Perineal Trauma in a Low-risk Maternity with High Prevalence of Upright Position during the Second Stage of Labor

Abstract

Objective Perineal trauma is a negative outcome during labor, and until now it is unclear if the maternal position during the second stage of labor may influence the risk of acquiring severe perineal trauma. We have aimed to determine the prevalence of perineal trauma and its risk factors in a low-risk maternity with a high incidence of upright position during the second stage of labor.

Methods A retrospective cohort study of 264 singleton pregnancies during labor was performed at a low-risk pregnancy maternity during a 6-month period. Perineal trauma was classified according to the Royal College of Obstetricians and Gynecologists (RCOG), and perineal integrity was divided into three categories: no tears; first/second-degree tears + episiotomy; and third and fourth-degree tears. A multinomial analysis was performed to search for associated factors of perineal trauma.

Results From a total of 264 women, there were 2 cases (0.75%) of severe perineal trauma, which occurred in nulliparous women younger than 25 years old. Approximately 46% (121) of the women had no tears, and 7.95% (21) performed mediolateral episiotomies. Perineal trauma was not associated with maternal position (p = 0.285), health professional (obstetricians or midwives; p = 0.231), newborns with 4 kilos or more (p = 0.672), and labor analgesia (p = 0.319). The multinomial analysis showed that white and nulliparous presented, respectively, 3.90 and 2.90 times more risk of presenting perineal tears.

Conclusion The incidence of severe perineal trauma was low. The prevalence of upright position during the second stage of labor was 42%. White and nulliparous women were more prone to develop perineal tears.

Resumo

Objetivo O trauma perineal é um desfecho negativo durante o parto, e é incerto, até o momento, se a posição maternal durante o período expulsivo pode influenciar o risco de evoluir com trauma perineal severo. Nós objetivamos determinar a prevalência de trauma perineal e seus fatores de risco em uma maternidade de baixo risco com alta prevalência de posição vertical durante o período expulsivo.

Métodos Um estudo de coorte retrospectivo de 264 gestações únicas durante o trabalho de parto foi realizado durante 6 meses consecutivos. O trauma perineal foi classificado de acordo com o Royal College of Obstetricianns and Gynecologists (RCOG). A integridade perineal foi dividida em três categorias: períneo íntegro; trauma perineal leve (primeiro e segundo graus + episiotomia); e trauma perineal severo (terceiro e quarto graus). Uma análise multinomial foi realizada para buscar variáveis associadas ao trauma perineal.

Resultados De um total de 264 mulheres, houve 2 casos (0,75%)de trauma perineal severo m nulíparas com menos de 25 anos. Aproximadamente 46% (121) das mulheres não tiveram trauma perineal e 7,95% (21) realizaram episiotomias mediolaterais. Não houve correlação do trauma perineal com a posição de parto (p = 0,285), tipo de profissional que realizou o parto (p = 0,231), recém-nascidos com 4.000 gramas ou mais (p = 0,672), e presença de analgesia de parto (p = 0,319). Uma análise multinomial evidenciou que mulheres brancas e nulíparas apresentaram, respectivamente, um risco 3,90 e 2,90 vezes maior de apresentar trauma perineal.

Conclusão A incidência de trauma perineal severo foi baixa. A prevalência de parto vertical durante o período expulsivo foi de 42%. Mulheres brancas e nulíparas foram mais suscetíveis a apresentar trauma perineal.

Keywords

perineal trauma - retrospective cohort study - birth position - obstetric anal sphincter injuries

Palavras-chave

trauma perineal - estudo retrospectivo de coorte - posição vertical - lesões obstétricas do esfíncter anal

Contributions

All authors met the International Committee of Medical Journal Editors (ICJME) criteria: 1. substantial contributions to conception and design, data collection or analysis, and interpretation of data; 2. writing of the article or critical review of the intellectual content; and 3. final approval of the version to be published.

• References

• 1 Oliveira LS, Brito LG, Quintana SM, Duarte G, Marcolin AC. Perineal trauma after vaginal delivery in healthy pregnant women. Sao Paulo Med J 2014; 132 (04) 231-238 . Doi: 10.1590/1516-3180.2014.1324710
• 2 Jangö H, Langhoff-Roos J, Rosthøj S, Sakse A. Modifiable risk factors of obstetric anal sphincter injury in primiparous women: a population-based cohort study. Am J Obstet Gynecol 2014; 210 (01) 59.e1-59.e6 . Doi: 10.1016/j.ajog.2013.08.043
• 3 Elvander C, Ahlberg M, Thies-Lagergren L, Cnattingius S, Stephansson O. Birth position and obstetric anal sphincter injury: a population-based study of 113 000 spontaneous births. BMC Pregnancy Childbirth 2015; 15: 252 . Doi: 10.1186/s12884-015-0689-7
• 4 Soong B, Barnes M. Maternal position at midwife-attended birth and perineal trauma: is there an association?. Birth 2005; 32 (03) 164-169 . Doi: 10.1111/j.0730-7659.2005.00365.x
• 5 Meyvis I, Van Rompaey B, Goormans K. , et al. Maternal position and other variables: effects on perineal outcomes in 557 births. Birth 2012; 39 (02) 115-120 . Doi: 10.1111/j.1523-536X.2012.00529.x
• 6 Edqvist M, Blix E, Hegaard HK. , et al. Perineal injuries and birth positions among 2992 women with a low risk pregnancy who opted for a homebirth. BMC Pregnancy Childbirth 2016; 16 (01) 196 . Doi: 10.1186/s12884-016-0990-0
• 7 Gupta JK, Sood A, Hofmeyr GJ, Vogel JP. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev 2017; 5: CD002006 . Doi: 10.1002/14651858.CD002006.pub4
• 8 Marcolin AC. [Until when will Brazil be known as the country of cesarean section?]. Rev Bras Ginecol Obstet 2014; 36 (07) 283-289 . Doi: 10.1590/SO100-720320140005087
• 9 Royal College of Obstetricians & Gynaecologists. The Management of Third- and Fourth-Degree Perineal Tears . June 2015. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-29.pdf . Accessed March 20, 2017
• 10 Hauck YL, Lewis L, Nathan EA, White C, Doherty DA. Risk factors for severe perineal trauma during vaginal childbirth: a Western Australian retrospective cohort study. Women Birth 2015; 28 (01) 16-20 . Doi: 10.1016/j.wombi.2014.10.007
• 11 Smith LA, Price N, Simonite V, Burns EE. Incidence of and risk factors for perineal trauma: a prospective observational study. BMC Pregnancy Childbirth 2013; 13: 59 . Doi: 10.1186/1471-2393-13-59
• 12 Vale de Castro Monteiro M, Pereira GM, Aguiar RA, Azevedo RL, Correia-Junior MD, Reis ZS. Risk factors for severe obstetric perineal lacerations. Int Urogynecol J Pelvic Floor Dysfunct 2016; 27 (01) 61-67 . Doi: 10.1007/s00192-015-2795-5
• 13 Epidural and Position Trial Collaborative Group. Upright versus lying down position in second stage of labour in nulliparous women with low dose epidural: BUMPES randomised controlled trial. BMJ 2017; 359: j4471 . Doi: 10.1136/bmj.j4471
• 14 Deliktas A, Kukulu K. A meta-analysis of the effect on maternal health of upright positions during the second stage of labour, without routine epidural analgesia. J Adv Nurs 2018; 74 (02) 263-278 . Doi: 10.1111/jan.13447
• 15 Diorgu FC, Steen MP, Keeling JJ, Mason-Whitehead E. Mothers and midwives perceptions of birthing position and perineal trauma: An exploratory study. Women Birth 2016; 29 (06) 518-523 . Doi: 10.1016/j.wombi.2016.05.002
• 16 Johansson M, Thies-Lagergren L. Swedish fathers' experiences of childbirth in relation to maternal birth position: a mixed method study. Women Birth 2015; 28 (04) e140-e147 . Doi: 10.1016/j.wombi.2015.06.001
• 17 Dundes L. The evolution of maternal birthing position. Am J Public Health 1987; 77 (05) 636-641 . Doi: 10.2105/AJPH.77.5.636
• 18 Edozien LC, Gurol-Urganci I, Cromwell DA. , et al. Impact of third- and fourth-degree perineal tears at first birth on subsequent pregnancy outcomes: a cohort study. BJOG 2014; 121 (13) 1695-1703 . Doi: 10.1111/1471-0528.12886
• 19 Thies-Lagergren L, Hildingsson I, Christensson K, Kvist LJ. Who decides the position for birth? A follow-up study of a randomised controlled trial. Women Birth 2013; 26 (04) e99-e104 . Doi: 10.1016/j.wombi.2013.06.004
• 20 Aasheim V, Nilsen ABV, Reinar LM, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 2017; 6: CD006672 . Doi: 10.1002/14651858.CD006672.pub3