The relationship between obstetric perineal trauma, risk factors and postpartum outcomes immediately after childbirth.
Obstetric perineal trauma (OPT) commonly accompanies vaginal birth and can result from episiotomy, spontaneous lacerations, or both (Renfrew et al. 1998). Allen and Hanson (2005) reported an episiotomy rate of 48% of vaginal deliveries in a cohort study (n = 3120) in the USA. Some countries report lower percentages, such as Sweden at 9.7%, whereas other countries very high percentages, as in Taiwan (100%) and areas in Latin America (90%) (Graham, Carroli, Davies, & Medves, 2005).
In Jordan, the total annual number of births was 79,655 at governmental hospitals: of these, 64,585 (81.08%) of them were normal vaginal births, 463 (0.58%) were vacuum births, and 81 (0.10 %) forceps births (Ministry of Health, 2007). The incidence of obstetric perineal trauma in Jordan is still unknown, and statistics could not be found, indicating the extent of OPT is unknown and needs to be studied.
OPT is assumed to be a serious health problem for women during their childbirth. Estimation of the outcomes might modify the use of intrapartum interventions as related risk factors. Policies, procedures and philosophies for childbirth may change by adopting strategies that would modify the risk factors and reduce their frequencies.
An electronic search on the internet yielded mostly quantitative studies with very few qualitative research reports of recent publications (2000-2008) with a variety of designs. Many of these were descriptive with a prospective and retrospective approach. Randomized control trials, surveys and population-based studies, systematic reviews, case-control, cross sectional studies, and meta-analyses were scanty.
Birth-related research is problematic because of the nature of childbirth, which is characterized by complexity, variability as a biological process, and with multiple dimensions. Most studies are medically-based, and childbirth occurring in hospitals stresses hospital policies and standard procedures.
The objectives of this study are to estimate the frequency of obstetric perineal trauma during vaginal childbirth at a teaching hospital in Amman, Jordan, to describe the outcomes of perineal trauma and their frequencies immediately after vaginal childbirth, and to examine the associations of postpartum outcomes with risk factors and the obstetric perineal trauma.
Methodology and Ethical considerations
A descriptive design was used for women with vaginal births in the immediate postpartum period by convenient sampling at Jordan University Hospital (JUH), a 547-bed occupancy teaching hospital in the capital city Amman. The total annual number of births at JUH was 3,217 (1.9%) of the total births nationwide (Ministry of Health, 2007). Obstetricians and resident doctors attend to the birth of women, and no midwives are available. Two hundred women were included, calculated according to power analysis, to achieve a power of 0.80, with a level of significance of 0.05, and a moderate effect size of 0.13. Women with medical and obstetric problems were excluded.
Data were collected by the face to face interview method by the principal investigator, and women responded by self-report. Two structured instruments were developed by the investigator, based on a literature review. The first instrument included demographic, clinical information, obstetric information, the condition of the perineum with the history of OPT in previous births, the duration of the first and second stage of labor in minutes, and the position of the woman during birth.
The second part included the postpartum maternal and perineal outcomes of pain at the trauma site; bleeding; difficult posture; difficulty in handling the baby; difficult breastfeeding; urinary problems and urinary incontinence; elimination difficulties, including flatus and fecal incontinence.
Women were approached in their rooms at bedside, were asked for voluntary participation, given written consent, assured about confidentiality, privacy, and the use of data for the purposes of the study. The duration required to complete the interview was 5-10 minutes. Women were asked to withhold responding to embarrassing questions if they felt so. The sources of information were consistent with the questions whether from the women's response, the medical record or from the medical staff in case of missing or ambiguous data.
Content validity of the instruments was determined by five experts who provided a sufficient level of credibility about the structure, the sequence, and adequacy of the questions to answer the research questions and meet the objectives of the study.
Approval from the Institution Review Board at the University of Jordan and the administration at the Jordan University Hospital were obtained.
A pilot study of 20 cases was done where some statements of the instruments were restated in a way to be clearer to participants and consistent with the practices at the hospital.
The demographic and clinical characteristics of the study population (N=200), and the sub-population, operationally defined as women with OPT (n=142) are provided in Table 1. The frequencies of the different types of OPT are presented in Table 2. The frequencies and percentages of postpartum outcomes immediately after birth are demonstrated in Table 3.
The associations of postpartum outcomes and individual risk factors were calculated by chi square. Perineal pain was associated with perineal trauma, with previous OPT, and with difficult posture, difficulty handling the baby, difficult breast feeding and urinary problems which was in turn associated with the practitioner type as well. Women who gave birth in the lithotomy position were 2.23 times more likely to develop difficulties in breastfeeding after birth compared to those with perineal tears and at a percentage of 76.3%, compared to 23.7% who gave birth in the dorsal position.
OPT was associated with difficult posture, difficulty handling the baby, difficult breastfeeding, and flatus incontinence. The birth type was associated with flatus incontinence, and elimination difficulties were associated with the practitioner type. Induction of labor was associated with difficult posture.
There was no contact between the mothers and their babies in 33 (23.4.8%) cases after birth at the time of the interview which was several hours after birth.
Women who received anesthesia as epidural or analgesia as pethidine during birth were found 1.29 times more likely to develop urinary incontinence immediately after birth compared to those without anesthesia. All of the women who developed urinary incontinence immediately after birth were found to receive anesthesia during birth.
Flatus incontinence immediately after birth was associated with OPT. Women who had an episiotomy were 3.154 times more likely to develop flatus incontinence immediately after birth compared to women with perineal tears. Women who gave birth by instrumental delivery were found to be 0.165 more likely to develop flatus incontinence immediately after birth than women with spontaneous births.
Women who gave birth in the lithotomy position had flatus incontinence at a percentage of 82.6%, compared to 17.4% in the dorsal position, but the association did not reach statistical significance (p=0.069).
Women were comfortable during their response and did not show hesitation or embarrassment to the questions of the two instruments.
OPT, whether episiotomy or perineal tears, was highly prevalent among birthing women at Jordan University Hospital during childbirth. In the current study an intact perineum was maintained only in 29% of women, which is far less than what was reported in previous studies of 55.4% (Shorten, Donsante, & Shorten, 2002).
Episiotomies occur in an estimated 35.2 % of all vaginal deliveries in the United States and represent the most frequent type of surgery performed to women (Webb & Culhane, 2002). In this study 71 % women experienced obstetric perineal trauma. The total number of primipara in the study sample was 52(26%) of the total women and multipara were 148(74%) women. Episiotomy was done for 85% of primipara women, episiotomy with extensions was in 11.5%, and only 3.8% ended with perineal tears. For multipara episiotomy was done for 9% of women with 2% with extensions and 50% of women ended with perineal tears.
In the Middle East of which Jordan is included, episiotomy was found to be 37.6%, but the investigator could not find any official statistics about its incidence in Jordan.
Over the past 20 years, evidence supporting the restrictive use of episiotomy has been disseminated. International acceptance of the use of this approach to perineal management can be seen in policy statements and clinical practice recommendations issued by many recognized public health and professional bodies. The World Health Organization recommends that episiotomy must be used only for selected maternal and fetal indications (Liljestrand, 2003). The Society of Obstetricians and Gynecologists of Canada, in addition to The Royal College of Obstetricians and Gynecologists in the United Kingdom, recommend that routine episiotomy be abandoned and developed a policy of restricting the use of episiotomy (Graham et al., 2005).
Recurrence of obstetric perineal trauma in the current birth was found in 56.3% of women who had it in previous births. This study is consistent with previous studies which indicated that there is an increased risk of recurrence of perineal lacerations in subsequent deliveries (Handa, Danielsen, & Gilbert, 2001; Spydslaugh, Trogstad, Skrondal, & Eskil, 2005). This would alert health professionals to the high probability that women might develop OPT during the present birth if they have had it before.
It is surprising that OPT and perineal pain association did not show evidence immediately after birth despite the high prevalence of the symptom. Women in the immediate postpartum period were still under the effects of the anesthesia, and this finding is consistent with Declercq, Cunningham, Johnson, and Sakala (2008) who found that those women experiencing an episiotomy were more likely to report problems with a painful perineum, perineal infection, bowel problems, and pain interfering with routine activities.
Intrapartum interventions during birth are of an intrusive nature to the body of the woman, whether epidural, induction, instrumental use, cutting the perineum, and the lithotomy position. Women as a result may feel abused by such procedures and unable to verbalize their psychological pain, so they would express it by the somatic complaints manifested as perineal pain. Physical pain is not denied by this explanation but may be compounded with the psychological pain.
The pain was a reason for difficult posture in this study in 78.2% of women, and 43.7% could not handle the baby resulting in difficult breastfeeding in 41.5% of women, which interfered with the bonding process between the mothers and their newborns during the most important time for such attachment in the immediate postpartum period. This continued to be present with difficulty handling the baby due to OPT, with subsequent difficult breastfeeding. The findings of the study were consistent with Karacamand and Eroylu (2002) who found that mothers with less severe perineal trauma had less difficulty in taking care of themselves and their babies, resumed their daily activities earlier, and felt more comfortable when sitting and standing up.
Women with episiotomies were found to have difficult breastfeeding 2.161 times immediately after birth compared to women with perineal tears, consistent with Lundquist, Olsson, Nissen, and Norman (2000).
Women who gave birth in the lithotomy position were 2.23 times more likely to develop difficulty breastfeeding the baby than those with perineal tears.
Maternal health in the postpartum period is very important after childbirth. Urinary integrity is a vulnerable aspect, consistent with Eason, Labrecque, Marcoux, and Mondor (2004). In this study urinary incontinence was found in 14.1% immediately after birth in women, who complained of urge or stress urinary incontinence, consistent with Williams, Marx, and Knibb (2007).
The position during birth was associated with urinary problems immediately after birth, p=0.039, and women who gave birth in the lithotomy position were 2.46 times more likely to develop urinary problems than those who gave birth in the dorsal position consistent with Williams et al.(2007). The lithotomy and the dorsal positions are the only two birth positions adopted at the hospital.
Urinary incontinence was found to be associated with anesthesia use during birth, p=0.017, and women who used anesthesia were 1.29 times more likely to develop urinary incontinence immediately after birth than those who did not receive any. All of the women who developed urinary incontinence immediately after birth received anesthesia during birth. The incidence of obstetric perineal trauma was not associated with urinary incontinence in this study consistent with Karacam and Eroylu (2002) who found a small number in the episiotomy group experienced stress urinary incontinence during the 12 weeks following birth but that was not statistically significant (p=0.499).
Flatus incontinence immediately after birth was associated with birth type, with the obstetric perineal trauma immediately after birth. Women with episiotomy were found to have flatus incontinence 3.154 times immediately after birth than those with perineal tears.
Also women with instrumental births were 0.165 more likely to complain from flatus incontinence than those with spontaneous vaginal delivery consistent with Declercq et al. (2008) and Williams et al. (2007) who found that bowel problems were most commonly reported among primiparas with an assisted vaginal birth (64%), whereas multiparas reported no significant differences by method of delivery. Elimination difficulties were consistent with Andrews, Sultan, Thakar, and Jones (2006) and Meschia et al. (2002).
The conduct of the study at one hospital did not help in examining the variation in the incidence of OPT at different settings, and this influences the generalization of the results to childbearing women nationwide.
The results of this study support restructuring maternal health care services at hospitals to minimize the development of OPT with the subsequent postpartum outcomes. Comprehensive planning includes preparation of professionals at the academic setting, administration issues related to the approach to the system of care: the philosophy, policy, and practice. Women as consumers of the services have an important role in the change process. The system of maternal care is recommended to be based on the philosophy that most births are normal physiologic process; medicalization of the birth is minimized and is used according to indications, such as epidural and operative birth with other risk factors as evidenced from the study. A perineal clinic at hospitals and maternal and child health centers, with focus on perineal health, will serve women in relation to the morbidity associated with the perineal trauma in the postpartum period. A multi-disciplinary team of obstetricians, urogynecologists, anal surgeons, nurses, midwives, counselors especially for the continence and sexual difficulties problems, are expected to provide comprehensive perineal and maternal care for the childbearing women. Further research is recommended to study the obstetric perineal trauma, the risk factors, and the postpartum outcomes at multi-site settings including the public, military and private sectors.
The research about childbirth in Jordan is in its infancy, and financial support for further research is needed. Maternal health represents a landmark indicator for the overall health of the population in any country.
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Andrews, V., Sultan, A., Thakar, R., & Jones, P. (2006), Risk factors for obstetric anal sphincter injury: A prospective study. Birth, 33(2), 117-122.
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by Hanan J. Al-Zein, PhD CNM ICCE, Samiha Jarrah, MPH PhD RN, and Madi Al-Jaghbir, MD MD DSc
Dr. Hanan Al-Zein received her bachelor in nursing (1977), and master degree in nursing education (1993), and Ph.D in the philosophy of nursing (2009) all from the University of Jordan. Dr. Hanan worked in the United Nations Relief for Palestanian refugees, and a director of nursing at Hiba maternity hospital. Membership in ICEA 1996, and certification 1999, conducted training courses for nurses and midwives in childbirth education. Currently she is at Al-Ahliyyah Amman University as assistant professor, and is interested in education and research .
Dr. Samiha Jarrah received both her Bachelor in Nursing (1985), and Master in Nursing (19992) degrees from the University of Jordan, and she was awarded her Ph.D. degree from University of Wales, Cardiff-UK (1999). Dr. Jarrah direct many community health projects to help underserved populations and practice experience includes working with the elderly, displaced youth, families, and school health programs. At this time, she teaches graduate Nursing students and conducts research studies with special interest in women health and cultural aspects.
Dr. Madi T. Jaghbir received his Bachelors degree in medicine (1978) from The University of Jordan at Amman, Jordan, and was awarded a Masters degree (1982) and a Dr Sc degree (1984) in public health from Tulane University School of Public Health. Dr. Jaghbir's direct experience includes teaching public health to medical and nursing students at the undergraduate and postgraduate levels. His research interest is in public health-specifically environmental and occupational health as well as epidemiology. Dr. Jaghbir was the dean of the Hashemieh University medical college at Jordan (2007-2010). Currently he is the head of the Family and Public Health Department at The University of Jordan.
Table 1. Characteristics of Study Sample (N=200) and Obstetric Perineal trauma (N=142) Study Population Women with Obstetric (N =200) Perineal Trauma (N=142) Variable Mean Standard Mean Standard Deviation Deviation Age(years) 29.4 5.78 28.32 5.48 Education 13.65 2.71 14.04 2.25 Previous births 2.86 1.77 2.23 1.37 Previous pregnancies 3.47 2.44 2.72 2.12 Birth weight (kgs) 3.25 0.40 3.25 0.38 Duration of 1st 293 232.96 303.27 240.49 stage (minutes) Duration of 2nd 28.85 40.12 35.07 45.69 stage (minutes) Table 2. Frequencies and Percentages of Types of Obstetric Perineal trauma (N=142) Type of Trauma Frequency Percentage (%) Episiotomy 57 40.1 Episiotomy with extended tears 9 6.3 First degree tear 52.8 Second degree tear 1 0.7 Table 3. Frequencies and Percentages of Postpartum Outcomes of Opt Women Immediately After Birth (N=142) Frequency Percentage (%) Pain at trauma site 118 83.1 Bleeding 5 3.5 Difficult posture 111 78.2 Difficult handling the baby 62 43.7 Difficult breast feeding 59 41.5 Urinary problems 39 27.5 Urinary incontinence 20 14.1 Flatus incontinence 23 16.2 Elimination difficulties 27 19 Fecal incontinence 0 0
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|Author:||Zein, Hanan J. Al-; Jarrah, Samiha; Jaghbir, Madi Al-|
|Publication:||International Journal of Childbirth Education|
|Date:||Oct 1, 2013|
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