Permanent pelvic floor, anal sphincter, connective/support tissue and vaginal damage (and all first time births will cause this - it is why subsequent births are 'easier') are some of the reasons women should have the right to plan an unlabored cesarean instead of forced to plan a vaginal birth. Denying this choice is anti-woman. There is no 'right' birth option choice. Every individual woman will assess risks differently and that is her legal and ethical right.
Mode of Delivery and the Pelvic Floor
Pudendal nerve damage during labour: prospective study before and after childbirth*
• Abdul H. Sultan Research Fellow11St Bartholomew's (Homerton),
• Michael A. Kamm Consultant (Gastroenterology) and Director of Physiology Unit††St Mark's Hospitals, London,
• Christopher N. Hudson Professor (Obstetrics and Gynaecology)11St Bartholomew's (Homerton)
• 1St Bartholomew's (Homerton)†St Mark's Hospitals, London
Dr M. A. Kamm, Department of Physiology, St Mark's Hospital, City Road, London EC1V 2PS, UK.
*This paper has been presented at the British Society of Gastroenterology meeting (Sheffield) in 1992 and the abstract is published in Gut (1992) 33, S65.
Objective: To establish the effect of childbirth on pudendal nerve function and identify obstetric factors associated with such damage.
Design: A prospective investigational study.
Setting: Antenatal clinic, St Bartholomew's (Homerton) Hospital.
Subjects: One hundred and twenty-eight unselected pregnant women beyond 34 weeks' gestation.
Intervention: Pudendal nerve terminal motor latencies (PNTML) and perineal plane were measured during pregnancy and six to eight weeks after delivery, and remeasured in a subgroup (n = 22) at six months.
Main outcome measures: Effect of mode of delivery on PNTML and the plane of the perineum.
Results: Vaginal delivery resulted in a significant (P< 0.0001) prolongation of the mean PNTML bilaterally in both primipara (n = 57) 1.91 ms (SD 0.19) vs 2.00 ms (SD 0.22), antenatal vs postnatal, right PNTML; 1.96 ms (SD 0.21) vs 2.06 ms (SD 0.24) left PNTML, and multipara (n = 32) (P< 0.01). Perineal descent during straining was also increased after vaginal delivery (P< 0.001). Greater damage to the pudendal nerve occurred on the left side (P = 0.03). PNTML were not altered after elective caesarean section (n = 7), but were increased on the left side when caesarean section was performed during labour (1.94 ms (SD 0.13) vs 2.08 ms (SD 0.29), P< 0.01). A heavier baby and a longer active second stage of labour were both associated with significant prolongation of PNTML. Eight out of 12 women with a prolonged PNTML at six weeks had normal measurements when restudied six months after delivery.
Conclusion: Vaginal delivery, particularly the first, results in significant pelvic floor tissue stretching and pudendal nerve damage. Women who have a caesarean section during labour may also be at risk of pudendal nerve damage. The process of labour and vaginal delivery can both cause pudendal nerve damage which may be asymmetrical in extent.
Choosing Cesarean Birth:
An alternative to today’s Crisis in Natural Childbirth?
by Magnus Murphy, MD
II) The Pelvic Floor
As mentioned previously, muscles can only function if nerves innervate them. Damage to nerves can take many forms, and does not necessarily have to be permanent or complete. Nerves can be damaged by overstretching, by being crushed against a hard object (for instance a bony point), by tearing or by being cut (during an episiotomy, for instance). If the nerve is not completely severed, the term used is neuropraxia. Such injuries can usually repair themselves in time, although deficits often remain. More severe injuries can lead to the death of nerve fibers and subsequent dysfunction of the particular muscle innervated by that nerve fiber.
As we know, effective muscle action requires that the nerve supply be intact. Without this essential element, muscles degenerate and waste away (atrophy). The same is true for muscles which are not used for other reasons. Just think of someone whose leg is in a cast.
During vaginal childbirth there are multiple possibilities for nerve damage within the pelvic area. During descent of the fetus’s head through the pelvis, the pelvic nerve plexuses and individual nerves are compressed against the bony pelvis. One of the very important nerves that supply the pelvic floor, namely the pudendal nerve, is very vulnerable to a combination of crushing and stretching forces. These nerves, one on each side, supply most of the voluntary muscles of the pelvic floor and perineum and are essential to normal pelvic muscle action. During their course through the pelvis, they angle sharply around bony points called the ischial spines. It is apt to think of the Latin root of the words “ischial spine” which can be translated as “thorn of the hip joint”. The ischial spines (again one each side) are part of the ischial bones of which there are of course two. These are the lateral (side) bones of the pelvis. Since the inter-spinal distance is the narrowest part of the mid-pelvis, the fetal head invariably applies significant force to the pudendal nerves in these areas. Since the nerves are relatively unable to move because of their sharp angulation around these bony points, they are especially vulnerable to crushing, stretching and tearing forces.
Many investigators have proven, beyond reasonable doubt, that pelvic nerve injuries are extremely common during vaginal childbirth. It was found that the percentage of women who develop nerve injuries is as high as eighty percent13 . This was found in women who gave birth vaginally or in women who had emergency cesarean sections after they had reached the second stage of labor. A cervix that is fully opened with the fetal head ready to come out defines the second stage of labor. During this stage the mother is usually actively pushing, the fetal head is deep in the pelvis, and the vagina as well as the pelvic muscles and fascial layers are maximally stretched. All the factors to cause compression and shearing forces on the pelvic nerves are thus in play.
Researchers have found no nerve damage after elective cesarean births. With elective cesarean births the fetal head is usually still high in the pelvis, or even above the pelvis, and at any rate the tremendous compression and stretching forces have not been applied.
The pudendal nerves are, in addition, the main nerves of the pelvic organ sphincter muscles (voluntary component). These, mainly, include the external anal sphincter, the bladder neck sphincter and certain small muscles surrounding the lower part of the vagina. Other nerves that might be damaged include the sympathetic and parasympathetic nerve chains, and this can lead to the dysfunction and weakening of the levator ani muscles (which help support the pelvic floor).
13 Tetzschner et al. Acta Obstet Gynecol Scan 1997; 76: 324
Operative vaginal deliveries and nerve damage:
It is now well accepted that operative vaginal delivery has the potential to increase the risk for pelvic damage. Forceps delivery, especially, has been shown to carry this risk. The vacuum extractor, is associated with a lower risk for this complication. The dilemma is that these operative procedures are, in some cases, essential to expedite delivery, or to make vaginal delivery possible at all. In those cases where labor has already reached the second stage (often after prolonged pushing), and vaginal operative procedures are considered, it is to a large degree probably already too late to do a cesarean section (in preference to operative vaginal delivery) to make a meaningful difference to the protection of the pelvic floor.
As mentioned, some of this damage heals with enough time. There are, however, disturbing studies which show that significant nerve damage persists in a large percentage of women after vaginal delivery. The pelvic fascia can usually overcome the resultant weakness in the levator ani muscles for a while only. This is of course only true if the fascia is intact and attached to begin with. With aging, natural processes and the increasing stretching of the fascia under the influence of the intraabdominal weight it now solely has to bear, the fascia eventually cannot support its burden effectively anymore and prolapse develops. As will be seen later, this can manifest as overt genital prolapse, or urinary or fecal incontinence. Weak sphincter muscles usually lead to incontinence problems. Sphincter defects can arise from the above-mentioned neurological damage or from more direct damage.
III) Pelvic Floor Disorders
1) Urinary incontinence:
Imagined not being able to control your urine. Imagine wetting yourself every time you cough, sneeze, run, jump, walk down stairs, play golf, tennis, or just horse around with your children or grandchildren… Sadly, this is exactly what millions of women experience daily. It is estimated that up to 10 million American women suffer from urinary incontinence. Walk around the shelves of your neighborhood pharmacy. It will become abundantly clear that incontinence means huge profits to manufacturers of protective pads and devices.
Urinary incontinence is big business:
The economic impact of urinary incontinence in the United States alone was estimated at over 10 billion dollars per annum at 1987 prices, and this does not include indirect costs. As mentioned, the clearest indication of the prevalence of incontinence is the female sanitary market. It is a multi-billion dollar market and it is noticeable how often one encounters television advertisements for moisture protection which are targeted at women. Any way you look at it, incontinence is big business.
Effects on quality of life:
Urinary incontinence can be devastating to quality of life:
Urinary incontinence can be devastating physically, economically, and psychologically. It often leads to curtailment of enjoyable activities, social embarrassment, depression, and even isolation. The typical scenario is that any activity that would increase the pressure inside the abdominal cavity of women suffering from urinary incontinence could precipitate an uncontrolled squirt of urine. This typically occurs as a result of damage to
the pelvic floor, the bladder sphincters or the integrity of some finer control mechanisms, and is called genuine stress incontinence. These unfortunate women often tell me that whenever they leave their houses, they have to plan their trip or visit around the availability of washrooms. They are intimate with the exact location of every toilet in the immediate vicinity. By going to the toilet at every possible opportunity, they attempt to keep their bladders completely empty to avoid embarrassment and physical discomfort.
One of the common complaints I get from patients is that they cannot play with their children/grandchildren like before anymore for fear of embarrassing accidents. Since this problem, of course, also intrudes upon their professional lives, many women have an all-encompassing fear of public embarrassment. I have seen young women with major clinical depression as a result. It is therefore surprising and disconcerting that only an
estimated 25 to 50 percent of women with incontinence seek medical help.
Incontinence can also become a problem during the most intimate of all acts, namely, sexual intercourse. I once browsed through a book in a respected bookshop, which describes how to reach sexual ecstasy. One of the main points of this book was the phenomenon of female ejaculation. The author describes how a woman at the top of her excitement would and should ejaculate a large volume of clear fluid. Well – I’m sorry to disappoint, but…
Urinary incontinence is pervasive:
It is estimated that up to 50 percent of women will experience symptomatic urinary incontinence! This figure is even higher in institutionalized elders. The figures vary widely from study to study. Even if given a conservative overall figure, the incidence of urinary incontinence is absolutely shocking. A stress urinary incontinence has been found to be the most prevalent, making up 77 percent of the incontinence in women in some studies. The figures vary according to the definitions used in the different studies as well as whether the studies used self-reporting or objective investigative results. Some women report incontinence but do not necessarily have significant problems with it since it might occasional, for instance, during a severe cold. The great tragedy, however, is the numbers of young woman that are inhibited from participating in ordinary activities that they enjoy or must do on a daily basis.
Types of urinary incontinence:
“stress vs. urgency”:
An understanding of urinary incontinence is complicated by the fact that there are different types of incontinence, and that not all types of incontinence are related to pelvic floor damage. The most common type is stress urinary incontinence, also called genuine stress urinary incontinence and which usually is a consequence of pelvic floor damage or dysfunction. The typical case history is that a squirt of urine occurs in the event of increased intra-abdominal pressure (coughing, sneezing and the other triggers already mentioned). The great majority of women suffering from this have had vaginal childbirth, a fact that has been known since early times. In fact, in 1919, Howard A. Kelly, the first professor of gynecology at the Johns Hopkins Medical School, co-authored a text entitled “ Disease of the Kidney, Ureters and Bladder". He wrote: "The commonest form of incontinence is the result of childbirth, entailing an injury to the neck of the bladder; it is occasionally seen in the elderly nullipara and is most common after the age of 40. It is usually progressive, beginning with an occasional dribble, later becoming more frequent and occurring on slight provocation. In its incipiency, a strain, cough, sneeze or stepping up to get on a tram car starts a little spurt of urine which, in the course of time, initiates the act which empties the Bladder".
Most studies have found a high incidence of urinary incontinence in pregnancy in healthy young women even during the first pregnancy. Prevalence rates as high as 50 percent have been reported. Most of these women recover urine control after the pregnancy, but not all. Unfortunately, a great many of those who recover control have sustained sufficient pelvic floor damage to destine them for future renewed urinary incontinence, with or without genital prolapse and anal incontinence.
One of the other relatively common causes of incontinence is so-called bladder instability. This would typically cause the feeling of urgency ("I have to go right now!") not necessarily associated with increased intra-abdominal pressure or urgency incontinence ("I have to go right now--oops--too late!"). Triggers for this kind of incontinence often include things such as hearing water running, feeling cold water on your hands, or seen a washroom.
Regrettably, it is usually impossible to determine which of the two causes predominate without further testing, since patients’ histories alone are notoriously inaccurate. These two main causes of incontinence often occur together in the same patient, which makes it difficult to determine what therapeutic approach would be most effective or likely to succeed. Obvious pelvic floor prolapse, especially a prolapse of the bladder into the
vagina (so called cystocele), in the setting of a typical history, together with urine leakage during coughing make genuine stress incontinence the likely diagnosis. The price of being wrong however is so high that one would seldom resort to surgical intervention in the absence of corroborative information. This information can be obtained from a cystometrogram. This basically involves measuring the pressures inside the bladder during different activities, and during bladder filling with sterile water. Typically, urgency incontinence occurs after a rise in pressure inside the bladder related to a bladder muscle contraction. Somewhat simplistically, it is abnormal for the pressure inside the bladder to rise except when purposely voiding. Such abnormal pressure increases is the result of bladder instability, the causes of which will be shortly discussed later. More sophisticated cystometrogram instruments also measure contractions of the pelvic floor muscles and the bladder sphincters, as well as the pressure differentials between the bladder, the urethra, and the intra-abdominal cavity. The main purpose of a cystometrogram is to diagnose or exclude bladder instability, the presence of which has to be known to plan an intelligent therapeutic approach to the incontinence. The reason that it is important to rule out bladder instability is that surgery, in the setting of bladder instability, has a high risk of increasing the instability. Bladder instability (the medical term is "detrusor instability") means that the bladder muscle contracts when it is not supposed to. Under normal circumstances the bladder has the ability to distend enormously without any increase in pressure inside the bladder. This occurs as a result of passive distention without the occurrence of any detrusor contractions. As a result the normal person would still be comfortable with a bladder that is quite full, although he/she will be intermittently aware of it. The unstable detrusor, however, contracts with bladder filling or other external stimuli, for instance, to see or to hear running water, certain body movements and sometimes for no discernible reason that all. This then causes an intense feeling of the need to urinate even if there is only a little urine. This is sometimes the result of infection or interstitial cystitis (at a relatively common and extremely frustrating urological condition), and may also be caused by diabetes or other medical diseases. Very commonly, however, no obvious cause is found.
The presence of detrusor instability does not necessarily contraindicate surgery. Although this seems to contradict what I said before, I will try to explain. One of the worst mistakes a surgeon can make is to attempt surgical treatment on a patient who has only detrusor instability. Surgery in this setting is very unlikely to be of any benefit to the patient and, ironically, can lead to a significant increase in the problem. With pure, or so-called genuine stress incontinence (in the absence of detrusor instability) surgery does have a definite role to play. Alternatives to surgery will be discussed a bit later.
More complicated are the cases where both types of incontinence occur together. It is well known that detrusor instability can sometimes be the result of pelvic floor damage and the resultant abnormal position of the bladder base. In such a case, surgery often cures not only the stress incontinence, but also the detrusor instability. It is a highly unpredictable outcome, nonetheless, and there is a risk that the instability will persist or increase postoperatively. Fortunately, postoperative instability is commonly transient and there are strong drugs available to suppress the abnormal detrusor contractions, which usually leads to significant improvement. It has to be noted however that this is a potential complication that might render a technically perfect operation a failure.
Unfortunately women are anatomically at much higher risk than men for the development of urinary incontinence. This is not only related to childbirth, but also in some degree, to the short urethra and it's anatomical relationship to the vagina. As a result of this, a significant number of perfectly young women suffer from the occasional urinary leak, but fortunately usually not to any serious degree.
Urinary incontinence and the pelvic floor:
Clinically important, so-called genuine stress incontinence, on the other hand, usually occurs in the setting of pelvic floor defects. The normal control mechanisms of urinary continence are very complicated processes, which I will greatly simplify. An understanding of the main concepts is however necessary to understand why the intact pelvic floor is so important in this regard.
The urinary bladder is basically a reservoir. It is a sack lined with an impenetrable membrane, which is then surrounded by a strong muscle called the detrusor muscle. The outflow tube of this sack is called the urethra and it is approximately 4-5 cm in length. The junction between the urethra and the bladder is called the bladder neck area. A relatively sharp angle is formed between these two, which is important in continence control.
A strong sphincter muscle (clamp) surrounds the bladder neck area and is under voluntary control. In contrast to this voluntary control the bladder muscle itself is not under voluntary control, but is carefully regulated by a special center in the spinal column called the micturition (urination) center. The brain does have some control over the micturition center, which gives one the ability to postpone urination until it is convenient. The normal position of the bladder is immediately on top of the vagina and lower part of the uterus, whereas the urethra lies on the lower part of the vaginal roof and is integrally associated with, and attached to, the top vaginal wall (its roof).
The pelvic fascia we have heard so much about surrounds the urethra and the vagina, and is suspended from the pelvic side walls (see illustrations). This creates suspension support for the urethra, the vaginal roof (also called the anterior or upper vaginal wall) as well as the bladder neck and the bladder itself. The integrity of the pelvic fascia, the anterior vaginal wall and the pelvic musculature is essential to maintain the normal position of the urethra, the bladder neck, and the bladder itself.
Continence is provided by a variety of finely balanced factors, which include the position of the bladder neck, the bladder neck sphincters, parts of the levator ani muscles, compression of the urethra and characteristics of the internal urethra itself. The bladder neck contains an involuntary internal (inside), and a voluntary external (outside), sphincter. These sphincter muscles, as do all other muscles, depend on the above-mentioned factors for their effective action. Damage to pelvic fascia or pelvic innervation seriously and negatively affect their action. These muscles are the same ones that one contracts to consciously stop the urine stream and do so by constricting the urethra. During this squeezing action, most of the pelvic voluntary muscles are at the same time contracted, including the levator ani muscles, the rectal sphincter and certain small muscles surrounding the opening of the vagina.
The position of the bladder neck is extremely important. To recap, there is an angle between the bladder and the urethra. When intraabdominal pressure is increased for instance during coughing, sneezing, etc., this tends to increase the angle, effectively kinking the urethra the way we would bend a garden hose to stop the flow. With an intact pelvic floor, especially the fascia, there will be little sagging in the anterior vaginal wall so that the increased pressure on the urethra (transmitted from the abdomen), will tend to effectively compress it against this unyielding floor, and thereby prevent leakage.
The internal structure of the urethra also helps to prevent urine leakage. The mucosal lining fits tightly together and prevents urine flow initiation. With aging, especially as estrogen levels fall, this lining fits together less tightly, which contributes to the problem. Less well understood is the function of the internal urethral muscles, but it is now well known that internal urethral deficiencies can lead to stress urinary incontinence.
Urinary incontinence and vaginal delivery:
It has been adequately demonstrated that vaginal delivery increases the bladder neck descent and decreases the ability of the pelvic muscles to elevate the urethra and the bladder base. During episodes of increased abdominal pressure, for instance during straining, the bladder neck is lower in women after vaginal delivery, compared to women who have not had children or women who have had elective cesarean sections. It was found that this positional change occurs in more than 50 percent of women after vaginal delivery and is usually persistent. In contrast, in patients who had elective cesarean births there is almost no difference. Damage to the pelvic floor with urethral detachment was already described in 1945, and it was estimated at that time to occur in a third of patients.
It is now known that the very first vaginal delivery can cause damage not only to the pelvic floor muscles and fascia, but also to the nerve innervation of the muscles, and in particular to branches of the pudendal nerve. Further deliveries are thought to add to this risk, although the contributory effect of subsequent deliveries is thought to be considerably smaller than the first. It is a well-known fact that subsequent births are usually easier than the first one. This makes sense not only if one considers the possibility of a “memory” effect in the effectiveness of the uterine muscles, but also the decreased difficulty in downward movement of the fetus. This, of course, is the result of decreased pelvic muscle tone, and generally relaxed vaginal tissues and fascia, resultant from the first birth.
The Odds Ratio (a statistical entity calculating the probability of something occurring, and used frequently in medicine) for vaginal childbirth as a risk for urinary incontinence has been calculated to be 11.15. This means that women are 11.15 times more likely to develop urinary incontinence after vaginal childbirth, compared to women who have not had vaginal births. This is an incredible statistic and equates to a thousand one hundred percent increased risk!
The above information is courtesy of www.obgyn.net
Elective cesarean choice
The choice exists, it is legitimate, and it is here to stay
Written by Pauline McDonagh Hull
In a consumer driven world, we’ve become increasingly accustomed to demanding and attaining choice - be that the place we want to shop, the things we want to buy, the price we’re willing to pay or the quality we expect to receive. And rightly or wrongly, the 21st Century has continued to witness one of the most controversial developments in consumer choice of all - its emergence within the traditionally revered boundaries of medicine.
As technological advances expand and new methodologies emerge, options for treatment and care multiply, leaving choices to be made. Patient-doctor consultation is vital, as is a patient’s own knowledge, understanding and responsibility (e.g. researching your doctor’s credentials and reading about your condition). And yet nowhere is the controversy surrounding patient choice more heightened than on the painfully sensitive issue of childbirth.
Advocates of natural childbirth argue that choice is restricted in overly medical environments where fetal monitoring, epidurals and emergency cesareans are too readily administered. They believe more home births should be supported. Conversely, there are women who choose hospital-assisted vaginal delivery but in the end, feel that their specific ideal birth plan was neither respected nor accomplished.
Then there are women who decide to have a cesarean - the most contentious choice of all - a decision they soon discover must be defended far beyond the reach of a hospital ward. Which brings us to perhaps the most commonly asked cesarean question: “Why would any intelligent woman choose surgery ahead of entrusting her own body to deliver her baby safely?”
Major Surgery versus Mother Nature
As we might expect, there is no simple ‘catch all’ answer to this because every woman is different, but fundamentally, it boils down to her own personal assessment of the risks and benefits involved in each type of delivery. Unfortunately, this assessment is far from straightforward, largely because the data available is limited - a fact highlighted by the National Institutes of Health in 2006: “There is insufficient evidence to evaluate fully the benefits and risks of CDMR as compared to PVD, and more research is needed.”*
Incorporating the vast majority of comparative birth studies to date in a contemporary appraisal of elective cesarean delivery in healthy women is flawed, primarily because their data includes outcomes from emergency surgeries and elective surgeries in women (and babies) with pre-existing medical conditions. In addition, much of the data compiled on vaginal delivery looks at ‘positive outcomes’ alone (i.e. a planned vaginal delivery that ends up as a vaginal delivery) rather than ‘all planned vaginal delivery outcomes’ (including those that result in emergency cesareans) and their subsequent mortalities or morbidities.
There is also a tendency to place more emphasis on grave cesarean morbidities such as hemorrhage and infection (regardless of prevalence), and apply reduced significance to the less extreme (but nonetheless frequent) vaginal delivery morbidities such as immediate post-birth pelvic floor pain and long-term repercussions. Unless genuine comparative studies can look at healthy women who deliver vaginally and surgically, relevant debate (including the debate over cesarean cost) is hampered.
Until then, it is comforting to know that an increasing number of obstetricians and other health professionals worldwide (including the current Vice-President and former President of the American College of Obstetricians and Gynecologists) are satisfied that elective surgery is favorably comparable with vaginal delivery, and therefore they support a woman’s right to request it. Furthermore, in 2003, an ACOG ethics committee stated that it is ethical for doctors to perform elective caesarean sections on pregnant women who face no known risks from vaginal delivery.**
This is good news for women in America, although there are always medical caveats to be mindful of (e.g. cesareans are not recommended for women who plan to have large families or who are obese, and babies should not be delivered prior to 39 weeks or without verification of lung maturity). Overall, cesarean delivery appeals to a minority of women in much the same way as do the options of home birth, water birth or drug-free delivery, but ultimately, all birth choices should be respected.
Society may still be slightly more inclined to give out medals to women who achieve a DIY vaginal delivery while making disparaging comments about women who are “too posh to push,” but the fact remains that if a baby is born healthy and a woman has had a positive birth experience, the prospect for their future health and relationship is equally good, and for most mothers, that’s all that really matters in the end.
Pauline McDonagh Hull is a journalist and pregnant with her first child. She founded the website www.electivecesarean.com in 2006, which provides more detailed information on the risks and benefits of planned cesarean delivery, in-depth interviews with a range of medical professionals, plus much more. If you have any questions or feedback on the site or if you’re a medical professional who would like to talk about your views on cesarean delivery, you can reach Pauline via the elective cesarean ‘Contact us’ page.
*27-29 Mar 06 NIH State-of-the-Science Conference Statement: Cesarean Delivery on Maternal Request
CDMR (Cesarean Delivery on Maternal Request)
PVD (Planned Vaginal Delivery)
**03 Nov 03 Non-Medically Indicated C-Sections Ethical, ACOG Ethics Committee Says, Kaiser Network
Intracranial Hemorrhage in Asymptomatic Neonates: Prevalence on MR Images and Relationship to Obstetric and Neonatal Risk Factors1
Christopher B. Looney, BS, J. Keith Smith, MD, PhD, Lisa H. Merck, MD, MPH, Honor M. Wolfe, MD, Nancy C. Chescheir, MD, Robert M. Hamer, PhD and John H. Gilmore, MD
1 From the Department of Psychiatry, CB No. 7160, 7025A Neurosciences Hospital, University of North Carolina School of Medicine, Chapel Hill, NC 27599-7160. From the 2005 RSNA Annual Meeting. Received January 23, 2006; revision requested March 23; revision received June 7; accepted June 21; final version accepted August 21. J.H.G. supported by National Institute of Mental Health grant 1 P50 MH064065. C.B.L. supported by a Distinguished Medical Scholarship from UNC School of Medicine. Address correspondence to J.H.G. (e-mail: firstname.lastname@example.org).
Purpose: To retrospectively evaluate the prevalence of neonatal intracranial hemorrhage (ICH) and its relationship to obstetric and neonatal risk factors.
Materials and Methods: Pregnant women were recruited for a prospective study of neonatal brain development; the study was approved by the institutional review board and complied with HIPAA regulations. After informed consent was obtained from a parent, neonates were imaged with 3.0-T magnetic resonance (MR) imaging without sedation. The images were reviewed by a neuroradiologist with 12 years of experience for the presence of ICH. Medical records were prospectively and retrospectively reviewed for selected risk factors, which included method of delivery, duration of labor, and evidence of maternal or neonatal birth trauma. Risk factors were assessed for relationship to ICH by using Fisher exact test statistics.
Results: Ninety-seven neonates (mean age at MR imaging, 20.8 days ± 6.9 [standard deviation]) underwent MR imaging between the ages of 1 and 5 weeks. Eighty-eight (44 male and 44 female) neonates (65 with vaginal delivery and 23 with cesarean delivery) completed the MR imaging evaluation. Seventeen neonates with ICHs (16 subdural, two subarachnoid, and six parenchymal hemorrhages) were identified. Seven infants had two or more types of hemorrhages. All neonates with ICH were delivered vaginally, with a prevalence of 26% in vaginal births. ICH was significantly associated with vaginal birth (P < .005) but not with prolonged duration of labor or with traumatic or assisted vaginal birth.
Conclusion: Asymptomatic ICH following vaginal birth in full-term neonates appears to be common, with a prevalence of 26% in this study.
The forces of labor and delivery occasionally cause physical injury to the infant. The incidence of neonatal injury from difficult or traumatic deliveries is decreasing due to increasing use of cesarean section in place of difficult versions, vacuum extractions, or mid- or high-forceps deliveries.
A traumatic delivery is anticipated when the mother has small pelvic measurements, when the infant seems large for gestational age (often the case with diabetic mothers), or when there is a breech or other abnormal presentation, especially in a primipara. In such situations, labor and the fetal condition should be monitored closely. If fetal distress is detected, the mother should be positioned on her side and given O2. If fetal distress persists, an immediate cesarean section should be performed.
Head molding is common in vaginal delivery due to the high pressure exerted by uterine contractions on the infant's malleable cranium as it passes through the birth canal. This rarely causes problems or requires treatment.
Caput succedaneum is edema of the presenting portion of the scalp. It occurs when the area is forced against the uterine cervix. Subgaleal hemorrhage results from greater trauma and is characterized by a boggy feeling over the entire scalp, including the temporal regions.
Cephalhematoma, or hemorrhage beneath the periosteum, can be differentiated from subgaleal hemorrhage because it is sharply limited to the area overlying a single bone, the periosteum being adherent at the sutures. Cephalhematomas are commonly unilateral and parietal. In a small percentage, there is a linear fracture of the underlying bone. Treatment is not required, but anemia or hyperbilirubinemia may result.
Depressed skull fractures are uncommon. Most result from forceps pressure or rarely from the head resting on a bony prominence in utero. Infants with depressed skull fractures or other head trauma may also have subdural bleeding, subarachnoid hemorrhage, or contusion or laceration of the brain itself. Depressed skull fractures produce a palpable (and sometimes visible) step-off deformity, which must be differentiated from the palpable elevated periosteal rim occurring with cephalhematomas. CT scan is obtained to confirm the diagnosis and rule out complications. Neurosurgical elevation may be needed.
Cranial Nerve Injury
The facial nerve is injured most often. Although frequently attributed to forceps pressure, most injuries probably result from pressure on the nerve in utero, which may be due to fetal positioning (eg, from the head lying against the shoulder, the sacral promontory, or a uterine fibroid).
Facial nerve injury usually occurs at or distal to its exit from the stylomastoid foramen and results in facial asymmetry, especially during crying. Identifying which side of the face is affected can be confusing, but the facial muscles on the side of the nerve injury cannot move. Injury can also occur to individual branches of the nerve, most often the mandibular. Another cause of facial asymmetry is mandibular asymmetry resulting from intrauterine pressure; in this case, muscle innervation is intact and both sides of the face can move. In mandibular asymmetry, the maxillary and the mandibular occlusal surfaces are not parallel, which differentiates it from a facial nerve injury. Testing or treatment is not needed for peripheral facial nerve injuries or mandibular asymmetry. They usually resolve by age 2 to 3 mo.
Brachial Plexus Injuries
Brachial plexus injuries follow stretching caused by shoulder dystocia, breech extraction, or hyperabduction of the neck in cephalic presentations. Injuries can be due to simple stretching, hemorrhage within a nerve, tearing of the nerve or root, or avulsion of the roots with accompanying cervical cord injury. Associated injuries (eg, fractures of the clavicle or humerus or subluxations of the shoulder or cervical spine) may occur.
Injuries of the upper brachial plexus (C5 to C6) affect muscles around the shoulder and elbow, whereas lesions of the lower plexus (C7 to C8 and T1) primarily affect muscles of the forearm and hand. The site and type of nerve root injury determine the prognosis.
Erb's palsy is an upper brachial plexus injury causing adduction and internal rotation of the shoulder with pronation of the forearm. Ipsilateral paralysis of the diaphragm is common. Treatment includes protecting the shoulder from excessive motion by immobilizing the arm across the upper abdomen and preventing contractures by passive range-of-motion exercises to involved joints performed gently every day starting at 1 wk of age.
Klumpke's palsy is a lower plexus injury resulting in paralysis of the hand and wrist, often with ipsilateral Horner's syndrome (miosis, ptosis, facial anhidrosis). Passive range-of-motion exercises are the only treatment needed.
Neither Erb's nor Klumpke's palsy usually produces demonstrable sensory loss, which suggests a tear or avulsion. These conditions usually improve rapidly, but deficits can persist. If a significant deficit persists > 3 mo, MRI is performed to determine the extent of injury to the plexus, roots, and cervical cord. Surgical exploration and repair have sometimes been helpful.
When the entire brachial plexus is injured, the involved upper extremity cannot move, and sensory loss is usually present. Ipsilateral pyramidal signs indicate spinal cord trauma; an MRI should be performed. The involved extremity's subsequent growth may be impaired. The prognosis for recovery is poor. Management may include neurosurgical exploration. Passive range-of-motion exercises can prevent contractures.
Other Peripheral Nerve Injuries
Injuries to other peripheral nerves (eg, the radial, sciatic, obturator) are rare in neonates and are usually not related to labor and delivery. They are usually secondary to a local traumatic event (eg, an injection in or near the sciatic nerve). Treatment includes placing the muscles antagonistic to those paralyzed at rest until recovery. Neurosurgical exploration of the nerve is seldom indicated. In most peripheral nerve injuries, recovery is complete.
Spinal Cord Injury
Spinal cord injury is rare and involves variable degrees of cord disruption, often with hemorrhage. Complete disruption of the cord is very rare. Trauma usually occurs in breech deliveries after excess longitudinal traction to the spine. It can also follow hyperextension of the fetal neck in utero (the “flying fetus”). Injury usually affects the lower cervical region (C5 to C7). When the injury is higher, lesions are generally fatal because respiration is completely compromised. Sometimes a click or snap is heard at delivery.
Spinal shock with flaccidity below the level of injury occurs initially. Usually, there is patchy retention of sensation or movement below the lesion. Spasticity develops within days or weeks. Breathing is diaphragmatic, because the phrenic nerve remains intact as it arises higher (C3 to C5) than the typical cord lesion. When the spinal cord lesion is complete, the intercostal and abdominal muscles become paralyzed and rectal and bladder sphincters cannot develop voluntary control. Sensation and sweating are lost below the involved level, which can cause fluctuations of body temperature with environmental changes.
An MRI of the cervical cord may demonstrate the lesion and excludes surgically treatable lesions, such as congenital tumors or hematomas pressing on the cord. The CSF is usually bloody.
With appropriate care, most infants survive for many years. The usual causes of death are recurring pneumonia and progressive loss of renal function. Treatment includes nursing care to prevent skin ulcerations, prompt treatment of urinary and respiratory infections, and regular evaluations to identify obstructive uropathy early.
Hemorrhage in or around the brain can occur in any neonate but is particularly common in those born prematurely; about 20% of premature infants < 1500 g have intracranial hemorrhage. Hypoxia-ischemia, variations in BP, and pressures exerted on the head during labor are major causes. The presence of the germinal matrix (a mass of embryonic cells lying over the caudate nucleus on the lateral wall of the lateral ventricles and present only in the fetus) makes hemorrhage more likely. Risk also is increased by hematologic disorders (eg, vitamin K deficiency, hemophilia, disseminated intravascular coagulation).
Hemorrhage can occur in several CNS spaces. Small hemorrhages in the subarachnoid space, falx, and tentorium are frequent incidental findings at autopsy of neonates dying from non-CNS causes. Larger hemorrhages in the subarachnoid or subdural space, brain parenchyma, or ventricles are less common but more serious.
Subarachnoid hemorrhage probably is the most common type of intracranial hemorrhage. Neonates may present with apnea, seizures, lethargy, or an abnormal neurologic examination. With large hemorrhages, the associated meningeal inflammation may lead to a communicating hydrocephalus as the infant grows.
Subdural hemorrhage, which is now less common because of improved obstetric techniques, results from tears in the falx, tentorium, or bridging veins. Such tears tend to occur in neonates of primiparas, in large neonates, or after difficult deliveries—conditions that can produce unusual pressures on intracranial vessels. The presenting finding may be seizures; a rapidly enlarging head; or an abnormal neurologic examination with hypotonia, a poor Moro reflex, or extensive retinal hemorrhages.
Intraventricular and/or intraparenchymal hemorrhage generally occurs during the 1st 3 days of life and is the most serious type of intracranial bleeding. Hemorrhages occur most often in premature infants, are often bilateral, and usually arise in the germinal matrix. Most bleeding episodes are subependymal or intraventricular and involve a small amount of blood. In severe hemorrhage, there may be bleeding into the parenchyma or a cast of the ventricular system with large amounts of blood in the cisterna magna and basal cisterns. Hypoxia-ischemia often precedes intraventricular and subarachnoid bleeding. Hypoxia-ischemia damages the capillary endothelium, impairs cerebral vascular autoregulation, and can increase cerebral blood flow and venous pressure, all of which make hemorrhage more likely. Most intraventricular hemorrhages are asymptomatic, but larger hemorrhages may cause apnea, cyanosis, or sudden collapse.
Intracranial hemorrhage should be suspected in any neonate with apnea, seizures, lethargy, or an abnormal neurologic examination. Infants should have head CT. Although cranial ultrasound is risk free, requires no sedation, and can readily identify blood within the ventricles or brain substance, CT is more sensitive for thin layers of blood in the subarachnoid or subdural spaces. If the diagnosis is in doubt, the CSF can be examined for RBCs: it usually contains gross blood. However, some RBCs are often present in the CSF of term neonates. In subdural hemorrhage, transillumination of the skull may reveal the diagnosis after the blood has lysed.
Additionally, clotting studies, a CBC, and metabolic studies to identify other causes of neurologic dysfunction (eg, hypoglycemia, hypocalcemia, electrolyte imbalance) should be performed. An EEG may help establish prognosis if the infant survives the acute bleeding episode.
The prognosis for subarachnoid hemorrhage is generally good. The prognosis for subdural hemorrhage is guarded, but some infants do well. Most infants with small intraventricular hemorrhages survive the acute bleeding episode and do well. Infants with large intraventricular hemorrhages have a poor prognosis, especially if the hemorrhage extends into the parenchyma. Many will be left with neurologic deficits.
Treatment is mostly supportive unless a hematologic abnormality contributed to the bleeding. All should receive vitamin K if it was not previously given. If deficient, platelets or clotting factors should be given. Subdural hematomas should be managed by a neurosurgeon; evacuation of the hemorrhage may be needed.
Midclavicular fracture, the most common fracture during birth, occurs with shoulder dystocia and with normal, nontraumatic deliveries. Initially, the neonate is irritable and does not move the arm on the involved side either spontaneously or when the Moro reflex is elicited. Most clavicular fractures are greenstick and heal rapidly and uneventfully. A large callus forms at the fracture site within a week, and remodeling is completed within a month. Treatment consists of making a sling by pinning the shirt sleeve of the involved side to the opposite side of the infant's shirt.
The humerus and the femur may be fractured in difficult deliveries. Most of these are greenstick, mid-shaft fractures, and excellent remodeling of the bone usually follows, even if moderate angulation occurs initially. A long bone may be fractured through its epiphysis, but prognosis is excellent.
All soft tissues are susceptible to injury during birth if they have been the presenting part or the fulcrum for the forces of uterine contraction. Edema and ecchymosis often follow injury, particularly of the periorbital and facial tissues in face presentations and of the scrotum or labia during breech deliveries. Breakdown of blood within the tissues and conversion of heme to bilirubin result whenever a hematoma develops. This added burden of bilirubin may produce sufficient neonatal hyperbilirubinemia to require phototherapy, and rarely, exchange transfusion. No other treatment is needed.
Last full review/revision November 2005
Content last modified November 2005
The above information is from www.merck.com
Breastfeeding worsens asthma, allergies in children
• May 01, 2007
BREASTFEEDING for longer does not protect babies from developing asthma or eczema as young children, according to Australian research that conflicts with national guidelines.
Results from a new Sydney study show babies breast fed longer than six months may actually be more susceptible to allergies at five years old.
Allergy experts at the The Children's Hospital Westmead tracked more than 500 children with a family history of asthma to analyse the benefits of extending breastfeeding to six months, and delaying the introduction of solid foods.
Both practices are recommended to Australian mothers wanting to protect their children from allergic diseases, but evidence has been mixed.
This new research, published in the journal Clinical and Experimental Allergy, confirmed they offered no protection.
They did nothing to reduce chances of developing asthma or eczema, and in fact increased the likelihood a child would return a positive skin test for allergies, known as atopy.
Furthermore, the early introduction of solids before three months actually appeared to protect against allergies.
“We have shown that ... longer duration of breast feeding and later introduction of solid foods did not prevent the onset of asthma, eczema or atopy by age five,” the authors wrote.
They concluded that breastfeeding probably only stops babies developing early respiratory illnesses that are not linked to allergies or family-inherited factors.
The association between infant feeding practices and subsequent atopy among children with a family history of asthma
• S. Mihrshahi**Department of Allergy Immunology and Infectious Diseases, The Children's Hospital, Westmead, NSW, Australia, ,
• R. Ampon The Woolcock Institute of Medical Research, University of Sydney, NSW, Australia, ,
• K. Webb School of Public Health and Human Nutrition Unit, School of Molecular and Microbial Biosciences, University of Sydney, NSW, Australia, ,
• C. Almqvist §¶ The Woolcock Institute of Medical Research, University of Sydney, NSW, Australia, §Department of Woman and Child Health, Astrid Lindgren Children's Hospital and Karolinska Institutet, Stockholm, Sweden, ¶NHMRC Centre for Clinical Research Excellence in Respiratory and Sleep Medicine, NSW, Australia, and ,
• A. S. Kemp* *Department of Allergy Immunology and Infectious Diseases, The Children's Hospital, Westmead, NSW, Australia, Discipline of Paediatrics and Child Health, Children's Hospital at Westmead Clinical School, University of Sydney, NSW, Australia,
• D. Hector School of Public Health and Human Nutrition Unit, School of Molecular and Microbial Biosciences, University of Sydney, NSW, Australia, and
• G. B. Marks The Woolcock Institute of Medical Research, University of Sydney, NSW, Australia,
• for the CAPS Team
• *Department of Allergy Immunology and Infectious Diseases, The Children's Hospital, Westmead, NSW, Australia, The Woolcock Institute of Medical Research, University of Sydney, NSW, Australia, School of Public Health and Human Nutrition Unit, School of Molecular and Microbial Biosciences, University of Sydney, NSW, Australia, §Department of Woman and Child Health, Astrid Lindgren Children's Hospital and Karolinska Institutet, Stockholm, Sweden, ¶NHMRC Centre for Clinical Research Excellence in Respiratory and Sleep Medicine, NSW, Australia, and Discipline of Paediatrics and Child Health, Children's Hospital at Westmead Clinical School, University of Sydney, NSW, Australia
Andrew Kemp, Department Allergy Immunology and Infectious Diseases, The Children's Hospital, Westmead, Locked Bag 4001, Westmead, NSW 2145, Australia. E-mail: email@example.com
Background Although longer duration of breastfeeding and later introduction of solid foods are both recommended for the prevention of asthma and allergic disease, evidence to support these recommendations is controversial.
Objective To examine the relation between infant feeding practices and the risk of asthma and allergic disease at age 5 years.
Methods A cohort of children with a family history of asthma in Sydney, Australia, was followed from birth to age 5 years. Data on infant feeding practices and on early manifestations of eczema were collected prospectively. The presence of eczema, asthma and atopy (positive allergen skin prick tests) were determined at age 5 years.
Results In 516 children evaluated at age 5 years, there was no significant association between the duration of breastfeeding or timing of introduction of solid foods and protection against asthma or other allergic disease, after adjustment for confounding factors. However, breastfeeding for 6 months or more and introduction of solid foods after 3 months were both associated with an increased risk of atopy at age 5 years (P=0.02 and 0.01, respectively). There was no significant association between the presence of eczema at 4 weeks and at 3 months and continued breastfeeding beyond those times.
Conclusion Longer duration of breastfeeding and later introduction of solid foods did not prevent the onset of asthma, eczema or atopy by age 5 years.
: Med J Aust. 1990 Jan 1;152(1):9-12.
Med J Aust. 1990 Apr 2;152(7):386-7.
Recovery after childbirth: a preliminary prospective study
Department of Obstetrics and Gynaecology, University of Sydney, NSW.
This prospective study examined the time for 93 women to cease to feel discomfort in their perineal areas after the births of their first babies. Sixty-two of the women had experienced a spontaneous delivery that did not require forceps assistance. In 58 patients, an episiotomy was performed. Of the 35 women in whom an episiotomy was not performed, 24 women required sutures and only four women did not suffer any perineal damage. The median time for perineal comfort in general (including walking and sitting) was one month (range, zero to six months); 20% of women took more than two months to achieve general perineal comfort. For comfort during sexual intercourse, the median time was three months (range, one to more than 12 months); 20% of women took longer than six months to achieve comfort during sexual intercourse. Factors that were associated with discomfort for longer than the median time were delivery by forceps; spontaneous vaginal (not perineal) tears; and, in the three to four days after the birth, oedema and the breakdown of muscle or skin sutures. There was no significant difference in these times between patients who did not undergo an episiotomy and those who underwent an episiotomy without a forceps delivery.
PMID: 2294386 [PubMed - indexed for MEDLINE]
Thursday, January 7, 1999
BIOETHICS & SCIENCE
CESAREAN BIRTHS: Obstetricians Criticize Goal To Reduce Rate
The "Healthy People 2000 goal of reducing the cesarean-delivery rates to 15% may have a detrimental effect on maternal and infant health," four leading obstetricians charge in today's New England Journal of Medicine. They contend "[t]here is no evidence to support this target," and that "[s]etting a target rate is an authoritarian approach to health care delivery" that "implies that women should have no say in their own care" (Sachs et al., NEJM, 1/7 issue). The New York Times reports that the Department of Health and Human Services set the 15% goal in 1990 out of concern that unnecessary C-sections were driving up health costs. In 1988, the C-section rate was 25.5% of deliveries up from only 5% in 1970; it dropped to 23.5% in 1990 and "hovers around 21%" today (Brody, New York Times, 1/7).
Taking A Chance?
Dr. Benjamin Sachs, chair of obstetrics as Beth Israel Deaconess Medical Center and lead author, said, "We think the current push to reduce the C-section rate is increasing complications to mothers and infants." He said pressure to reduce rates was "coming from many sources, including the managed care companies. They believe that lower C-section rates mean better care and lower costs. We think they are wrong on both counts." Sachs and his co-authors charge that these pressures lead doctors "to encourage women to try vaginal delivery even when risks are higher than those of a C-section," particularly when a women has had a previous C-section. The result is higher rates of uterine rupture, "as well as injuries to babies caused by vacuum devices and forceps." Sachs commented, "In some parts of the country, some people have tried to mandate a trial of labor and not given the women the option of a repeat caesarean delivery. There is enormous apprehension in the medical community about these mandates and approaches" (Lasalandra, Boston Herald, 1/7). Sachs and his colleagues note that a repeat caesarean delivery at their Boston hospital costs approximately $7,700 -- only $900 more than a normal vaginal delivery. However, a failed vaginal delivery followed by a caesarean drives up the cost $3,000 more than a normal vaginal delivery, and complications stemming from a botched procedure can add an additional $6,000 to the total bill (NEJM, 1/7). Co-author Dr. Frederic Frigoletto, chief of obstetrics at Massachusetts General Hospital, concluded, "We should begin by identifying what the rate should be for given conditions: multiple births, breech presentation, diabetes in the mother, etc. We need data to determine this so we can establish rates based on the best outcomes, not rates set by bureaucrats with economically driven motives" (New York Times, 1/7).
Kaiser Daily Reproductive Health Report
Br J Obstet Gynaecol. 1991 Jul;98(7):667-74.
Delivery in an obstetric birth chair: a randomized controlled trial.
Crowley P, Elbourne D, Ashurst H, Garcia J, Murphy D, Duignan N.
Coombe Lying-In Hospital, Dublin, Ireland.
OBJECTIVE--To determine whether nulliparae whose second stage of labour is conducted in an obstetric birth chair have a lower incidence of instrumental delivery than those using a conventional delivery bed. DESIGN--Randomized controlled trial using sealed, opaque envelopes for allocation. SETTING--Delivery ward in a busy teaching hospital. PATIENTS--1250 nulliparae with a singleton live fetus with cephalic presentation, without epidural anaesthesia, who had achieved full dilatation. INTERVENTION--Intention to conduct second and third stages of labour in either the Birth-EZ chair or the conventional delivery bed, as randomly allocated. MAIN OUTCOME MEASURES--Primary measure: vaginal operative delivery; principal secondary measures: duration of second stage, perineal trauma, blood loss, women's views, and neonatal status. RESULTS--Delivery in the birth chair did not result in a reduction in operative delivery, overall. However, there was a reduction in vaginal operative delivery for fetal heart rate abnormality. There was no beneficial effect on perineal trauma or puerperal perineal pain. Post-partum haemorrhage was more frequent in the birth chair group. CONCLUSIONS--Delivery in the birth chair does not offer an advantage to women over delivery on a bed.
HOW CAN WE INFORM PREGNANT PATIENTS
ABOUT OBSTETRIC ANAESTHESIA • 11 RC 3
Charles Marc SAMAMA, MD, PhD, Meyer Michel SAMAMA, MD, PhD
Sunday 30 May 1999 Amsterdam
"No one understands another's pains nor another's joys"
Franz Shubert, 1824
Attitudes to labour pain
Despite developments in obstetrics, opinions still vary about the appropriate management of pain during childbirth. In the past, paternalistic medicine did not pay much attention to womens’ views, and this neglect may still affect attitudes towards the control of labour pain. Some proponents of natural childbirth have increased the controversy on the nature, function and intensity of labour pain by poor information about labour pain and poor information about treatment[1,2]. Some parturients are misinformed about the risks of effective analgesia and not aware of the benefits of appropiate control of intense pain, and are thus reluctant to accept effective pain relief. Other parturients do not want any anaesthetic intervention and are strongly motivated to cope effectively even with intense pain [3-5]. In a study of the antenatal expectations of 1091 parturients, 4 % of primiparas and 14 % of multiparas expected that they would not need any analgesia during labour, but when in labour, 52 % of these women changed their mind and requested pharmacological pain relief . Melzack et al. found that the parturients who had attended antenatal classes reported less pain than those who had not, but equal proportions of both groups (more than 80%) requested epidural analgesia during labour .
Intensity of labour pain
Many studies show that most primi- and multiparas experience severe to unacceptable levels of pain during childbirth [2,4-6,8]. Labour pain is unique in that under no other circumstances is the patient allowed to suffer such intense pain under a physician's care. Melzack compared the mean total pain scores (0-50) for several pain syndromes and found that those for labour pain were 8 — 10 points higher than those associated with, for example, back pain, cancer pain, toothache or fractures [6,8]. The intense pain provokes a stress response, with stimulation of respiration, circulation, hypothalamic and autonomic centres, and neuroendocrine and psychodynamic responses. Unnecessary maternal suffering can harm both the mother and the fetus/neonate [2,9]. Pain can be treated with a range of methods, especially epidural analgesia.
Because pain is a personal experience, it is difficult to quantify. The patients' own report is the most valid measure of the severity of labour pain. Professionals' estimations of the intensity of labour pain are significantly less than the pain reported by the parturients themselves. This can lead to a misunderstanding, and affect the availability of pain relief .
In modern obstetric units, the practice is to use some form of pharmacological pain relief. Pregnant women have a right to basic information about the severity of labour pain and its treatment as well as other aspects of care during childbirth.
Finding out what is available
Most women living in the developed countries give birth in hospital. In the Nordic countries, for instance, over 99 % of deliveries take place in hospitals and all obstetric units have an anaesthetic service of some kind. Pregnant patients are informed antenatally by maternity health care clinics, which coordinate antenatal education, and over 95 % of Nordic mothers currently use these services . However, different hospitals and different countries show huge variation in the range of options available for pain relief and anaesthesia in childbirth [5,11]. There are several reasons for these disparities. Some units do not have adequate staffing or facilities.. In each centre, the opinions and traditions of the obstetric and nursing staff have an important influence on the pain relief facilities that are available. Some centres are more receptive to consumer opinion than others and try to obtain the opinions of parturients about their expectations and experiences [4-5, 11-12].
According to the study of Ranta et al., 90 % of Finnish parturients expected to receive pain relief during labour, knew of the analgesic options available, and knew what to request . This differs strikingly from the study by Senden et al., where only 20 % of Dutch and 60 % of American women anticipated receiving treatment . In Holland, most deliveries take place at home, and only 20 % of pregnant patients give birth in hospital, which might explain the differences in maternal expectations (personal communication).
If there are no effective methods to relieve labour pain, the parturient should be warned about the severity of the pain she might experience during labour and delivery and told honestly about the facilities on offer. Physicians and hospitals should not promise what they cannot provide. Realistic expectations might help the parturient to cope with the necessities of labour and to control her body during pain .
In practice, prenatal preparation of parturients, including education on pain, analgesia and anaesthesia, is provided most commonly by general practitioners, obstetricians and midwives. Modern midwives are well-trained and certainly have the broadest view of childbirth, which makes it appropriate for them to be responsible for pregnant patients' antenatal information and care .
Perinatal team management
Education of antenatal caregivers of expectant mothers
Anaesthesiologists, are experts in pain control and obviously have a role in the antenatal preparation of obstetric patients. Beilin et al. studied the knowledge and concerns of parturients concerning obstetric anaesthesia. They found that 28 % did not feel sufficiently informed about obstetric anaesthesia before labour, and 59 % would have wanted a preoperative visit from an anaesthesiologist [14 ].
Pregnant patients have a right to be informed objectively and reliably about the severity of labour pain, its effects, and the available pain control. At present, in most countries it is not possible for anaesthesiologists to be able to prepare every parturient. Good communication with midwives, physicians and obstetricians should be maintained in antenatal care and the anaesthesiologist should be available for consultation.
Anaesthesiologists should take more responsibility for pain relief in childbirth by providing education on obstetric pain control. Their own knowledge should be be checked and updated regularly 4,12,14 .
Who should inform the mothers?
All pregnant women may possibly need anaesthesia or pain relief. Consequently all expectant mothers should be told about labour pain and its treatment by an experienced anaesthesiologist as a part of the anaesthetic services. In clinical practice, anaesthesiologists may not meet the parturients before they are in labour or having difficult deliveries. Ideally, the expectant mother should have the opportunity to meet an obstetric anaesthesiologist if she feels unsure or anxious about her abilities to cope with the necessities of labour or has unrealistic expectations about labour pain and does not get appropiate assurance from her midwife. A woman who has appropiate expectations and trusts her caregivers will accept their advice with greater equanimity, and this will reduce the chances of problems with a difficult labour .
Parturients themselves should not be expected decide what is the best and safest analgesia, before childbirth or even during the progress of labour. They lack experience and cannot be prepared for all the circumstances that may occur. Even very experienced parturients, may encounter unexpected complications where they need the help of skilled professionals [4,7]. Fridh et al. have shown that neither primiparas, nor multiparas had realistic antenatal expectations of the pain 
During labour and delivery
Non-pharmacological pain relief
Antenatal classes should minimise anxiety, fear and ignorance associated with childbirth, create strategies for coping with labour,and help parturients cooperate and participate during labour . Psychological support and encouragement by midwives, other professionals and support companions are essential parts of the proper care of obstetric patients, but they cannot guarantee a normal, uncomplicated and easy labour. There are no good data supporting the view that non-pharmacologic pain relief provides effective control of severe labour pain. Parturients should be told of this beforehand, although the safety of these methods have been confirmed and the methods are generally accepted by midwives and many parturients [3, 15]. These methods can naturally be used to complement pharmacological pain relief.
Pharmacological pain relief
The benefits of analgesic management should be discussed with the parturients. Since local facilities may vary, discussion about the available methods is essential. Each mother should be told of each method: the efficacy, how it is done, the most common side-effects and complications, and the effects on the baby. Although evidence is accumulating that properly administered regional analgesia provides efficient and safe pain relief and reduces both maternal and perinatal morbidity, especially in high risk pregnancies [9,12], not all parturients accept invasive methods, in which case systemic analgesia, volatile agents and opioids, are appropriate choices.
What should the mother be told about epidural analgesia?
Informed consent must be obtained before regional analgesia, as before any medical procedure. In many centres, epidural analgesia is given on request. If the request for regional anaesthesia is made by an obstetrician or other professional who considers the parturient could benefit, it is important, in a case of maternal refusal, to find out why the parturient is reluctant. If she has been misinformed or has unrealistic fears of anaesthetic intervention, she should be properly and objectively informed and reassured of the benefits and positive effects ( an explanation about what the epidural is, how it works, and what special indications there are for epidural in her case which makes the epidural advantageous).
Mothers are naturally anxious about the adverse effects of regional analgesia on the baby, the outcome of labour and themselves. Answers should be based on good evidence. The most common side-effects should be explained to the mother even without her asking, such as the quality of pain relief, the degree of motor block, the risk of headache after accidental dural puncture, pruritus if spinal opioids are used, etc. There are always some risks when invasive methods are used. On the other hand, in expert hands the technique of regional analgesia is very safe and reliable, and has many benefits for the mother and baby, especially in high-risk pregnancies [9,12]. Ideally, the consequences and complications of the procedure should be discussed with the patient before she is under stress and labour has started. This is rarely possible, however, and it is therefore important that written information on the analgesic treatments should be made available in antenatal management, and that all professionals agree on the policy of obstetric anaesthesia. The best persons to inform the expectant mothers are the closest professionals, who, in the Nordic practice, are the midwives
Anaesthesia during operative delivery
The possibility of operative delivery and the anaesthetic options for this should be discussed with expectant mothers. Delivery by caesarean section has become more common in the western countries, from 10 to 25 %, even up to 60 % [11,15-16], reflecting changes in obstetric practice. At present, regional anaesthesia is considered the method of choice if the parturient's medical condition does not require emergency treatment. In each case, the method should be discussed with the patient. Both regional and general anaesthesia are safe and have different advantages, which should be considered .
Informed or written consent
Good medical practice requires good communication between doctors, other health care providers and patients. Patients should receive appropriate information about the treatments, alternatives and risks with an estimate of the probability of occurrence, to allow them to make a balanced judgement before giving consent to invasive procedures. The patient should always have the opportunity to ask questions. In Nordic countries, we aim at mutual confidence between the professionals and the parturient. An anaesthetic would not be given if the patient objected or did not cooperate. The same standards should apply in obstetric care, as those considered routine for surgical patients. The patient always has the right to give or withhold her consent, or to withdraw her consent after it has been given . As with other patients, obstetric patients rely on their attendants’ ability to choose and perform procedures, with as little risk as possible, taking account of the medical indications based on scientific data. Informed consent is the appropriate standard. Discussion about written consent indicates anaesthesiologists' desire to protect themselves, and to this day, the Nordic practice sees no useful point in that for either the professionals or the patients. Parturients should be informed of the local facilities, including any possibility that the facilities may provide limited anaesthetic services, including limited availibility of epidural analgesia. At any rate, all discussion with the patient and the obtained verbal consent should be documented in the notes [19-20].
Mutual trust and confidence between the parturient and the health care professionals, and effective control of intense pain such as epidural analgesia, are appropriate choices and constitute the essential part of the labour pain treatment. Different treatments can be used at the same time, and are not exclusive, unless the fully informed parturient so chooses.
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17. Lanigan C, Reynolds F. Risk information supplied by obstetric anaesthetists in Britain and Ireland to mothers awaiting elective caesarean section. Int J of Obstet Anesth 1995; 4; 7-13.
18. Rosenberg P, Gisvold SE, Flatten H, Nuutinen l, Stenqvist O, Tryggvason B, Viby-Mogensen. Guidelines for anaesthesia care in the Nordic countries. Acta Anaesthesiol Scand 1992; 36: 741-744.
19. Recommended minimum standards for obstetric anaesthesia services. Obstetric Anaesthetists' Association. Int J of Obstet Anesth 1995; 4: 125-128.
20. Grice SC, Eisenach JC, Dewan DM, Robinson ML. Evaluation of informed consent for anesthesia for labor and delivery (abstract). Anesthesiology 1988; 69: A664.
OBGYN.net Conference Coverage
From the 24th Annual American Urogynecology Society Meeting, Hollywood, FL - September 2003
Magnus Murphy, MD & Barbara Nesbitt discuss Pelvic Health & Childbirth
a book by Magnus Murphy, MD and Carol L. Wasson
Barbara Nesbitt: “Hi, I’m Barbara Nesbitt, I’m at AUGS and I have the pleasure of sitting here today with Dr. Magnus Murphy from the University of Calgary. I think you are all familiar with him, he has written a book that we’ve had on OBGYN.net for quite a while, “Choosing Caesarean Birth” and it’s been a little controversial with people that don’t want to choose that way.
But we’re at an Urogynecology conference and obviously we’re talking about incontinence and prolapse and all the things that come from, a lot of times, vaginal birth. We have Dr. Murphy’s new book, “Pelvic Health and Childbirth” and we’re going to discuss it and the reason he wrote this as a follow-up to his first book. It will also be available to us to buy and to read sections of. Dr. Murphy is also a member of the Editorial Advisory Board of OBGYN.net, Urogynecology. Nice talking to you doctor.”
Magnus Murphy, MD: “Well, thank you Barbara. It’s my pleasure, and the privilege is entirely mine. Especially sitting here and looking at this beautiful view out here, all the birds out in the woods. Thank you for having me.”
Barbara Nesbitt: “You wrote the first book, and then you were telling me that there was a whole area left that you wanted to explore in this second book.”
Magnus Murphy, MD: “Yes, the first book, I started working on that in 1998, and as you mentioned, called “Choosing Caesarean Birth”. It basically focuses on caesarean as a possible preventative measure for preventing urinary incontinence and other pelvic floor disorders. What really led to this book is the perceived need, specifically in my own practice, and I’m sure in many of my colleagues’ practices, of education. Educating women on, firstly, what the pelvic floor actually is. I usually get a blank stare when I start talking about the pelvic floor because it’s this esoteric part of our bodies that many people don’t have any idea that even exists. Secondly, to explain what is actually going wrong.
For instance, to give an example, one of the comments I often hear from patients is that they have a bulge in the vagina and so I’m trying to explain what this bulge is, where it came from, why it happened, what can be done about it through various ways; non-surgical, including surgical, and then also what could possibly have been done to prevent it.
So the book will be hopefully, of enough use to women who already have problems, but also for those who still have to decide, specifically then, in terms of how they are going to have their babies.”
Barbara Nesbitt: “So this is something that I think is important because we’re seeing more older women having a first child. We’re not talking about 20 or 30 years ago when it was 18 or 19 year-old girls who didn’t even think to ask the question. Now we’re into 35-year-old and older women having infertility treatments and there’s a plan there. Now they don’t want or need to ruin a bladder system that’s been working fine for years.”
Magnus Murphy, MD: “The other thing is also, not only are women postponing pregnancies, but they are also having fewer babies. Obviously I can’t generalize, it’s a certain section of the population, but in general in western countries anyway, the fecundity, that means the number of babies women are having, has dropped remarkably. Now there has been a slight rise again in certain countries but still it’s incredibly low. The point is that women are having fewer babies, maybe one, or two, at the most three, later in life.
They are also living a lot longer and living more active, productive lives. They want to be able to enjoy life after childbirth, whereas you know in the older days women were either having babies every two years, or life expectancy basically ended at the time when fertility wasn’t an issue anymore. That’s certainly not the case now fortunately, and therefore the long-term effects of childbirth and pregnancy are today a major issue and it’s of prime importance in my view. Whereas in previous centuries and previous years, obstetrics focused specifically firstly on, whether the mother was going to survive childbirth because that was the main issue, and the fetus really was of secondary importance.
In the previous century it all evolved regarding saving the fetus and making obstetrics and delivery and having babies safe for the baby because, to a large degree, we’ve overcome the immediate life-threatening risks to the mother. We’ve gotten to a point where having babies is relatively safe, not only for the mother but also for the baby. My point is that it’s now time to think about the mother’s morbidity, meaning the health of the mother and the effects of having children on their future quality of life. So, it’s not only survival that’s of importance anymore, but now quality of life, and that is to a large degree what this book is about.”
Barbara Nesbitt: “I think we can say that, as you said, in the different generations, this is a generation of a more educated woman who knows to ask questions; maybe more than 20 years ago, ten years ago but they don’t always know what options are available for them. So is this something that they should go to their obstetrician and say, ‘I want to look at having a c-section?’”
Magnus Murphy, MD: “That’s a very good question. I think the important thing is that I fully believe in the principle of not only informed consent but complete understanding of the implications of decisions. The days of paternalistic medicine are long past. I believe women should educate themselves about decisions made, and not have the physicians make decisions completely on their own. Therefore, yes, I think the book discusses childbirth, the pros and cons of vaginal birth and caesarean. The caesarean choice doesn’t necessarily come without risks attached, and it’s important to note that I am not suggesting that women should have a caesarean. What I’m suggesting is that women educate themselves about the choices, about the risks of the different choices, including those risks of caesarean; there are many. And then go to their physicians and discuss this with the physicians.
I’ll give you an example. My sister lives in Pennsylvania and she is a highly educated professional woman. She’s 37-years-old, she’s having her first baby. She asked her obstetrician for a caesarean. This was a few weeks ago. According to her, this person almost fell off his chair. I want to educate women that it’s their right to discuss this, and also physicians that it is their duty to discuss with patients the implications on childbirth of vaginal delivery and also discuss the risks of caesarean.
I think one of the problems with pre-natal care is that we don’t have time. We don’t have the time to discuss many of these things and because of that it becomes neglected. There was this well known study that’s being talked about a lot at these conferences, where in Britain, female obstetricians and female obstetrical senior residents were asked what they would like for themselves for a first baby. More than 30% actually indicated they would like to have a primary, preventative, elective caesarean section. Eighty-five percent of those indicated that they would want this specifically for protection of the pelvic floor. A minority indicated they would want it because caesarean is arguably, although I think there is enough proof of it, safer for the baby.
The point is I am quite sure that very few of those female obstetricians will then go to their offices and discuss this with their own patients. It is something that’s neglected and I think that women have the right to know and have the obligation to educate themselves. Then discuss it and then make their own decision jointly with their physician.”
Barbara Nesbitt: “You and I have been emailing back and forth and you certainly have submitted access to your first book. Anyone who wants to can go online and read chapters from it. You have answered questions. You freely let women write to you and you answer them. Some are very upset with you, some are very glad to hear what you have to say. Controversy is always good. It opens minds, doesn’t it? Makes people think.”
Magnus Murphy, MD: “Yes, I think so. I don’t know if you’ve actually noticed, in this book I have abstracts from certain comments that were posted on my own personal website, which is www.pelvicfloor.net . There was one particular posting that was very poignant, and this lady just tore into me about how dare I make comments like this. And it illustrated to me what a passionate topic this is, and of course, it’s bringing a new life into the world, it is very passionate. This is why I want to again stress that I and Carol Wasson, my co-author, whom I’d really like to acknowledge here, has made a large contribution to the project, we are not suggesting what women should decide. We’re not telling them what they need to do; we are trying to educate them about the fact that they should make a choice.”
Barbara Nesbitt: “You are giving them the option to learn both ways and then make the choice, which they feel is the right one.”
Magnus Murphy, MD: “Exactly, but of course, as you mentioned, it is a continual source of controversy, and I think as women become more knowledgeable, it will be even more so.
I have been told, and this is second-hand information, but I have been told that Germaine Greer, who is a well-known person in feminist circles, has made a comment in Australia where she has said that “the battle for vaginal delivery has already been lost.” Now I apologize if I have this wrong but this is something that I heard second hand. There was also a very, very good lecture by Mrs. Margaret Summerville, who is a well-known ethicist in North America, in Toronto last November 2002. She gave one of the seminal lectures on ethics regarding elective caesarean, and basically indicated that the whole evolution of law and medical ethics, is developing in a direction where physicians may actually be found negligent not having informed people of these issues. That is quite a frightening thought as you can imagine. It is not being done today, and it is very problematic because it is almost like opening a can of worms.
But I do believe that the tide is turning and it’s unstoppable and I wanted to do my part in educating.”
Barbara Nesbitt: “So, come on the website, read the excerpts from this book.* There will be a few chapters on it to begin with before we get the whole thing. Read the whole first book, “Choosing Cesarean Birth.” And write to Dr. Murphy if you have anything that you want to ask him because he has his email address on there, readily available.
I thank you. I was from a day when you just had a baby and you didn’t ask any questions. I like this new way very much.”
Magnus Murphy, MD: “Thank you Barbara.”
Reducing Genital Tract Trauma at Birth
from Journal of Midwifery & Women's Health
Evidence on Relevant Care Measures
While the case for prevention of childbirth trauma is strong, how to actually accomplish this goal is less clear. Four clinical interventions during the second stage of labor have been studied to assess their effects on genital tract trauma. These include: 1) the use of episiotomy, 2) maternal position for birth, 3) the style of pushing, and 4) perineal management techniques used by the birth attendant. All of these are potentially important if they lower the incidence of genital tract trauma, because these interventions may be under the control of clinician to perform or encourage. Of the topics listed above, episiotomy is the only clinical intervention that has been extensively studied.
Episiotomy is a surgical incision in the perineum, performed to enlarge the vaginal opening for birth. Its widespread use has historically been supported by two assumptions: that overall trauma would be reduced by substitution of a controlled incision for a jagged tear in the perineum, and that episiotomy would somehow protect the pelvic floor musculature.[10, 14-17] In the past 15-20 years, numerous randomized trials, observational studies (cohort and case-control designs), and meta-analyses have compared liberal or routine use of episiotomy versus restricted use for specific maternal or fetal indications.[15-17] These studies have been conducted in various countries, populations, and clinical environments. The combined results form a cohesive body of evidence that, while episiotomy may be indicated to shorten the second stage of labor for reasons of maternal or fetal distress, no data confirm any short- or long-term health benefits of routine episiotomy. Further, lacerations of the anal sphincter and rectal mucosa almost never occur except in conjunction with episiotomy.
One aspect of the episiotomy research that needs further investigation is the effect of episiotomy on anterior lacerations of the external genitalia (those to the labial, periurethral, and clitoral areas). While some studies have indicated that lacerations to these sites are less frequent when an episiotomy is performed, much of the episiotomy research is limited by incomplete reporting of trauma in these sites. Also, trauma to these sites tends to be shallow, require less suturing, and confer less long-term pain. Therefore, the evidence to date indicates that the net effect of routine episiotomy is a greater risk of serious trauma to the genital tract (especially third- and fourth-degree tears) with no long-term improvements in postpartum urinary or sexual function, or pelvic muscle tone.[10, 15-17]
No definitive conclusions can be drawn about the effects of maternal positioning or style of pushing in the second stage of labor on genital tract trauma, because of small samples and methodologic weaknesses in much of the research. A meta-analysis of the available research on position for birth suggests that non-lithotomy positions (upright or lateral) for birth might lower overall rates of genital tract trauma. However, disentangling the key variables is difficult. For example, episiotomies are more difficult to perform in non-lithotomy positions, and the need for an episiotomy may dictate the lithotomy position for birth. Spontaneous, self-paced pushing might be preferable to forceful, Valsalva pushing for perineal trauma reduction, but the very small samples studied to date do not permit any firm conclusions.[19, 20]
Two recent studies used large clinical populations to assess the relationship of hand maneuvers by the midwife to genital tract trauma. One study examined hand maneuvers at delivery (expulsion) of the baby, and the other compared perineal massage with usual care in the second stage of labor. The first was a study from Great Britain that assessed the role of hand maneuvers for the actual birth in a large, randomized controlled trial. In this study (called the HOOP trial, for "hands on or poised"), some 5,471 women were randomized to either "hands on" (one hand flexing the baby's head and the other hand guarding the perineum) or "hands poised" (both hands off, but ready to apply light pressure to the advancing head in the case of rapid expulsion) at delivery of the baby. Both approaches are taught in British midwifery education programs for management of birth, and both are practiced in the United Kingdom.
Midwife compliance with the experimental allocation was 84% overall, 95% in the "hands on" group and 70% with "hands poised." After each birth, trauma to all sites in the genital tract was systematically assessed and recorded by the attending midwife. This was the first large clinical study to provide a detailed and complete picture of the total array of genital tract trauma sustained by women having normal, spontaneous vaginal births.
Results of the HOOP trial showed that trauma is indeed a very common experience of low-risk childbearing women: 68% had major or minor trauma to the perineum, 61% had vaginal lacerations, and 11% had episiotomies. The trauma profiles of women in the "hands on" versus "hands poised" groups were virtually identical (recall that the techniques were used at expulsion of the baby, and not earlier in the labor). However, marginally fewer women in the "hands on" group reported perineal pain at the 10th postpartum day (31% versus 34% for the "hands poised" group). This represents a 3% absolute difference (95% confidence interval, 0.5% to 5.0%; statistically significant because the confidence interval for the risk difference does not overlap 0). While this difference is small, it is of interest to U.S. midwives because "hands on" for management of the actual delivery is the practice norm in this country.
Perineal management late in the second stage of labor but prior to expulsion of the baby might facilitate stretching and thinning of the perineum, and thus minimize spontaneous tears. Hand techniques in this time interval were compared in a recent clinical trial from Australia. Midwives randomized 1,340 women to perineal massage with a water-soluble lubricant versus "usual care" in the control group (defined as any method preferred by the clinical midwife except massage with lubricant). No data are reported for midwife compliance with the experimental allocation, length of time the technique was used, or the specific strategies included in "usual care."
The perineal outcomes were similar in the two study groups. No significant differences were observed for intact perineum (27.5% of all study participants), episiotomy (26%), or first-or second-degree tears (43%). Third- and fourth-degree tears occurred in 12 women in the massage group and 24 women in "usual care," but the study sample was not large enough to assess this rare outcome. No harmful effects of perineal massage were found. Women were followed to the third postpartum month to assess differences in perineal pain, dyspareunia, bowel and urinary symptoms, with no differences found.
Conclusions that can be drawn from these two large midwifery studies include the following: "hands on" for a baby's birth appears preferable in terms of decreased perineal pain after delivery, and perineal massage with lubricant in the second stage of labor does not appear harmful. However, genital tract trauma was not reduced in either study. In the HOOP trial, this was probably because the focus was not on "protecting the perineum," and in the Australia study questions remain about separation of the policies (i.e., how much massage did women in the massage group receive, and what was received by the control group with which the massage group was compared?).
Finally, two recent clinical trials have examined the effect of perineal massage in the weeks before delivery on the likelihood of an intact perineum at birth. One study included 861 nulliparous women under the care of midwives in England. The other included 493 nulliparous and 1,034 multiparous women under the care of physicians in Canada. Both randomized women to regular (either daily or every-other-day) massage versus no massage in the final 5 to 6 weeks of pregnancy. The majority of women allocated to massage in each study did not adhere to the recommended frequency and timing of perineal massage. Nonetheless, massage was associated with an increase in the rate of intact perineum in first-time mothers (from 25% to 31% in the English study, and from 15% to 24% in the Canadian study). In the Canadian study, better outcomes occurred in women who performed the most massage. These research findings suggest that perineal massage may have therapeutic value, and that more may be better.
J Midwifery Womens Health 48(2):105-110, 2003. © 2003 Elsevier Science, Inc.
Reducing Genital Tract Trauma at Birth
from Journal of Midwifery & Women's Health
Care Measures Utilized by U.S. Midwives
In the absence of national datasets that describe perineal care measures used by U.S. midwives at birth, estimates must be derived from observational reports. As such, large samples or data from multiple sites are preferable. Two reports, one from hospital settings and one from home birth practices, provide baseline information on techniques used by midwives in the United States.
The hospital data reported perineal management techniques used by midwives in three hospitals, in 2,595 spontaneous vaginal births. The intact perineum rate was 49% for the study population (44% nulliparas and 56% multiparas). The following techniques were used in the second stage of labor: manual support of the perineum was used in 48% of births, warm compresses in 20%, oils/lubricants in 18%, and perineal massage in 9%. Warm compresses to the perineum and a lateral position for birth were associated with intact perineum. The use of oils or lubricants and the lithotomy position were associated with spontaneous lacerations. But because the care measures were not randomly assigned, these associations cannot be interpreted as causal. When queried about their practice after the data collection was completed, midwives reported that they used lubricants and massage when they felt a tear was likely.
The home birth data were derived from a prospective study of planned home births with certified nurse-midwives from 28 practices in the United States. Perineal management techniques were reported for 1,068 women who gave birth at home. The intact perineum rate was 70% for the study population (20% nulliparas and 80% multiparas). The following techniques were used: manual support in 72% of births, warm compresses in 41%, oils/lubricants in 37%, and perineal massage in 27%. Manual support was associated with intact perineum, but both compresses and massage with lubricants were associated with lacerations. Again, midwives may have used these care measures in anticipation of trauma.
These studies indicate that midwives are familiar with and utilize an array of perineal management techniques in labor, particularly in home settings, in the belief that they may be helpful to women. While observational data can quantify the association of specific perineal management techniques to an intact perineum at birth, a causal link cannot be established without randomization in the data.
Reducing Genital Tract Trauma at Birth
from Journal of Midwifery & Women's Health
Potential Therapeutic Effects of Compresses and Perineal Massage
Late in the second stage of labor, the perineal tissues and vaginal outlet must thin and stretch. This structural remodeling of the lower genital tract is necessary for progressive fetal descent and birth. Late in the second stage, unanesthetized women commonly report a strong burning sensation that accompanies acute perineal stretching, vaginal distension, and fetal head pressure. The manual techniques used by nurse-midwives are intended to provide comfort and facilitate the normal physiologic process. Two of the techniques, warm compresses and massage with lubricants, are used for therapeutic purposes elsewhere in the body (e.g., low back pain or muscle spasms).
Current textbooks of both Physical Therapy and Massage Therapy detail the potential therapeutic effects of warm compresses and massage with lubricants.[26-30] The superficial (surface) application of moist heat increases blood supply by vasodilatation, promotes relaxation, encourages tissue stretching or extensibility, and provides some degree of pain relief.[26-28] The ideal temperature range for the superficial application of heat is 104°F-113°F (40°C-45°C). Within 6 to 8 minutes, heat penetration of tissues to a depth of 3 cm can be reached. Massage improves local circulation by direct biomechanical responses to manipulation, encourages relaxation and stretching of tissues, and influences sensation and pain perception.[29, 30] Ideal massage strokes are firm, slow, even, and repetitive. The purpose of lubricants is to reduce skin friction during massage.
Both warm compresses and massage with lubricants encourage muscle relaxation and tissue extension, and increase blood supply to the areas of the body to which they are applied. Both can send competing sensory signals to the brain, providing a distraction from other discomforts being experienced late in labor, when the time of delivery is near. The effects of these manual techniques may be modified by factors related to the physiologic process of thinning and stretching of the vaginal and perineal tissues at birth: parity, length of the second stage of labor, the style of pushing, maternal position, epidural analgesia, and size and position of the infant.[9, 14-16] Thus, for a study to evaluate the relative contribution of these hand techniques, data collection must include all relevant factors in a sample of adequate size.
Reducing Genital Tract Trauma at Birth
from Journal of Midwifery & Women's Health
Why Conduct a Clinical Trial?
Conducting a clinical trial on care measures that might lower trauma to the genital tract at birth is important for several reasons:
1. It addresses a common problem. Childbirth is a common clinical event, and most women who give birth experience some type of trauma to the birth canal. This trauma can negatively affect the health and well-being of new mothers, in some cases for a very long time.
2. Preventive care strategies have not been identified. Preventing even some childbirth trauma would benefit many women, and would simplify both early and longer-term postpartum care. Limiting the use of episiotomy is the only care strategy that has clear support in a substantial body of evidence. But many other clinical practices have not been fully evaluated; in particular, the hand maneuvers used by the birth attendant. The choice of hand maneuvers is a clinical decision at every birth, and can vary according to patient data, clinician preference, and institutional norms, but the contribution to trauma reduction is not clear.
3. The results of a clinical trial will generate evidence for practice. The strongest evidence for a treatment or intervention comes from comparisons of people who have been randomized to alternate forms of care in prospective trials. At present, no clear evidence is available to guide clinical practice in reducing genital tract trauma, apart from limiting the routine use of episiotomy.
4. Although clinical trials are not common in midwifery, a midwifery practice is the ideal setting to test the relationship of hand maneuvers in second stage labor to likelihood of an intact perineum after birth. In midwifery practices, rates of episiotomy (intentional trauma) tend to be low, but rates of spontaneous trauma are still high. Midwives already use a variety of techniques to "protect the perineum," so a structured comparison of the care measures does not require a drastic change in usual care.
In a randomized trial, patients who give consent and meet specific inclusion criteria are assigned to different clinical care measures. The groups are followed forward in time, and an outcome is later measured in all participants. Because the care measures are assigned by a random process (such as sealed and numbered envelopes, or a random numbers table, as opposed to clinician or patient preference), selection bias is eliminated. This means that known and unknown factors that could explain differences in outcomes will be equally distributed in the study groups. Thus, any differences found will likely be due to the experimental intervention.
Reducing Genital Tract Trauma at Birth
from Journal of Midwifery & Women's Health
Overview of the Intact Study
The midwifery study at the University of New Mexico teaching hospital began in the fall of 2001.
Study procedures in the HOOP trial were used as a model for the consent, randomization, and data collection steps in this study. Consent is sought in prenatal clinics from healthy women in midwifery care who anticipate a vaginal birth. Following verbal and written consent, the patient's chart is marked to indicate her consent. Randomization occurs in active labor, when vaginal delivery appears likely. The midwife draws a sealed, numbered opaque envelope that assigns the perineal management technique to be used (warm compresses, massage with water-soluble lubricant, or no touching until crowning is imminent). The midwife records the technique used, the length of time in which the technique was used (if warm compresses or massage with water-soluble lubricant), and whether the woman asked the midwife to stop the specific care measure. For all births, the midwife is free to use "hands on," as defined in the HOOP study, for crowning and expulsion of the baby.
After the birth, the midwife performs a complete examination of the genital tract and completes a data sheet that asks for demographic, clinical, and outcome items. These include maternal age, parity, ethnicity, body mass index, weight gain in pregnancy, birth position, use of epidural or oxytocin, length of second stage, style of pushing used by the mother, position of the baby's head at expulsion, whether the birth occurred with or between contractions, whether terminal fetal bradycardia or compound presentation occurred, and birthweight and Apgar scores. Additional data are collected at hospital discharge, and at the postpartum office visit.
Factors expected to minimize bias in the study include the random assignment of the perineal care measures, recording by the midwife of the duration of use of the allocated perineal management technique, and assessment of midwife compliance with the experimental allocation and assessment of genital tract trauma by self-report, and by report of a second observer in 15% of the births. The planned sample size is 1,200 women, 400 for each hand technique, which will detect an increase in intact perineum from 50% to 60%, if a change truly exists. Regression analysis will be used to assess the relationship of the hand techniques used by the midwife to the likelihood of an intact perineum, with simultaneous adjustment for potentially related clinical variables.
Why the University of New Mexico?
Midwifery is relatively well established in New Mexico, and a large midwifery service has operated at the University of New Mexico teaching hospital since 1978. The 13 midwives are mature clinicians: their average age is 48, and their mean number of years in midwifery practice is 16. The group has been active in research for over a decade, utilizing standardized data collection techniques for analysis of practice data on various topics. The midwives serve a diverse patient population (non-Hispanic whites, Hispanics, and American Indians) from five ambulatory clinics. The episiotomy rate is under 10%, and the baseline rate of intact perineum is 50%, a higher rate than reported in published research with hospital births. If a particular hand technique lowers genital tract trauma in this clinician group, it may have a greater impact in settings with higher rates of spontaneous childbirth lacerations.
In the first year of the clinical operations, 425 women have been randomized into the study. The plan calls for 1,200 women to be randomized by 2004, and data will be available in 2005. Results will inform the practice of all maternity care clinicians as to whether the hand maneuvers under investigation should or should not be utilized prior to birth. This is because random assignment of the clinical care measures (in this case, perineal management techniques used by midwives prior to vaginal birth) is the preferred way of assessing the causal connection to a specific health outcome, such as intact perineum.
Dr. Leah Albers is the principal investigator. Kay Sedler, CNM, MN, FACNM, is co-investigator and has primary oversight of the clinical operations. All UNM midwives are essential participants in the study: Dympna Bartlett, Ginie Capan, Ellen Craig, Betsy Greulich, Martha Kayne, Robyn Lawton, Laura Migliaccio, Regina Manocchio, Barbara Overman, Deborah Radcliffe, Martha Rode, and Beth Tarrant. Patricia Peralta is the Administrative Assistant for the study.
Genital Tract Trauma in Three Intervention Groups*
|Outcome in nullipara and multipara women combined|
40% nullipara 60% multipara
| Warm compresses|
| Massage With Lubricant|
|Hands Off |
| Any Trauma||310(76.7)||309(76.7)||314(77.7)|
| No Trauma||94(23.3)||94(23.3)||90(22.3)|
| PERINEAL TRAUMA|
| 1st degree||97(24.4)||91(22.6)||89(22.0)|
| 2nd degree||70(17.3)||73(18.1)||74(18.3)|
| 3rd degree||3(0.7)||4(1.0)||2(0.5) |
| 4th degree||0(0.0)||1(0.3)||4(1.0)|
| LOCATION OF OTHER TRAUMA|
|Labial||198(49.0) ||198(49.1) ||191(47.3) |
|Periurethral||58(14.4) ||40(9.9) ||53(13.1) |
|Clitoral||16(4.0) ||13(3.2) ||20(4.9) |
|Cervical||2(0.5) ||0(0.0) ||0(0.0) |
| TRAUMA SUTURED||83(20.5) ||75(18.6) ||88(21.8) |
| reported as n(%)|
J Midwifery Womens Health. Author manuscript; available in PMC 2006 January 25.
Published in final edited form as:
J Midwifery Womens Health. 2005; 50(5): 365–372.
Results of this study indicate that warm compresses or massage with lubricant provide no apparent advantage or disadvantage in reducing obstetric genital tract trauma, when compared with keeping hands off the perineum late in the second stage of labor. Spontaneous childbirth lacerations are neither more nor less frequent following use of any of the three methods of perineal management tested in this clinical trial.
These results are unlikely to be explained by selection bias. The randomization procedure produced groups that were very similar with regard to demographic and prognostic variables. Midwives followed the ordered sequence of the randomization scheme correctly. Concealment of the allocated perineal strategy from the clinical midwife was not possible. Therefore, the potential for reporting bias in data collected immediately after birth was a possibility. However, with 12 expert midwives participating in the study and no midwife performing over 13% of study births, any clinician bias in data collection would be unlikely to influence group data.
The results are also unlikely to be explained by poor or uneven compliance with the study protocol. Midwife self-reported compliance was very high, and was equal across study groups. This self-reported compliance was documented by a second midwife observer in a random sample of 25% of the study births. To their credit, midwives in the study setting were willing to suspend their individual preferences in perineal management to carry out this investigation. In 84% of births observed by a second midwife, complete agreement between the two midwives occurred for the site and extent of all obstetric lacerations. Three-quarters of disagreements concerned diagnosis of the degree of minor trauma to the external genitalia.
The midwives at UNM have a high degree of expertise in the conduct of normal childbirth, and their rate of an intact genital tract (defined as no tissue separation at any site) in the study was 23%. This is higher than the rate of 16% (using the same definition of “intact”) found in the HOOP trial from the UK16. Studies of perineal outcomes have commonly defined an intact genital tract as “no trauma, or minor and unsutured trauma”. If this broader definition were used in the current study, the midwives’ rate of “intact” would be 73%, a startlingly high rate, given that 40% of all study participants were first-time mothers. Episiotomies are rarely cut by any care providers at the UNM teaching hospital, and the obstetric culture favors patience and vaginal delivery technique that is calm and controlled, with emphasis on slow expulsion of the infant.
Women who experienced genital tract trauma received warm compresses or massage with lubricant for greater time in the second stage of labor, but a cause and effect relationship cannot be assumed from this finding. Other clinical factors associated with a longer second stage could increase the risk of trauma while permitting longer receipt of these perineal care measures.
Multivariate analysis identified six variables that predicted genital tract trauma in this study. Two variables, nulliparity and high infant birthweight, have been repeatedly observed in prior research17. The effects of race/ethnicity and greater maternal education were small but significant. These four factors cannot be altered by clinicians, but may indicate a need for special efforts to minimize genital tract trauma in vaginal birth.
Two care measures were associated with a lower risk of trauma. Giving birth sitting upright and delivery of the infant’s head between uterine contractions are measures familiar to practicing midwives and indicate several things. A sitting position allows the mother greater comfort and autonomy at delivery. It allows face-to-face proximity and direct visual contact between the mother and midwife. Delivery of the head between contractions requires communication, synchrony, and shared responsibility for a slow and gentle expulsion of the infant.
Several factors might limit generalizability of the findings reported here. First, the study setting may be unusual in that episiotomy and vaginal operative procedures are rarely performed by any care providers. This allowed spontaneous lacerations to be a relatively pure focus of the study. In settings where use of episiotomy and vaginal operative procedures are more common, it is difficult to isolate spontaneous trauma from clinician-induced trauma. Second, the 12 midwives who performed this study already have a high degree of expertise at minimizing trauma in vaginal birth. The research team hypothesized at the start of the study that if the hand techniques could lower trauma rates with these clinicians, they would likely have greater health potential elsewhere. Third, the possibility exists that the hand techniques used in this setting might improve patient outcomes in other places where clinicians have higher baseline rates of childbirth lacerations. Warm compresses and massage with lubricant require the constant bedside presence of the birth attendant, which women appreciate. Greater support and intensity of interaction may affect how women respond to what clinicians do. Strengths of the study include the random assignment of the perineal care measures, the large sample of healthy gravidas, the high degree of midwife compliance with the study protocol, and the accuracy of data collection.
Data from this study demonstrated that with rare use of episiotomy and vaginal operative delivery, low rates of serious obstetric trauma were achieved. Most trauma was minor, and affected the external genitalia, the outer vagina, or perineum (first-degree). Neither the use of warm compresses or perineal massage with lubricant late in the second stage of labor increased or decreased the overall rates of genital tract trauma. These results support the choice of perineal management strategy by individual women and their birth attendants, based on maternal comfort and other clinical factors, but not for presumed trauma reduction. However, clinicians are advised to review their usual practices regarding maternal positioning at birth and infant delivery technique to help lower the incidence of obstetric genital tract trauma.
This study was supported by grant 1 R01 NR05252-01A1 from the National Institute of Nursing Research/National Institutes of Health. All the UNM midwives share responsibility for the success of this investigation: Ginie Capan, Ellen Craig, Kelly Gallagher, Betsy Greulich, Martha Kayne, Robyn Lawton, Regina Manocchio, Laura Migliaccio, Deborah Radcliffe, Martha Rode, Dympna Ryan, Kay Sedler, and Beth Tarrant.
precis: Selected midwifery strategies for management of the perineum in childbirth (warm compresses, massage with lubricant, or hands off until crowning) were not associated with more or fewer spontaneous lacerations.
bio sketches: Leah Albers, CNM, DrPH, FACNM, FAAN, has been a midwifery teacher and researcher at the University of New Mexico College of Nursing since 1991. She was the PI for this study.
Kay Sedler, CNM, MN, FACNM, has been Chief of the Nurse-Midwifery Division and a faculty member in the Department of Obstetrics and Gynecology, University of New Mexico Health Sciences Center since 1983. She was a co-investigator for the study and managed the clinical operations.
Edward J. Bedrick, Ph.D., is Professor of Statistics at the University of New Mexico. He was the study’s statistician.
Dusty Teaf, MA, is a computer hardware and software expert at the University of New Mexico. She generated the randomized allocation sequence, created the data-entry platform for the study, and served as the database manager.
Patricia Peralta was administrator for the study and coordinated all data collection, entry, and verification. She assisted Dr. Albers with endless decisions.
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Reducing Genital Tract Trauma at Birth
from Journal of Midwifery & Women's Health
Prevalence of Genital Tract Trauma Following Birth
Trauma to the genital tract can be secondary to episiotomy, spontaneous lacerations, or both. Although genital tract trauma is common, its full extent may be underestimated. Reasons for this include incomplete assessment of trauma by birth attendants, underreporting of some types of injury, practice variations in determining which lacerations need to be sutured, and differences in how minor trauma is classified.
Clinical data from a midwifery randomized trial in the United Kingdom conducted in the mid-1990s was the first to address this gap. After each birth in the study (n = 5,471) the midwife conducted a complete assessment of the location and extent of all trauma to the genital tract. Including episiotomies (11% for the study), 2/3 of women experienced first- or second-degree perineal trauma, half had tears in the outer vaginal vault, and 1/3 had labial tears.[3, 4] The majority of all women required suturing. Because the study participants were low-risk women in midwifery care, these data may underestimate the full array of genital tract trauma in unselected obstetric populations.
While episiotomy rates in the United States have declined over the past two decades, rates of spontaneous trauma have actually increased. Episiotomy has fallen from 64% of all vaginal births in 1980 to 39% in 1998, but spontaneous trauma has risen from 14% to 48% of all births in the same time interval when no episiotomy was performed. Lacerations to the anal sphincter and rectum are consistently more likely with, than without, episiotomy.[
Reducing Genital Tract Trauma at Birth
from Journal of Midwifery & Women's Health
Consequences of Genital Tract Trauma after Birth
Three population-based studies published in the 1990s were the first to document the high prevalence of health problems reported by women after childbirth.[6-8] Perineal pain features as a common symptom, being reported by 21% of new mothers at 6-7 months after vaginal birth, and 10% at 12-18 months. This protracted pain can impact daily activities and family functioning because of the links to bowel and urinary dysfunction, interference with sexual activity, fatigue, and depression. For new mothers, none of these issues can be viewed as inconsequential.
Postnatal perineal pain bears a direct relationship to the extent of trauma to the genital tract at birth.[3, 9-11] Such pain is rarely reported by women who experience no trauma at all with vaginal birth (i.e., women with an intact perineum). A gradient in reported perineal pain has been demonstrated according to the degree and complexity of the genital tract injury sustained. The highest reports of perineal pain follow third- and fourth-degree lacerations (those that extend through the anal sphincter and rectal canal respectively) and sulcus tears (those that extend to the mid-upper vaginal vault), all of which are more common with antecedent episiotomy.[3, 10] Maternal reports of pain following first- and second-degree perineal lacerations (those to the skin, subcutaneous, and muscle layers) or those to the outer vaginal vault vary according to the depth and extent of injury to these sites, and the amount of suturing required.[3, 11] That is, more trauma and suturing means more pain and other problems for new mothers.
Women who deliver over an intact perineum have less blood loss, less risk of postpartum infection, and report less perineal pain after birth. They also have stronger pelvic floors and report less urinary and anal incontinence than do women who deliver with either episiotomies or spontaneous lacerations.[10-12] Because an intact perineum may require a longer second stage to allow the perineum time to stretch, there has been concern about potential adverse effects on the fetus/neonate. However, no data have demonstrated any harm to term infants of healthy mothers, as measured by low Apgar scores, birth injury, or cerebral palsy, by delivery over an intact perineum.
What is apparent is that lowering the frequency and severity of genital tract trauma could result in reductions in pain and other functional impairments in new mothers. Given the health benefits for women that accompany an intact perineum after childbirth, renewed interest in investigating techniques to preserve perineal integrity is justified.