Epidemiology of maternal depression, risk factors, and child outcomes in low-income and middle-income countries.

ContextEpisiotomy at the time of vaginal birth is common. Practice patterns
vary widely, as do professional opinions about maternal risks and benefits
associated with routine use.ObjectiveTo systematically review the best evidence available about maternal
outcomes of routine vs restrictive use of episiotomy.Evidence AcquisitionWe searched MEDLINE, Cumulative Index to Nursing and Allied Health Literature,
and Cochrane Collaboration resources and performed a hand search for English-language
articles from 1950 to 2004. We included randomized controlled trials of routine
episiotomy or type of episiotomy that assessed outcomes in the first 3 postpartum
months, along with trials and prospective studies that assessed longer-term
outcomes. Twenty-six of 986 screened articles provided relevant data. We entered
data into abstraction forms and conducted a second review for accuracy. Each
article was also scored for research quality.Evidence SynthesisFair to good evidence from clinical trials suggests that immediate maternal
outcomes of routine episiotomy, including severity of perineal laceration,
pain, and pain medication use, are not better than those with restrictive
use. Evidence is insufficient to provide guidance on choice of midline vs
mediolateral episiotomy. Evidence regarding long-term sequelae is fair to
poor. Incontinence and pelvic floor outcomes have not been followed up into
the age range in which women are most likely to have sequelae. With this caveat,
relevant studies are consistent in demonstrating no benefit from episiotomy
for prevention of fecal and urinary incontinence or pelvic floor relaxation.
Likewise, no evidence suggests that episiotomy reduces impaired sexual function—pain
with intercourse was more common among women with episiotomy.ConclusionsEvidence does not support maternal benefits traditionally ascribed to
routine episiotomy. In fact, outcomes with episiotomy can be considered worse
since some proportion of women who would have had lesser injury instead had
a surgical incision.

https://jamanetwork.com/journals/jama/articlepdf/200799/jcr50003.pdf

Outcomes of routine episiotomy: a systematic review.

Background
Domestic violence in the perinatal period is associated with adverse obstetric outcomes, but evidence is limited on its association with perinatal mental disorders. We aimed to estimate the prevalence and odds of having experienced domestic violence among women with antenatal and postnatal mental disorders (depression and anxiety disorders including post-traumatic stress disorder [PTSD], eating disorders, and psychoses).

https://journals.plos.org/plosmedicine/article/file?id=10.1371/journal.pmed.1001452&type=printable

Domestic Violence and Perinatal Mental Disorders: A Systematic Review and Meta-Analysis

Hypericum perforatum L.

Background
Most vaginal births are associated with trauma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including perineal massage, warm or cold compresses, and perineal management techniques have been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011.

Objectives
To assess the effect of perineal techniques during the second stage of labour on the incidence and morbidity associated with perineal trauma.

Search methods
We searched Cochrane Pregnancy and Childbirth's Trials Register (26 September 2016) and reference lists of retrieved studies.

Selection criteria
Published and unpublished randomised and quasi-randomised controlled trials evaluating perineal techniques during the second stage of labour. Cross-over trials were not eligible for inclusion.

Data collection and analysis
Three review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. We checked data for accuracy.

Main results
Twenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Overall, trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques.

Most studies did not report data on our secondary outcomes. We downgraded evidence for risk of bias, inconsistency, and imprecision for all comparisons.

Hands off (or poised) compared to hands on

Hands on or hands off the perineum made no clear difference in incidence of intact perineum (average risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.12, two studies, Tau² 0.00, I² 37%, 6547 women; moderate-quality evidence), first-degree perineal tears (average RR 1.32, 95% CI 0.99 to 1.77, two studies, 700 women; low-quality evidence), second-degree tears (average RR 0.77, 95% CI 0.47 to 1.28, two studies, 700 women; low-quality evidence), or third- or fourth-degree tears (average RR 0.68, 95% CI 0.21 to 2.26, five studies, Tau² 0.92, I² 72%, 7317 women; very low-quality evidence). Substantial heterogeneity for third- or fourth-degree tears means these data should be interpreted with caution. Episiotomy was more frequent in the hands-on group (average RR 0.58, 95% CI 0.43 to 0.79, Tau² 0.07, I² 74%, four studies, 7247 women; low-quality evidence), but there was considerable heterogeneity between the four included studies.

There were no data for perineal trauma requiring suturing.

Warm compresses versus control (hands off or no warm compress)

A warm compress did not have any clear effect on the incidence of intact perineum (average RR 1.02, 95% CI 0.85 to 1.21; 1799 women; four studies; moderate-quality evidence), perineal trauma requiring suturing (average RR 1.14, 95% CI 0.79 to 1.66; 76 women; one study; very low-quality evidence), second-degree tears (average RR 0.95, 95% CI 0.58 to 1.56; 274 women; two studies; very low-quality evidence), or episiotomy (average RR 0.86, 95% CI 0.60 to 1.23; 1799 women; four studies; low-quality evidence). It is uncertain whether warm compress increases or reduces the incidence of first-degree tears (average RR 1.19, 95% CI 0.38 to 3.79; 274 women; two studies; I² 88%; very low-quality evidence).

Fewer third- or fourth-degree perineal tears were reported in the warm-compress group (average RR 0.46, 95% CI 0.27 to 0.79; 1799 women; four studies; moderate-quality evidence).

Massage versus control (hands off or routine care)

The incidence of intact perineum was increased in the perineal-massage group (average RR 1.74, 95% CI 1.11 to 2.73, six studies, 2618 women; I² 83% low-quality evidence) but there was substantial heterogeneity between studies). This group experienced fewer third- or fourth-degree tears (average RR 0.49, 95% CI 0.25 to 0.94, five studies, 2477 women; moderate-quality evidence).

There were no clear differences between groups for perineal trauma requiring suturing (average RR 1.10, 95% CI 0.75 to 1.61, one study, 76 women; very low-quality evidence), first-degree tears (average RR 1.55, 95% CI 0.79 to 3.05, five studies, Tau² 0.47, I² 85%, 537 women; very low-quality evidence), or second-degree tears (average RR 1.08, 95% CI 0.55 to 2.12, five studies, Tau² 0.32, I² 62%, 537 women; very low-quality evidence). Perineal massage may reduce episiotomy although there was considerable uncertainty around the effect estimate (average RR 0.55, 95% CI 0.29 to 1.03, seven studies, Tau² 0.43, I² 92%, 2684 women; very low-quality evidence). Heterogeneity was high for first-degree tear, second-degree tear and for episiotomy - these data should be interpreted with caution.

Ritgen's manoeuvre versus standard care

One study (66 women) found that women receiving Ritgen's manoeuvre were less likely to have a first-degree tear (RR 0.32, 95% CI 0.14 to 0.69; very low-quality evidence), more likely to have a second-degree tear (RR 3.25, 95% CI 1.73 to 6.09; very low-quality evidence), and neither more nor less likely to have an intact perineum (RR 0.17, 95% CI 0.02 to 1.31; very low-quality evidence). One larger study reported that Ritgen's manoeuvre did not have an effect on incidence of third- or fourth-degree tears (RR 1.24, 95% CI 0.78 to 1.96,1423 women; low-quality evidence). Episiotomy was not clearly different between groups (RR 0.81, 95% CI 0.63 to 1.03, two studies, 1489 women; low-quality evidence).

Other comparisons

The delivery of posterior versus anterior shoulder first, use of a perineal protection device, different oils/wax, and cold compresses did not show any effects on perineal outcomes. Only one study contributed to each of these comparisons, so data were insufficient to draw conclusions.

Authors' conclusions
Moderate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent. Poor-quality evidence suggests hands-off techniques may reduce episiotomy, but this technique had no clear impact on other outcomes. There were insufficient data to show whether other perineal techniques result in improved outcomes.

Further research could be performed evaluating perineal techniques, warm compresses and massage, and how different types of oil used during massage affect women and their babies. It is important for any future research to collect information on women's views.

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

Depression, anxiety and influencing factors in pregnancy: a study in a Turkish population.

Factors associated with menopausal symptoms and their relationship with the quality of life among Turkish women.

Effects of unplanned pregnancy on maternal health in Turkey.

Background. Historically, episiotomy has been carried out during labour to facilitate delivery, shorten the duration of the second stage and prevent spontaneous lacerations. However, recent studies of episiotomy have recommended that it be carried out only when necessary. In Turkey, midwives are authorized to perform episiotomy.

Aim. To analyse the effects of episiotomy on mothers’ health and mother–infant bonding.

Design. A cohort study of 100 women who gave birth by normal vaginal delivery in a Turkish hospital between 15 March 1999 and 6 April 2000.

Methods. Participants were divided into episiotomy (n = 50) and control (n = 50) groups. Data on biographical characteristics and the process of labour were collected in hospital, and follow-up was conducted at home 1, 3 and 12 weeks after labour.

Results. Mean duration of the second stage was longer in the episiotomy group than the control group, but the difference was not significant. The number of spontaneous lacerations was significantly lower in the episiotomy group. Mean time from delivery to maternal rest and time taken to bond with the infant were significantly longer in the episiotomy group. There were significantly higher scores for overall incidence and severity of pain on the first day, and pain incidence and severity at 1 week in the episiotomy group. Significantly fewer women in the episiotomy group were able to do chores and to sit/stand up comfortably in the first postpartum week

Conclusion. Episiotomy should not be used unless indicated. Measures should be taken to avoid perineal trauma during labour, establish bonding between mother and infant as soon as possible, and minimize perineal discomfort after delivery.

Effects of episiotomy on bonding and mothers’ health

Aim. The aim of this study was to evaluate the sexual problems in women during the first postpartum year and related conditions.



Background.  In the postpartum period, women encounter numerous physical, psychological and sociocultural factors. These factors negatively affect both the sexual function and the quality of life of woman.



Design.  A descriptive survey.



Methods.  In this study, 230 women were included. The study was conducted between September 2007 and December 2008 in Izmir, Turkey. A questionnaire form developed by authors, the Arizona Sexual Experience Scale-female version and the Beck depression inventory were applied for participants.



Results.  The women began to have sexual intercourse within 7·06 weeks after delivery. Of the women, 58·3% reported that they had dyspareunia in the postpartum period. According to Arizona Sexual Experience Scale, the total score was ≥11 in 91·3% of women and they had sexual problems in the first postpartum year. The results of the multivariate analysis revealed that the increase in age, the presence of sexual problems during pregnancy and the increase in time after delivery significantly increased the possibility of postpartum sexual problems.



Conclusion.  This study revealed that the majority of the women had postpartum sexual problems and the possibility of postpartum sexual problems increased with the increase in age, the presence of sexual problems during pregnancy and the increase in time after delivery.



Relevance to clinical practice.  Healthcare professionals should evaluate women in terms of their sexual functions during both pregnancy and postpartum period. Health education, counselling, referral services for early diagnosis and treatment might contribute to the protection and improvement of the sexual health of women during the postpartum period.

Zekiye Karaçam

Papers

Depression, anxiety and influencing factors in pregnancy: a study in a Turkish population.

Factors associated with menopausal symptoms and their relationship with the quality of life among Turkish women.

Effects of unplanned pregnancy on maternal health in Turkey.

Effects of episiotomy on bonding and mothers’ health

Sexual problems in women during the first postpartum year and related conditions.