Ergonomía

MacArthur and MacArthur (2004) reported immediate postpartum perineal pain to be common but an increasing incidence of perineal pain was associated with greater degrees of perineal trauma. In their study perineal pain was present on day one in 75% of women with an intact perineum, 95% with first /second degree tear, 97% with episiotomy and 100% with third/fourth degree tear. This pattern persisted to day seven, however, the incidence of pain reported had fallen to 38%, 60%, 71% and 91% respectively. By six weeks postpartum no statistically significant differences were found between the groups although no pain was reported by women with an intact perineum whereas 20% of women with a third/fourth degree tear were still experiencing pain. In addition to the observed differences in incidence the severity of pain reported increased with degree of trauma. Over one third of women sustaining an episiotomy used the word distressing or worse on the present pain intensity (PPI) scale of the McGill pain questionnaire on day one

as did 48% of women suffering an anal sphincter tear compared to 24% in the minimal trauma group or 13% where the perineum remained intact. Pain was reported to persist for longer also with increasing degrees of perineal trauma ranging from 1.9 weeks for women with an intact perineum, 2.4 weeks with minimal trauma, 2.6 weeks with episiotomy to 3.2 weeks for women with a third/fourth degree tear. Pain was found to be less reported in multiparous women compared to primiparae.

Support for these findings can be found in the study by Albers et al. (1999) in their analysis of data from the HOOP trial, an RCT comparing a “hands on” approach versus a “hands poised” approach to perineal management at vaginal delivery. They reported on perineal pain up to three months postpartum, and found that even women without perineal trauma experienced perineal pain at each time point (two days, ten days and three months postpartum) however in all cases, as expected, levels declined with time. More pain was experienced by primiparae versus multiparae, sutured versus unsutured trauma and with increasing degrees of trauma i.e. anal sphincter tears were associated with most postpartum pain.

Glazener (1999) found perineal pain to be significantly related to mode of delivery prior to hospital discharge, at two months and at 12-18 months postpartum. Rates diminished over time but a substantial proportion of women (30%) still complained of residual perineal pain up to 18 months after delivery (Figure 1.13).

Figure 1.13 Perineal pain by method of delivery to 18 months postpartum

Source Glazener 1999

A paper by Declerq et al. (2008) gives insight into women’s postpartum experiences of pain by mode of delivery elicited from a representative national survey of women who gave birth during 2005 in the US. At spontaneous birth, women were significantly more likely to report perineal pain as a major problem in the immediate puerperium if episiotomy was performed rather than when no episiotomy was performed (32.9% vs 23.6%, p=0.03 in primiparae; 17.9% vs 5.1%, p<0.001 for multiparae). Perineal pain was commonly reported by mothers at OVD (by 77% primiparae and 52% multiparae). Mothers with both episiotomy and OVD were more likely to report perineal pain (77% with 43% describing it as severe) than those with either of these interventions alone (63% and 25% respectively). One third of primiparae reported pain which had interfered with their daily tasks (11% in a significant way). Pain persisting at six months postpartum was reported among 15% of primiparae delivered by OVD compared to 2% of primiparae

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delivered by SVD. From these studies it would appear that OVD has significant implications in terms of pain which is exacerbated by the use of episiotomy.

A subjective assessment of post episiotomy pain was conducted by Reading et al. (1982) by interview within the first 24 hours after delivery and postal questionnaire follow-up at three months postpartum. A total of 101 women participated with follow-up data available on 69(68%). The majority (63%) reported pain from their episiotomy as “discomforting” at delivery with 10% rating it as “distressing” and 7% “horrible”. At three months however 43% reported pain as “discomforting” whilst there was no change in the numbers reporting more significant pain. Almost all pain associated with their episiotomy was on sitting and a smaller proportion with pain on defecation although not with pain on micturition. They also found pain to be associated with the mode of delivery. More complex deliveries were associated with higher pain levels, a greater usage of postpartum analgesia and retrospective recall of episiotomy related pain through the puerperium. From the evidence base of episiotomy use at vaginal birth (Carroli and Belizan 1999) there would appear to be no consensus on the effect of a restrictive approach to episiotomy use in terms of postpartum pain. Harrison et al. (1984) analysed perineal pain in the first four days postpartum among 77 primigravid women delivered spontaneously who had participated in their RCT of routine versus restrictive use of episiotomy at vaginal birth by the degree of trauma sustained. Forty participants were allocated to receive an episiotomy routinely, 37 were allocated to a restrictive use of episiotomy and had spontaneous tearing. Women who retained an intact perineum or sustained a first degree tear fared best as would be expected. Women who had an epidural anaesthesia and episiotomy fared worst with the highest degree of swelling and bruising. Analgesia requirements correlated well with the observed differences in pain measurements between groups and

over time. However, no significant differences were found between the two groups with regard to perineal pain or healing complications.

The RCT by Sleep et al. (1984) reported the severity and incidence of perineal pain, as assessed by mothers, was very similar for each study arm (liberal and restrictive use of episiotomy) at ten days and three months postpartum. Use of oral analgesia at ten days was reported in 3% of mothers in the restrictive group and 2% in the liberal group. At three months postpartum 12% of women in each group had sought medical advice due to perceived perineal problems. The findings in the study by Klein et al. (1992) were similar, with no significant differences in postpartum pain between groups.

One trial however, the Argentine Episiotomy Trial Collaborative Group (1993) reported that a selective approach to episiotomy use at vaginal delivery was associated with less perineal pain at hospital discharge than a routine approach [RR 0.72(95%CI 0.65 – 0.81)]. No results however were reported in any of the aforementioned trials of women who underwent OVD. This paucity of evidence requires to be addressed in any future RCT of episiotomy approach at OVD.