Minimizing Genital Tract Trauma and Related Pain Following Spontaneous Vaginal Birth

Leah L. Albers, CNM, DrPH; Noelle Borders, CNM, MSN

Disclosures

J Midwifery Womens Health. 2007;52(3):246-253. 

In This Article

Abstract and Introduction

Genital tract trauma is common following vaginal childbirth, and perineal pain is a frequent symptom reported by new mothers. The following techniques and care measures are associated with lower rates of obstetric lacerations and related pain following spontaneous vaginal birth: antenatal perineal massage for nulliparous women, upright or lateral positions for birth, avoidance of Valsalva pushing, delayed pushing with epidural analgesia, avoidance of episiotomy, controlled delivery of the baby's head, use of Dexon (U.S. Surgical; Norwalk, CT) or Vicryl (Ethicon, Inc., Somerville, NJ) suture material, the "Fleming method" for suturing lacerations, and oral or rectal ibuprofen for perineal pain relief after delivery. Further research is warranted to determine the role of prenatal pelvic floor (Kegel) exercises, general exercise, and body mass index in reducing obstetric trauma, and also the role of pelvic floor and general exercise in pelvic floor recovery after childbirth.

Approximately three million women give birth vaginally each year in the United States.[1] Perineal pain from childbirth lacerations is a common symptom reported by new mothers, and if protracted, the pain may interfere with activities of daily living and family functioning.[2,3] Because the well-being of newborn infants is so dependent on the health and functional abilities of their mothers, the overall health status of new mothers is a priority concern for all who work in maternity care. Women who have spontaneous vaginal births and minimal or no genital tract trauma have the best health postpartum. Such women have the fewest hospital readmissions for postdelivery morbidity, less perineal pain, stronger pelvic floors, better sexual function, less depression, and optimum functional status.[4,5,6]

Genital tract trauma can be caused by episiotomy, spontaneous lacerations, or both. Episiotomy rates in the United States have steadily declined over the past 25 years,[7] but in 2003, were performed in approximately 25% of all vaginal births.[8] Conversely, spontaneous lacerations requiring suturing have gradually risen as episiotomies have declined, and in 2003, 41% of the women who had vaginal births in the United States experienced spontaneous lacerations.[8] Because some lacerations are not sutured, this proportion is an undercount.

A direct relationship exists between the extent and complexity of genital tract trauma sustained with vaginal birth and subsequent pain and functional impairment.[9,10] More genital tract trauma equals greater postpartum morbidity, and vice versa. While delivery over an intact perineum may require additional time in second stage and greater patience from the birth attendant, it is associated with fewer maternal health problems in the short run (blood loss, pain, and need for suturing) and in the long run (continued pain, pelvic floor weakness, sexual problems, and bowel and urinary incontinence).[11] Therefore, clinical care that enables women to give birth without genital tract lacerations will improve the health of new mothers.

This article reviews the available research on the reduction of genital tract trauma and related postdelivery pain. Key concepts for practicing clinicians will be summarized for the periods before, during, and after birth, and areas for future research will be highlighted.

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