Perineal Trauma: Incidence and Its Risk Factors

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Table of Contents

Introduction
Background Information and Statistics
Purpose, Rationale, and Recommendations for Practice
Benefits, Barriers, and Facilitators
Implementation and Evaluation
Conclusion
References

Introduction

Trauma to the perineum is among the most common adverse events associated with giving birth. Considering the consequences of this medical issue and women’s unpreparedness for facing obstetric complications, proper patient education efforts are required to facilitate post-discharge recovery in perineal tear patients. This paper proposes the creation of a patient education brochure summarising self-care practices and recommended lifestyle changes associated with recovery from perineal trauma.

Background Information and Statistics

Speaking in general terms, perineal trauma is an injury to the skin and tissues between the anal orifice and the vagina that occurs as a result of labor. Depending on the type of laceration and its anatomical features, modern specialists single out four categories of perineal tears (Hauck, Lewis, Nathan, White, & Doherty, 2015). First- and second-degree tears are lacerations that do not involve injuries to the anal sphincter (Priddis, Dahlen, & Schmied, 2012; Priddis, Schmied, & Dahlen, 2014).

Traumas of the third and the fourth type are more severe and harder to treat since they affect the majority of parts of the perineum. Not all tears require immediate treatment since such traumas can be superficial. However, healthcare professionals providing services to parturient patients and new mothers need to have enough knowledge to react to the problem when it occurs.

Studying perineal trauma and disseminating new research results among specialists and patients are tasks of paramount importance since it is a complication that affects new mothers’ physical health and even has adverse psychological effects. In women with perineal tears, the absence of adequate and timely treatment and education contributes to multiple physiological complications, including bleeding, infection, purulent inflammation, bowel incontinence, and involuntary urination (Abedzadeh-Kalahroudi, Talebian, Sadat, & Mesdaghinia, 2018). Moreover, the consequences of perineal tears are presented by the weakness of the muscles in the affected area and intense pain in the perineum (Abedzadeh-Kalahroudi et al., 2018).

Concerning the problem’s psychological effects, perineal trauma affects women’s sex life, ability to breastfeed, and independence, which can contribute to emotional distress (Priddis et al., 2014). Therefore, new measures to reduce the problem’s harmful consequences, including the creation of patient education materials, are absolutely necessary. Apart from the complications of perineal tears, the need to increase obstetric professionals’ awareness of perineal trauma and recovery is linked to the extent of the problem.

The incidence of perineal tears may vary depending on multiple factors, including the presence of specific health conditions in women and the state of medicine in a country. Modern studies demonstrate that 95% of parturient women in Great Britain and 91% of Spanish puerperal face some form of perineal trauma, including lacerations that do not require treatment (Abedzadeh-Kalahroudi et al., 2018, p. 206).

From 60% to 70% of women with perineal tears require surgical interventions, such as suturing (Ugwu, Iferikigwe, Obi, Eleje, & Ozumba, 2018, p.1252). According to international estimates, severe perineal trauma (three- and four-degree tears) occurs in 5-10% of vaginal deliveries (Priddis et al., 2014, p. 1). Based on modern research, the risks of having perineal tears vary depending on a woman’s age, parity, birthing positions, the use of labor induction, fetal size, malpresentation of the fetus, and other variables (Abedzadeh-Kalahroudi et al., 2018; Priddis et al., 2014). Considering the abundance of risk factors, the problem may affect almost any woman.

Purpose, Rationale, and Recommendations for Practice

As the background information related to perineal trauma demonstrates, parturient women face enormous risks of developing this obstetric complication despite all the research in this scientific area. If the size of these risks is taken into consideration, it becomes clear that the situation with scientific analysis and professional training has to be improved by encouraging further research. Such measures are needed to make sure that all healthcare providers that specialize in gynecology and obstetrics have access to educational resources summarising evidence-based recommendations for women and can disseminate them among patients who have perineal tears or are at risk of getting them.

The purpose of the proposed information resource is to generalize on the most recent findings linked to postpartum perineal trauma self-care and patient risk factors associated with the medical issue to improve women’s health literacy. The impacted populations are presented by expecting mothers and women who have given birth vaginally and received treatment for perineal tears.

To begin, new research devoted to recovery from perineal trauma is needed to make sure that women receive high-quality patient education even if care providers’ knowledge on the topic is limited. The problem is that concerns related to practitioners’ expertise are voiced in both high- and low-GDP countries. For instance, according to the UK-based study conducted by Fernando and Sultan, more than fifty percent of practicing obstetricians are dissatisfied with the quality of training in perineal trauma diagnosis and management in their country (Ali-Masri et al., 2018).

In poorer countries, such as Palestine, healthcare providers underutilize solid scientific findings peculiar to perineal tear classification and management (Ali-Masri et al., 2018). Such issues can compromise the quality of medical help, and eliminating them is one of the key goals that the proposed resource should achieve.

Moreover, the resource is required to improve women’s adherence to recommendations from care providers and prevent perineal tear patients from engaging in activities that affect the success of wound recovery. Even researchers from countries with well-developed healthcare systems, such as Australia, admit that perineal trauma education is not always standardized, which has implications for quality and new mothers’ health (Diaz & Steen, 2017).

To deal with variations in care outcomes, health institutes, and nursing schools invest in the development of national educational projects (Diaz & Steen, 2017). Appropriate antenatal and postnatal education that focuses on wound healing is inextricably connected with women’s postnatal recovery outcomes and allows promoting self-care (O’Kelly & Moore, 2017). Therefore, the proposed resource is needed to guarantee the success of patient education and prevent both physiological and psychological complications resulting from poor health literacy.

Based on the findings cited above, it is recommended to work on new strategies to standardize perineal tear education for patients and, to the extent practicable, reduce the impact of knowledge gaps on patient outcomes after hospital discharge. Almost 17% of midwives report the limited knowledge of perineal tear anatomy, which justifies the use of additional information resources in patient education (Selo-Ojeme, Pathak, & Joshi, 2014, p. 1266).

Educational materials should be based on scientific evidence, provide information in a well-organized manner, and be written with reference to the needs of the general audience (Patel et al., 2015). Thus, it is critical to review the scholarly literature on perineal trauma and postpartum recovery, understand patient education needs and formulate clear and justified recommendations.

Benefits, Barriers, and Facilitators

The proposed informational resource is to summarise and add to modern research on the principles of self-care during recovery from perineal trauma, factors and behaviors that increase the risks of complications, and this issue’s implications for women’s psychological condition and sexual relationships. Today, many expecting mothers are unaware of health risks for the perineum and are not prepared for living with perineal tears, which causes multiple issues (O’Kelly & Moore, 2017).

Thus, the expected benefits of the planned resource include its ability to increase patients’ risk awareness, reduce the veil of silence surrounding the consequences of vaginal delivery, and improve perineal tear patients’ healthcare compliance (O’Kelly & Moore, 2017). The listed advantages will affect women for the most part, but the resource will also improve care practice by filling midwives’ knowledge gaps (Rikard-Bell, Iyer, & Rane, 2019). Patient education alone does not help to eliminate the long-term consequences of perineal trauma (Rikard-Bell et al., 2019). However, being tasked with presenting the informational resource to patients, midwives and O&B doctors will have to recapitulate the problem of perineal tears or even get new knowledge, which will involve practice-related benefits.

The potential barriers to the resource’s implementation are linked to patients’ psychological conditions, midwives’ expert knowledge, and taboo topics. To begin with, the topic of perineal trauma is a sensitive one and can make many patients upset and disgusted, especially when it comes to primigravidas suffering from multiple fears (O’Kelly & Moore, 2017). Thus, women’s emotional and psychological unpreparedness to discuss obstetric complications is likely to affect the results of the implementation process. The next barrier is the quality of midwives’ knowledge on the topic. Since these specialists will be involved in implementation efforts, they should be able to answer any questions of the target audience, but midwives sometimes misunderstand even basic concepts linked to perineal trauma (O’Kelly & Moore, 2017; Selo-Ojeme et al., 2014).

Finally, the educational booklet will contain information concerning the effects of perineal tears on women’s sexual function, including recommendations for their intimate partners. Given the existence of social taboos, there is the risk that the representatives of some cultures or religions will regard such discussions as offensive or inappropriate and refuse to get acquainted with the handout materials.

Among the expected facilitators to the resource’s implementation are doctors’ and midwives’ professional collaboration and teamwork and opportunities to reach the audience through multiple sources. As it has been mentioned, midwives sometimes have superficial knowledge concerning the anatomy of obstetric complications, but effective communication can reduce this barrier to success (Selo-Ojeme et al., 2014).

For instance, apart from consulting the results of scientific studies and midwifery books to fill some knowledge gaps, specialists working with the target audience may engage in interprofessional experience exchange. Moreover, with the development of information technology, it has become much easier to reach the right audience and provide patient education. Apart from the traditionally used written instructions and printed materials, modern healthcare specialists can provide education with the help of e-learning platforms, social media, and other tools.

Implementation and Evaluation

To implement the strategy, it is critical to select the best ways to source the information and reach the target audience (expecting mothers and those recovering from perineal tears). Since the problem affects the majority of pregnant women, the results of the planned research are to be disseminated using as many channels as possible. In particular, it will be possible to design a brochure providing detailed information concerning perineal tears and risk factors, complications, wound recovery, and implications for sexual and physical activity and also locate this information online. To raise people’s awareness of the project, the patient education brochure will be advertised with the help of flyers disseminated among pregnant patients, announcements in hospitals, TV commercials (optionally), and social media posts by healthcare institutions.

Midwives and O&G doctors from different institutions will actively participate in implementation by providing patient education with the help of the brochure, organizing in-service training to teach newly-hired specialists how to work with this informational product, and disseminating flyers among patients in the target group. Moreover, it will be advantageous to use and present the resource in e-learning courses for midwives and resort to general practitioner involvement so as to reach more pregnant women.

To evaluate both the strategy and the final product, it will be of paramount importance to initiate the process of clinical audit, use both objective and subjective data to make conclusions, and identify additional areas for improvement. To begin with, the information resource will be evaluated by experienced O&G practitioners and researchers to exclude the presence of controversial and potentially harmful recommendations.

Pregnant women’s perceptions of the resource’s readability, importance, and usability will also be studied and summarised. After the stage of implementation, the links between the resource’s use and post-discharge complications of perineal tears related to poor adherence to medical recommendations will be studied, thus facilitating the use of objective data and medical records (Paracchini et al., 2017). The entire process is planned to take about six months and be followed by some error correction efforts.

Conclusion

To sum up, the international medical community recognizes perineal trauma as a common form of obstetric labor complications. The proposed patient education brochure is to prepare pregnant women for potential unwanted outcomes of vaginal delivery and support those having perineal tears during the period of recovery. The final product is to be disseminated with the help of medical professionals, healthcare institutions, and media and undergo the clinical audit process.

References

Abedzadeh-Kalahroudi, M., Talebian, A., Sadat, Z., & Mesdaghinia, E. (2018). Perineal trauma: Incidence and its risk factors. Journal of Obstetrics and Gynaecology, 39(2), 206-211.

Ali-Masri, H., Hassan, S., Ismail, K., Zimmo, K., Zimmo, M., Fosse, E.,… Laine, K. (2018). Enhancing recognition of obstetric anal sphincter injuries in six maternity units in Palestine: An interventional quality improvement study. BMJ Open, 8(6), e020983. Web.

Diaz, M. P., & Steen, M. (2017). Perineal wound care: Education and training in Australia. Australian Nursing and Midwifery Journal, 24(8), 41.

Hauck, Y. L., Lewis, L., Nathan, E. A., White, C., & Doherty, D. A. (2015). Risk factors for severe perineal trauma during vaginal childbirth: A Western Australian retrospective cohort study. Women and Birth, 28(1), 16-20.

O’Kelly, S. M., & Moore, Z. E. (2017). Antenatal maternal education for improving postnatal perineal healing for women who have birthed in a hospital setting. Cochrane Database of Systematic Reviews, 12, 1-20.

Paracchini, S., Masturzo, B., Tangolo, D., Roletti, E., Piazzese, A., Attini, R.,… Todros, T. (2017). Upcoming strategies in obstetrics: How the technology of clinical audit may reduce cesarean birth. Minerva Ginecologica, 69(6), 548-554.

Patel, S. K., Gordon, E. J., Wong, C. A., Grobman, W. A., Goucher, H., & Toledo, P. (2015). Readability, content, and quality assessment of web-based patient education materials addressing neuraxial labor analgesia. Anesthesia & Analgesia, 121(5), 1295-1300.

Priddis, H., Dahlen, H., & Schmied, V. (2012). Women’s experiences following severe perineal trauma: A meta-ethnographic synthesis. Journal of Advanced Nursing, 69(4), 748-759.

Priddis, H., Schmied, V., & Dahlen, H. (2014). Women’s experiences following severe perineal trauma: A qualitative study. BMC Women’s Health, 14(32), 1-11.

Rikard-Bell, J., Iyer, J., & Rane, A. (2019). Perineal outcome following educational intervention: A retrospective audit of primiparous women. Journal of Obstetrics and Gynaecology, 39(1), 36-40.

Selo-Ojeme, D., Pathak, S., & Joshi, V. (2014). The knowledge, practice and opinion of midwives’ in the UK on their training in obstetric perineal repair. Archives of Gynecology and Obstetrics, 291(6), 1265-1270.

Ugwu, E. O., Iferikigwe, E. S., Obi, S. N., Eleje, G. U., & Ozumba, B. C. (2018). Effectiveness of antenatal perineal massage in reducing perineal trauma and post-partum morbidities: A randomized controlled trial. Journal of Obstetrics and Gynaecology Research, 44(7), 1252-1258.

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