CHAPTER ONE

INTRODUCTION

Perineal tears refer to any lacerations or injuries to the skin and muscles around the vagina and anus that occur during delivery. They can cause pain, bleeding, infections, sexual dysfunction, and anal incontinence. Therefore, it is important to identify and implements effective strategies to reduce the risk and severity of perineal tear. The female perineum is the diamond shaped inferior outlet of the pelvis. This structure is at risk of trauma during labor because of spontaneous perineal tear of varying degree or iatrogenic episiotomies’.

These injuries can result in immediate and long-term complications in the woman. The aim of this article is to provide general practitioners (GPs) with a good understanding of perineal tears by discussing the different risk factors, available technique uses, challenges face in the prevention, long-term complications and recommendations for future deliveries. Although the majority of perineal tears are managed by obstetricians and gynecologists, it is important for GPs to understand the prevention. in the event that a patient presents to general practice with concerns during the antenatal or postpartum period.

1.1 Background 0f study

 Labor and delivery (childbirth) refer to the set of processes that allow the expulsion of the fetus and its annexes out through the maternal genital tract [1]. Tears (or lacerations) of the genital tract are lesions resulting from breakage of the continuity of the genital tract during birth [2]. Trauma to the genital tract can be secondary to episiotomy, spontaneous obstetric laceration or both [3]. These common injuries include precisely the cervix, vagina, vulva and perineum and are responsible for maternal morbidity and mortality [2] [4]. Human childbirth is seldom completed without the occurrence of at least a slight injury to the birth canal and, sometimes, even deep tearing may occur despite skill and care. Slight abrasions and lacerations of the cervix, vagina, vulva, and perineum are inevitable accompaniments of labor in all primigravidae and most multipara. Various injuries observed during delivery are as under: perineal tears, lacerations of the vagina, tears of the cervix, vaginal and vulva hematomas and rupture of the uterus [5]. In the United States, approximately 3.8 million women give birth vaginally each year and most of them experience trauma to the genital tract [6]. 0ver 85% of women having a vaginal birth suffer some perineal trauma. Spontaneous tears requiring suturing are estimated to occur in at least one-third of women in the UK and USA, with anal sphincter tears in 0.5% to 7% of women [7].2015, a study in the Niger state of Nigeria revealed a prevalence of lower genital tract injuries of 9.1% with the most frequent lower genital tract injury being a first-degree perineal tear at 40.2% [8].

In the literature, few data are available on the risk factors of genital tract trauma in Cameroon. A study carried out in 2009 at the Yaoundé Central Hospital revealed that the incidence of perineal tears was 13.5 (76.5% first-degree perineal tears, 22.1% second degree, 1.3% third degree, and no fourth degree was recorded) [9]. Another study done in the same hospital in 2015 showed the prevalence of genital tract lacerations to be 12%. Perineal tears accounted for 92.6% of genital tract lacerations, cervical tears 8.8% and vaginal tears 7.4% [2].

In 2013 the prevalence of perineal tears was found to be 19.2% and that of episiotomy was 2.3% in the Limbe Regional hospital [10]. Although genital tract injuries are this common, their full extent may be underestimated. Reasons for this include incomplete assessment of trauma by birth attendants, underreporting of some types of injury, practice variation in determining which lacerations need to be sutured, and differences in how minor trauma is classified [11]. Genital tract trauma is a common outcome of vaginal birth and can cause short-term and/or long-term problems for the new mother. It can disrupt breastfeeding, family life and sexual relations. 7% – 10% of women continue to have long term pain 3 – 18 months after delivery. It is clear that the effects of perineal trauma can be lasting and, in some cases, severe, leading to significant dysfunction and distress for the individual involved. Short term complications of perineal trauma include pain, bleeding and infection, while long term effects include dyspareunia, incontinence of urine (obstetric fistula), flatus or faces and prolapse. Therefore, effective management is very important in the early postnatal period to minimize the impact of both the acute symptoms and any sustained effect caused by perineal trauma [12]. Primary postpartum hemorrhage is an important complication of lower genital tract injury and a significant contribution to maternal morbidity and mortality [8]. Although serious long-term consequences have been identified for severe perineal lacerations, less attention has been paid to lacerations in other locations and how the risk factors vary for different lacerations [13].

Genital tract trauma is a common outcome of vaginal birth and can cause short-term and/or long-term problems for the new mother. It can disrupt breastfeeding, family life and sexual relations. 7% – 10% of women continue to have long term pain 3 – 18 months after delivery. It is clear that the effects of perineal trauma can be lasting and, in some cases, severe, leading to significant dysfunction and distress for the individual involved. Short term complications of perineal trauma include pain, bleeding and infection, while long term effects include dyspareunia, incontinence of urine (obstetric fistula), flatus or faces and prolapse. Therefore, effective management is very important in the early postnatal period to minimize the impact of both the acute symptoms and any sustained effect caused by perineal trauma [12].

Primary postpartum hemorrhage is an important complication of lower genital tract injury and a significant contribution to maternal morbidity and mortality [8]. Although serious long-term consequences have been identified for severe perineal lacerations, less attention has been paid to lacerations in other locations and how the risk factors vary for different lacerations [13]. In modern medicine, some risk factors have been identified for cervical lacerations including gestational diabetes, shoulder dystocia, delivery with forceps, vacuum or both, history of cerclage, cervical conization, as well as dilatation and evacuation. [14].

Among various obstetric parameters, primiparity, assisted forceps delivery, persistent occiput posterior position and birth weight of more than 4000 g were previously found to be significantly associated with severe perineal tears. Other, less established, risk factors include maternal age (advancing maternal age [15]); postdate pregnancies, induction of labor a prolonged second stage of labor precipitate labor, epidural anesthesia and various maternal birth positions. Randomized controlled trials (RCTs) have failed to demonstrate a significant reduction in perineal trauma in women who received an episiotomy compared with women who did not [16]. Instrument assisted vaginal delivery is a significant risk factor for severe perineal lacerations.

1.2. Problem Statement

Perineal tears remain a major threat to the woman of the developing countries according to the latest perineal tears statistics, third- and fourth-degree tears are the highest course of perineal damage which can lead to many complications and even death of women during labor and delivery most especially in developing countries meaning more than 80% of women in the developing countries. perineal tears trauma brings a lot of complications to the maternal wellbeing sometimes after post-partum which might turn to affect future deliveries. Several measures have been put in place by international and national bodies to ensure that the risk of perineal tears is reduced among paturients during vaginal deliveries.

Some of the measures include policies adopted from the sustainable development of goal of preventing perineal tears and episiotomies as the occurrence of perineal tears serve as a risk factor to maternal post-partum hemorrhage and infections which can even lead to death. Several nations have adopted these policies and implement them within many health package or facilities with evidence that  it is actually being used by nurses with  positive patients outcome[18]. Although the perineal tears prevention  process is a major element of nursing and midwifery education in sub-Saharan Africa [18,19,20], most countries face major issues with its effective implementation in almost all health care settings and the extent to which it is implemented is still very unclear. It is on these bases that this piece of work will be carry out to explore the challenges faced in the prevention of perineal tears among nurses and midwives in thAlthough the nursing process is a major element of nursing education in sub-Saharan Africa [18,19,20], most countries face major issues with its effective implementation in almost all health care settings and the extent to which it is implemented is still very unclear. It is on these bases that this piece of work was carried out to explore the challenges of nursing process utilization among nurses in the  Bamenda Regional Hospital. 

1.3 Research Question

1.3.1 General Research Questions

What are the measures employed in the prevention of perineal tears during labor by nurses and midwives in BRH

1.3.2 Specific Research Questions

-what are the techniques use by nurses and midwives in the BRH in the prevention of perineal tears.

-What are the risk factors for perineal tears in pregnant women by nurses and midwives in the BRH.

-wha is the proportion of women who sustain perineal tear during normal vaginal delivery in the BRH?  

-what are the challenges face by nurses and midwives in the prevention of perineal tears in the BRH?