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persalinan pervaginam!!!!!…

Vaginal Delivery

The preservation and promotion of the normalcy of labor and delivery, including the woman’s active participation in the birth process to the extent it is possible and desirable, are issues that are integral to the philosophy of most certified nurse midwives (CNM) (Roberts, 2002). The safe birth of an infant in a manner that is as non-traumatic as possible to both mother and infant is a cornerstone of midwifery care and one that has been taught meticulously in midwifery education (Varney, Kriebs, & Gregor, 2004a). Looking at each woman holistically and focusing on her whole structures, abilities, and needs are critical pieces to promote the best possible post-delivery outcomes. Facilitating the best long and short-term outcomes for childbearing women includes addressing research that assesses the effects of labor on the PF, as well as methods that may reduce negative long-term impact on the PF. Utilizing findings from such studies could help decrease the potential consequences of reproduction and birth, including PF dysfunction and the burden of UI.

Incidence of UI after vaginal birth ranges from 22% in spontaneous vaginal births to 33% in forceps-assisted births (McFarlin, 2004). The majority of childbirth-related injuries that have long-term affects on the PF occur significantly with the first vaginal delivery (Altman et al., 2006; Heit, Mudd, & Culligan, 2001; Viktrup, Rortveit, & Lose, 2006). Women with stress urinary incontinence (SUI) symptoms three months postpartum are placed at an even higher risk of severe incontinence in the long term (Nygaard, 2006). An understanding of the pelvic floor anatomy and physiology is important to successfully protect and/or repair perineal traumas, which can occur at or during delivery (Stepp, Siddiqui, Emery, & Barber, 2006).

The urethra lies on a “hammock” of ligaments and muscle. If this hammock is stretched, urethral compression weakens, and leaks can occur (Kelleher, 2003). Obstetric issues, including babies with high birth weight and prolonged second stage of labor, increase the risk of neural damage to the pelvic floor (Peeker & Peeker, 2003). UI symptoms may more likely be related to pudendal nerve damage and tissue stretching than supportive tissue damage (Altman et al., 2006).

Neural damage mirrors continence status, and pudendal neuropathy is specifically implicated in pathogenesis of pelvic organ prolapse (POP), and urinary and anal incontinence (Sultan & Fernando, 2001). Stretching of the pudendal nerve at the point where it curves around the ischial spine may cause damage and injury to the nerve during a vaginal delivery. This can lead to weakness and atrophy of the medial portions of the levator ani (LA) muscles, as well as the voluntary muscles of the perineum. These injuries further predispose the woman to vaginal support defects as well as reduction in fast twitch pelvic muscle contraction, both of which are factors that contribute to SUI (Lingam, 2001; Sultan & Fernando, 2001).

Altman et al. (2006) performed a 10-year prospective, observational cohort study to estimate the effects of the first delivery on bladder function, as well as to assess the effects of subsequent pregnancy and obstetric events. These authors found that the rate of UI episodes increased 5 to 6 times after the first vaginal delivery. Symptoms of UI at nine-month follow-up was strongly predictive of symptoms 10 years later. Subsequent pregnancies were not found to be as influential on UI development as the first (Altman et al., 2006; Viktrup et al., 2006).

Viktrup and colleagues (2006) performed a longitudinal cohort study of 241 women to assess SUI symptoms after first delivery and 12 years after first delivery. SUI within 3 months after the first delivery was a predictor of SUI both 5 and 12 years post-delivery. Among women who had resolution of SUI at 3 months postpartum in this study, 50% had symptoms at 12 years. In women without SUI at all with the first pregnancy, 30% had symptoms of SUI at 12 years post-delivery. SUI symptoms occurring in the postpartum period was the most significant indicator of long-term SUI 12 years after first delivery (Viktrup et al., 2006).

Second-Stage Labor

The second stage of labor generally begins when the cervix is fully dilated and ends with fetal expulsion (see Figure 1). Spontaneous maternal pushing efforts may begin just before or after complete dilatation (Roberts, 2002; Varney et al., 2004b). Women are traditionally encouraged to push when the cervix is fully complete (10 cm) and not to push before that time. Women are also encouraged to hold their breath and sustain each push for at least 10 seconds, a process that is usually repeated until each contraction ends. This directed pushing, especially when prolonged in such a sustained and strenuous manner, can lead to maternal fatigue, which increases the use of instrument-assisted deliveries, and therefore, perineal trauma. Directed pushing may also challenge a woman’s confidence in her own body and ability to birth her child (Roberts, 2002; Roberts & Hanson, 2007).

Figure 1. (click image to zoom)Stages of Labor

Most importantly, the practice of routine, sustained, and strenuous active pushing during the second stage of labor contributes to long-term pressure on the pelvic floor, which increases adverse pelvic floor and perineal outcomes (Roberts & Hanson, 2007). Being told to push “on complete” cervical dilation in the absence of maternal spontaneous effort results in prolonged maternal bearing down, which can invoke the physiologic consequences of the Valsalva maneuver. Women who use Valsalva pushing techniques have been shown to demonstrate unfavorable urodymanic indices after delivery, which may result in pelvic floor disorders (PFDs) from forceful pushing (Albers & Borders, 2007).

Prolonged, active second-stage labor (> 30 minutes) is associated with pudendal nerve damage (Heit et al., 2001; Sultan & Fernando, 2001) and has been found to correlate with pelvic organ descent (Deitz & Bennett, 2003). A further consequence of sustained bearing down is reduction of the oxygen load to the placenta, resulting in potential harm to the fetus (bradycardia, prolonged decelerations, hypoxia, and acidosis) (Albers & Borders, 2007; Roberts, 2002; Roberts & Hanson, 2007). Passive descent of the fetus has not been associated with these outcomes, and involuntary pushing has the potential to minimize perineal trauma (Albers & Borders, 2007; Roberts, 2002; Roberts & Hanson, 2007).

Early pushing in the absence of maternal urge, as well as pushing when the infant remains at a high station in the pelvis, is associated with increased damage to bladder fascia and the pelvic floor. Sometimes fetal station (marking descent into the pelvis) is not low enough to reasonably encourage pushing efforts (Roberts, 2002). Early pushing has not been found to enhance fetal descent (Mayberry, Hammer, Kelly, True-Driver, & De, 1999). Delaying pushing until fetal descent encourages the natural, spontaneous maternal urges and can shorten the active phase of pushing, which may decrease the risks of structural damage to tissue and nerves (Heit et al., 2001; Leslie, 2004). Increasing evidence supports that the exact timing of second-stage duration is not as important as its progression. During normal, uncoached labor, uterine contraction intensity increases to a point when an involuntary pushing urge is provoked. Women will naturally push several times over the duration of the contraction, taking a few breaths between each short push, and the force of the pushing will increase as fetal descent occurs (Roberts, 2002).

Preservation of the pelvic floor structures and functions may be best accomplished by a longer “passive” phase of second stage (Handa, Harris, & Ostergard, 1996). Spontaneous urge pushing has been associated with lower incidence of both perineal lacerations and episiotomies. This may be due to the fact that the slower fetal descent with spontaneous effort allows the pelvic and perineal tissues the time to comply with the demands of the passing fetus (Roberts, 2002). As a point of reference, precipitate deliveries can cause perineal lacerations because maternal tissues have not had enough time to adjust to the stretch of delivery forces (Sultan & Fernando, 2001).

Second-stage interventions have become synonymous with procedures. With procedures come increases in financial burden to the patient, as well as a new set of positive and negative outcomes (Roberts, 2002). In many instances, care during second-stage labor consists of providers wanting to help women achieve birth in a timely yet satisfactory manner (Roberts, 2002). However, as women become fatigued or procedures do not bring about delivery, the need for operative vaginal techniques can increase (Roberts & Hanson, 2007).

In the event of a deeply engaged fetal head and incomplete cervical dilatation, the practitioner should redirect the pushing efforts of the mother to spare the cervix from edema or tearing (Roberts, 2002). Pelvic structures also play a role in second-stage injury. Women with short obstetrical (OB) conjugates may incur more trauma to structures along the anterior sacrum, including origins of LA, uterosacral ligaments, and hypogastric nerve. The platypelloid pelvis, which is associated with deep transverse arrest in labor, may predispose these women to neuropathy, resulting from a prolonged second stage (Handa et al., 2003).

Fraser et al. (2000) randomized 1,862 nulliparous women at time of full dilatation to an early push group or delayed (waiting 2 hours after “complete” dilation) pushing group. All women in the study were undergoing continuous epidural analgesia. Delayed pushing was found to be associated with reduction in difficult deliveries, including CS, operative delivery from mid-pelvic position, and low-pelvic procedures. Episiotomy was performed in 75% of difficult deliveries, compared with 37.5% of non-difficult deliveries, with third and fourth-degree tears more likely in the difficult delivery group. However, in this study, delayed pushing was not found to be associated with reduction in enough difficult deliveries to produce better perineal outcomes (Fraser et al., 2000; Heit et al., 2001). It is valid to suggest, however, that the risks for serious PFD secondary to delivery may be minimized in women who have normal, spontaneous vaginal births without forced or early pushing, instrumental assistance, or episiotomy (Leslie, 2004).

Vaginal/Perineal Injury

Most women are willing to accept some risk to themselves for the benefit of their baby (Penna, 2004); as such, perineal injury is the most common form of maternal obstetric injury. Risk factors for PF injury include increased fetal birth weight, malpresentation or malposition of the fetus, duration of labor and rate of delivery, episiotomy, instrumental delivery (especially forceps), and supine (lithotomy) birth position (Fernando & Sultan, 2004; Mayerhofer et al., 2002; Peeker & Peeker, 2003).

Up to 65% of women incur a laceration or episiotomy during vaginal delivery that will require repair (Stepp et al., 2006). Perineal trauma is associated with postpartum pain and morbidity, including bleeding and infection (McCandlish, 2001). Vaginal delivery is independently associated with significant long-term increases in SUI symptoms and urgency, regardless of maternal age or number of deliveries (parity), and PF damage is proportional to the perineal trauma sustained (Altman et al., 2006; Lukacz, Lawrence, Contreras, Nager, & Luber, 2006; McCandlish, 2001).

Increased birth weight of greater than 4,000 g is associated with perineal injury, including third and fourth-degree tears. Large babies may preclude women to longer second-stage labors and more instrumental deliveries. A larger baby may also disrupt the fascial support of the PF, causing stretch injury to pelvic and pudendal nerves (Sultan & Fernando, 2001). Fetal malposition and/or malpresentation present a larger fetal head diameter to the pelvis and are associated with difficult delivery (Sultan & Fernando, 2001). Pelvic nerve injury after delivery has been associated with instant or delayed SUI (Viktrup et al., 2006)

Delivery itself decreases the ability of the PF to contract, predisposing women to SUI, and evidence exists to suggest vaginal delivery may specifically cause the levator ani and PF soft tissues to be damaged (Handa et al., 2003). However, there may be potential for reinnervation (Peeker & Peeker, 2003).

Perineal Management at Fetal Expulsion

Perineal trauma is directly related to use of oxytocin, mechanical maneuvers of perineal protection, delivery position, second-stage duration, and continuous fetal monitoring (Albers et al., 1996; Albers & Borders, 2007; Roberts & Hanson, 2007). Fa vorable results to the perineum may be associated with left lateral birth position, spontaneous pushing, non-use of oxytocin, support person of the woman’s choice, and excellent CNM or provider care (Caroci de Costa & Riesco, 2006). Hands-on interventions contribute to a more interactive presence with the birth attendant, which women prefer, and these factors are sometimes more important than implementation of protective techniques for the perineum (Albers & Borders, 2007; Albers et al., 2005; Caroci de Costa & Riesco, 2006; Roberts, 2002).

Practitioners may implement techniques to guard against perineal trauma during delivery of the infant. At present, many perineal management techniques that are believed to reduce trauma are classified as category C (see Figure 2), or “practices with no sufficient evidence to support a clear recommendation and that should be used with caution until further research clarifies the issue” (Caroci de Costa & Riesco, 2006). Two techniques used by CNMs to reduce perineal damage during second-stage labor are warm compresses to the perineum and perineal massage with a lubricant. These methods have the potential to reduce perineal damage by increasing vasodilation to the area, which can help with tissue stretching, increasing muscle relaxation and altering pain perception (Albers et al., 2005).

Figure 2. (click image to zoom)U.S. Preventive Services Task Force Ratings

Albers and colleagues (2005) performed a randomized controlled trial (RCT) on 1,211 births to examine one of three perineal management techniques (warm compresses, perineal massage, no perineal touching until crowning of the fetal head) during late second-stage labor to determine if one method was more effective in reducing genital tract lacerations. The facility in which the study was performed had an overall episiotomy rate of less than 1% for all provider groups. Women who consented to be in the study were randomized into one of the three groups.

Results of the Albers et al. (2005) study showed that 23% of women experienced no perineal trauma. This was equal across the three management groups; spontaneous lacerations were no more or less frequent with any of the three methods. Women who received a warm compress or massage for a longer time period in second stage experienced more frequent genital tract trauma. However, other clinical factors may have contributed to a longer second stage, and no cause-effect could be identified to a specific perineal treatment.

Outcomes of the study showed that warm compresses and massage with lubricant provide no apparent advantage or disadvantage in reducing obstetric genital tract trauma, compared with hands-off management of second-stage labor. Strong predictors of genital tract trauma were found to be nulliparity and high infant birth weight. Two factors associated with lower risk of trauma were birthing in an upright position and delivering the fetal head between uterine contractions.

A study by Caroci de Costa and Riesco (2006) evaluated the hypothesis that maneuvers related to perineal protection (hands-poised or hands-on) may be associated with a greater frequency and degree of perineal laceration. Hands-poised delivery involves no touching of the perineum or the crowning head, and the infant’s shoulders and body deliver spontaneously. Hands-on delivery includes pressure on the fetal head to increase flexion during delivery, while the second hand supports the perineum. Birth of shoulders is facilitated by lateral flexion of the fetal head with both hands and supporting the body as it is delivered (Caroci de Costa & Riesco, 2006; McCandlish, 2001). In their study, women responded to uterine contractions spontaneously during labor, with no direction in bearing-down efforts. Of the 70 women included in the study, none had oxytocin, and all delivered in a lateral position.

Severity of lacerations was similar between both groups, with 82.7% (hands-on) versus 82.2% (hands-poised) incurring first-degree lacerations, and 17.3% versus 17.8% incurring second-degree tears. The hands-on group had slight increase in the incidence of lacerations of the anterior region (clitoris, vestibular and urethra region, labia majora and minora, and vaginal mucosa), while the hands-poised group had slightly higher incidence of laceration in the posterior region (including fourchette) (Caroci de Costa & Riesco, 2006).

This study reflected results of McCandlish (2001), who also found essentially no difference in severity of lacerations and perineal trauma with hands-poised or hands-on methods. Both studies found that the hands-poised technique is associated with lower episiotomy rates, while the hands-on technique is associated with less pain 24-hours post-delivery. Manual support was found to be an effective intervention for perineal protection, but neither study supported enough empirical evidence to recommend hand-poised versus hands-on in reduction of perineal trauma (Albers & Borders, 2007; Caroci de Costa & Reisco, 2006; McCandlish, 2001).

In contrast to the traditional lithotomy position (supine with legs in stirrups), upright and lateral birthing positions have been found to have many benefits to the delivering mother. These include shorter second stages, reduction in assisted deliveries, fewer episiotomies, and reduced anterior and perineal tearing (Albers & Borders, 2007; Roberts, 2002; Roberts & Hanson, 2007). A study composed of 3,049 women with midwife-assisted births indicated that perineal support (including warm compresses and counter pressure against the fetal head) during delivery while maintaining the woman in left lateral lying position can reduce the frequency of degree of perineal laceration when compared to the more common lithotomy position (Albers et al., 1996). The lithotomy position is associated with factors that may predispose use of episiotomy, such as fetal bradycardia and prolonged second-stage labor.

The myth that strong pelvic floor muscles (PFMs) may actually obstruct labor and prolong fetal expulsion exists (Salvesen & Morkved, 2004). Using data from Morkved, Bo, Schei, and Salvesen (2003), Salvesen and Morkved (2004) performed a randomized study to evaluate the effectiveness and impact of pelvic floor exercises (PFEs) during pregnancy on labor and birth. They found that women randomized to intensive PFE training had a lower rate of prolonged second-stage labor, and theorize that PFEs and strong PFMs may actually facilitate labor. When the muscles of the PF and vaginal outlet are routinely exercised, they are more able to stretch and contract at the time of birth, thereby reducing the trauma to the muscles, which can result in lower incidence post-delivery UI (Saunders, 2004). PFEs may be beneficial antenatally, and may be a useful and inexpensive addition to routine prenatal care.

Episiotomy

Episiotomy was first de scribed in the 18th century, and by the 1970s, had become a widely used and accepted practice by CNMs and physicians around the world (Hayman, 2005). Liberal and routine use of episiotomy has been widely studied and has been determined to be a form of care that is likely to be ineffective and may actually produce harm (McCandlish, 2001). Evidence often refutes routine use of episiotomy (Albers & Borders, 2007; Heit et al., 2001; McCandlish, 2001).

One theory suggests that it may be better for the woman to sustain a laceration of her perineum that is repaired in a timely fashion than to incur an overly stretched but intact perineum that becomes too lax to adequately support the pelvic structures (McCandlish, 2001). However, episiotomy is often used as a routine practice during deliveries without medical indications. Restricting the use of episiotomy to times when it is necessary to facilitate the delivery of the fetus reduces perineal trauma that necessitates suturing. Restricted use of episiotomy is associated with reduced risk of posterior perineal trauma and has been found to be associated with an increase in anterior lacerations of the perineum; however, it is not associated with increased pain or urinary and pelvic symptoms (Hayman, 2005; Sultan & Fernando, 2001). Liberal use of episiotomy does not prevent perineal or anal sphincter tears (Heit et al., 2001).

Episiotomy does not entirely prevent damage to the PF, and more severe damage may result from an extension of the episiotomy (McCandlish, 2001). Midline episiotomy is associated with a 22-fold increase in the risk of third and fourth-degree tears, which are also 12% more likely to extend into the anal sphincter when compared with mediolateral episiotomy (Heit et al., 2001; Stepp et al., 2006; Sultan & Fernando, 2001).

Instrumental/Operative Vaginal Delivery

Descriptions of instrument-assisted deliveries exist dating to approximately 1500 BC. The Chamberlen family is credited with inventing the modern forceps in the late 1500s. Three generations of Chamberlen family men practiced obstetrics, and they managed to keep the invention completely secret for over a century. In the early 18th century, their secret was finally made public. The subsequent development and refinement of the forceps helped instrument-assisted deliveries become a widely accepted and practiced vaginal delivery intervention (Hayman, 2005; Varney et al., 2004a).

Two considerations when defining indications for instrumented-assisted vaginal delivery are fetal and maternal. Fetal indications may include malposition of the fetal head, fetal distress, and breech delivery (Piotrowski, 2004). Maternal indications in clude distress, exhaustion, prolonged second stage (> 2 hours in primigravida [> 3 hours with epidural] or > 1 hour in multipara [> 2 hours with epidural]), or development of medically significant conditions (Hayman, 2005; Varney et al., 2004b). Unfor tunately, operative vaginal delivery has been identified as a major risk factor for fetal morbidity and mortality (Hayman, 2005).

Instrument-assisted vaginal deliveries are generally performed either by forceps or vacuum extraction. Both types of instrumental deliveries, especially in combination with episiotomy, are related to an increased risk of sphincter tears and also have a negative impact on pelvic organ support. Forceps delivery with episiotomy carries the highest risk, while vacuum with no episiotomy carries the lowest risk (Dandolu et al., 2005). Dietz and Bennett (2003) investigated the effects of instrument-assisted vaginal delivery on 169 women and found significant increases in organ mobility with Valsalva, particularly after forceps. Forceps use during delivery contributes to weaker PFMs post-delivery over women who deliver spontaneously, and women who deliver spontaneously have weaker PFMs post-delivery than women who undergo CS (Heit et al., 2001).

Forceps are more likely than vacuum extractors to cause PF injury for a number of reasons. The application of forceps and their shanks stretch the perineum and may cause injury to the anal sphincter during flexion of the head. They also expand the space in the pelvis by almost 10%, and excessive force may be unintentionally applied when the woman has epidural anesthesia. Epi siotomy is routine with forceps, whereas most vacuum procedures can be performed without one (Sultan & Fernando, 2001). When necessary and indicated, vacuum delivery is the preferred method because it is better for the maternal PF (Fernando & Sultan, 2004; Piotrowski, 2004). How ever, birthing situations sometimes preclude use of one or the other instrument (such as with prematurity or face presentation) (Hayman, 2005; Sultan & Fernando, 2001).

The risk for an instrument-assisted delivery increases with use of epidural analgesia because it has been associated with longer first and second stages of labor, increased incidence of fetal malposition, and increased use of oxytocin. Further, difficult instrumental deliveries may be associated with shoulder dystocia after birth of the fetal head, which has its own potentially negative impacts on the PF and urinary structures (Hayman, 2005).

Anal Sphincter Trauma

Damage to pelvic nerves or direct muscle injury during birth can also interfere with the anal continence mechanism, leading to symptoms of fecal urgency and anal incontinence. Anal sphincter laceration is a serious complication of vaginal delivery, and a large proportion (between 20% and 57%) of women with anal sphincter lacerations remain incontinent after primary repair (Borello-France et al., 2006; Dandolu et al., 2005; Heit et al., 2001; Stepp et al., 2006; Sultan & Fernando, 2001). The greatest incidence of sphincter trauma occurs during a woman’s first vaginal delivery. Between 5% and 10% of primiparous women will develop impaired anal incontinence, and approximately one-third of women incur some anal trauma that is unrecognized during delivery (Sultan & Fernando, 2001). Persistent sphincter defects are the main cause of postpartum fecal incontinence (Hayman, 2005).

During delivery, mechanical disruption of the sphincter, and stretching of the pudendal nerve most likely contributes to anal incontinence (Lukacz et al., 2006). Perineal trauma that causes separation of the perineal body from the perineal membrane can result in perineal descent and contributes to defecatory dysfunction (DeLancey, 1999). Traumatic vaginal delivery, especially with instrumentation, is one of the most important risk factors for fecal incontinence post-delivery (Hayman, 2005). Women who deliver with forceps assistance have more anal sphincter trauma than women who deliver by vacuum extraction (Heit et al., 2001). To accurately assess repair and risk of anal incontinence, women may need to be referred to a specialist (Sultan & Fernando, 2001). Presently, no association has been found between UI and anal rupture (Altman et al., 2006).

Suturing

Decreasing the risk of infection is one reason to suture the perineum; however, restoration of the function and integrity of the perineum is more important (McCandlish, 2001). The extent and complexity of genital tract trauma is directly related to the amount of suturing required (Albers & Borders, 2007). Although questions exist regarding which types of perineal trauma should be sutured, immediate repair of the perineum is important (see Table 1 ) (Fernando & Sultan, 2004). Though the creation of a third or fourth-degree perineal tear during birth is seldom culpable, missing such a tear post-delivery is considered to be negligent. A rectal examination must be performed before perineal repair to determine the full extent of perineal lacerations or episiotomy extensions (Sultan & Fernando, 2001).

Suturing is not always necessary for minor lacerations that can heal spontaneously. Labial lacerations and first-degree tears usually do not need to be sutured. Second-degree tears should be repaired after careful vaginal inspection to rule out third-degree or buttonhole tears (Fernando & Sultan, 2004; Sultan & Fernando, 2001). Third and fourth-degree tears demand careful and focused inspection and repair. Periurethral tears must be sutured with great care to maintain urethral patency (Varney et al., 2004c).

Though it has not yet been established as a completely effective method to reduce perineal trauma, regular antepartum perineal massage has the potential to reduce the amount of perineal trauma that requires suturing, (Albers & Borders, 2007; Heit et al., 2001; McCandlish, 2001). Level II evidence (see Figure 3) from 3 RCTs, including over 1,500 women, showed that perineal massage in the weeks before delivery can decrease incidence of perineal trauma in nulliparous women (Stepp et al., 2006). Studies have also found that antepartum perineal massage may contribute to less anal sphincter tearing.

Figure 3. (click image to zoom)Levels of Evidence Grading System

All women should start PFEs as soon as possible after repair to improve muscle recovery (Fernando & Sultan, 2004; McCandlish, 2001). More re search regarding proper repair of perineal trauma is necessary to determine if suturing or non-suturing of first-degree tears results in a less painful recovery for the mother and which are specifically associated with PFDs or UI (Stepp et al., 2006)

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