- Email: [email protected]
Perineal outcomes and nurse-midwifery management
Mona T. Lycbn-Rochek, CNM,MSN,Lash Abers, CNM,IMJH,and DustyTd, MA
Gin
the magnitude
of the problem
OfpHifld~UIl?ilttiSSU~that
the heaith oubme intact pel+?ewl appears so meIy In the literature. Increasing the occurrence of intact perineum may be accomplished by identifying and reducing the rfsks of petined~lunaRecentstucIieshave documented that perineal damage causes known short- and long-term sequelae that negativdy impact the l-m&h of women after childbit& (l5). Yet there is hck of agreement as towhichriskfactorsincreaseordecrease perineal lnum (1. 2. G15). Perineal tTawm owLus either from spontaneous Iamahts or epkiob my; the highest proportion results from epiSc&my (6). Durhy~ 1991, 1,684.OOd women underwent epi-AddreamrqodmcetoMo~T dul-RaheQc, 11317 L&t kkuxk WA 98110.
LyPkKe.
l3aaMge
siotomies in the United States, and epidotomy ranked as the most commonly performed swgical procedure in women (16). 7he reported rates for lacerations. on the other hand, are difhzult to interpret or compare Etue to differing class&cation qtstems (1, 4. 8, 171 and inconsistendes in case definitions (171. In rhis paper, we precent the resulk of an observational cohort study in which we investigated the ass&alions between selected factors and theriskofperineallmumain&nk cared ior b certi5ed nurse-midwives UXMsl. Our pup is to describe he association of perineal outcomes withaueptedriski3ctoisandvatilions in alternative intfapartum cIincaIplYa&es. MATuuALsmThe Div&ion of Nurse-Midwifery the University of New Mexico
at has
recorded data using the NurseMidwifery Clinical Data Set (NMCDS) since 1991(18). The NMfBS wasdevelopedbytheDivisionofResearchoftheAtne&nCo@eof Nurse-Midwives in the iate 1980s (19). It is a standarM data c&ctiontdforlJsebycNMsacrossttle country to accrue data that can describe nurse-midwifery care prac&2s m-tdoutcornes.Illthisshdyu43l&sed theNMCDSforeac.hnomaIqmnh neouSVaginal~thatocx*med
fronlJuly19!31throughJune1!393 WeidzhidedaUwonmmwhowexeattmdedbyaCNMandwhohada
cephalic pres~ntatiun, a sing&on gestation.andagestationaIage~37 weeks.AIlnonozpldkpresenBtiom fUldforcepsiscuwnmdt?&Verieswreexch&d.-b these criteria yielded 1.211 births (Table 1). For each thornan the foBowing
C-L
n
%
zz iA25
301 50
1. Lithotomy
with legs flexed in stir-
4
254
715 242
2. ztc&it$withknees,,(no
534 677
Mona T. Lydon-Rcdek.
ii
studied Nlusirlg 11977). degrees Mexico Resem
19
mu, urn, nurse+nitiwiJery crt the Fmntkr !ikndce school c# Mldwifeq she n?~ued her nuYsing at the Uniuensity of New @!iN, 1988) and case western Uniuenfty (MSN, 199.2). She
ha9pmuiced@w
midwifely in
multiple seuings, i&ding
home, birth center, priuate p-e, and uniue&ty pmdiO?. SkQWledrhereswrch pmgwn for the Nurse-Midw#my
Dhision ut the Uniwrsily MeldcOfoI3&eamsheisadtx.tod stucknt at the Uniwrsify
of New of Washingtan.
3. Any alternative
position, such as squatting, standing, bteml Sims, or handsknees.
Second-stage management of the perineum had four ciassihcations. These inch&d the use of hot compresses, water-based lubricant perineal support (6, 17). or massage
(20). Leah
t. Albets,
uw.
cwm.
receiued
her
nursfng degrees from Vanderbii Univmity (BSN, 1971 and MSIG, 19741. She studied nurse-midwifery at the Unix
4 Medkine
and Dentistry
of New JerSqr (19771. She was in jihcope pmdtce for J J years ond fhen compkted the LWH degree at the Uniue&ty of North Carolina School of Public Health (19!N}. She ho& a joint
appointment in the Uniw Mexia~.
Cdlege
01 Nmsing.
oj New and the
Deptuiment oj Ohsmia and Gpmdogy. School of Medicine. Du+ty Tea!, WI. mdwd her degrees in sxidogy fmm the University oj New Mexico #A, 1981 and MA. 19831. She hasworkedforthepaaJOyeorsasa computer anal@ at the Computer and lnforrmdion Research and Technology
Departmenr of rhe Uniuenity of New MtEdCO.
14
Laceration and midLne episiotomy were the outcomes of interest Clinically significant lacerations that required suturing were disaggregated from supdcial bcerations or minor abrasions. For the purpose of our study, all second-, third-, and fourthdegree lacerations were combined under the category “laceration.” These perineal tears were defined according to Wilfiarns O&e&s (21). Second-degree lacerations Inc!ude injuq of the perineal body, but not the sphincter ani muscle; thirddegree includes any injury of the sphincter ani muscle; and fourthdegree extends through the rectal mucusa. All episiotomies were midline, as no mediolateral episiotomies were performed by our CNMs. The indications for episiotomy anz not explicit& detailed on the NMCDS.
Rebtiverlsks(RR)were~ byllrtiwate~todesaibeassociatiarsbehveen~valiaMes interest and perkeal ou~oomes W = 1,184~.RRt&thestrengthofas6e Uiionbeiweenexposureandoutcome,thusitisausefulmeasureof effectblising~eproblentsurere minimal (2% of cases for perineal outcomes); consequendy the sampIe size is slightly less than 1.231 III Tables 2 through 4. Greenland, Robins, 95% confidence intervals for RRs were dcubt& and skaliskal &icant;e was assessed by Yatescorrected x2 (23). The SAS System 124) was used to export data Into Epi Info (23). RESULTS Characteristics of women cared for by CNMs in our institution during the 2-year study period are shown in Table 1. The perineal outcomes of interest are presented in Table 2 by parity. Our intact perineum rate was 57% for the 2-year study period. The mte of ciinicaUy s@nikant lacerations was 31% (second degree 271, third
TAESLE
2
Perinea! Outcome Rates by Purity uv = 1,184)
679 138
l.Ei 2m alsa o-87 1.43.2m 0.50.0.70
083 1.20
a 2.3Mdd increafe in6tpkumyltl qrhnigmtidas.Thefrequenqraf -=&Y~A~~~
0.53, 1.04 0.96, 1.89
UX!tAWHkeqrtOW~* otorny, whereas American In&an andl-jbpank womenwereless~ toreceive~epMtCMtly.FFactorsaS fLociatedwithepijlotomywereepjdurala~,fetalbisbress,arrd6 thotomy position DeeWry pos&ms otherthanltthotomyhadaprotective effectontheper&umE#rthweQtrt ~3.5OOgmrnsandthepfzsenceof mecontum had a mar$nal asso& tion with episbatomy. Theltseofanpedledmarragement measuces combined reduced theIikefihoodofep&iotomybyM No significant relationships was found between episiotomy and the use of lubrication. Hot compresses had a marginal -tionWttbded epkioromy rates, lzowedy massagehadamar@na~~atPsodatian WithillCT~episidonry~~A large. statWcally signifkcnt efkt wasfwtedbetweenuseofpained support and decreased-.
0.77. 1.59 0.63. 1.30 c.04 <.I)4
1.10
degree
2.7%,
and
four&h
degree re-
0.4%). and 15% of our clienk
ceivedanepisiotorny.hshouldbe noted that episiotomy and lacerations were not mutually exclusive. In the univariate analysis. the facttxsshowninTable3werefoundto habe an asjociation with kcemtiorts. F%higratihadneartwicetherkk of lacemtiotl compared with multi~WCmensrrstainingbcemtions weremorelihdytohavebeennon-
0.70, 0.99 1.01, 1.42 OBEi, 1.37 0.36. 1.23 0.67. 1.10
SE
fTaMe2LTal1b4strrwrs~aa-
socMed~~.~ucbs
1.02. 1.44 0.73. 1.11 0.72. 1.06
0.74. 1.17 0.86, 1.35 I.11 0.90
srreentbe-dm andtb3u!mdibepltshd~ --dwlpOaaO.tmm%arlhe-dPdlb P-.l-sqPotbd -k OLK~af~~l.5%
0.66 1.51
c .oool c .Oool
0.56. 0.78 1.28. 1.79
0.52 1.93
c .cHml i mol
0.44. 0.61 1.64, 2.27
1.04 0.97
0.82, 1.32 0.76. 1.23
l.CMi 0.94 1.17 0.85
0.88, 1.29 0.7.E. 1.14 @.88, 1.56 0.44. 1.13
Hispanic white, xxeiwed epiduml MHhesia, and canied larger infants thanwomenwhodidnotsustainlacesation!xwllellwomen whohadlacerationswerecomparedwiththose whodidnonofthefeuG%stlot%igl&mt difference in the inciderue of fetal distms and meconium, or chosen rrderrtal deliway position. ThepmporMnoftaeerationswas s@geadybwerhwanenwhodid rrotreceke~~d
bill cm and zkimdam k?SStfran1O%dphl@Wkk P%-w%oi~~~ perimmminwh-by
7 &SW pm&m”h” Amekan
Indian
F4p YeS Fotd disirea Absent F-resent
679 330
1.68 Of0
c.cKe C.002
1.19.2.36 0.42. 0.84
419 615
2.35 0.43
c .tmOl < .tMot
1.76. 3.13 0.32, 0.57
411
1.51 0.86 0.70
c .mz c .03
1.15, 1.98 0.62, 1.20 0.51. 0.98
io iiixi
E 44
6 (14%)
997 37
163 (14%) 14 (27%)
0.51 1.95
c.oos <.W
0.32. 0.82 1.22. 3.12
897 137
134 (13%) 43 (24%)
0.54 1.84
c .oool c .oool
0.40. 0.74 1.36, 2.49
972 62
161(:4%) 16 (21%)
0.69 1.44
a9 383
98 (13%) 77 (17%)
0.78 1.28
c .08
0.59. 1.03 0.97. 1.a
131 725 178
66 04%) 44 (11%) 18 (9%)
3.06 0.54 0.59
c .oool c .c001 c .02
2.35, 3.98 0.41. 0.70 0.37. 0.93
bkconium Absent Fre$eilt y3=
(wd
5 3:500 Maternal position Lithotomyt3imrp5 -f-a Altematiw Perineal management c-w=Absent Fvesznt Lubhcant Absent ha2rlt suw Absent Present %Et Present No measures AU measures
117 (16%) 60 (12%)
E
1;
133
901
38 (22%) 139 (13%)
1.66 0.60
737 297
114 (13%) 63 (18%)
9z
28 w%) 149 (13%)
0.77 1.31 2.18 0.46
hers are reflective of the general population of New Mexico. life intact perineum rate in our study (57%) was similar to those observed by Format0 (25) and Paciomik (26). Unlike our tertiary care setting of low- to moderate-risk women, Formato’s study population was selected from a private home birth setting and comprised low-risk women. TWO studies of nursemidwife attended births reported fre-
16
chdedt.hetithatfhfe~c%d not desaibe ethnkity (1, 7, 10, 11, 25).ZiJldtWOWereOn~ white populations (2, St Vatbbles suchasmceand~~be examined in clinical studies. In addition. many of the st~clfes had sample sizestoosmanforfmn~ (3.4,~~9.22,w.a 29); hourwer, futureh-gersam~studiesmaybe able to clarifjf the effect of promising inteWntions. Our 31% Iacemtion rate was difficult to compare with other studies due to differences in birth attendant case definitions of lacer&ion, and client populations. Our rate was similar to those de&bed by Olson et al (9) and Paciornik (26) but lower than Roberts and Mokos (8) and Henrikson et al (lO!. Two studies did not exchcle operative deliveries, reporting mtes of 22% (2) and 45% (1). Parity, birth weight, and mce were factors associated wtth an increased frequency of perineal lacerations and are beyond the contml of the bti attendant Nulliparity is a welJ documented risk factor for lacetation (7. 13, 30. 31). Most studies report an increased risk of lacer&on with increasing bii weight (8, 13, 15. 30, 32). Ours is the first study showing an increased risk of penneal lacerations in non-&panic white women oompared with other ethnic groups. This study did not establish whether selfidentified rac&thnicity had a biological versus sociological association with the outcome. Green and SW Ho0 C301 found that Asian women had a higher risk for perineal lacers tion in nonopemtive births. Combs et al 112) reported an odds rabio for severe lacerations of 1.31 for Asian women in operative births when compared with other ethnic groups
0.96. 1.72 0.58. 1.04
613 421
$%;
physidatlsinamedi+andMridybw-riskpoplhtion.umietionsintheprece&ngstudiesin-
0.44, 1.10 0.91. 2.29
c .08
0.77. 1.51 0.66. 1.29
1.08
0.93 c .@I2 c ,002
1.21, 2.29 0 44.0.83
< .oool c .oclcll
058, 0.99. 1.54. 0.32.
1.01 1.73 3.08 0.65
quencies of intact perineum ranging from a low of 28% (21 to a high of 44% (11); however, these invest@ ton only studied primtgtavidas and included operative deliveries. Other studies of midwife attended births did not differentiate parity, reporting intact perineum of rates of 18% (7). 38% (10). and45% (1). Robertsand Mokos (8) noted a 40% intact perineum rate based on a very small sample from a physician practice.
&aimd
d
Nurse-~
rsspu&d
l
Vol. 40. No. I. denuary*ebuay
1995
Beearrre~~anZiiFiZZ~ signed and were ch.zen molher~~atsendM~thUS~ternaltieandprov&r&cr&on
by the
COddConfoundtheobsavedassoci-
tllmqmd shate&ior&Perbreal giesasso&&dwilhincreasedriskof laceratiwerehotcompressesand lubrication; CNMS may have been moreindin0dtouseslrateg&ifIacerations were anti-ted To date, no eu&nce for the efficacy of hot compresses or lubtkatiun isavailabhz in the hmture. Many authors have described the ilwread likelihood of perineallacerations when episioiomy is performed (13, 15, 17, 27. 34). In fact, thirdand foutthdegree lace&ions almost never occur except in conjunction with episiotomy. One randomized control trial comparing liberal with res&ted use of episiotomy by British midwives found that neither increased perineal lacerations (35). liowever, all fqdstotomies were mediolateml. so despite the rigorous M. the results are not directiy applicable to many pmctice situations in the United States where midline episiotorny is the predominant procedure. Our clients undergoing episiotomy experienced significantly fewer hcemtions. As with !ac#am, non-Hi white women had a significantly hi mte of episidomy. whereas American lndian women expericnced a signSandy lower rate of this slugid procedure. our fildil-fgsinclcated semdting and alternative delivery positions were protective against episiotcmy. while the liti my position carried a three-f& increased risk of ep&tony. This is
Perlne$~anduredaap inealmanagement~combhL?ddam#rsbaleda~dfdEiphStep’rsiotomv.YYefthein~ofaltemittiwstmtegiesfor perineal management has rarely beenaddres&inthelitaature,and whenithas,onlyontiorb&e.d sarr&s(6,22,29).%1dybiasintt1e tWOStUdieSOnperinealmassagepredude&abM.ingaba&forguiding chidpractice. These observations pose two thought provoking questions: Are crws pzlrbcdady skined in minimizing pained fmma? Or, could ethnic differencesinlhewomencaredfor byCN?&betheexplanatinfora relatively high rate of intact perineum? Future work with larger samples will heIp clarify these issues. One s@ength of this study is that i&mentions and outcomes are cofnpared between CM. In CNM versusMDstudies.manyvarialionsin clinical practice may be operating at once, not simply differences in management of the perineum. We suggest perineal outcomes for women attended by CNMs may differ from those of physicians because of the v&&ions in alternative approaches to care. Further, a -n’s ethnic@ may partially explain perineal outcome. In U.S. hospiti setings CNMs are more likely than physicians to cafefortheveryyoung,lhepoor, and minority women (36, 371. Our study population reflects De&q’s
(37) fIndings; twmlell -sKlungn; predominantly on Medicaid, and of minority status. Their age and ethnic background may contribute to our high intact perineum rate. The challenge remains to investigate and identify factors that probect thepelineumand-paineal h;aurrra(3B).Theuseoicta~to
2!3.AuayMD.J3hetEtAEBedd perindmssqeonttshddencedepC *tomy and w lacemtion
7. f&&eP,RoberisJ.Fadznsaso-
&%d chib%&.
with perbd d l’kmas
ouicome Mii
during 19B7;32:
wllay 8 fbberisd.WasD.Delhroryp &bBSwd~auocOmeaJNune haId&aq
19. Greener D. Development i&ion of lhe nurse-mictwifq data st. J Nurse Midwffery 174-83.
1984$918f%o.
9.Ob0nROfsctnC~CoxfSMat0ndbfrthhgpclduonand~injury. J Fam Pratt 199Q3055%7.
20. R&trc.-~.Lundonz Hebwmann.
10. Hen&en IB. Bek KM, HedegardM,Sche~l’Ll. Epfswmyandpaheal I&om in sportlaneous aglnal deEver&BrJObstetGynwcof1992;99: 95&4. 11. Rockner G, Ofund A The use of @&ot0myinp&nipamsin!%ueden.Acta Obset Gynecol Stand 1991;70:325-30.
22. Avery MD. massage. J Nurse 181-4.
gmn for epidemidagy ers Stone 1990.
33. Wkox G. Dellinger
26. Paciornfk M. Arguments -my in favor of squatting Birth 199@17:Io4-5.
15. HehvigJT,l’horpJM,BcwesWA Jhs midline episioiomy increase the risk of third- and fourthdegree facerations in crpemtive vaginal deliveries Obstet Gynecol 1993;82:27&9.
35. S&p J. Grant A. Ga&fa J, EL boume D, Spencer J, ChaImer 1. West Berkshire perineal management trial BMJ 1984.289:587-90.
agains! for birth.
36. National Center for Health Setirtics. Advance report of finaf statistics. 1991. Monthly vital statishc~ repoh vol. 42 no. 3. Hya;tsville (MD): Public Health Service, 1993. 37. Declerq ER The bansformalion Amerkan midwifery: 1975-1938. Public Health 1992;82:-.
L, Piening SL. Cohen of episiotomy and deliucry position with deep perineal lacemtion during spontaneous deliveq in null@-
- -
38. ReynoldsJLllleffMlbfowtoroutirle episioromy. Birth 199320
162-3.
..-...-
hmwaIdNurse-pGdrwlfery
Baruf6
34. Sultan AH. Kamm MA. Huckon CN. Thomas JM. Bartram. Analsphincter disruption dur@ vaginal d&very. N Engl J Med 1993;329:1905-11.
28. Borgatta WR. Association
lac-
DM.
a maternity center and a tertiary hospital obstetric service. Am J O&et 1=16@ 1047-52.
27. Klein MC, Gauthii RJ, Jorgerwn SH. Robbins JM. Kauorowski J, Corii~eau M, et al. Does episiotomy prevent perineal trauma and pelvic floor relaxation? Online Journal of Current Ctinical Trials July 1. 1992: (Dcx. No. IO).
16. Graves W. Summary; National Hbspital Disctwge Survey Advanced &la for vital and hea& *&tics. no 210. Hyattstille (MD]: National Center for Health Stabtics. 1992.
IS, Strobino WS. Ep%iotomy
and its mfe tn the incidence of perineal lacemtfons in
25. Format0 LS. Routine prophylactic epkhtomy J Nurse Midwifery 1985;30: 144-8.
Walker MPR, Farine D. Rolbin SH. Rrachie JWK Epidmat an&&a, eptslobrny. and oti laceration. Obstel Gyrtecol1991;77:66%71
18
Mountain
AH, version 5: a word and statistics proon mXrwomput[GA): USO, Inc..
24. SAS Institute Inc. SAS language and procedures guide, v&n 6.3rd ed. cay (NC): SAS lnsutule hlc, 1930.
14.
P. Severe
32. Mokr Bek K La&erg S. Intervention dwing labor risk factors aswciated with complete tear of the anal sphincter. Ada Obstet Gynecd &and 198&67:31S-8.
?dale LV. Ptineal Midwifery 1987;32:
23. Dean AG, Dean JA. Burton
13. Shhmo P. Klebanoff MA. Carey JC. Midline episiotomies: more harm than good? O&et Gyrtecol 1990;75: 7670.
K. Bergsjo
31. Lfqino u. woods IMP, Raybum WF.MiGOpLS.Third-andfomthdegmetears.5Oyears’expl&nczata univmsity hospital J Rqxcd Med 1%3& 33r423-6.
FG. MxDxtald PC. NF. Gilstap LC. 19th ed. East Nor& Lanqe. 1993.
Dicker RC. Epi Info. processlrg database.
1986c31: 12%134.
and vztfdlnkal 1991;,%
198&101-2.
21. Cunningham Levino KJ, Gant wilhats obaemcs, udk (CT): Appleton
12. combs CA Robertson PA, Laros RK Risk factors for third-degree and forathdegree bCQdOM in forceps and VfWUlldeliveria.hJObStetGynecd rm, 163: 100-4.
17. Hordnes
in a
nurse-Klk&#[email protected]
l
Vol.40.N~.
1.danu&Fehary1995
of
Am J
Gin
the magnitude
of the problem
OfpHifld~UIl?ilttiSSU~that
the heaith oubme intact pel+?ewl appears so meIy In the literature. Increasing the occurrence of intact perineum may be accomplished by identifying and reducing the rfsks of petined~lunaRecentstucIieshave documented that perineal damage causes known short- and long-term sequelae that negativdy impact the l-m&h of women after childbit& (l5). Yet there is hck of agreement as towhichriskfactorsincreaseordecrease perineal lnum (1. 2. G15). Perineal tTawm owLus either from spontaneous Iamahts or epkiob my; the highest proportion results from epiSc&my (6). Durhy~ 1991, 1,684.OOd women underwent epi-AddreamrqodmcetoMo~T dul-RaheQc, 11317 L&t kkuxk WA 98110.
LyPkKe.
l3aaMge
siotomies in the United States, and epidotomy ranked as the most commonly performed swgical procedure in women (16). 7he reported rates for lacerations. on the other hand, are difhzult to interpret or compare Etue to differing class&cation qtstems (1, 4. 8, 171 and inconsistendes in case definitions (171. In rhis paper, we precent the resulk of an observational cohort study in which we investigated the ass&alions between selected factors and theriskofperineallmumain&nk cared ior b certi5ed nurse-midwives UXMsl. Our pup is to describe he association of perineal outcomes withaueptedriski3ctoisandvatilions in alternative intfapartum cIincaIplYa&es. MATuuALsmThe Div&ion of Nurse-Midwifery the University of New Mexico
at has
recorded data using the NurseMidwifery Clinical Data Set (NMCDS) since 1991(18). The NMfBS wasdevelopedbytheDivisionofResearchoftheAtne&nCo@eof Nurse-Midwives in the iate 1980s (19). It is a standarM data c&ctiontdforlJsebycNMsacrossttle country to accrue data that can describe nurse-midwifery care prac&2s m-tdoutcornes.Illthisshdyu43l&sed theNMCDSforeac.hnomaIqmnh neouSVaginal~thatocx*med
fronlJuly19!31throughJune1!393 WeidzhidedaUwonmmwhowexeattmdedbyaCNMandwhohada
cephalic pres~ntatiun, a sing&on gestation.andagestationaIage~37 weeks.AIlnonozpldkpresenBtiom fUldforcepsiscuwnmdt?&Verieswreexch&d.-b these criteria yielded 1.211 births (Table 1). For each thornan the foBowing
C-L
n
%
zz iA25
301 50
1. Lithotomy
with legs flexed in stir-
4
254
715 242
2. ztc&it$withknees,,(no
534 677
Mona T. Lydon-Rcdek.
ii
studied Nlusirlg 11977). degrees Mexico Resem
19
mu, urn, nurse+nitiwiJery crt the Fmntkr !ikndce school c# Mldwifeq she n?~ued her nuYsing at the Uniuensity of New @!iN, 1988) and case western Uniuenfty (MSN, 199.2). She
ha9pmuiced@w
midwifely in
multiple seuings, i&ding
home, birth center, priuate p-e, and uniue&ty pmdiO?. SkQWledrhereswrch pmgwn for the Nurse-Midw#my
Dhision ut the Uniwrsily MeldcOfoI3&eamsheisadtx.tod stucknt at the Uniwrsify
of New of Washingtan.
3. Any alternative
position, such as squatting, standing, bteml Sims, or handsknees.
Second-stage management of the perineum had four ciassihcations. These inch&d the use of hot compresses, water-based lubricant perineal support (6, 17). or massage
(20). Leah
t. Albets,
uw.
cwm.
receiued
her
nursfng degrees from Vanderbii Univmity (BSN, 1971 and MSIG, 19741. She studied nurse-midwifery at the Unix
4 Medkine
and Dentistry
of New JerSqr (19771. She was in jihcope pmdtce for J J years ond fhen compkted the LWH degree at the Uniue&ty of North Carolina School of Public Health (19!N}. She ho& a joint
appointment in the Uniw Mexia~.
Cdlege
01 Nmsing.
oj New and the
Deptuiment oj Ohsmia and Gpmdogy. School of Medicine. Du+ty Tea!, WI. mdwd her degrees in sxidogy fmm the University oj New Mexico #A, 1981 and MA. 19831. She hasworkedforthepaaJOyeorsasa computer anal@ at the Computer and lnforrmdion Research and Technology
Departmenr of rhe Uniuenity of New MtEdCO.
14
Laceration and midLne episiotomy were the outcomes of interest Clinically significant lacerations that required suturing were disaggregated from supdcial bcerations or minor abrasions. For the purpose of our study, all second-, third-, and fourthdegree lacerations were combined under the category “laceration.” These perineal tears were defined according to Wilfiarns O&e&s (21). Second-degree lacerations Inc!ude injuq of the perineal body, but not the sphincter ani muscle; thirddegree includes any injury of the sphincter ani muscle; and fourthdegree extends through the rectal mucusa. All episiotomies were midline, as no mediolateral episiotomies were performed by our CNMs. The indications for episiotomy anz not explicit& detailed on the NMCDS.
Rebtiverlsks(RR)were~ byllrtiwate~todesaibeassociatiarsbehveen~valiaMes interest and perkeal ou~oomes W = 1,184~.RRt&thestrengthofas6e Uiionbeiweenexposureandoutcome,thusitisausefulmeasureof effectblising~eproblentsurere minimal (2% of cases for perineal outcomes); consequendy the sampIe size is slightly less than 1.231 III Tables 2 through 4. Greenland, Robins, 95% confidence intervals for RRs were dcubt& and skaliskal &icant;e was assessed by Yatescorrected x2 (23). The SAS System 124) was used to export data Into Epi Info (23). RESULTS Characteristics of women cared for by CNMs in our institution during the 2-year study period are shown in Table 1. The perineal outcomes of interest are presented in Table 2 by parity. Our intact perineum rate was 57% for the 2-year study period. The mte of ciinicaUy s@nikant lacerations was 31% (second degree 271, third
TAESLE
2
Perinea! Outcome Rates by Purity uv = 1,184)
679 138
l.Ei 2m alsa o-87 1.43.2m 0.50.0.70
083 1.20
a 2.3Mdd increafe in6tpkumyltl qrhnigmtidas.Thefrequenqraf -=&Y~A~~~
0.53, 1.04 0.96, 1.89
UX!tAWHkeqrtOW~* otorny, whereas American In&an andl-jbpank womenwereless~ toreceive~epMtCMtly.FFactorsaS fLociatedwithepijlotomywereepjdurala~,fetalbisbress,arrd6 thotomy position DeeWry pos&ms otherthanltthotomyhadaprotective effectontheper&umE#rthweQtrt ~3.5OOgmrnsandthepfzsenceof mecontum had a mar$nal asso& tion with episbatomy. Theltseofanpedledmarragement measuces combined reduced theIikefihoodofep&iotomybyM No significant relationships was found between episiotomy and the use of lubrication. Hot compresses had a marginal -tionWttbded epkioromy rates, lzowedy massagehadamar@na~~atPsodatian WithillCT~episidonry~~A large. statWcally signifkcnt efkt wasfwtedbetweenuseofpained support and decreased-.
0.77. 1.59 0.63. 1.30 c.04 <.I)4
1.10
degree
2.7%,
and
four&h
degree re-
0.4%). and 15% of our clienk
ceivedanepisiotorny.hshouldbe noted that episiotomy and lacerations were not mutually exclusive. In the univariate analysis. the facttxsshowninTable3werefoundto habe an asjociation with kcemtiorts. F%higratihadneartwicetherkk of lacemtiotl compared with multi~WCmensrrstainingbcemtions weremorelihdytohavebeennon-
0.70, 0.99 1.01, 1.42 OBEi, 1.37 0.36. 1.23 0.67. 1.10
SE
fTaMe2LTal1b4strrwrs~aa-
socMed~~.~ucbs
1.02. 1.44 0.73. 1.11 0.72. 1.06
0.74. 1.17 0.86, 1.35 I.11 0.90
srreentbe-dm andtb3u!mdibepltshd~ --dwlpOaaO.tmm%arlhe-dPdlb P-.l-sqPotbd -k OLK~af~~l.5%
0.66 1.51
c .oool c .Oool
0.56. 0.78 1.28. 1.79
0.52 1.93
c .cHml i mol
0.44. 0.61 1.64, 2.27
1.04 0.97
0.82, 1.32 0.76. 1.23
l.CMi 0.94 1.17 0.85
0.88, 1.29 0.7.E. 1.14 @.88, 1.56 0.44. 1.13
Hispanic white, xxeiwed epiduml MHhesia, and canied larger infants thanwomenwhodidnotsustainlacesation!xwllellwomen whohadlacerationswerecomparedwiththose whodidnonofthefeuG%stlot%igl&mt difference in the inciderue of fetal distms and meconium, or chosen rrderrtal deliway position. ThepmporMnoftaeerationswas s@geadybwerhwanenwhodid rrotreceke~~d
bill cm and zkimdam k?SStfran1O%dphl@Wkk P%-w%oi~~~ perimmminwh-by
7 &SW pm&m”h” Amekan
Indian
F4p YeS Fotd disirea Absent F-resent
679 330
1.68 Of0
c.cKe C.002
1.19.2.36 0.42. 0.84
419 615
2.35 0.43
c .tmOl < .tMot
1.76. 3.13 0.32, 0.57
411
1.51 0.86 0.70
c .mz c .03
1.15, 1.98 0.62, 1.20 0.51. 0.98
io iiixi
E 44
6 (14%)
997 37
163 (14%) 14 (27%)
0.51 1.95
c.oos <.W
0.32. 0.82 1.22. 3.12
897 137
134 (13%) 43 (24%)
0.54 1.84
c .oool c .oool
0.40. 0.74 1.36, 2.49
972 62
161(:4%) 16 (21%)
0.69 1.44
a9 383
98 (13%) 77 (17%)
0.78 1.28
c .08
0.59. 1.03 0.97. 1.a
131 725 178
66 04%) 44 (11%) 18 (9%)
3.06 0.54 0.59
c .oool c .c001 c .02
2.35, 3.98 0.41. 0.70 0.37. 0.93
bkconium Absent Fre$eilt y3=
(wd
5 3:500 Maternal position Lithotomyt3imrp5 -f-a Altematiw Perineal management c-w=Absent Fvesznt Lubhcant Absent ha2rlt suw Absent Present %Et Present No measures AU measures
117 (16%) 60 (12%)
E
1;
133
901
38 (22%) 139 (13%)
1.66 0.60
737 297
114 (13%) 63 (18%)
9z
28 w%) 149 (13%)
0.77 1.31 2.18 0.46
hers are reflective of the general population of New Mexico. life intact perineum rate in our study (57%) was similar to those observed by Format0 (25) and Paciomik (26). Unlike our tertiary care setting of low- to moderate-risk women, Formato’s study population was selected from a private home birth setting and comprised low-risk women. TWO studies of nursemidwife attended births reported fre-
16
chdedt.hetithatfhfe~c%d not desaibe ethnkity (1, 7, 10, 11, 25).ZiJldtWOWereOn~ white populations (2, St Vatbbles suchasmceand~~be examined in clinical studies. In addition. many of the st~clfes had sample sizestoosmanforfmn~ (3.4,~~9.22,w.a 29); hourwer, futureh-gersam~studiesmaybe able to clarifjf the effect of promising inteWntions. Our 31% Iacemtion rate was difficult to compare with other studies due to differences in birth attendant case definitions of lacer&ion, and client populations. Our rate was similar to those de&bed by Olson et al (9) and Paciornik (26) but lower than Roberts and Mokos (8) and Henrikson et al (lO!. Two studies did not exchcle operative deliveries, reporting mtes of 22% (2) and 45% (1). Parity, birth weight, and mce were factors associated wtth an increased frequency of perineal lacerations and are beyond the contml of the bti attendant Nulliparity is a welJ documented risk factor for lacetation (7. 13, 30. 31). Most studies report an increased risk of lacer&on with increasing bii weight (8, 13, 15. 30, 32). Ours is the first study showing an increased risk of penneal lacerations in non-&panic white women oompared with other ethnic groups. This study did not establish whether selfidentified rac&thnicity had a biological versus sociological association with the outcome. Green and SW Ho0 C301 found that Asian women had a higher risk for perineal lacers tion in nonopemtive births. Combs et al 112) reported an odds rabio for severe lacerations of 1.31 for Asian women in operative births when compared with other ethnic groups
0.96. 1.72 0.58. 1.04
613 421
$%;
physidatlsinamedi+andMridybw-riskpoplhtion.umietionsintheprece&ngstudiesin-
0.44, 1.10 0.91. 2.29
c .08
0.77. 1.51 0.66. 1.29
1.08
0.93 c .@I2 c ,002
1.21, 2.29 0 44.0.83
< .oool c .oclcll
058, 0.99. 1.54. 0.32.
1.01 1.73 3.08 0.65
quencies of intact perineum ranging from a low of 28% (21 to a high of 44% (11); however, these invest@ ton only studied primtgtavidas and included operative deliveries. Other studies of midwife attended births did not differentiate parity, reporting intact perineum of rates of 18% (7). 38% (10). and45% (1). Robertsand Mokos (8) noted a 40% intact perineum rate based on a very small sample from a physician practice.
&aimd
d
Nurse-~
rsspu&d
l
Vol. 40. No. I. denuary*ebuay
1995
Beearrre~~anZiiFiZZ~ signed and were ch.zen molher~~atsendM~thUS~ternaltieandprov&r&cr&on
by the
COddConfoundtheobsavedassoci-
tllmqmd shate&ior&Perbreal giesasso&&dwilhincreasedriskof laceratiwerehotcompressesand lubrication; CNMS may have been moreindin0dtouseslrateg&ifIacerations were anti-ted To date, no eu&nce for the efficacy of hot compresses or lubtkatiun isavailabhz in the hmture. Many authors have described the ilwread likelihood of perineallacerations when episioiomy is performed (13, 15, 17, 27. 34). In fact, thirdand foutthdegree lace&ions almost never occur except in conjunction with episiotomy. One randomized control trial comparing liberal with res&ted use of episiotomy by British midwives found that neither increased perineal lacerations (35). liowever, all fqdstotomies were mediolateml. so despite the rigorous M. the results are not directiy applicable to many pmctice situations in the United States where midline episiotorny is the predominant procedure. Our clients undergoing episiotomy experienced significantly fewer hcemtions. As with !ac#am, non-Hi white women had a significantly hi mte of episidomy. whereas American lndian women expericnced a signSandy lower rate of this slugid procedure. our fildil-fgsinclcated semdting and alternative delivery positions were protective against episiotcmy. while the liti my position carried a three-f& increased risk of ep&tony. This is
Perlne$~anduredaap inealmanagement~combhL?ddam#rsbaleda~dfdEiphStep’rsiotomv.YYefthein~ofaltemittiwstmtegiesfor perineal management has rarely beenaddres&inthelitaature,and whenithas,onlyontiorb&e.d sarr&s(6,22,29).%1dybiasintt1e tWOStUdieSOnperinealmassagepredude&abM.ingaba&forguiding chidpractice. These observations pose two thought provoking questions: Are crws pzlrbcdady skined in minimizing pained fmma? Or, could ethnic differencesinlhewomencaredfor byCN?&betheexplanatinfora relatively high rate of intact perineum? Future work with larger samples will heIp clarify these issues. One s@ength of this study is that i&mentions and outcomes are cofnpared between CM. In CNM versusMDstudies.manyvarialionsin clinical practice may be operating at once, not simply differences in management of the perineum. We suggest perineal outcomes for women attended by CNMs may differ from those of physicians because of the v&&ions in alternative approaches to care. Further, a -n’s ethnic@ may partially explain perineal outcome. In U.S. hospiti setings CNMs are more likely than physicians to cafefortheveryyoung,lhepoor, and minority women (36, 371. Our study population reflects De&q’s
(37) fIndings; twmlell -sKlungn; predominantly on Medicaid, and of minority status. Their age and ethnic background may contribute to our high intact perineum rate. The challenge remains to investigate and identify factors that probect thepelineumand-paineal h;aurrra(3B).Theuseoicta~to
2!3.AuayMD.J3hetEtAEBedd perindmssqeonttshddencedepC *tomy and w lacemtion
7. f&&eP,RoberisJ.Fadznsaso-
&%d chib%&.
with perbd d l’kmas
ouicome Mii
during 19B7;32:
wllay 8 fbberisd.WasD.Delhroryp &bBSwd~auocOmeaJNune haId&aq
19. Greener D. Development i&ion of lhe nurse-mictwifq data st. J Nurse Midwffery 174-83.
1984$918f%o.
9.Ob0nROfsctnC~CoxfSMat0ndbfrthhgpclduonand~injury. J Fam Pratt 199Q3055%7.
20. R&trc.-~.Lundonz Hebwmann.
10. Hen&en IB. Bek KM, HedegardM,Sche~l’Ll. Epfswmyandpaheal I&om in sportlaneous aglnal deEver&BrJObstetGynwcof1992;99: 95&4. 11. Rockner G, Ofund A The use of @&ot0myinp&nipamsin!%ueden.Acta Obset Gynecol Stand 1991;70:325-30.
22. Avery MD. massage. J Nurse 181-4.
gmn for epidemidagy ers Stone 1990.
33. Wkox G. Dellinger
26. Paciornfk M. Arguments -my in favor of squatting Birth 199@17:Io4-5.
15. HehvigJT,l’horpJM,BcwesWA Jhs midline episioiomy increase the risk of third- and fourthdegree facerations in crpemtive vaginal deliveries Obstet Gynecol 1993;82:27&9.
35. S&p J. Grant A. Ga&fa J, EL boume D, Spencer J, ChaImer 1. West Berkshire perineal management trial BMJ 1984.289:587-90.
agains! for birth.
36. National Center for Health Setirtics. Advance report of finaf statistics. 1991. Monthly vital statishc~ repoh vol. 42 no. 3. Hya;tsville (MD): Public Health Service, 1993. 37. Declerq ER The bansformalion Amerkan midwifery: 1975-1938. Public Health 1992;82:-.
L, Piening SL. Cohen of episiotomy and deliucry position with deep perineal lacemtion during spontaneous deliveq in null@-
- -
38. ReynoldsJLllleffMlbfowtoroutirle episioromy. Birth 199320
162-3.
..-...-
hmwaIdNurse-pGdrwlfery
Baruf6
34. Sultan AH. Kamm MA. Huckon CN. Thomas JM. Bartram. Analsphincter disruption dur@ vaginal d&very. N Engl J Med 1993;329:1905-11.
28. Borgatta WR. Association
lac-
DM.
a maternity center and a tertiary hospital obstetric service. Am J O&et 1=16@ 1047-52.
27. Klein MC, Gauthii RJ, Jorgerwn SH. Robbins JM. Kauorowski J, Corii~eau M, et al. Does episiotomy prevent perineal trauma and pelvic floor relaxation? Online Journal of Current Ctinical Trials July 1. 1992: (Dcx. No. IO).
16. Graves W. Summary; National Hbspital Disctwge Survey Advanced &la for vital and hea& *&tics. no 210. Hyattstille (MD]: National Center for Health Stabtics. 1992.
IS, Strobino WS. Ep%iotomy
and its mfe tn the incidence of perineal lacemtfons in
25. Format0 LS. Routine prophylactic epkhtomy J Nurse Midwifery 1985;30: 144-8.
Walker MPR, Farine D. Rolbin SH. Rrachie JWK Epidmat an&&a, eptslobrny. and oti laceration. Obstel Gyrtecol1991;77:66%71
18
Mountain
AH, version 5: a word and statistics proon mXrwomput[GA): USO, Inc..
24. SAS Institute Inc. SAS language and procedures guide, v&n 6.3rd ed. cay (NC): SAS lnsutule hlc, 1930.
14.
P. Severe
32. Mokr Bek K La&erg S. Intervention dwing labor risk factors aswciated with complete tear of the anal sphincter. Ada Obstet Gynecd &and 198&67:31S-8.
?dale LV. Ptineal Midwifery 1987;32:
23. Dean AG, Dean JA. Burton
13. Shhmo P. Klebanoff MA. Carey JC. Midline episiotomies: more harm than good? O&et Gyrtecol 1990;75: 7670.
K. Bergsjo
31. Lfqino u. woods IMP, Raybum WF.MiGOpLS.Third-andfomthdegmetears.5Oyears’expl&nczata univmsity hospital J Rqxcd Med 1%3& 33r423-6.
FG. MxDxtald PC. NF. Gilstap LC. 19th ed. East Nor& Lanqe. 1993.
Dicker RC. Epi Info. processlrg database.
1986c31: 12%134.
and vztfdlnkal 1991;,%
198&101-2.
21. Cunningham Levino KJ, Gant wilhats obaemcs, udk (CT): Appleton
12. combs CA Robertson PA, Laros RK Risk factors for third-degree and forathdegree bCQdOM in forceps and VfWUlldeliveria.hJObStetGynecd rm, 163: 100-4.
17. Hordnes
in a
nurse-Klk&#[email protected]
l
Vol.40.N~.
1.danu&Fehary1995
of
Am J