Study On The Influences Of Episiotomy During Vaginal Birth After Cesarean And Decision-making Of Midwife

1.BackgroundNowadays,with the implementation of the domestic universal two-child policy,there is an increasing number of pregnant women with scared uterus due to the high c-section rate before,making the concept of TOLAC accepted by the majority of obstetricians.The American National Institutes of Health discussed the safety and outcomes of TOLAC at a seminar in 2010 and an agreement was reached that TOLAC was a reasonable choice for many pregnant women who had previous c-section and successful vaginal delivery was an effective way to reduce the rate of c-section.Therefore it encouraged more hospitals to provide TOLAC services.With the development of research on scared uterus and TOLAC in China,the rate of success vaginal birth has reached 60-90%.The main risk TOLAC is uterine rupture.However,Complete uterine rupture is rare.The clinically determined rupture rate is 0.5%to 0.9%.The Obstetrics and Gynecology Branch of Chinese Medical Association reached an agreement that it mentioned the length of second stage of labor should not be too long during TOLAC and operative delivery was suggested if necessary at the premise of no uterus rupture detected.In this way,some clinicians and midwives believed that episiotomy should be adopted in order to shorten the length of second stage of labor and prevent uterine rupture during TOLAC.However,several evidence-based researches reported that routine episiotomyincreased the blood loss after delivery,the postpartum pain and infection,as well as the risk of long-term urinary incontinence and severe sexual pain.There are also some researchers said that no significance had been seen in shortening the second stage of labor and reducing the neonatal asphyxia by performing episiotomy during labor.There is still a heated discussion in China towards episiotomy during TOLAC at present and the domestic episiotomy rate during TOLAC varies from 15.43%to 100%in different areas.Therefore,the study of the necessity of performing episiotomy during TOLAC will have great clinical significance.As the main decision makers and performers of episiotomy,midwives will also play an important role in this study.In order to effectively manage the use of episiotomy during TOLAC,the analysis of factors that influence midwife’s decision of whether to perform episiotomy will be a very instructive research for future clinicalwork.2.ObjectiveThe historical cohort study was used to analyze the outcome of VBAC involving episiotomy.And the qualitative interview and cross-sectional survey were also used to explore the factors that influence midwife’s decision of whether to perform episiotomy during TOLAC,so as to provide valuable suggestions for medical workers to apply episiotomy,reducing postpartum complications and improving maternal quality of life.3.Method3.1 Analysis of the effects of episiotomy on the outcome of delivery during TOLAC by a historical cohort study3.1.1 Data collectionAccording to the retrospective research method,755 cases of VBAC from severa-1 hospitals in Guangzhou from January to February in 2018 were selected as the rese a-rch subjects and divided into two groups:episiotomy group andnon-episiotomy gro u-p.Inclusioncriteria:①no previous vaginal delivery;②full-term delivery.Exclusion c rit-eria:①operative delivery;②previous vaginal delivery;③fetal macrosomia;④inco mp-lete data.The records included personal information,gestational age,pregnancy hi st-ory,the length of labor,perineum condition,neonatal weight,Apgar scores,postpa rtu-m blood loss,and the rate of uterine rupture,etc.3.1.2 Statistical methodTwo researchers were required to use Epidata3.1 software to input research data and establish an analysis database for crosscheck and correction by comparing original case data.Statistical analysis was performed by use of SPSS 20.0 statistical software.The measurement data of normal distribution was analyzed through t-test,the results of which were reported by(x±S)while the measurement data of skewed distribution was analyzed through rank-sum test and reported the median and quartile.The chi-square test was used to analyze the enumeration data,which was reported in the way of percentage(composition ratio).P<0.05 was considered statistically significant.3.2 Qualitative research on the midwife’s decision-making on episiotomy during TOLACAccording to the semi-structured interview method and the purpose sampling method,midwives of different levels from three general hospitals in Guangzhou was recruited as the research objects.Inclusion criteria:①obtaining midwifery qualification and working for more than one year;②clear language expression;③voluntary participation in this study;④informed of consent;⑤able to complete the interview.Exclusion criteria:① training worker.Interview outline:① In which situation would you perform episiotomy during TOLAC?② What are the factors that you think would affect your decision to perform the episiotomy during TOLAC?How would you deal with them?③ Do you think it is necessary to routinely performthe episiotomy during TOLAC?Why?④Do you have any opinions or suggestions about whether it is necessary to perform the episiotomy during TOLAC?To get the most information you need.If the sample is repeated with a refined theme with no new one coming up after data analysis,then data is considered saturated and 10 midwives are decided to be interviewed.3.3 Research on the factors influencing the midwife’s decision-making on episiotomy during TOLAC3.3.1 Data collectionAccording to the cross-sectional survey research method,the self-made question naires were used to investigate the midwives from tertiary and secondary hospitals in Guangdong Province from June 2019 to August 2019.A total of 253 questionnaires w ere collected,231 of which were qualified(91.3%).The contents of the questionnaire mainly include:①general information.②the principles andstandards related to episiot-omy.③midwife decision-making during TOLAC.3.3.2 Statistical methodIn this study,SPSS 20.0 software was used for statistical analysis,and whether the midwife would perform episiotomy was considered as the dependent variable for the ordered multi-class logistic regression analysis(statistics are wald chi-square),in order to explore the influence factors of the midwife’s decision-making.The compare between two groups of the ranked data was involved the Mann-Whitney U test(statistics are Z);the compare among several groups of the ranked data was involved the Kruska-Wallis test(statistics are approximate χ2 values).4.Outcomes4.1 The outcomes of episiotomy-involved VBACThe perineal injury in episiotomy group was significantly worse than that in the non-episiotomy group(X2=5.945,P<0.015).The length of the second stage waslonger than the non-episiotomy group(P<0.05).And the amount of blood loss in 2 hours after birth was more than that in the non-episiotomy group(P<0.05).1 case of uterine rupture occurred in episiotomy group,and no uterine rupture occurred in the non-episiotomy group,with no statistically significant difference.There was also no significant difference in the incidence of neonatal asphyxia between the twogroups(X2=0.3738,P=0.541).4.2 Qualitative research on the midwife’s decision-making on episiotomy during TOLACApart from the medical indications before,four main factors influencing midwif-e’s decision-making were concluded:personal knowledge and clinical working experi-ence;obstetrician decision-making;maternal factors;organization management and environmental factors.4.3 Research on the factors influencing the midwife’s decision-making on episiotomy during TOLACIt is found that if the midwife has rich working experience(OR=0.87,P=0.007)and pays attention to new midwifery techniques(OR=0.20,P=0.025)an d also the department has regular supervisio on episiotomy rate,analyzes the problems and takes measures to improve it(OR=0.17,P=0.002),then there wo uld be lower episiotomy rate.The fetal heart condition(OR=7.81,P=0.02),wh ether the TOLAC mother is combined with hypertension(OR=3.83,P=0.030),the perineum condition(OR=6.12,P<0.001)and the obstetrician’s advice on epi siotomy(OR=4.30,P<0.001),are the main factors that have significant impacts on the midwife’s decision-making on episiotomy.5.Conclusion(1)We do not support the view that episiotomy can shorten the length of the second stage and prevent the occurrence of uterine rupture and reduce the perineal injury and postpartum blood loss in VBAC.(2)If the midwife has rich working experience and pays attention to new midwifery techniques and also the department has regular supervision on episiotomy,analyzes the problems and takes measures to improve it,then there would be lower episiotomyrate.(3)If the fetal heart is abnormal even though the amniotic fluid is clean,the TOLAC mother is combined with hypertension and has poor perineum condition and the obstetrician gives advice of performing episiotomy,then the midwife will perform episiotomymore.