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Oliveira LB de, Mattos DV de, Matão MEL et al. Perineal laceration associated with...
English/Portuguese
J Nurs UFPE on line., Recife, 11(6):2273-8, June., 2017 2273
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.10827-96111-1-ED.1106201703
PERINEAL LACERATION ASSOCIATED WITH THE USE OF EXOGENOUS OXYTOCIN
LACERAÇÃO PERINEAL ASSOCIADA AO USO DE OCITOCINA EXÓGENA LACERACIÓN PERINEAL ASOCIADA AL USO DE LA OXITOCINA EXÓGENA
Lorena Bernardes de Oliveira¹, Diego Vieira de Mattos², Maria Eliane Liégio Matão³, Cleusa Alves Martins4
ABSTRACT
Objective: to analyze the occurrence of perineal lacerations associated with the use of synthetic oxytocin in labor. Method: a retrospective, descriptive and exploratory study, with a quantitative approach, carried out in a public maternity hospital. Data collection took place in the medical records of women who had a natural birth. For the data analysis, the Microsoft® Excel 2010 program was used. Data was analyzed through descriptive, inferential and analytical statistics, presented in tables. Results: 281 medical records were analyzed, with a rate of oxytocin use in 42.7% of deliveries; 93.6% of the women who used oxytocin had their delivery in the horizontal position. 91.7% of deliveries with synthetic oxytocin were followed by medical professionals and the incidence of episiotomy was 18.5%. Conclusion: there was no relationship between spontaneous perineal lacerations and exogenous oxytocin use, but, it was possible to relate it to the use of horizontal delivery, analgesia and episiotomy. Descriptors: Humanizing Delivery; Perineum; Lacerations;
Oxytocin.
RESUMO
Objetivo: analisar a ocorrência de lacerações perineais associadas ao uso de ocitocina sintética no trabalho de parto. Método: estudo retrospectivo, descritivo e exploratório, com abordagem quantitativa, realizado em uma maternidade pública. A coleta de dados aconteceu em prontuários de mulheres que tiveram parto natural. Para a análise dos dados, foi utilizado o programa Microsoft® Excel 2010. Os dados foram analisados por meio de estatística descritiva, inferencial e analítica, apresentados em tabelas. Resultados: foram analisados 281 prontuários, tendo uma taxa de uso de ocitocina em 42,7% dos partos; 93,6% das mulheres que usaram ocitocina tiveram o parto na posição horizontal. 91,7% dos partos conduzidos com ocitocina sintética foram acompanhados por profissionais médicos e a incidência de episiotomia foi de 18,5%. Conclusão: não houve relação entre lacerações perineais espontâneas e uso de ocitocina exógena, porém, foi possível relacionar com uso do parto horizontal, analgesia e episiotomia. Descritores: Parto Humanizado; Períneo;
Lacerações; Ocitocina.
RESUMEN
Objetivo: analizar la incidencia de laceraciones perineales asociadas con el uso de oxitocina sintética en el trabajo. Método: estudio retrospectivo, descriptivo y exploratorio, con un enfoque cuantitativo, realizado en una maternidad pública. La recolección de datos llevó a cabo en registros médicos de mujeres que tuvieron parto natural. Para análisis de los datos, se utilizaron el Microsoft® Excel 2010. Los datos se analizaron mediante estadística descriptiva, inferencial y analítica, presentados en tablas. Resultados: se analizaron 281 prontuarios, con una tasa de uso de la oxitocina de 42,7% de los partos; 93,6% de las mujeres que utilizaron la oxitocina tuvieron el parto en posición horizontal. 91.7% de partos conducidos con oxitocina sintética fueron acompañados por profesionales médicos y la incidencia de episiotomía fue 18,5%. Conclusión: no había ninguna relación entre laceraciones perineales espontáneas y utilización de oxitocina exógena, pero, era posible relacionarse al uso de parto horizontal, analgesia y episiotomía. Descriptores: Parto Humanizado; Perineo; Laceraciones; Oxitocina.
¹Obstetrician Nurse, Nursing Coordinator, Aristina Cândida Maternity. Senador Canedo (GO), Brazil. E-mail: [email protected]; ²Obstetrician Nurse, Master in Environmental Sciences and Health, PhD student in Psychology, Pontifical Catholic University/PUC. Goiânia (GO), Brazil. E-mail: [email protected]; ³bstetrician Nurse, Professor, PhD in Psychology. Department of Nursing, Pontifical Catholic University/PUC. Goiânia (GO), Brazil. E-mail: [email protected]; 4Obstetrician Nurse, Professor, PhD in Nursing, College of Nursing / Professional Master's Degree in Health Education, Federal University of Goiás/UFGO. Goiânia (GO), Brazil. E-mail: [email protected]
ORIGINAL ARTICLE
Oliveira LB de, Mattos DV de, Matão MEL et al. Perineal laceration associated with...
English/Portuguese
J Nurs UFPE on line., Recife, 11(6):2273-8, June., 2017 2274
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.10827-96111-1-ED.1106201703
Since 1996, the World Health Organization
(WHO) has developed a practical guide on safe
motherhood. This document categorizes
obstetric care into four categories: (a) clearly
useful practices that should be encouraged; B)
practices that are clearly harmful or
ineffective and should be eliminated; C)
practices with insufficient evidence to support
a recommendation and should be used with
caution, while additional research proves the
subject, and d) practices frequently used
inappropriately, causing more harm than
good.1
In order to strengthen and encourage the
use of good practices recommended by WHO,
in 2011, the Ministry of Health, through the
Technical Area of Attention to Women's
Health, launched the Stork Network. This
strategy seeks to provide women with health,
quality of life and well-being during
pregnancy, childbirth, postpartum, as well as
the development of the child until the first
two years of life.2
Among the practices considered to be
clearly harmful or ineffective and that should
be eliminated, the administration of oocytes
at any time before delivery is emphasized in a
way that does not allow their effects to be
controlled.1
Oxytocin is a hormone that is intended to
initiate or increase rhythmic contractions at
any time during pregnancy, although the
uterine response is greater the closer to the
end of gestation. Intravenous infusion has
been the most widely used method for
induction and conduction of labor since its
introduction by Page, in 1943.3
The medicalized delivery of the child can
produce adverse effects such as tachysystole,
hypertonia and uterine hyperstimulation, and
may even cause uterine rupture. For the
fetus, the most frequent side effect is acute
fetal distress, motivated by the reduction of
blood perfusion in the intervillous space by
tachysystole and/or hypertonia. Side effects
depend on dosage, increased drip and time of
use.3-4
A study carried out in 2009, with a review
of clinical and pharmacological data on the
drug, emphasized that the recommendations
for the administration of oxytocin were vague
regarding indication, time of use, dosage and
monitoring of side effects. It has also been
shown that the indiscriminate use of oxytocin
today is for the convenience of the physician
or the patient. No other area of medicine
supports that a potentially dangerous drug be
administered to accelerate the attainment of
a physiological process which, if left on its
own, would generally be achieved without
incurring the risk of administering a drug.5
Trauma in the perineal region occurs during
fetal expulsion and can be classified into
episiotomy and spontaneous perineal
lacerations. Perineal laceration is a solution of
continuity of vulvovaginal and perineal
tissues, with different extension and depth,
reaching the mucosa, skin and muscles of
these structures of the female anatomy.6
The perineal lacerations are classified in
relation to the depth and the affected tissues.
First-degree lacerations reach only the skin or
mucosa. In the second degree, muscle bundles
also suffer some solution of continuity. When
the laceration reaches the anal sphincter, it is
considered of third degree. If there is an
injury involving the rectal mucosa, it is
considered of the fourth degree.7
The factors associated with perineal
lacerations can be subdivided into: maternal
conditions (age, ethnicity, parity, preparation
of the perineum in pregnancy, height of the
perineum and episiotomy in a previous birth);
fetal conditions (weight, cephalic perimeter,
presentation, position variety and biacromial
diameter); (Maternal position, duration of the
expulsive period, directed pulling, perineal
protection and fetal management, care
provider, emotional support and use of
synthetic oxytocin).6
In this sense, this study aims to analyze the
occurrence of perineal lacerations associated
with the use of synthetic oxytocin in labor.
A retrospective, descriptive and
exploratory study with a quantitative
approach, carried out by means of medical
records of women who had a natural
childbirth and a public maternity hospital in
Goiânia (GO), Brazil. Data collection took
place in January and February 2016, and the
hospital records of women who had normal
birth in the last quarter of 2014, the period of
greatest hospitalization in the unit, were
analyzed.
The following variables, were considered in
the collection instrument: socioeconomic
profile (age, marital status, schooling,
profession); obstetric data (parity, number of
prenatal consultations, pathologies during
gestation, gestational age); labor and delivery
data, as well as assistance and interventions
in driving.
The study included records of parturients
admitted to labor and delivery care in said
maternity. Patients who did not respond to
METHOD
INTRODUCTION
Oliveira LB de, Mattos DV de, Matão MEL et al. Perineal laceration associated with...
English/Portuguese
J Nurs UFPE on line., Recife, 11(6):2273-8, June., 2017 2275
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.10827-96111-1-ED.1106201703
50% of the answers referred to in the
collection instrument and those who had
cesarean indication were excluded.
For the collection of the sample, 302
medical records were separated, based on the
records of births in the period studied. In this
process, 21 records were excluded due to lack
of data, duplication, absence of records and
record failures, and the final composed of 281
records were analyzed. The Microsoft® Excel
2010 program was used to analyze the data.
The data was analyzed through descriptive,
inferential and analytical statistics, presented
in tables.
The research project was evaluated and
approved by the Research Ethics Committee
of the Clinical Hospital of the Federal
University of Goiás / UFGO with the approval
through opinion number 852 830, issued on
12/11/2014.
Data from the sample of 281 medical
records analyzed showed that, in relation to
the socioeconomic profile, 163 (58%) women
have complete secondary education; 117
(41.6%) had a stable union and, with respect
to the profession, 119 (42.3%) are
characterized as house wives.
Regarding obstetrical data, 102 (36.2%)
were primiparous, and 136 (48.3%) had up to
six consultations as recommended by the
Ministry of Health. Induction of labor with
prostaglandin was present in 27 (9.7%)
partirients and 120 (42.7%) used oxytocin for
labor and delivery, according to table 1.
Tabela 1. Distribution of the occurrence of perineal lacerations in women with and without exogenous oxytocin during labor and delivery. Goiânia (GO), Brazil, 2014.
Lacerations Oxytocin % Without oxytocin
% Total
Without laceration 29 40,8 42 59,2 71 1st degree 32 35,1 59 64,9 91 2nd degree 21 46,6 24 53,4 45 3rd degree 2 50 2 50 4 4th degree 0 0 0 0 0 Episiotomy 29 55,7 23 44,3 52 Ignored 7 38,8 11 61,2 18
Total 120 42,7 161 57,3 281
Of the women who had the use of synthetic
oxytocin, 38 (31.6%) were monitored without
any partograph record. Among those with
parturition records, only 22 (26.8%)
contemplated completing the document,
emphasizing that this percentage applies to
deliveries monitored by obstetrician nurses.
When analyzing from a laceration
perspective, among women who did not have
perineal trauma, 40.8% used oxytocin in labor
and delivery. Regarding lacerations of 1st
grade, 64.9% did not use it. Regarding the
lacerations of 2nd degree, 46.6% of them were
in women who made use of this synthetic
hormone. Of the women who had a 3rd degree
laceration, 50% did not use any type of
medication that could accelerate labor. No
lacerations of 4th degree were identified.
18 (6.4%) records were ignored due to lack
of registration of the laceration type
classification. Regarding the episiotomy,
55.7% of the women submitted to the
procedure had their delivery performed with
oxytocin to speed up the labor closely, being a
relevant data for the study..
RESULTS
Oliveira LB de, Mattos DV de, Matão MEL et al. Perineal laceration associated with...
English/Portuguese
J Nurs UFPE on line., Recife, 11(6):2273-8, June., 2017 2276
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.10827-96111-1-ED.1106201703
Table 2. Distribution of the frequency of perineal lacerations in women who used oxytocin in relation to
the position of labor, use of analgesia, raffia and the attending professional. Goiânia (GO), Brazil, 2014.
Perineal Trauma Without
Laceration
n (%)
1st
degree n
(%)
2nd
degree n
(%)
3rd
degree n
(%)
4th
degree
n (%)
Episiotomy
n (%)
Ignored
n (%)
Labour position
Horizontal 27 (22,5) 30 (25) 19 (15,8) 1 (0,8) 0 (0) 29 (24,2) 7 (5,8)
Vertical 2 (1,7) 2 (1,7) 2 (1,7) 1 (0,8) 0 (0) 0 (0) 0 (0)
Analgesia
Yes 16 (13,3) 7 (5,8) 10 (8,3) 0 (0) 0 (0) 18 (15) 3 (2,5)
No 13 (10,8) 25 (20,8) 11 (9,2) 2 (1,7) 0 (0) 11 (9,2) 4 (3,3)
Raffia
Yes 0 (0) 19 (15,8) 21 (17,5) 2 (1,7) 0 (0) 29 (24,2) 0 (0)
No 29 (24,2) 13 (10,8) 0 (0) 0 (0) 0 (0) 0 (0) 0 (0)
Assistance
Medical Obstetrician
26 (21,7) 17 (14,2) 18 (15) 1 (0,8) 0 (0) 29 (24,2) 7 (5,8)
Obstetrician Nurse 3 (2,5) 15 (12,5) 3 (2,5) 1 (0,8) 0 (0) 0 (0) 0 (0)
Among the variables (labor position,
analgesia, need of raffia and the attending
professional in labor) related to the type of
laceration in women who had oxytocin use, it
was possible to identify that, among the
women who gave birth in a horizontal position
(94.1%), 25% had laceration of the 1st degree
and 24.2% underwent episiotomy. Only 5.9% of
deliveries took place in upright positions, with
no recorded laceration recorded.
In the variable related to labor analgesia in
women who used oxytocin, 44.9% were
submitted to some type of pharmacological
method for pain relief. Associating oxytocin
with labor analgesia, 15% of these women
underwent episiotomy, overcoming
spontaneous lacerations, or even parturients
without lacerations.
The need for raffia was present in 59.2% of
the patients who used oxytocin, and 40.8% of
the sutures were made with episiotomy
results; 44.9% of these women had no
lacerations or lacerations without the need for
raffia.
In relation to the professional who gave
birth assistance, 81.7% of oxytocin deliveries
were monitored by medical obstetrician and
18.3%, by obstetrician nurse. In the registry
analysis, it was possible to identify that,
among all deliveries monitored by nurses,
oxytocin as a method of conduction was
prescribed by the medical professional in a
shared assistance modality.
According to the data obtained, it was
observed that 42.7% of the parturients
evaluated in this study used synthetic oxytocin
as a mechanism to accelerate the first stage
of labor. It is important to note that among
women with oxytocin, adherence to the use of
the partograph was low.
The importance of the partograph confirms
when, at a defined moment, the complete
evolution of the birth is evaluated. It brings
all the necessary information: cervical
dilation; declining presentation; fetal
position; variety of position; fetal heart rate;
uterine contractions; infusion of fluid and
analgesia. A complete examination of all
these variables allow us to know the evolution
of labor and the etiological factors responsible
for its normal and abnormal evolution.13
One of the causes of unnecessary
interventions, such as amniotomy or infusion
of oxytocin, is when the onset of labor is
erroneously established, and can be
considered as prolonged labor, requiring the
conduct of the professional who is performing
the follow-up. However, there is no evidence
that the prevention of prolonged labor,
through the liberal use of oxytocin in normal
labor, is beneficial. The question is raised
whether labor with correction of dynamics by
oxytocin infusion can still be considered
normal.1
These interventions are the most common,
included in the active phase of labor.
Traditionally, in addition to amniotomy and
oxytocin, the prospective diagnosis of labor
was used, continued professional social
support, limited the use of epidural
anesthesia, maternal ambulation at the start
of work, as well as the selective use of
electronic fetal monitoring. The approach to
these co-interventions is likely to have an
impact on the overall effects of such a
program.8
Another relevant fact for this study was
that 94.1% of the women who used oxytocin
DISCUSSION
Oliveira LB de, Mattos DV de, Matão MEL et al. Perineal laceration associated with...
English/Portuguese
J Nurs UFPE on line., Recife, 11(6):2273-8, June., 2017 2277
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.10827-96111-1-ED.1106201703
had their delivery in the horizontal position.
In a study carried out in a public maternity
hospital in Rio de Janeiro, 3540 deliveries of
the year 2005 were analyzed for vertical and
horizontal positions. It is evidenced that, with
the adoption of the vertical position, even if
routine episiotomy was not performed, there
were no perineal lacerations requiring suture
or reconstitution. And even with the influence
of the medicalized hospital environment, the
study showed that the nurse opts for a less
interventionist attitude that protects the
woman's integrity, and that 81.7% of the
deliveries carried out with synthetic oxytocin
were accompanied by medical professionals.9
Obstetric Nursing, when implementing its
practices in the health services, in search of
the humanization recommended by the World
Health Organization, places at the disposal of
the parturients, a specific and qualified
professional attention, being essentially
relational and derived from a structured
knowledge in the Nursing service. This
knowledge is applied in a transversal way,
integrating popular knowledge and diverse
disciplines in the construction of care, aiming
to provide comfort and autonomy by
encouraging women to recognize and develop
their own abilities. With the support and basis
of scientific evidence, obstetrical nurses
began to use techniques that they consider
favorable to the physiological evolution of
labor, minimizing interventions in the conduct
of labor.10
Regarding the spontaneous perineal
lacerations and episiotomy, it was possible to
observe that there was no significant
difference between the women conducted
with or without oocytes, but the episiotomy
rates of 18.5% were above the WHO,
recommended maximum that is less than 10%.
In addition, among the charts analyzed, it was
possible to identify that women who used
combined oxytocin analgesia had higher rates
of episiotomy.1
It is believed that humanized childbirth
would be one that respects the physiology of
women during gestation and childbirth. It goes
beyond an area of obstetrical knowledge,
seeking to direct all attention to the needs of
the woman and to give her control of the
situation at the time of childbirth, showing
the options of choice based on science and
the rights she has. Pain is understood as a
normal physiological function and can be
alleviated with widely based non-
pharmacological methods, but the woman may
choose to use analgesia. There have been
increasing indications of non-pharmacological
methods for pain relief, based on the
assumption that the use of analgesia may lead
to a number of other interventions, such as
oxytocin and episiotomy.10
Episiotomy continues to be a routine
procedure in childbirth in many countries, but
the reasons for this are unknown. The reason
most commonly reported to perform an
episiotomy by both obstetricians and midwives
was to reduce lacerations of 3rd and 4th
degree and lack of training in how to minimize
lacerations and maintain the perineum intact,
and the obstacle is commonly reported.
Although several factors that may prevent or
facilitate the practical change of episiotomy
having been identified by this research,
training and confidence in normal vaginal
delivery without episiotomy should be
stimulated.11
A Cochrane systematic review of eight
Randomized Clinical Trials and 5541 women,
analyzing the routine and selective use of
episiotomy, has identified that the use of
episiotomy selectively can reduce rates of
severe perineal laceration (3rd and 4th grade)
as well as minor risk of infection and
postpartum perineal pain.12
Based on this research, it was possible to
verify that, among the charts evaluated the
rates of women who used synthetic oxytocin
to accelerate labor were high. The rates of
episiotomy, performed in the women
evaluated in the study, are above that
recommended by the WHO and all were
performed in deliveries conducted by medical
professionals.
Concerning women who used oxytocin
combined with labor analgesia, it was possible
to perceive a significant increase in
episiotomy rates, bringing an important
association to the study. Regarding the
positions performed during the expulsive, the
horizontal position was predominant.
The practice of oxytocin was higher among
deliveries conducted by medical professionals,
and, when conducted by nurses, oxytocin was
prescribed by the physician in a shared care
model. It should also be pointed out that the
deliveries attended in an upright position
were completely assisted by the obstetrician
nurse.
Therefore, it was concluded that there was
no association of spontaneous perineal
lacerations with the use of synthetic oxytocin,
but, the use of the medication may be
associated with the use of other interventions,
such as labor analgesia and episiotomy.
CONCLUSION
Oliveira LB de, Mattos DV de, Matão MEL et al. Perineal laceration associated with...
English/Portuguese
J Nurs UFPE on line., Recife, 11(6):2273-8, June., 2017 2278
ISSN: 1981-8963 ISSN: 1981-8963 DOI: 10.5205/reuol.10827-96111-1-ED.1106201703
We suggest new studies that seek to
associate the use of synthetic oxytocin with
other interventions during labor and delivery,
as well as maternal and neonatal outcomes.
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Submission: 2016/11/01 Accepted: 2017/01/26 Publishing: 2017/06/01
Corresponding Address
Diego Vieira de Mattos Rua Belo Horizonte, Qd.164, lote 4, C-3. Bairro Parque Amazônia
CEP: 74843-100 Goiânia (GO), Brazil
REFERENCES
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