction instead of depth-to-surface to prevent the enlargement of the rectal fistula, promoting granulation tissue growth towards the rectum. This eso-endo-NPWT technique allowed for the primary suture of the perineal wounds bilaterally, simultaneously treating the rectal fistula and the perineum lesions. A systematic review of the literature underlines the spreading of NPWT and its effects.
PubMed: 36294834
DOI: 10.3390/jpm12101695 -
Archives of Gynecology and Obstetrics Aug 2023Most women suffer from perineal trauma during childbirth, whether it is natural tears or episiotomy. (Meta-Analysis)
Meta-Analysis
BACKGROUND
Most women suffer from perineal trauma during childbirth, whether it is natural tears or episiotomy.
OBJECTIVES
To perform a systematic review and network meta-analysis investigating the effectiveness of different PFMT relevant strategies in the prevention of perineal trauma.
SEARCH STRATEGY
PubMed, Embase, the Cochrane Library, CINAHL, CNKI, CBM, WANFANG DATABASE, and ClinicalTrials.gov were searched for citations published in any language from inception to 1 July 2021.
SELECTION CRITERIA
Randomized controlled trials (RCTs) of PFMT relevant prevention strategies for preventing perineal trauma during childbirth.
DATA COLLECTION AND ANALYSIS
Data were independently extracted by two reviewers. Relative treatment effects were estimated using network meta-analysis (NMA).
MAIN RESULTS
Of 12 632 citations searched, 21 RCTs were included. Comparing with usual care, "PFMT combine with perineal massage" and PFMT alone showed more superiority in intact perineum (RR = 5.37, 95% CI: 3.79 to 7.60, moderate certainty; RR = 2.58, 95% CI 1.34-4.97, moderate certainty, respectively), episiotomy (RR = 0.26, 95% CI 0.14-0.49, very low certainty; RR = 0.63, 95% CI 0.45-0.90, very low certainty, respectively), and OASIS (RR = 0.35, 95% CI 0.16-0.78, moderate certainty; RR = 0.49, 95% CI 0.28-0.85, high certainty, respectively). "PFMT combine with perineal massage" showed superiority in reducing perineal tear (RR = 0.41, 95% CI 0.20-0.85, moderate certainty).
CONCLUSIONS
In view of the results, antenatal "PFMT combine with perineal massage" and PFMT were effective strategies for the prevention of perineal trauma.
Topics: Female; Humans; Pregnancy; Delivery, Obstetric; Episiotomy; Lacerations; Network Meta-Analysis; Parturition
PubMed: 36107230
DOI: 10.1007/s00404-022-06769-w -
BMC Pregnancy and Childbirth Aug 2022The World Health Organization in recent years has emphasized reducing the possibility of unnecessary interventions in natural childbirth, but little is known about the... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The World Health Organization in recent years has emphasized reducing the possibility of unnecessary interventions in natural childbirth, but little is known about the accuracy of non-invasive methods when assessing the progress of labor. This paper presents a literature review to assess strategies that support non-invasive methods for labor during the first stage. It evaluates the available evidence to provide the most suitable assessments and predictions that objectively identify the progress of low-risk labor during the first stage of labor.
METHODS
A search for relevant literature was conducted using the electronic databases of PubMed, CINAHL, Web of Sciences, the Cochrane Library, Scopus, Medline (OVID), and CEPS, with publications up to November 2021. Records were screened against pre-specified inclusion/exclusion criteria and the potential papers from Google Scholar were examined to identify additional papers that may have been missed. The Quality Assessment of Diagnostic Accuracy Studies-2 (QUADAS-2) tool was used to appraise the methodological quality of the included studies. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. Two independent investigators extracted the review's characteristics, and discrepancies were resolved by consensus. This review calculated individual and pooled sensitivity, specificity, and positive predictive values, which were exported to STATA (version 14; Stata Corp., College Station, TX) to represent the performance of diagnostic testing.
RESULTS
Our search returned 2283 reports of which 13 fulfilled the inclusion criteria, accounting for 2594 women. The subjects were divided into groups according to the diagnostic tests used to assess the progress of their labor, including appearance assessment and sonographic imaging parameters (head perineum distance, HPD; angle of progression, AOP, and other parameters). HPD pooled sensitivity was 0.74 (0.65-0.82), and specificity was 0.77 (0.69-0.84). The pooled diagnostic odds ratio (DOR) was 8.21 (4.67-14.41) and 10.34 (5.02-21.27), respectively. The results of subgroup analysis showed that the summary sensitivity and specificity were of medium accuracy overall. The quality of evidence as assessed with GRADE was low.
CONCLUSION
Vaginal examination is an intrinsic element in the use of the partogram, while transperineal ultrasound can also be used as an auxiliary tool. However, the presence of publication bias within the parameters of ultrasound indicates that the diagnostic performance may be overestimated. Thus, randomized controlled trials or large-scale prospective cohort studies are necessary.
Topics: Female; Humans; Labor, Obstetric; Perineum; Pregnancy; Prospective Studies; Sensitivity and Specificity; Ultrasonography
PubMed: 35915400
DOI: 10.1186/s12884-022-04938-y -
Frontiers in Medicine 2022Episiotomy, a surgical procedure that enlarges the vaginal opening during childbirth, was common practice until the early 2000s. Other sources, including the World...
BACKGROUND
Episiotomy, a surgical procedure that enlarges the vaginal opening during childbirth, was common practice until the early 2000s. Other sources, including the World Health Organization (WHO), advocate for the selective use of episiotomy. Episiotomy rates, on the other hand, have remained high in developing countries, while declining in developed countries. As a result, the current study sought to determine the overall prevalence of episiotomy in Africa as well as the risk factors associated with its practice.
METHODS
Articles were searched in international electronic databases. A standardized Microsoft Excel spreadsheet and STATA software version 14 were used for data extraction and analysis, respectively. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) checklist was used to write this report. A random-effects meta-analysis model was used to determine the pooled prevalence of episiotomy. A heterogeneity test was conducted using I-Squared ( ) statistics. Egger's test and funnel plots were conducted to detect publication bias. Subgroup analysis was also conducted. Association was expressed through a pooled odds ratio (OR) with a 95% Confidence Interval (CI).
RESULT
A total of 21 studies with 40,831 participants were included in the systematic review and meta-analysis. The pooled prevalence of episiotomy practice was 41.7% [95% CI (36.0-47.4), = 99.3%, < 0.001). Primiparity [OR: 6.796 (95% CI (4.862-9.498)), < 0.001, : 95.1%], medical doctors- assisted delivery [OR: 3.675 (95% CI (2.034-6.640)), < 0.001, : 72.6%], prolonged second stage of labor [OR: 5.539 (95% CI (4.252-7.199)), < 0.001, : 0.0%], using oxytocin [OR: 4.207 (95% CI (3.100-5.709)), < 0.001, : 0.0%], instrument -assisted vaginal delivery [OR: 5.578 (95% CI (4.285-7.260)), < 0.001, : 65.1%], and macrosomia [OR: 5.32 (95% CI (2.738-10.339)), < 0.001, : 95.1%] were factors associated with episiotomy practice.
CONCLUSION
In this review, the prevalence of episiotomy among African parturients was high. A selective episiotomy practice should be implemented to reduce the high episiotomy rates.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021293382, identifier: CRD42021293382.
PubMed: 35865171
DOI: 10.3389/fmed.2022.905174 -
JPRAS Open Sep 2022This is a paucity of data regarding plastic surgeons' opinions on robotic-assisted surgery (RAS). We developed a questionnaire aimed to survey plastic surgeons regarding... (Review)
Review
BACKGROUND
This is a paucity of data regarding plastic surgeons' opinions on robotic-assisted surgery (RAS). We developed a questionnaire aimed to survey plastic surgeons regarding training in robotics, concerns about widespread implementation, and new research directions.
METHODS
A survey was created using Google Forms and sent to practicing plastic surgeons and trainees. Responses regarding desired conference proceedings about robotics, robotic residency training, and perceived barriers to implementation were elicited. Survey responses were utilized to direct a systematic review on RAS in plastic surgery.
RESULTS
The survey received 184 responses (20.4%; 184/900). The majority (92.8%) of respondents were/are plastic surgery residents, with the most common fellowships being microsurgery (39.2%). Overall, 89.7% of respondents support some integration of robotics in the future of plastic surgery, particularly in pelvic/perineum reconstruction (56.4%), abdominal reconstruction (46.5%), microsurgery (43.6%), and supermicrosurgery (44.2%). Many respondents (66.1%) report never using a robot in their careers. Respondents expressed notable barriers to widespread robotic implementation, with cost (73.0%) serving as the greatest obstacle. A total of 10 studies (pelvic/perineum = 3; abdominal = 3; microsurgery = 4) were included after full-text review.
CONCLUSIONS
Evidence from our survey and review supports the growing interest and utility of RAS within the plastic and reconstructive surgery (PRS) and mirrors the established trend in other surgical subspecialties. Cost analyses will prove critical to implementing RAS within PRS. With validated benefits, plastic surgery programs can begin creating dedicated curricula for RAS.
PubMed: 35812356
DOI: 10.1016/j.jpra.2022.05.006 -
Journal of Clinical Nursing Jul 2023To evaluate and quantify the best available evidence regarding risk factors for severe perineal lacerations. (Meta-Analysis)
Meta-Analysis Review
AIMS AND OBJECTIVES
To evaluate and quantify the best available evidence regarding risk factors for severe perineal lacerations.
BACKGROUND
Many studies have evaluated the risk factors for severe perineal lacerations. However, the results of those studies are inconsistent, and meta-analysis which thoroughly evaluates the risk factors for severe perineal lacerations is still lacking.
DESIGN
Systematic review and meta-analysis of cohort studies based on the PRISMA guideline.
METHODS
PubMed, Embase, the Cochrane Library, CINAHL, ClinicalTrials.gov, CNKI, Wanfang Data, VIP and SinoMed were systematically searched for cohort studies reporting at least one risk factor for severe perineal lacerations from 1 January 2000 to 2 June 2021. Two reviewers independently conducted quality appraisal by NOS scale and extracted data. Data synthesis was conducted via RevMan 5.3 using a random-effects or fixed-effects model.
RESULTS
A total of 47 studies with 7,043,218 women were included. The results showed that prior caesarean delivery (OR: 1.46, 95% CI 1.12-1.92) and pre-pregnant underweight (OR: 1.31, 95% CI 1.22-1.41) significantly increased the risk of severe perineal lacerations. The results also demonstrated that episiotomy was protective against severe perineal lacerations in forceps delivery (OR: 0.56, 95% CI 0.42-0.74), but not spontaneous vaginal delivery (OR: 1.30, 95% CI 0.81-2.07) or vacuum delivery (OR: 0.76, 95% CI 0.45-1.28). Nulliparity, foetus in occipitoposterior or occipitotransverse position, and midline episiotomy were also independent risk factors for severe perineal lacerations.
CONCLUSIONS
Severe perineal lacerations are associated with many factors, and evidence-based risk assessment tools are needed to guide the midwives and obstetricians to estimate women's risk of severe perineal lacerations.
RELEVANCE TO CLINICAL PRACTICE
This systematic review and meta-analysis identified some important risk factors for severe perineal lacerations, which provides comprehensive insights to guide the midwives to assess women's risk for severe perineal lacerations and take appropriate preventive measures to decrease the risk.
Topics: Pregnancy; Female; Humans; Lacerations; Perineum; Obstetric Labor Complications; Delivery, Obstetric; Parturition; Episiotomy; Cohort Studies; Risk Factors
PubMed: 35791260
DOI: 10.1111/jocn.16438 -
BMJ Open Jul 2022Water immersion during labour using a birth pool to achieve relaxation and pain relief during the first and possibly part of the second stage of labour is an... (Meta-Analysis)
Meta-Analysis
OBJECTIVES
Water immersion during labour using a birth pool to achieve relaxation and pain relief during the first and possibly part of the second stage of labour is an increasingly popular care option in several countries. It is used particularly by healthy women who experience a straightforward pregnancy, labour spontaneously at term gestation and plan to give birth in a midwifery led care setting. More women are also choosing to give birth in water. There is debate about the safety of intrapartum water immersion, particularly waterbirth. We synthesised the evidence that compared the effect of water immersion during labour or waterbirth on intrapartum interventions and outcomes to standard care with no water immersion. A secondary objective was to synthesise data relating to clinical care practices and birth settings that women experience who immerse in water and women who do not.
DESIGN
Systematic review and meta-analysis.
DATA SOURCES
A search was conducted using CINAHL, Medline, Embase, BioMed Central and PsycINFO during March 2020 and was replicated in May 2021.
ELIGIBILITY CRITERIA FOR SELECTING STUDIES
Primary quantitative studies published in 2000 or later, examining maternal or neonatal interventions and outcomes using the birthing pool for labour and/or birth.
DATA EXTRACTION AND SYNTHESIS
Full-text screening was undertaken independently against inclusion/exclusion criteria in two pairs. Risk of bias assessment included review of seven domains based on the Robbins-I Risk of Bias Tool. All outcomes were summarised using an OR and 95% CI. All calculations were conducted in Comprehensive Meta-Analysis V.3, using the inverse variance method. Results of individual studies were converted to log OR and SE for synthesis. Fixed effects models were used when I was less than 50%, otherwise random effects models were used. The fail-safe N estimates were calculated to determine the number of studies necessary to change the estimates. Begg's test and Egger's regression risk assessed risk of bias across studies. Trim-and-fill analysis was used to estimate the magnitude of effect of the bias. Meta-regression was completed when at least 10 studies provided data for an outcome.
RESULTS
We included 36 studies in the review, (N=157 546 participants). Thirty-one studies were conducted in an obstetric unit setting (n=70 393), four studies were conducted in midwife led settings (n=61 385) and one study was a mixed setting (OU and homebirth) (n=25 768). Midwife led settings included planned home and freestanding midwifery unit (k=1), alongside midwifery units (k=1), planned homebirth (k=1), a freestanding midwifery unit and an alongside midwifery unit (k=1) and an alongside midwifery unit (k=1). For water immersion, 25 studies involved women who planned to have/had a waterbirth (n=151 742), seven involved water immersion for labour only (1901), three studies reported on water immersion during labour and waterbirth (n=3688) and one study was unclear about the timing of water immersion (n=215).Water immersion significantly reduced use of epidural (k=7, n=10 993; OR 0.17 95% CI 0.05 to 0.56), injected opioids (k=8, n=27 391; OR 0.22 95% CI 0.13 to 0.38), episiotomy (k=15, n=36 558; OR 0.16; 95% CI 0.10 to 0.27), maternal pain (k=8, n=1200; OR 0.24 95% CI 0.12 to 0.51) and postpartum haemorrhage (k=15, n=63 891; OR 0.69 95% CI 0.51 to 0.95). There was an increase in maternal satisfaction (k=6, n=4144; OR 1.95 95% CI 1.28 to 2.96) and odds of an intact perineum (k=17, n=59 070; OR 1.48; 95% CI 1.21 to 1.79) with water immersion. Waterbirth was associated with increased odds of cord avulsion (OR 1.94 95% CI 1.30 to 2.88), although the absolute risk remained low (4.3 per 1000 vs 1.3 per 1000). There were no differences in any other identified neonatal outcomes.
CONCLUSIONS
This review endorses previous reviews showing clear benefits resulting from intrapartum water immersion for healthy women and their newborns. While most included studies were conducted in obstetric units, to enable the identification of best practice regarding water immersion, future birthing pool research should integrate factors that are known to influence intrapartum interventions and outcomes. These include maternal parity, the care model, care practices and birth setting.
PROSPERO REGISTRATION NUMBER
CRD42019147001.
Topics: Female; Humans; Immersion; Infant, Newborn; Labor, Obstetric; Natural Childbirth; Pain; Parturition; Pregnancy
PubMed: 35790327
DOI: 10.1136/bmjopen-2021-056517