Incidence, severity, and determinants of perineal pain after vaginal delivery: A prospective cohort study

doi:10.1016/j.ajog.2004.02.064

American Journal of Obstetrics and Gynecology

Volume 191, Issue 4, October 2004, Pages 1199-1204

https://doi.org/10.1016/j.ajog.2004.02.064 Get rights and content

Abstract

Objectives

The purpose of this study was to determine the frequency of perineal pain in the 6 weeks after vaginal delivery and to assess the association between perineal trauma and perineal pain.

Study design

This was a prospective cohort study of parturients at 1 day, 7 days,' and 6 weeks' post partum in an academic tertiary obstetric unit in Toronto, Canada. Four hundred forty-four women were followed up, including women with an intact perineum (n = 84), first-/second-degree tears (n = 220), episiotomies (n = 97), or third-/fourth-degree tears (n = 46). Primary outcome was the incidence of perineal pain on day of interview; secondary outcomes were pain score measurements and interference with daily activities.

Results

Perineal trauma was more common among primiparous women, those with operative vaginal deliveries, and those with epidural analgesia during the second stage of labor. The incidence of perineal pain among the groups during the first week was intact perineum 75% (day 1) and 38% (day 7); first-/second-degree tears 95% and 60%; episiotomies 97% and 71%; and third-/fourth-degree tears 100% and 91%. By 6 weeks, the frequency of perineal pain was not statistically different between trauma groups.

Conclusion

Acute postpartum perineal pain is common among all women. However, perineal pain was more frequent and severe for women with increased perineal trauma.

Section snippets

Material and methods

A prospective cohort study was conducted at Women's College Hospital, a tertiary care perinatal unit in Toronto, Canada. After institutional research ethics review and approval, this study was carried out over an 8-month consecutive period, with subjects recruited and interviewed by one research nurse. The study population consisted of all women over the age of 18 years who were delivered of a live neonate vaginally and were in hospital for at least 24 hours after delivery.

Women participating

Results

The study population consisted of 447 women followed up for 6 weeks after vaginal delivery. Refusal to participate in the study was negligible, with only 3 women declining to participate. Grouping the women by exposure yielded 84 women with an intact perineum (control group), 220 women with first-/second-degree tears, 97 women with episiotomies, and 46 women with third-/fourth-degree tears (12 of who had a preceding episiotomy). The majority of the episiotomies (91/109) were median episiotomies.

Comment

This prospective cohort study followed 447 postpartum women for 6 weeks to define the incidence and severity of perineal pain after vaginal delivery, and to quantify the association between perineal trauma and perineal pain. Our results indicate that postpartum perineal pain is common in the initial period after delivery, regardless of perineal trauma. Increased perineal trauma was associated with greater pain scores, the choice of more severe pain descriptors, and more frequent use of narcotic

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The severity of second-degree perineal tears and perineal pain during three months postpartum: A prospective cohort study
2024, Midwifery
Second-degree perineal tears are common and can vary widely in the extent of tissue trauma. Therefore, a better understanding of perineal pain based on tissue trauma severity in second-degree tears is needed.
The primary aim of this study was to assess differences in perineal pain according to the severity of perineal tears, with a focus on subcategories of second-degree tears, during the first three months postpartum. The secondary aim was to assess the use of pain medication and breastfeeding patterns according to the severity of the second-degree tears.
In this observational cohort study, nulli- and multiparous women with singleton pregnancies were included during pregnancy. After birth, perineal tears were classified using the latest international classification system. In addition, second-degree tears were subcategorised according to percentage of damage to the perineum (<50 %=2A,>50 % but less than entire perineum=2B, affecting entire perineum, anal sphincter not involved=2C). Perineal pain, use of pain medication and breastfeeding patterns were assessed during a phone interview seven to ten days postpartum and through an electronic questionnaire three months postpartum.
Out of 880 vaginal births, 852 participants completed the phone interview and 715 answered the electronic questionnaire. During the first three months postpartum, women with 2C-tears reported statistically significantly higher pain scores and more frequent use of pain medication compared to women with 2A-tears. There was no statistically significant difference between the number of participants not breastfeeding between second-degree tear subcategories.
Women with 2C-tears reported higher perineal pain scores and more use of pain medication compared to those with less severe tears during three months postpartum.
A women-centred exploration of postpartum perineal pain when the perineum is diagnosed as intact: A French Gadamerian research study
2024, Midwifery
Postpartum perineal pain is a frequent symptom (90%) with consequences on postnatal health regardless of whether the perineum remains intact. The impact of that pain on both short and long-term health has been studied and literature suggests midwives have a role to play in addressing this issue. However, the determinants of perineal pain when no lesions are identified are under researched and there is little understanding of women's views on this topic.
The aim of the study was to gain an understanding of postpartum perineal pain when the perineum is considered to be intact. The objectives were
•To gain an understanding of postpartum pain and its consequences on health and well-being
•To explore women's views and understanding of perineal pain postpartum
•To gain an understanding of the determinants of postpartum perineal pain when no anatomic lesion is diagnosed.
A Gadamerian hermeneutic approach was used to achieve a shared understanding of the issue. Participants were recruited from two maternity hospitals in the French area of Vaucluse. All women aged 18 to 45 years old, having given birth vaginally to a single live child and diagnosed with an intact perineum, were invited to participate in face-to-face interviews. Eleven participants were interviewed once, six of whom agreed to a second interview which took place over the telephone due to Covid lockdown.
The findings identified three major themes 1. Can't honestly call it pain, 2. Reassurance in normality, 3. Managing the unexpected. The use of the word pain to describe perineal sensations in postpartum was questioned by the participants, who used inner resources to deal with these sensations. Fostering self-confidence, having the possibility to explain the sensations and qualifying them as normal were some approaches women usedto manage their postpartum perineal sensations in a positive manner.
A novel obstetrical surgical intervention – New episiotomy: Case series study
2023, European Journal of Obstetrics and Gynecology and Reproductive Biology
To establish anatomical structures responsible for creating a resistance force on a fetal head during vaginal delivery at term; to develop a new episiotomy to widen the vaginal outlet.
A prospective observational case series study.
International centers.
Eighteen consecutive women at term during vaginal delivery.
V-shape excision made on the hymeneal membrane, hymeneal ring, and hymeneal plate without extending an incision to the posterior perineal structures. Outlectorrhaphy (repairing the vaginal outlet to repair the surgical defect. Excisional specimens are subjected to histological examinations.
The primary maternal outcome measures were postpartum posterior perineum pain associated with vaginal outlectomy. The secondary outcomes measured a) complication of vaginal outlectomy; b) occurrence of dyspareunia after vaginal outlectomy; c) applicability of vaginal outlectomy; d) neonatal outcome measured by an APGAR score to show how the neonate tolerated the vaginal delivery process with vaginal outlectomy implementation.
The V-shape excision widened the vaginal outlet sufficiently for a vaginal delivery without a perineal incision. Outlectorrhaphy requires two or three simple interrupted sutures to close surgical defects and eliminate the vaginal gapping appearance. Eleven out of eighteen women were primigravida (61.1 %), and four multiparas (38.9 %) delivered a live newborn vaginally with a newly developed vaginal outlectomy. A median newborn’s weight was 350 g ± 250 g, and APGAR scores at 5 min were median of 9 ± 1. One out of eighteen patients experienced extension of the skin, perineal fascia, and bulbospongiosus muscle. Bleeding from the extension tearing of vaginal outlectomy was heavier than from uncomplicated vaginal outlectomy but negligible. Immediately postpartum, patients reported no moderate or severe perineal pain. At a 3-month postpartum, none of the subjects reported superficial or deep dyspareunia. Histology from the vaginal outlectomy specimens described the direct connection of the longitudinal vaginal smooth muscles to the hymeneal plate and compact connective tissues (like cartilage) of the hymeneal ring. Additionally, the histological examination showed the absence of the perineal skeletal muscle within the vaginal outlectomy specimens.
The vaginal outlet is responsible for the most vital resistance force on a fetal head during delivery. Vaginal outlectomy widens the vaginal outlet sufficiently for a fetal vaginal birth with minimal bleeding and is easy to repair. No moderate-severe perineal pain or dyspareunia occurred in this study group.
Vaginal outlectomy eliminates postpartum moderate-to-severe perineal pain and superficial dyspareunia.
The posterior perineum creates no resistance force on the fetal head during vaginal delivery to warrant incision.
Effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women: A systematic review and meta-analysis
2023, International Journal of Nursing Studies
Perineal massage during childbirth has been recommended as an effective measure to prevent perineal injury. However, the overall effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women remain inconclusive. Particularly, the effects of perineal massage begun during different stages of labor need to be further investigated.
To comprehensively review the effects of perineal massage during childbirth on primiparous health outcomes, including perineal-related outcomes, duration of labor, hemorrhage and postpartum perineal pain, and neonatal outcomes, including Apgar scores and neonatal complications, and to further explore the effects of perineal massage begun during different stages of labor.
A systematic review and meta-analysis following the Cochrane Handbook guidelines and PRISMA2020.
A systematic search strategy was developed following the three-phase search approach, and the literature search was conducted in electronic databases and clinical trial registers from inception to 7th January 2022. Study selection and data extraction were completed independently by two researchers. The updated Cochrane risk of bias 2.0 tool for randomized trials was chosen to evaluate the quality of included studies. Data analyses were conducted using the Revman5.4 software, and subgroup analyses were performed based on the different start times of perineal massage. Furthermore, the certainty of body of evidence for each outcome was assessed utilizing the GRADEpro online tool.
Seventeen randomized controlled trials involving 3248 primiparous women were included in the review. The pooled results of meta-analyses indicated that perineal massage begun during the second stage of labor significantly increased the occurrence of intact perineum (RR = 2.78, 95 % CI: [1.52, 5.05], P < 0.001), reduced the rate of second- and third-degree perineal lacerations (P < 0.05), and decreased the incidence of episiotomy (RR = 0.63, 95 % CI: [0.50, 0.79], P < 0.001), while perineal massage during the first stage of labor effectively shortened the duration of the first and second stages of labor (P < 0.05). The available evidence also suggests the potential role of perineal massage on hemorrhage and long-term postpartum perineal pain (P < 0.05). However, the aggregated results failed to demonstrate the beneficial effects of perineal massage on neonatal outcomes (P > 0.05).
Perineal massage begun during the second stage of labor effectively improves the perineal-related outcomes in primiparous women, while perineal massage during the first stage of labor significantly shortens the duration of labor. High-quality studies exploring the standardized procedure for perineal massage and the short- and long-term effects of perineal massage are warranted.
CRD42022302336 (PROSPERO).
Association of pain, analgesic, psychological, and socioeconomic factors with sub-acute pain after childbirth: A prospective cohort study
2022, Journal of Clinical Anesthesia
To determine if acute postpartum pain, psychological distress, socioeconomic factors, and labor analgesia were associated with sub-acute pain after childbirth (SAPC; pain starting after childbirth and lasting between four weeks to three months).
Prospective cohort study, from pre-conception to post-partum three months.
Singapore's major public maternity institution.
We included women planning to conceive within a year. We excluded women who were pregnant, taking chemotherapy or psychotropic medications, had diabetes mellitus, received assisted fertility interventions or contraception, did not conceive after 12 months, with multiple pregnancies, or who developed obstetric complications.
None.
We investigated the relationship between average pain score during the three days after childbirth (primary exposure) and incidence of SAPC at postpartum three months (primary outcome). Secondarily, psychological distress at pre-conception (Beck Depression Inventory (BDI), Edinburgh Postnatal Depression Scale (EPDS), State-Trait Anxiety Inventory (STAI), Perceived Stress Scale (PSS), General Health Questionnaire-12 (GHQ-12), Life Experiences Survey (LES)) and second trimester of pregnancy (BDI, EPDS, STAI, PSS, Pregnancy Experience Scale (PES)) were assessed. Baseline maternal and socioeconomic characteristics, labor analgesia, maternal and neonatal outcomes were also collected accordingly.
Of 317 women who met the study criteria, 30 (9.5%) developed SAPC. Higher average pain score during the three days after childbirth (adjusted odds ratio (aOR) 1.46, 95% CI 1.17 to 1.82, p = 0.001), use of meperidine for labor analgesia (aOR 4.23, 95% CI 1.03 to 17.43, p = 0.046), higher pre-conception GHQ-12 score (aOR 1.14, 95% CI 1.03 to 1.27, p = 0.013), and lack of employment with income during pregnancy (aOR 9.62, 95% CI 3.07 to 30.30, p < 0.001) were independently associated with SAPC, with area under the curve (AUC) of 0.837.
Higher acute postpartum pain scores, use of meperidine for labor analgesia, poorer pre-conception general psychological health, and lack of employment with income during pregnancy are associated with SAPC.
Biomechanics of pregnancy and vaginal delivery
2022, Current Opinion in Biomedical Engineering
During pregnancy, the female reproductive organs and pelvic structures undergo dramatic changes in geometry, anatomical position, and function to accommodate the growing fetus and prepare for delivery. During these processes, various complications can occur significantly impacting the baby and mother's health and are understudied from a biomechanical perspective. Biomedical engineers work cooperatively with clinicians and biologists to understand the changes that occur during pregnancy and vaginal delivery and how this impacts maternal and fetal health. To accomplish this, engineers and their collaborators' design and leverage various imaging modalities, computational tools, and tissue engineering systems to quantify how and why the reproductive organs and surrounding structures evolve throughout pregnancy. This review focuses on the techniques and methods developed over the past five years to improve our understanding of the biomechanics of the female reproductive organs and pelvic structures during pregnancy and vaginal delivery.

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Presented at the 17th Annual Meeting of the Society of Perinatal Obstetricians (SPO), January 20-25, 1997, Anaheim, Calif.

Supported by study grants from Canadian Anesthesia Society–Zeneca Canadian Research Award in Anesthesia and Women's College Hospital Research Foundation.

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General Obstetrics and Gynecology: ObstetricsIncidence, severity, and determinants of perineal pain after vaginal delivery: A prospective cohort study☆

Abstract

Objectives

Study design

Results

Conclusion

Section snippets

Material and methods

Results

Comment

Pain

Pain

Pain

Am J Obstet Gynecol

Obstet Gynecol

The history of obstetric anesthesia

Epidural morphine for the relief of postoperative pain after cesarean delivery

Anesth Analg

The McGill Pain Questionnaire: major properties and scoring methods

Pain

Manual for scoring socioeconomic status for research on health behavior

Public Health Rep

General Obstetrics and Gynecology: Obstetrics
Incidence, severity, and determinants of perineal pain after vaginal delivery: A prospective cohort study☆