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Selective versus routine use of episiotomy for vaginal birth

Normal birth can cause tears to the vagina and the surrounding tissue, usually as the baby's head is born, and sometimes these tears extend to the rectum. These are repaired surgically, but take time to heal. To avoid these severe tears, doctors have recommended making a surgical cut to the perineum with scissors or scalpel to prevent severe tearing and facilitate the birth. This intervention, known as an episiotomy, is used as a routine care policy during births in some countries. Both a tear and an episiotomy need sutures, and can result in severe pain, bleeding, infection, pain with sex, and can contribute to long term urinary incontinence.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2017

Continuous and individual interrupted sutures for repair of episiotomy or second‐degree tears

Continuous stitching causes less pain than interrupted absorbable stitches when used for repairing the perineum after childbirth.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Absorbable stitches for repair of episiotomy and tears at childbirth

Approximately 70% of women who have a vaginal birth will experience some degree of damage to the perineum, due to a tear or cut (episiotomy), and will need stitches. This damage may result in perineal pain during the two weeks after the birth, and some women experience long‐term pain and discomfort during sexual intercourse. The impact of perineal trauma can be distressing for the new mother when she is trying to cope with hormonal changes and the demands of her baby, and it can have a long‐term effect on her sexual relationship. Most modern materials that are used to stitch the perineum are gradually absorbed and do not need to be taken out. Sometimes, however, stitches have to be removed by the doctor or midwife. A small number of perineal wounds come open (break down) or have delayed healing, and some of these may need to be re‐stitched.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2010

Indometacin in use as a single dose for treating acute postoperative pain

Indometacin is a non‐steroidal anti‐inflammatory drug (NSAID) used for treating postoperative pain. This review found only one small study of women with post‐episiotomy pain where the effectiveness of the drug (taken by mouth) was compared with a placebo. Conclusions about the effectiveness of orally administered indometacin cannot be made until more studies are undertaken.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2011

Rectal analgesia for pain from perineal trauma following childbirth

Rectal suppositories give short‐term pain relief for perineal trauma after childbirth.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

Topically applied anaesthetics for treating perineal pain after childbirth

Not enough evidence to say if local anaesthetics applied to the perineum help to relieve perineal pain after childbirth.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

Local cooling for relieving pain from perineal trauma sustained during childbirth

Perineal tears are common during the birth of a baby. In addition, sometimes the caregiver will cut the perineum to give extra space for the baby to be born (episiotomy). These tears and cuts often cause pain for women in the hours, days and sometimes months after the birth. This can reduce a woman's ability to walk and to sit comfortably, and it may affect her ability to care for her baby, including breastfeeding. Women often use a number of methods to relieve the pain, including cold baths, ice or cold packs on the area. It is important to know if cooling works, and that, even though it is unlikely to occur in this region of the body, too much cooling may possibly delay healing or cause ice burns.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2012

Methods of repair for obstetric anal sphincter injury

Ways of repairing damage to the muscles of the back passage following tearing during a difficult vaginal birth.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2014

Women’s position for giving birth without epidural anaesthesia

Women often give birth in upright positions like kneeling, standing or squatting. Some women give birth on their backs in what are known as ‘supine’ positions ‐ including dorsal (the woman flat on her back), lateral (the woman lying on her side), semi‐recumbent (where the woman is angled partly upright) or lithotomy (where the woman’s legs are held up in stirrups). Birth position can be influenced by many different factors including setting, mother's choice, caregiver preference, or medical intervention. This Cochrane review assessed the possible benefits and risks to the mother and baby, by giving birth in upright positions compared with supine positions and also looked at some individual upright positions for benefits and harms.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2017

Therapeutic ultrasound for postpartum perineal pain and dyspareunia

Too little evidence from trials to show whether women have less pain if they have ultrasound treatment for perineal pain after childbirth.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2009

Effektivitat der liberalen vs. der restriktiven Episiotomie bei vaginaler Geburt hinsichtlich der Vermeidung von Harn-und Stuhlinkontinenz: eine systematische Ubersicht [Effectiveness of liberal vs. restrictive episiotomy in reducing urinary and anal incontinence following vaginal delivery: systematic review]

Episiotomy is the most common surgical intervention in the world. In Europe the rate of episiotomy is approximately 30% (23). Reasons for this intervention are the reduction of risk for tears and incontinence. To assess the effects of restricted episiotomy in the prevention of urinary and faecal incontinence. Medline search for 1990-7/2002, Cochrane Library (Issue 2, 2002), GEROLIT and SOMED and the Internet. RCTs analysing restrictive or non-restrictive episiotomy were included if they had comprehensive randomisation, follow-up and exclusion of selection bias. Cohort studies were assessed to evaluate the risk of developing faecal incontinence. If possible, data were pooled. Included were all pregnant women with vaginal delivery. Intervention/exposition: Restrictive vs. liberal episiotomy (median, lateral or mediolateral). Incontinence rate (urine and stool) 3 months and 3 years post partum. All included randomised controlled studies met the criteria above, one randomised controlled study used blinded assessment of outcome parameter. Lots of follow-up was 33% (after 3 years). Cohort studies partly were retrospective. 2 randomised controlled studies measuring urinary incontinence were included. The rate for episiotomy was 60% in the intervention group with liberal episiotomy and 27% in the restricted group. No difference could be found in groups measuring urinary incontinence (RR 0.98, 95% CI 0.83-1.20). Only two included cohort studies measured the effect of episiotomy on faecal incontinence. The chance of developing faecal incontinence in association with episiotomy was more than threefold (OR = 3.64, 95% CI 2.15-6.14). Restrictive episiotomy neither effects the development of urinary incontinence of post partum women (RR 0.98 95%, CI 0.83-1.20) three months and three years after vaginal delivery, nor the risk for trauma. Women without episiotomy suffer significantly less from faecal incontinence (OR = 3.6). Further investigation is required to measure the effect of no intervention versus liberal episiotomy.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2003

Perineal techniques during the second stage of labour for reducing perineal trauma

Vaginal births are often associated with some form of trauma to the genital tract, and tears that affect the anal sphincter or mucosa (third‐ and fourth‐degree tears) can cause serious problems. Perineal trauma can occur spontaneously or result from a surgical incision (episiotomy). Different perineal techniques are being used to slow down the birth of the baby's head, and allow the perineum to stretch slowly to prevent injury. Massage, warm compresses and different perineal management techniques are widely used by midwives and birth attendants. The objective of this updated review was to assess the effect of perineal techniques during the second stage of labour on the incidence of perineal trauma. This is an update of a review that was published in 2011.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2017

The use of episiotomy in obstetrical care: a systematic review

This review evaluated the effects of episiotomy (incision of the perineum at the time of vaginal childbirth). The authors concluded that the evidence does not support the routine use of episiotomy and that evidence about its long-term effects is limited. Despite the risk of language bias in the review, the conclusions appear likely to be generally reliable.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2005

Outcomes of free-standing, midwife-led birth centers: a structured review

BACKGROUND: Over the last two decades, childbirth worldwide has been increasingly concentrated in large centralized hospitals, with a parallel trend toward more birth interventions. At the same time in several countries, interest in midwife-led care and free-standing birth centers has steadily increased. The objective of this review is to establish the current evidence base for free-standing, midwife-led birth centers.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2004

Codeine-acetaminophen versus nonsteroidal anti-inflammatory drugs in the treatment of post-abdominal surgery pain: a systematic review of randomized trials

This review compared the efficacy and safety of NSAIDs with acetaminophen plus codeine for pain control after post-laporotomy pain. The authors concluded that NSAIDs appeared to have an overall better risk-benefit ratio than acetaminophen plus codeine for postpartum pain. Given that review scoping decisions and study selection were not fully explained, the reliability of the conclusion is unclear.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2009

Antibacterial Sutures for Wound Closure After Surgery: A Review of Clinical and Cost-Effectiveness and Guidelines for Use [Internet]

Surgical site infections (SSIs) account for approximately 20% of all compromised wounds in the Canadian healthcare setting. It is estimated that 6.3% of surgical wounds in Canada result in infection. An overall SSI rate of 2.5% was reported in a sample of hospitalized adults across Canada. In addition to increasing the risk of morbidity, delayed recovery, and prolonged hospital stay, SSIs may increase Canadian healthcare costs associated with surgical procedures. It is estimated that the incidence of SSIs could be reduced by over 50% with the implementation of various evidence-based prevention strategies. Risk factors for SSIs include patient related factors (e.g., diabetes, obesity), category of wound (e.g., clean, clean-contaminated), bacterial species, and hospital-related infection prevention measures. Sutures may act as a medium for bacterial growth and it has been demonstrated by in-vitro and in-vivo animal studies that antimicrobial coating may reduce the risk of SSIs. Antimicrobial sutures, which are currently commercially limited to triclosan coated sutures (TCS) (e.g., Vicryl [polyglactin 910] Plus, Monocryl [poliglecaprone 25] Plus, PDS [polydioxanone] Plus), are targeted for the prevention of SSIs. Although antimicrobial sutures are more costly than conventional sutures, if effective for SSI prevention they may reduce surgery related costs. The reported clinical efficacy of antimicrobial sutures is inconsistent, with some systematic reviews reporting an overall benefit, while others do not. A previous CADTH report summarized evidence suggesting that TCS reduced SSIs compared to non-coated sutures. This report will provide an update and augment a recent CADTH Rapid Response reference list.

Rapid Response Report: Summary with Critical Appraisal - Canadian Agency for Drugs and Technologies in Health.

Version: November 21, 2014
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Alleviating postnatal perineal trauma: to cool or not to cool?

This review examined localised cooling for perineal trauma following childbirth. The authors concluded that it may be effective in reducing inflammatory responses, but that further research is needed to evaluate the impact on healing. The review used relatively rigorous methodology, however, it is difficult to assess the reliability of the conclusions as no statistical data or effects sizes were reported.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2006

Midwife‐led continuity models of care compared with other models of care for women during pregnancy, birth and early parenting

There are several ways to look after the health and well‐being of women and babies during pregnancy, birth and afterwards – these ways are called ‘models of care’. Sometimes, an obstetrician or another doctor is the lead healthcare professional and at other times it is a midwife. Sometimes, the responsibility is shared between obstetricians and midwives. One of the models is called ‘the midwife‐led continuity model’. This is where the midwife is the lead professional starting from the initial booking appointment, up to and including the early days of parenting. We wanted to find out if women and babies do better with this midwife‐led continuity model, compared with other models.

Cochrane Database of Systematic Reviews: Plain Language Summaries [Internet] - John Wiley & Sons, Ltd.

Version: 2016

Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis

The maternal and newborn safety of planned home and planned hospital birth were compared.The authors concluded that less medical intervention during planned home birth was associated with a tripling of neonatal mortality. The conclusions should be interpreted with some caution as they did not reflect all the evidence presented and there was unexplained variability between studies for several outcomes.

Database of Abstracts of Reviews of Effects (DARE): Quality-assessed Reviews [Internet] - Centre for Reviews and Dissemination (UK).

Version: 2010

Intrapartum Care: Care of Healthy Women and Their Babies During Childbirth

The guideline is intended to cover the care of healthy women with uncomplicated pregnancies entering labour at low risk of developing intrapartum complications. In addition, recommendations are included that address the care of women who start labour as ‘low risk’ but who go on to develop complications. These include the care of women with prelabour rupture of membranes at term, care of the woman and baby when meconium is present, indications for continuous cardiotocography, interpretation of cardiotocography traces, and management of retained placenta and postpartum haemorrhage. Aspects of intrapartum care for women at risk of developing intrapartum complications are covered by a range of guidelines on specific conditions (see section 1.8) and a further guideline is planned on intrapartum care of women ‘at high risk’ of complications during pregnancy and the intrapartum period.

NICE Clinical Guidelines - National Collaborating Centre for Women's and Children's Health (UK).

Version: December 2014
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