Document Details
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Document Type |
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Thesis |
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Document Title |
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THE ASSOCIATION BETWEEN EPISIOTOMY AND URINARY INCONTINENCE AMONG POST PARTUM WOMEN العلاقة بين قص العجان وسلس البول لدى السيدات بعد الولاده |
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Subject |
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Faculty of Nursing |
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Document Language |
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Arabic |
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Abstract |
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Introduction:
Episiotomy is an intentional perineal trauma. It is a surgical, planned incision on the perineum and posterior vaginal wall performed during the second stage of labor to help delivery of the baby. Episiotomy was first described in 1741, and medio-lateral episiotomy was first recommended in 1920 for all nulliparous women as a protective measure against pelvic floor and fetal head trauma and extreme lacerations.
The practice of episiotomy spread widely throughout the world, with a steady increase in rates in the first half of the 20th century. However, research claiming that episiotomy has no benefits has been published, and many studies have stressed that routine use of episiotomy should be avoided.
In the Kingdom of Saudi Arabia, episiotomy is still practiced routinely, but the rate for the whole kingdom is unknown due to poor reporting and documentation. In a descriptive cross-sectional study by Saadia (2014) on 291 women who underwent vaginal delivery during the study period, the episiotomy rate was 51.20% overall and 100% among primigravida. The most frequent episiotomy indications were breech delivery, previous perineal tears, fetal occipito-posterior position, instrumental delivery, reduction of the risk of perineal injury, need to shorten the second stage of labor, and maternal exhaustion when the mother failed to push.
Restrictive episiotomy was correlated with incidence of stress urinary incontinence at 6 weeks postpartum. Major complaints of urinary morbidities were recorded at 6 weeks postpartum.
Urinary incontinence is defined as the involuntary loss of urine and manifests as a social and hygienic problem. It can lead to significant emotional and physical distress, including depression, decreased self-esteem, and social isolation as it limits patients’ daily activities. The financial burden of rehabilitation and management of urinary incontinence in the USA alone annually exceeds 20 billion dollars which is similar to or higher than the expected annual cost of conditions such as breast cancer, pneumonia, arthritis and influenza. Additionally, the worldwide burden of incontinence is probable to increase significantly over time, as life expectancy is still rising.
Approximately 1 in 3 women reports postpartum urinary incontinence. The urinary incontinence rate has not been estimated for the whole Kingdom of Saudi Arabia, but in three studies, it was 29%, 41.4%, and 44.25% in Riyadh, Jeddah, and Jazan, respectively.
Urinary incontinence among Saudi women was investigated in a cross-sectional study of 400 women conducted by Dayili et al. (2017), which revealed a moderate prevalence of urinary incontinence. Vaginal delivery was correlated with a lower urinary incontinence rate than CS delivery. High parity, old age, and baby weight ≥ 4 kg were considered to be the most common risk factors for urinary incontinence.
Urinary incontinence can be categorized into three main types: urge, stress, and mixed type. Stress urinary incontinence is leakage of urine during physical activity and all activities that increase intra-abdominal pressure, such as coughing, sneezing, and straining. Stress urinary incontinence is most commonly due to damage to the anatomical support of the urethro-vesical junction, which can take the form of urethral hypermobility, urethral sphincter insufficiency, or both. Urge incontinence is loss of urine accompanied by a strong desire to void and is caused by hyperactivity of the bladder wall’s smooth muscles. Mixed type UI is the complaint of any involuntary leakage of urine associated with urgency and also with effort or exertion or sneezing or coughing.
Urinary incontinence has multifactorial causes. Obesity, aging, chronic coughing, constipation, and obstetric trauma are known to be the most significant risk factors.
Management of urinary incontinence in women is an interrelated process. For some affected women, urinary incontinence is sufficiently bothersome and intrusive to warrant consideration of management options varying from lifestyle modifications to more-invasive surgical interventions. Otherwise healthy women may also prioritize resolution of urinary incontinence through active performance of pelvic floor rehabilitation, lifestyle modifications (including fluid optimization), pharmacological treatments, and surgery to control persistent symptoms.
Midwifes play a crucial role in the care of women throughout all childbirth phases. Nurses and Midwives believe that women vary in their preferences, expectations, and desires, but most women want to avoid perineal trauma. They advocate and protect women from harmful and inessential interventions that may result in negative birth experiences.
Midwifery care must be planned and personalized for each woman, identifying potential distressing factors. Midwives should prepare women to preserve the perineum intact early in antenatal visits during pregnancy. They support and encourage women to use antenatal perineal massage and providing health education on performing Kegel exercises for pelvic floor muscles can be beneficial.
The time has come for those qualified to take on the responsibility to establish and attain goals to reduce the practice of episiotomy. Much as surgical specialists have decreased use of procedures such as tonsillectomy in children and knee surgery for arthritis, clinicians must apply research evidence to episiotomy use.
Research Aim:
The aim of the present study is to identify the association between episiotomy and urinary incontinence among postpartum women.
Objectives of the Study
To achieve the aim of the study, the following objectives are set:
1-Assess the episiotomy type, indications, and suturing among postpartum women
2- Identify the level and types of urinary incontinence among postpartum women
3-Determine the associations of urinary incontinence and selected demographic variables.
4- Determine the relationship between episiotomy and urinary incontinence.
Research Question
Are there any associations between episiotomy and urinary incontinence?
Study Design:
This study was a Quantitative, descriptive, cross sectional design.
Study Sitting:
This study was conducted at the main hospital in Medina, Saudi Arabia. The Medina Maternity and Children’s Hospital (MMCH).
Study Sample:
A non-probability convenience sampling was used. The study sample inclusion criteria was clarified as all postpartum women who delivered through SVD with episiotomy since 6weeks and more until 2 years, with no previous medical or urogynaecological diseases and free of past urological surgery. The current study included a total of 192 women who met the inclusion criteria over May–October 218.
Sample Size:
The sample size was calculated by using Stephen Thompson formula for sample size calculation, and with consultation of statistician [CI = 95.0%, confidence limit = 0.05].
The sample size required for this study is supposed to be 166 women as calculated through previous formula, but to the fact that this study has specific sampling inclusion criteria, extra participants was taken in order to represent the non-response rate (dropouts).The current study included 192 women who met the previous inclusion criteria.
Ethical Approval:
The research proposal for this study was firstly approved by the ethical committee of the nursing faculty at King Abdulaziz University (KAU) in Jeddah. In addition, the researcher obtained approval from both ministry of health and MMCH committees to facilitate access to the participants' and to gather the necessary data with full respect for the privacy of participant's records and information while ensuring confidentiality.
Also, in order to keep participants' rights, the researcher developed an informed consent sheet which clarify to participants the purpose of study and all other necessary information to assist them to decide freely to participate or not. Before the participant voluntarily involved, the researcher obtained written informed consent at the commencement of data collection and ensured that participants had a clear understanding the purpose of the study.
To evaluate the efficiency, reliability, and validity of the instrument in this study, the content of the tool was revised by the researcher’s supervisors and three scholars in maternity and women’s health nursing.
Pilot Study
A pilot assesses the achievability of and supports enhancements of the methods, protocols, and procedures to be used in the larger study. In this case, a pilot study was performed with 20 women who met the inclusion criteria. These participants were not involved in the main study sample.
Research Instrument:
Data Collection Sheet
The tool in this study was aimed to assess the women’s demographics, clinical data, reproductive data, delivery and immediate postpartum data and urinary incontinence data. The questionnaire consisted of three parts; these are socio - demographic data and clinical data, obstetrical history, assessment of urinary incontinence which is discussed in detail below.
Part I: Socio - demographic Data and Clinical Data Assessment
This part included an eleven questions about ; age, marital status, nationality, educational level, monthly income, body mass index, smoking habit and performance of pelvic floor muscle exercise .Additionally, the women's current and past medical and surgical history.
Part II: Clinical Characteristics
This part included a reproductive history and medical, surgical data. It encompasses fourteen questions about the current and previous obstetric data, such as gravidity, parity, number of abortions, previous obstetric complications, and history of previous delivery. It included also, information about last recent delivery, epidural anesthesia, type of episiotomy, indication of episiotomy and the way of its repair, intrapartum and immediate postpartum complication.
Part III. Structured Questionnaire to Assess Urinary Incontinence
It was adapted from the Australian Centre for Health Service Development (Sansoni et al., 2015). Revised urinary incontinence scale is a short, reliable and valid five items scale to assess urinary incontinence and it support from the Australian Government Department of Health and Ageing.
It consist of 5 Likert question regarding to urine leakage related to urgency, physical activity, coughing or sneezing, frequency and amounts of urine leakage. The RUIS total score is then calculated by adding up a person’s score for each question. Adding the score for each of the five questions results in a possible score range of 0 – 16, a score of less than 4 wasn’t considered a urinary incontinence while 4-8 is considered mild urinary incontinence, 9-12 score is considered moderate and a score of 13 or above is considered severe urinary incontinence.
Process of Data Collection
Data collection started after ethical approval obtained from the ethical committee from the faculty of nursing and research committee in both ministry of health and MMCH for the application of the study. The researcher spent 4 days per week in hospital during the study data collection. Taking participant from both waiting area of maternity and pedia outpatient clinics. A total of 213 participants were included, then 21 was excluded from study due to incomplete of the main questionnaire variables and some due to inapplicable to participate in the study due to either chronic disease or surgery.
The sample size for the current study ended up with 192 participants. The sample selection procedure is composed of two phases;
Phase I: Interview and Tool Distribution
In the early morning, the researcher visit the outpatient clinics for both maternal and Pediatric side. Then individual interview done for each client's in the waiting area outside clinics, before approaching the woman, the researcher introduce herself, maintaining the privacy of woman and give brief explanation about the purpose, procedures of the study and who can participate in study.
Then the women who fulfilled the inclusion criteria and agree to participate in study was selected and after obtaining the woman's verbal agreement to voluntarily participate in the study, the researcher gained a written informed consent.
Thereafter, the questionnaire distributed between women and women start answering while the researcher being around for any question or clarification.
Phase II: Collection of the Tool
Women was complete answering the sheet from 10-15 minutes then the researcher get the answered sheet and thank the participants for their participation in the study.
Main Findings:
All study participants was delivered vaginally with episiotomy and majority of them are less than thirty years old (59.9%).
Almost all of study participant was married (97.9%) and most of them were highly educated (59.9%).
Most of study participants were Saudi (84.9%) and have mild to moderate monthly income (60.9%).
All study participants were free of chronic disease and most of them free of surgical history (93.8%).
More than two third of study participants were primipara (77.1%)
The most episiotomy indications were primipara (69.3%) followed by doctor preference and maternal order (14.6%).
About half of postpartum women had a mild urinary incontinence (51%), SUI was higher rate than the rate of UUI (19.3% versus 9.4%).
Age, education level and postpartum period from1-3months was significantly correlated to the urinary incontinence.
Level of income, nationality, marital status, smoking, BMI and Kegel exercise were not correlated to postpartum urinary incontinence.
Episiotomy, indications for episiotomy and way of episiotomy repair was not correlated to the presence of postpartum urinary incontinence.
No correlation between multiparty, epidural anesthesia and site of delivery with UI.
6.3 Recommendations
Based on the findings of this study, the following recommendations could be made related to the future clinical practice, research studies and education programs for both women and health care professionals, in particular, nurses.
6.3.1 Recommendations for Clinical Practice
Develop an ideal protocol for health care providers following the WHO guidelines for restrictive, not routine, use of episiotomy to standardize care based on evidence.
6.3.2 Recommendations for Research Studies
The researcher recommends conducting future research in:
The researcher recommends studying doctors’ and midwifes’ performance and attitudes as factors behind the high rate of routine episiotomy practice.
The effects of urinary incontinence on women’s daily life and ways to overcome this issue should be included in future research because they were not covered in the present study.
Using different study methods and designs (e.g. cohort studies and quasi-experimental and qualitative research) with large sample size is recommended to better understand this issue.
Future studies should focus on educational interventions, guidelines, and recommendations regarding episiotomy and urinary incontinence to reduce adverse outcomes.
6.3.3 Recommendations for Educational Programs
Encourage the role of doulas, who “provide emotional, social, and educational support to childbearing women and represent a newer formal addition to the maternity care team.” Activation of their role during the antenatal period can increase pregnant women’s awareness of alternative natural methods for preserving the perineum intact without need for episiotomy. Doulas can also help and educate postnatal women about suitable care for the best recovery, encourage women to have postnatal visits, and teach proper performance of Kegel exercises.
Women thus can improve their choices, make knowledgeable decisions, and have better birth experiences and control of their bodies. Additionally, nurses and midwives can provide research outcomes to clinical staff and play a significant role in advocating for limiting episiotomy use, following the WHO’s recommendations. Traditional beliefs in obstetric practice can also be changed.
Conclusions:
Episiotomy was not correlated to the presence of postpartum urinary incontinence. |
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Supervisor |
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Dr. Hala Ahmed Thabet |
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Thesis Type |
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Master Thesis |
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Publishing Year |
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1441 AH
2020 AD |
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Added Date |
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Monday, January 20, 2020 |
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Researchers
| أم كلثوم أحمد المختار | Almukhtar, Umkalthom Ahmed | Researcher | Master | |
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