Normal labor and delivery

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2. 2 Objectives At the end of session, the student is able to Diagnose true labor Describe factors influence vaginal birth Assess maternal and fetal condition Assess progress of labor Manage first stage of labor Describe mechanism of normal vaginal delivery Describe steps for conduction vaginal delivery

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10. 10 Diagnosis of true labor pain History A history of regular painful uterine contraction in every 5- 8 min, accompanied by the history of a bloody show or spontaneous rupture of membrane Physical examination Reduction of interval between uterine contractions Abdominal pain of increasing intensity Cervical effacement (= 50%) Cervical dilation (= 2 cm)

11. 11 Different between true labor and false labor

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13. 13 Stage of labor First stage ( true labor pain until cervix fully dilate or 10 cm Latent phase Active phase Second stage(cervix fully dilate until deliver the baby) Third stage (deliver the baby until deliver placenta)

14. 14 Management in first stage :admission assessment Take history: LMP, EDC , labor pain , bleeding, ruptured membrane, fetal movement, maternal diseases, review ANC records , lab test Perform physical examination : 2.1 General examination 2.2 Leopold maneuver, 2.3 Auscultation fetal heart sound 2.3 Uterine contraction 2.4 Pelvic examination

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16. 16 Uterine contraction (Power) Interval Duration Intensity Good contraction ( I= 2-3 min, D 45-60 sec)? If not : correct by using oxytocic drug

17. 17 Pelvic examination  1. Birth canal 2. Cervical condition and related part

18. 18 Birth canal ( passage) Inlet diagonal conjugate diameter > 12 cm Mid pelvis interspinous diameter > 10 cm Outlet subpubic angle > 90 0 intertuberosity diameter > 10 cm

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21. 21 Cervical condition and related part Cervical condition * dilatation 0-10 cm * effacement 0-100%

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31. 31 Presentation Denominating point Vertex Face Breech Shoulder Occiput Mentum Sacrum Acromium

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33. 33 . 5 Membrane :  Status : intact or rupture  Color : clear or meconium stain Amount : normal or abnormal

34. 34 Assess fetal condition Auscultation of fetal heart (normal range 120-160 bpm) High risk : 1st stage every 15 min , 2nd stage every 5 min Low risk : 1st stage every 30 min , 2nd stage every 15 min Electronic fetal heart rate monitoring (not essential in low risk pregnancy) Ultrasound (not essential in low risk pregnancy) Biophysical profile (not essential in low risk pregnancy) : 5 component: fetal tone , fetal breathing , fetal movement, NST, Amniotic fluid pocket (Modified BPP = NST + AFI)

35. 35 Characteristics of normal low-risk labor No pregnancy complications that may affect labor( with adequate ANC) Spontaneous onset of labor between 37-42 week of gestation Singleton fetus with cephalic presentation Estimate fetal weight > 2,500 g, < 4,000 g Adequate volume of clear amniotic fluid No abnormal intrapartum bleeding Acceptable rate of cervical dilatation (1 cm/hr in active phase) Normal fetal heart rate

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42. 42 Management in first stage (cont) Maternal vital signs Regular record uterine contraction and record fetal heart rate Food / IV fluid consideration Maternal position Analgesic drug consideration Record and assess progress of labor

43. 43 Second stage Mechanism of labor : 7 cardinal movements in occiput anterior presentation engagement descent flexion internal rotation extension external rotation expulsion Conduct vaginal delivery

44. 44 Episiotomytype 1. median or midline 2. mediolateral Routine episiotomy Restrictive episiotomy

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48. 48 Third stage Delivery of placenta sign of placental separation (uterine sign, vulva sign, cord sign) Modified Crede, Brandt Andrew Controlled cord traction

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52. 52 Prevent postpartum hemorrhage oxytocic drugs Syntocinon� : IV push, IV drip, IM Methergin� : IM, IV

53. 53 Repairing episiotomy wound Perineal tear during vaginal birth First-degree tear Second-degree tear Third-degree tear Fourth-degree tear

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57. 57 Postpartum care : 10 Bs Blood pressure Bladder Bloody discharge Basket Bowel Breast engorgement Breast feeding Baby Blue Brain

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59. 59 From the 2005 World Health Report �make every mother and child count� 4m child globally will not survive the first month of life, and � m women will die in pregnancy, childbirth or soon after. SEA 1.4 m newborn deaths, 1.3 m still births Although a good start in life begins well before birth, it is just before, during, and in the very first hours and days after birth that life is most at risk. Babies continue to be very vulnerable throughout their first week of life, after which their chances of survival improve markedly. The main causes of neonatal mortality are intrinsically linked to the health of the mother and the care she receives before, during and immediately after giving birth. Asphyxia and birth injuries usually result from poorly managed labour and birth and lack of access to obstetric services. Many neonatal infections, such as tetanus and congenital syphilis, can be prevented by care during pregnancy and childbirth. Inadequate calorie or micronutrient intake also results in poorer pregnancy outcomes ( 6 ). It has been argued that nearly three quarters of all neonatal deaths could be prevented if women were adequately nourished and received appropriate care during pregnancy, childbirth and the postnatal period ( 7 ). From the 2005 World Health Report �make every mother and child count� 4m child globally will not survive the first month of life, and � m women will die in pregnancy, childbirth or soon after. SEA 1.4 m newborn deaths, 1.3 m still births Although a good start in life begins well before birth, it is just before, during, and in the very first hours and days after birth that life is most at risk. Babies continue to be very vulnerable throughout their first week of life, after which their chances of survival improve markedly. The main causes of neonatal mortality are intrinsically linked to the health of the mother and the care she receives before, during and immediately after giving birth. Asphyxia and birth injuries usually result from poorly managed labour and birth and lack of access to obstetric services. Many neonatal infections, such as tetanus and congenital syphilis, can be prevented by care during pregnancy and childbirth. Inadequate calorie or micronutrient intake also results in poorer pregnancy outcomes ( 6 ). It has been argued that nearly three quarters of all neonatal deaths could be prevented if women were adequately nourished and received appropriate care during pregnancy, childbirth and the postnatal period ( 7 ).

60. 60 So, how do you know that you are giving the best care possible to a pregnant women or a woman in labour? How do you know you are doing most good and least harm? Because as doctors, midwives and nurses we want to give the best care! How did I know that my daughter when she had a water birth at home that it was the best care for her and it was the least harm? So, how do you know that you are giving the best care possible to a pregnant women or a woman in labour? How do you know you are doing most good and least harm? Because as doctors, midwives and nurses we want to give the best care! How did I know that my daughter when she had a water birth at home that it was the best care for her and it was the least harm?

61. 61 Are these procedures essential in low risk vaginal birth? Shaving perineum Enema NPO IV fluid Keep in bed Continuous fetal monitoring Episiotomy Dorsolithotomy position Rush the mother to push

62. 62 Evidence-based practice This is a newish concept for health practitioners but it applies to everyone giving health care. Not just to doctors but nurses and midwives too. In the literature it has been shown that this approach will give the most effective care and produces good outcomes for the mother and the baby. What does the research say? What does the health professional say? What does the women say? What is the context? CPG�s and CSR For today we are just going to concentrate on the yellow circle. What does the evidence say about some of our clinical practices. How do we know what is the best available evidence? In terms of interventions, which are mostly quantitative research, we can assess the level of their quality, which looks like this�This is a newish concept for health practitioners but it applies to everyone giving health care. Not just to doctors but nurses and midwives too. In the literature it has been shown that this approach will give the most effective care and produces good outcomes for the mother and the baby. What does the research say? What does the health professional say? What does the women say? What is the context? CPG�s and CSR For today we are just going to concentrate on the yellow circle. What does the evidence say about some of our clinical practices. How do we know what is the best available evidence? In terms of interventions, which are mostly quantitative research, we can assess the level of their quality, which looks like this�

63. 63 What is Evidence-Based Practice? ..read side So research plus the woman plus our clinical expertise/judgement and in context. For example if no soap is available or water for washing hands then we can�t put it into practice. Anyway to put research into clinical practice there are always 6 steps involved. Taking the clinical practice example of routine episiotomies, which is common practice around the world and also in our 4 SEA countires, lets look at what those steps would involve to put evidence into practice. ..read side So research plus the woman plus our clinical expertise/judgement and in context. For example if no soap is available or water for washing hands then we can�t put it into practice. Anyway to put research into clinical practice there are always 6 steps involved. Taking the clinical practice example of routine episiotomies, which is common practice around the world and also in our 4 SEA countires, lets look at what those steps would involve to put evidence into practice.

64. 64 Levels of Evidence (therapeutic and preventive) Explain: systematic review and Cochrane Systematic Review with example of handwashing, effectiveness of results. Why do we wash hands? �..Prevent cross infection etc�. How long should we wash our hands with ordinary soap for a �social handwash� between patients, after using the toilet, after eating etc� (not surgical scrub) Let audience guess how many minutes or seconds does the research and systematic review say? We know hand washing is simple but very effective but� as health professionals we do not comply with it. Explain: systematic review and Cochrane Systematic Review with example of handwashing, effectiveness of results. Why do we wash hands? �..Prevent cross infection etc�. How long should we wash our hands with ordinary soap for a �social handwash� between patients, after using the toilet, after eating etc� (not surgical scrub) Let audience guess how many minutes or seconds does the research and systematic review say? We know hand washing is simple but very effective but� as health professionals we do not comply with it.

65. 65 1. Ask an answerable question 2. Access the appropriate evidence 3. Appraise the evidence 4. Discuss with the patient 5. Assess the context of care and apply the results to clinical practice 6. Evaluate your practice Is it a good idea to apply routine episiotomies to all birthing women? Is it good practice to do it only for primigravidas? Does it do the most good and the least harm? Often women come up with these questions as well. Is there any research about routine episiotomies? Any published studies or research articles on this? Any systematic review published? The Cochrane Library has a review on this, what does it say? This step is important. But how do you critically appraise the evidence? How do we know it was a good study? A clinical guideline based on good evidence? In two ways: 1. Learn how to critically appraise research, attend workshops that develop your skills in this area or become involved in research yourself to find the answers. 2. The second way is to rely on organisations that produce evidenced based information. The Cochrane Collaboration is one organisation etc. Guideline clearing house for evidence based clinical guidelines is another organisation 4. Discuss the treatment options with the patient. Does it make sense? Does the patient agree with the treatment option? Does she want a routine episiotomy? 5. Assess the context of care and apply the results to clinical practice, individually but also institutionally. Is suturing material available? Previous 4th degree tear? Do all clinicians involved know how to prevent perineal and vaginal tears? 6. Reflect on your practice and ask/listen to the woman, she might also be able to inform you about your performance or do a peer review. All this will assist you and me and all of us to giving better care that is truly evidence based. Did the episiotomy heal well? Did it extend out to a 3rd or 4th degree tear? At six weeks, how is intercourse? How did the woman feel about it? So lets have a look at the rate of routine episiotomies and what the research says, in fact a Cochrane systematic review.Is it a good idea to apply routine episiotomies to all birthing women? Is it good practice to do it only for primigravidas? Does it do the most good and the least harm? Often women come up with these questions as well. Is there any research about routine episiotomies? Any published studies or research articles on this? Any systematic review published? The Cochrane Library has a review on this, what does it say? This step is important. But how do you critically appraise the evidence? How do we know it was a good study? A clinical guideline based on good evidence? In two ways: 1. Learn how to critically appraise research, attend workshops that develop your skills in this area or become involved in research yourself to find the answers. 2. The second way is to rely on organisations that produce evidenced based information. The Cochrane Collaboration is one organisation etc. Guideline clearing house for evidence based clinical guidelines is another organisation 4. Discuss the treatment options with the patient. Does it make sense? Does the patient agree with the treatment option? Does she want a routine episiotomy? 5. Assess the context of care and apply the results to clinical practice, individually but also institutionally. Is suturing material available? Previous 4th degree tear? Do all clinicians involved know how to prevent perineal and vaginal tears? 6. Reflect on your practice and ask/listen to the woman, she might also be able to inform you about your performance or do a peer review. All this will assist you and me and all of us to giving better care that is truly evidence based. Did the episiotomy heal well? Did it extend out to a 3rd or 4th degree tear? At six weeks, how is intercourse? How did the woman feel about it? So lets have a look at the rate of routine episiotomies and what the research says, in fact a Cochrane systematic review.

66. Shaving for Labour Traditional belief: To reduce infection To facilitate suturing/makes it easier to stitch Best Evidence: Painful, embarrassing Re-growth uncomfortable Microabrasions cause infection Risk of HIV transmission No benefits shown for shaving Small cost benefit Traditionally we say that shaving for labour needs to be done to reduce infection and to facilitate suturing, as it makes it easier to stitch. But what does research (the evidence) say? When re-growth occurs women scratch hence microabrasions occur and infections mightoccur. Often we do not see them as this occurs back home in the community. That�s why we often do not want to believe the research. In Australia women do not receive routine shaves, neither for vaginal or caesarean birth. But remember, evidence based practice has three components. The research states quite clearly not to shave but if the women has a �forest� of hair or has pubic lice then the context might require a shave, or the woman is adamant that she wants to have a shave. She needs to have all the information though to make that decision. Another clinical practice is cortico-steroids for pre-mature labour? Do you sometimes give corticosteroids to women in premature labour? Sometimes? Why only sometimes? Traditionally we say that shaving for labour needs to be done to reduce infection and to facilitate suturing, as it makes it easier to stitch. But what does research (the evidence) say? When re-growth occurs women scratch hence microabrasions occur and infections mightoccur. Often we do not see them as this occurs back home in the community. That�s why we often do not want to believe the research. In Australia women do not receive routine shaves, neither for vaginal or caesarean birth. But remember, evidence based practice has three components. The research states quite clearly not to shave but if the women has a �forest� of hair or has pubic lice then the context might require a shave, or the woman is adamant that she wants to have a shave. She needs to have all the information though to make that decision. Another clinical practice is cortico-steroids for pre-mature labour? Do you sometimes give corticosteroids to women in premature labour? Sometimes? Why only sometimes?

67. Enemas in Labour Traditional belief: Encourages bowel movement (peristalsis) and therefore more prostaglandin is released, which in turn stimulates contractions Shortens labour Helps the baby�s head descend Necessary to avoid soiling at the birth (keep it clean) and therefore reduce the risk of maternal and neonatal infection Best Evidence: Painful, embarrassing Does not stimulate contractions Does not shorten labour No difference with neonatal infections Does not decrease soiling at birth, more messier bowel movements Marginally increases cost of health care Traditionally we say that giving an enema during labour needs to be done to � There is a Cochrane Systematic Review that gives us the best evidence as�. This gives us another clinical practice to think about. Everything we do to a woman in labour has an impact on her. We need to be so mindful of what we are doing is evidence-based. Of course now we know about enemas, how we are going to change practice. I encourage all of you here today to think about this and go home from this conference to at least take one clinical change with you that you will start working on next week. Remember change takes time but it will happen if we start one step at a time. Okay, what about shaving. Do many people in the audience do routinely shave for vaginal births and routinely shave for caesarean section? Why do we do this? Traditionally we say that giving an enema during labour needs to be done to � There is a Cochrane Systematic Review that gives us the best evidence as�. This gives us another clinical practice to think about. Everything we do to a woman in labour has an impact on her. We need to be so mindful of what we are doing is evidence-based. Of course now we know about enemas, how we are going to change practice. I encourage all of you here today to think about this and go home from this conference to at least take one clinical change with you that you will start working on next week. Remember change takes time but it will happen if we start one step at a time. Okay, what about shaving. Do many people in the audience do routinely shave for vaginal births and routinely shave for caesarean section? Why do we do this?

68. In Australia and many other countries just prior to an anaesthetic a antacid drug is given per mouth, to alkalise the stomach contents. Women are monitored with dip stick testing of their urine for acid and then encouraged to drink more before i.v. therapy is contemplated It is also more cost effective not to have to insert an i.v. into every women (being unnecessarily invasive as well) and pay for the i.v. fluid replacement, when she could drink without side effects. Up until now we have concentrated mostly on maternal well-being and evidence-based practice. Is there anyone here today that works with premature babies?? We do many procedures on these babies and therefore inflict a lot of pain. How do we inflict pain? Noise, light, cold, pushing on incubator, iv lines, surgery, gastro tubes, lumbar puncture, xrays, cold stethoscopes etc etc But traditionally we have believed neonates do not feel pain�. In Australia and many other countries just prior to an anaesthetic a antacid drug is given per mouth, to alkalise the stomach contents. Women are monitored with dip stick testing of their urine for acid and then encouraged to drink more before i.v. therapy is contemplated It is also more cost effective not to have to insert an i.v. into every women (being unnecessarily invasive as well) and pay for the i.v. fluid replacement, when she could drink without side effects. Up until now we have concentrated mostly on maternal well-being and evidence-based practice. Is there anyone here today that works with premature babies?? We do many procedures on these babies and therefore inflict a lot of pain. How do we inflict pain? Noise, light, cold, pushing on incubator, iv lines, surgery, gastro tubes, lumbar puncture, xrays, cold stethoscopes etc etc But traditionally we have believed neonates do not feel pain�.

69. 69 Continuous fetal monitoring No significant difference in overall perinatal death rate But was associated with a halving of neonatal seizures No significant difference was detected in cerebral palsy There was a significant increase in caesarean sections

70. Routine Episiotomy Traditional Belief: Clean incision Heals better Fewer 3 and 4 degree tears Less pain Use routinely It is true, for all of these reasons we do episitomies. But is that evidence based practice? Is this what the research shows. NO Here is a quick look at the statistics from the Cochrane Systematic Review �.It is true, for all of these reasons we do episitomies. But is that evidence based practice? Is this what the research shows. NO Here is a quick look at the statistics from the Cochrane Systematic Review �.

71. 71 Restrictive episiotomy 27.6% (673/2441) vs Routine episiotomy 72.7% (1752/2409)  �.Followed but the authors comments for the people in the audience (like me) that get very confused by statistics��.Followed but the authors comments for the people in the audience (like me) that get very confused by statistics�

72. 72 Cochrane Systematic Review Authors' conclusions Restrictive episiotomy policies appear to have a number of benefits compared to routine episiotomy policies. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma. But there was an increased risk of anterior perineal trauma with restrictive episiotomy. All the best as you apply these research findings into your clinical practices. Episitomies should only be used when necessary, most likely less than 10% of normal vaginal births should have had an episiotomy. Anterior perineal tears hardly ever need suturing. But if we stop applying to routinely doing episiotomies, how can we prevent tearing. This is what the research says, we can do certain things during the pregnancy, antenatally and during labour and birthAll the best as you apply these research findings into your clinical practices. Episitomies should only be used when necessary, most likely less than 10% of normal vaginal births should have had an episiotomy. Anterior perineal tears hardly ever need suturing. But if we stop applying to routinely doing episiotomies, how can we prevent tearing. This is what the research says, we can do certain things during the pregnancy, antenatally and during labour and birth

73. 73 This is a snap shot of all the 9 hospitals that are involved in SEA. You can see where the two Indonesian hospitals are. Why do we do routine episiotomies in the first place?This is a snap shot of all the 9 hospitals that are involved in SEA. You can see where the two Indonesian hospitals are. Why do we do routine episiotomies in the first place?

74. How to prevent perineal tears? Best Evidence: During Pregnancy Pelvic floor (Kegel) exercises during pregnancy Stretching exercises during pregnancy (Yoga) Perineal massage during pregnancy During Labour Mobility in labour for good fetal positioning Birth positions off the perineum, no more lithotomies vvv Slow pushing efforts vvv Hot packs on the perineum during second stage Undisturbed hormones What can you tell me about how to prevent tears?.....audience participation�. I have just listed them here quickly. I will go through them in details after this slide.What can you tell me about how to prevent tears?.....audience participation�. I have just listed them here quickly. I will go through them in details after this slide.

75. 75 Yes, these are all good reasons but what does the research say to this? The Cochrane Systematic Review shows that if we let women in labour move than improved progress of labour �� ensuring that the labour keeps normal, needing less interventions. If the baby is in a good position, good fetal descent, than it is more likely to have a normal restitution and sweep over the perineum with a better angle leaving it intact. Here are some diagrams to visualise how women can be mobile in labour, and not a lot of room is necessary. They can walk just around their bed. Ref. Lewis L, Webster J, Carter A, McVeigh C, Devenish-Meares P. Maternal positions and mobility during first stage labour. (Protocol) Cochrane Database of Systematic Reviews 2002, Issue 4. Art. No.: CD003934. DOI: 10.1002/14651858.CD003934. Yes, these are all good reasons but what does the research say to this? The Cochrane Systematic Review shows that if we let women in labour move than improved progress of labour �� ensuring that the labour keeps normal, needing less interventions. If the baby is in a good position, good fetal descent, than it is more likely to have a normal restitution and sweep over the perineum with a better angle leaving it intact. Here are some diagrams to visualise how women can be mobile in labour, and not a lot of room is necessary. They can walk just around their bed. Ref. Lewis L, Webster J, Carter A, McVeigh C, Devenish-Meares P. Maternal positions and mobility during first stage labour. (Protocol) Cochrane Database of Systematic Reviews 2002, Issue 4. Art. No.: CD003934. DOI: 10.1002/14651858.CD003934.

76. 76 If women mobilise, rotate their pelvis, what happens to the baby? Do you use routine fetal monitoring at your hospitals? There is a systematic review that shows electronic fetal monitoring should only be used with high risk case. There is no place for the commonly used (in Australia too) 20min admission CTG. The research shows that interventions in particular unnessarily ceasarian sections rise. But that is for another presentation or workshop. However, if your hospital requires to have your women routinely on CTG�s there is still no excuse, she still will be able to move around If women mobilise, rotate their pelvis, what happens to the baby? Do you use routine fetal monitoring at your hospitals? There is a systematic review that shows electronic fetal monitoring should only be used with high risk case. There is no place for the commonly used (in Australia too) 20min admission CTG. The research shows that interventions in particular unnessarily ceasarian sections rise. But that is for another presentation or workshop. However, if your hospital requires to have your women routinely on CTG�s there is still no excuse, she still will be able to move around

77. 77 Even with a monitor on, women can move around. Preventing perineal tears can also be achieved with birth positions. Traditionally we birth women lying down, the supine position and very often in lithotomy. Why do we do that? Feedback from audience� Even with a monitor on, women can move around. Preventing perineal tears can also be achieved with birth positions. Traditionally we birth women lying down, the supine position and very often in lithotomy. Why do we do that? Feedback from audience�

78. Continuous Support in Labour Traditional belief: Companions discouraged because of concerns about cross infections Extra people who are not health professionals always get in the way There is no privacy for other women in labour Staff are already overworked and can not care for labour support people as well Best Evidence: Better progress of labour Fewer caesariean sections Less pain More self-esteem Better relationship with the baby More breastfeeding Less depression Traditionally we have discouraged companions because of concerns about cross infections� etc But what does research (the evidence) say? Just knowing one person and having that person with the woman throughout labour and birth will make a huge difference. We have a mandate as health professionals to change this in our clinical practice I am suppose to speak on other clinical practice as well that have been identified through our SEA-ORCHID project. Do you all give routinely enemas do women in labour? They do in many countries. Why do we do this? brainstorm Traditionally we have discouraged companions because of concerns about cross infections� etc But what does research (the evidence) say? Just knowing one person and having that person with the woman throughout labour and birth will make a huge difference. We have a mandate as health professionals to change this in our clinical practice I am suppose to speak on other clinical practice as well that have been identified through our SEA-ORCHID project. Do you all give routinely enemas do women in labour? They do in many countries. Why do we do this? brainstorm

79. 79 Yes, this why we normally advise women to give birth on their backs and in stirrups. But what does the research say? Does everyone understand what supine hypotension means? If not, explain. If we all know about supine hypotension, why then do we put women on their back when it comes to birth, when the fetus really needs all the oxygen it can get? Some diagrammatic illustration of birth positions follow. Please note, women do not need to be naked to give birth, this is just the artists impression. Yes, this why we normally advise women to give birth on their backs and in stirrups. But what does the research say? Does everyone understand what supine hypotension means? If not, explain. If we all know about supine hypotension, why then do we put women on their back when it comes to birth, when the fetus really needs all the oxygen it can get? Some diagrammatic illustration of birth positions follow. Please note, women do not need to be naked to give birth, this is just the artists impression.

80. How to prevent perineal tears? Best Evidence: During Labour Slow pushing efforts - stretches the perineum slowly - non-directive pushing - not forcing/guiding the head - not rushing shoulders - no holding breaths, woman breathes at her own pace - panting/breathing the baby out If you wan to show the DVD with a segment of slow perineum stretching, it is on �Birth in water� chpt 7 22.05 and celebrating birth chapt 9 43.46If you wan to show the DVD with a segment of slow perineum stretching, it is on �Birth in water� chpt 7 22.05 and celebrating birth chapt 9 43.46

81. 81 Hot packs on the perineum  during second stage Perineal Preservation and Heat Application During Second Stage of Labour - Randomised Controlled Trial, (Musgrove, Heather) This study sought to examine the effectiveness of hot packs via a randomised controlled trial in the second stage of labour. The experimental group received hot packs (n=36) and the control group did not (n=35). There were a total of 71 women in the study. The results show high levels of patient comfort and pain relief from hot packs. This is demonstrated by results such as: 70% of the recipients of hot packs felt the packs relieved pain and 80% said they provided comfort. The midwifery staff involved also supported the women's view that hot packs were beneficial in reducing pain and perineal damage. In the experimental group 70% of the women required no suturing, being either intact (61%) or having a superficial first degree tear (8%). A further 8% had a first degree tear sutured, 22% of this group sustained a second degree tear (17%) or an episiotomy (3%). As compared to the control group with only 54% of women not requiring suturing and a second degree tear rate of 23% and episiotomy rate of 6%, sutured first degree tears were 17%.(i.e. 16% less suturing in the experimental group). BIBLIOGRAPHY Aikins Murphy P, Feinland JB(1998) Perineal Outcomes in a homebirth setting. Birth 25(4)226-34. Argentine Episiotomy Trial Collaborative Group.(1993) Routine vs selective episiotomy: a randomised controlled trial. Lancet 342(8886-8887):1517-8. Belizan JM and Carroli G (1998) Routine episiotomy should be abandoned. BMJ 317:1389. Carroli G and Belizan J (2000) Episiotomy for vaginal birth. Cochrane Database Syst Rev (2) CD 000081. de Leeuw JW, Struijk PC, Vierhout ME, Wallenburg HC (2001) Risk factors for third degree perineal ruptures during delivery. BJOG 108(4)383-7. Eason E and Labrecque M (2000) Preventing perineal trauma during childbirth:A systematic review. Obstet Gynecol 96(1):154. (eeason@ogh.on.ca) Goldberg J, Holtz D, Hyslop T, Tolosa J (2002) Has the Use of Routine Episiotomy Decreased? Examination of Episiotomy Rates from 1983-2000. ObGyn 99(3)395-400. Klein M, Gauthier R, Jorgensen S etal (1992) Does Episiotomy Prevent Perineal Trauma and Pelvic Floor Relaxation? Curr Clin Trials 1992; i:document 10. Klein MC, Gauthier RJ, Robbins JM, Kaczorowski J, Jorgensen SH, Franco ED, Johnson B, Waghorn K, Gelfand MM, Guralnick MS, et al.(1994) Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation.Am J Obstet Gynecol 171(3):591-8 Janssen PA, Lee SK, Ryan EM, Etches DJ, Farquharson DF, Peacock D, Klein MC (2002) Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. CMAJ 166(3) 315-323. Hillebrenner J, Wagenpfeil S, Schuchardt R, Schelling M, Schneider T (2000) Erste klinische Erfahrungen bei Erstgebarenden mit einem neuartigen Geburtstrainer Epi-No (First clinical experiences with the new birth trainer Epi-No in primiparous women. Z Geburtshilfe Neonatol 205(1):12-9. Labrecque M, Baillargeon L, Dallaire M, Tremblay A, Pinault JJ, Gingras S.(1997) Association between median episiotomy and severe perineal lacerations in primiparous women. Can Med Assoc J.156(6):811-3. Martin S, Labrecque M, Marcoux S, Berube S, Pinault J (2001) The association between perineal trauma and spontaneous perineal tears. J Fam Pract 50(4)333-337. Moller Bek K, Laurberg S (1992) Intervention during labor: risk factors associated with complete tear of the anal sphincter. Acta Ob Gyn Scand 71:520. Mor, Y( 1989) The 1984 National Perinatal Census. Israel J of Med Science 25:629-633. Pritchard JA and MacDonald PC (1980) Williams Obstetrics, 16th Edition. Appleton-Century-Crofts, N.Y. Shiono P, Klebanoff MA, Carey JC. (1990) Midline episiotomies: more harm than good? Obstet Gynecol 75(5):765-770. Signorello L Harlow B Chekos A Repke J(2000) Midline Episiotomies and Anal Incontinence. BMJ 320:86-90. Sleep J, Grant A, Garcia J, Elbourne D, Spencer J, Chalmers I (1984) West Berkshire perineal management trial.Br Med J (Clin Res Ed) 289(6445):587-90. Slome J (2002) A midwife`s private practice in Israel. British J of Midwifery 10(4)224-9. Sultan AH, Kamm MA, Bartram CI, Hudson CN(1993) Anal sphincter trauma during instrumental delivery. Int J Gynaecol Obstet 43(3):263-70. Thacker SB and Banta HD(1983) Benefits and risks of episiotomy: an interpretive review of the English language literature 1860- 1980. Obstet Gynecol Surv 38(6): 322-338. Wagner M(1999) Episiotomy: a form of genital mutilation. Lancet 353:1977-8. Wagner M(1994) Pursuing the birth machine: the search for appropriate birth technology. Sydney: ACE Graphics. World Health Organization (1996) Care in Normal Birth. A Practical Guide. World Health Organization, Geneva Zalcberg S, Berg A, Yuval D, Ivancovsky M (1999) Giving Birth in Israel: Findings from a 1995 Survey of Maternity Patients with Comparisons to 1993. JDC Brookdale Institute Research Report. JDC Brookdale Institute, Jerusalem. � Perineal Preservation and Heat Application During Second Stage of Labour - Randomised Controlled Trial, (Musgrove, Heather) This study sought to examine the effectiveness of hot packs via a randomised controlled trial in the second stage of labour. The experimental group received hot packs (n=36) and the control group did not (n=35). There were a total of 71 women in the study. The results show high levels of patient comfort and pain relief from hot packs. This is demonstrated by results such as: 70% of the recipients of hot packs felt the packs relieved pain and 80% said they provided comfort. The midwifery staff involved also supported the women's view that hot packs were beneficial in reducing pain and perineal damage. In the experimental group 70% of the women required no suturing, being either intact (61%) or having a superficial first degree tear (8%). A further 8% had a first degree tear sutured, 22% of this group sustained a second degree tear (17%) or an episiotomy (3%). As compared to the control group with only 54% of women not requiring suturing and a second degree tear rate of 23% and episiotomy rate of 6%, sutured first degree tears were 17%.(i.e. 16% less suturing in the experimental group). BIBLIOGRAPHY Aikins Murphy P, Feinland JB(1998) Perineal Outcomes in a homebirth setting. Birth 25(4)226-34. Argentine Episiotomy Trial Collaborative Group.(1993) Routine vs selective episiotomy: a randomised controlled trial. Lancet 342(8886-8887):1517-8. Belizan JM and Carroli G (1998) Routine episiotomy should be abandoned. BMJ 317:1389. Carroli G and Belizan J (2000) Episiotomy for vaginal birth. Cochrane Database Syst Rev (2) CD 000081. de Leeuw JW, Struijk PC, Vierhout ME, Wallenburg HC (2001) Risk factors for third degree perineal ruptures during delivery. BJOG 108(4)383-7. Eason E and Labrecque M (2000) Preventing perineal trauma during childbirth:A systematic review. Obstet Gynecol 96(1):154. (eeason@ogh.on.ca) Goldberg J, Holtz D, Hyslop T, Tolosa J (2002) Has the Use of Routine Episiotomy Decreased? Examination of Episiotomy Rates from 1983-2000. ObGyn 99(3)395-400. Klein M, Gauthier R, Jorgensen S etal (1992) Does Episiotomy Prevent Perineal Trauma and Pelvic Floor Relaxation? Curr Clin Trials 1992; i:document 10.

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