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  1. A clinician’s review of perineal tear repair in the UK

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    Where have we come from and where are we going?

    Author: Darya Kozlyk, Midwife at University College of London (UCLH) Hospital. PhD Candidate in Maternal Medicine at UCL. Qualified midwife since 2015.

    Around 85% of women who have a vaginal birth will sustain some degree of birth-related perineal trauma and of these around 70% will need perineal suturing, usually within an hour of the birth1. Critically, perineal trauma requires accurate examination, classification and adequate repair to avoid lifelong adverse consequences for the woman’s physical, sexual and psychological health2.

    2003 Milestone Moment

    The NHS supports approximately 350,000 women who sustain perineal trauma every year2. Yet despite this perineal repair via perineal suturing was not systematically incorporated into routine clinical practice in the U.K3 until the results of a seminal randomised control trial in 20034 were published which found that repair leads to improved healing. This, along with Cochrane systematic reviews recommending continuous suturing using absorbable sutures (which don’t need to be removed postnatally), has seen the practice of perineal repair firmly incorporated into the National Institute for Health and Care Excellence (NICE) guidelines5

    Today: Room for Improvement

    Despite the significant improvements new guidelines have led to, there remains significant areas for improvement. For example, second degree perineal tear repair is the most common intrapartum surgical procedure yet studies have shown considerable gaps and disparities in the methods used in clinical practice6. Studies of UK-based qualified midwives show that only 39% feel that their training was adequate, that 37% had no hands-on training prior to undertaking their first repair7 and only 6% of midwives used evidence-based suturing methods to repair all layers of the perineum6. To address this knowledge gap the Perineal Assessment and Repair Longitudinal Study (PEARLS)1 provides an interactive educational package that aims to improve evidence-based practice and is available to all Midwives through the Royal College of Midwives’ I-learn platform7.

    Despite the advances in training, current standard practice for postpartum suturing inherently limits every clinicians’ ability to comply with evidence-based best practice. Today’s standard guidelines require the suturing clinician to digitally retract vaginally tissue to locate the apex, classify the degree of trauma and maintain this position for the duration of the procedure. This puts the clinician at high-risk of needle stick injury, hinders the quality of repair and increases the risk of inadequate repair.

    The Future of Perineal Repair

    The Hegenberger Retractor for perineal repair is the next step in suturing best practice for clinicians and their patients.

    Designed to work in conjunction with PEARLS Training Package, Obstetric Anal Sphincter Injuries (OASIs) Two Bundle8 and NICE clinical guidelines5, it allows suturing clinicians to perform repairs according to evidence-based practice and using both hands for the duration of the procedure. Emerging international data from clinicians shows the retractor improves exposure and access for the suturing clinician, provides a safer, more ergonomic environment to perform routine repairs and complex OASIs and aids compliance with evidence-based suturing practice.

    References:

    1. Ismail KM, Kettle C, Macdonald SE, Tohill S, Thomas PW, Bick D (2013). Perineal Assessment and Repair Longitudinal Study (PEARLS): a matched-pair cluster randomized trial. BMC Medicine 11(209). https://doi.org/10.1186/1741-7015-11-209 [Accessed 14 June 2022].
    2. NHS Digital. NHS maternity statistics, England 2019-20. 2020. Available at: https://digital.nhs.uk/data-and-information/publications/statistical/nhs-maternity-statistics/2019-20 [Accessed 15 June 2022].
    3. Lundquist M, Olsson A, Nissen E, Norman M. Is it necessary to suture all lacerations after a vaginal delivery?. Birth. 2000 Jun;27(2):79-85. Available at: https://doi.org/10.1046/j.1523-536x.2000.00079.x [Accessed 20th July 2022].
    4. Fleming VE, Hagen S, Niven C. Does perineal suturing make a difference? The SUNS trial. BJOG: an international journal of obstetrics and gynaecology. 2003 Jul 1;110(7):684-9. Available at: https://doi.org/10.1016/S1470-0328(03)02353-X [Accessed 20th July 2022].
    5. National Institute for Health and Care Excellence (NICE) (2014). Intrapartum care for healthy women and babies [Last updated 21 February 2017]. https://www.nice.org.uk/guidance/cg190 [Accessed 25 May 2022].
    6. Bick DE, Ismail KM, Macdonald S, Thomas P, Tohill S, Kettle C. How good are we at implementing evidence to support the management of birth related perineal trauma? A UK wide survey of midwifery practice. BMC pregnancy and childbirth. 2012 Dec;12(1):1-0.
      https://doi.org/10.1186/1471-2393-12-57  [Accessed 14 June 2022].
    7. Royal College of Midwives (RCM). MaternityPEARLS; Perineal Repair and Suturing. 2018. Available at: (Accessed 2nd August 2022).
    8. Royal College of Obstetricians and Gynaecologists (RCOG). OASI Care Bundle Project. 2020. Available at: https://www.rcog.org.uk/oasicarebundle [Accessed 20th July 2022].

  2. Eureka! Inspiration for the invention of the Hegenberger Retractor

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    Author: Malene Hegenberger, practicing Clinical Specialist Midwife at Slagelse Hospital in Denmark and inventor of the Hegenberger Retractor. A certified Registered Nurse in Denmark (1998) and Certified Midwife in Norway (2002).

    Innovation from clinical experience

    As a midwife, it is essential to me that patients receive the best possible care. I have always enjoyed working in hospitals and healthcare environments and it is an important reminder for me that as a midwife I take care of a woman and their baby at a hugely significant moment in their lifetimes. 

    The satisfaction from performing a correct postpartum repair really makes my day. To finish off a vaginal delivery with the correct diagnosis, repair and normal (for the patient) looking vagina and external genital should be the standard expectation for all women. Yet, this can be very difficult to achieve. I have been fortunate enough to work as a nurse / midwife in the UK, Norway, Slovenia, Caribbean and the USA and found that the challenges facing midwifes and clinicians are universal. 

    For years I had difficulty inspecting, diagnosing, and managing my instruments, whilst keeping the trauma area dry of blood. I needed a third hand to hold aside the vagina and cause less manipulation for my patient, or a colleague to support during the procedure. All of this whilst continuing to look after the wellbeing and welfare of both mother and baby. I shared these experiences with my colleagues who related similar challenges and frustrations. Surely there was a better way? I researched best practice and devices to aid postpartum repair and found that despite the same issues occurring for clinicians worldwide, no one had yet solved the problem.

    I wanted to.

    Inventing a medical device

    Mimicking an assistant, the Hegenberger Retractor is a device that helps midwives, doctors and clinicians. It enables them to suture most patients alone, without requiring additional colleagues. Once inserted into the vagina, it enables a better view of the tear for clinicians, enabling accurate diagnosis and optimal understanding of how to close the tissue and muscles in the best way for the patient. It also leaves both hands free, enabling correct suturing techniques using a needle holder and forceps, and this reduces the risk of needlestick injuries for me and my colleagues.

    Lastly, I am especially proud of the role that the Retractor has in improving teaching conditions for the next generation of midwives, doctors and clinicians. It enables a greater understanding of the anatomy, visibility of different types of tissue and allows tutors and students to sit side by side and focus upon teaching and practice with both pairs of hands available, rather than a tutor simultaneously holding aside the vaginal walls, teaching and monitoring a student’s work.

    The future

    The Hegenberger Retractor is our first product, but my mission is to improve the care and information available for women’s pelvic and genital health globally. Change takes time, but I believe that our Hegenberger Retractor can directly contribute to increased levels of correct diagnosis and therefore correct suturing treatment. The consequences of inaccurate diagnosis have a long-term impact upon women’s physical, emotional and sexual health, and are now avoidable.

    In a few years I hope that the Hegenberger Retractor will be available as standard across the globe and that suturing women has same prestige as other procedures we perform during pregnancy and labour.

    I hope that my invention can contribute to improving wellbeing and care for women. Every woman has to live with a repair for the rest of her life and we should always keep that in mind.

  3. Why is what comes after birth an afterthought? Time to give postnatal care the spotlight

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    Author: Marie Louise, Founder of the Modern Midwife and a UK Midwife since 2012 and Senior Midwife in Australia (2013-15)

    Antenatal vs Postnatal care – mind the gap!

    Growing and giving birth to another human being requires a lot of nutrition, energy and physiological changes. This includes changes to the cardiovascular system, blood volume increasing by 50%, the lungs changing shape and the loosening of ligaments leading to supported fetal growth, to name just a few. Mums are often left with some form of wound either due to a c-section or trauma to the perineum. Yet rarely do we prepare mums for this or talk about wound care afterbirth. Why is this?

    If a mum goes on to breastfeed she needs to continue to share her body in many ways and makes around 600ml – 1200ml milk every 24 hours for her baby. Breastfeeding maybe a natural process but it does not come naturally to many mums as all maternity care providers know, mums need support, realistic expectations and a good understanding of normal newborn behaviour. Why isn’t more education and support provided?

    What comes afterbirth often remains an afterthought. During pregnancy the focus is often on fetal surveillance, the pregnancy and birth preparation. Lots of mums are left wondering, why wasn’t I prepared for this? Sadly postnatal care is the aspect of maternity care that women in England are least satisfied with1. Likely this will not come as a surprise for every clinician reading this, we have long been aware of the differences in antenatal and postnatal care. 

    Postnatal care internationally – how do approaches differ?

    The approach to postnatal care differs widely throughout the world by both country and culture. Let’s explore some examples.

    In Malysia, there’s real focus on the first six weeks following birth and nourishing the mum to support her healing and recovery.

    Nearby in China there is something known as ‘the one month sitting’ where new mums aren’t expected to get out of bed and everything is done for them. Some clinicians would argue this is not ideal due to the risk of blood clots and that movement promotes healing, yet it’s interesting that postpartum care is embedded so firmly into the nation’s tradition and consciousness.

    The ancient practice of Ayurveda in India is the world’s oldest holistic healing system and includes an approach for new mothers. The practice recognises the stress that birth can have on mums’ bodies and seeks to harmonise their vata energy with rest, warmth, food for their digestive system and nourishment.

    Closer to home, mums in the Netherlands are given access to a Kraamzorg which is a unique form of postnatal care where a professional supports a new mum with daily recovery checks, a daily review of the baby (checking weight, temperature, etc.), supports (if necessary) with breastfeeding and teaches both parents about basic childcare. A Kraamverzorgende will even help with light household work such as laundry and cleaning of the household including the bathroom, toilet and mother and baby’s rooms to ensure a clean environment for the family and their newborn.

    So what learnings can we take for the UK? 

    It’s important to consider different international practices and how they are supporting new mums when considering our approach to postpartum care in the UK.

    Postnatal care has an important role in enabling a safe and positive transition to parenthood, especially for first time parents2. The consequences of poor postnatal care may be especially problematic for first-time mothers, who need to develop parental confidence, new skills understanding of their body and their babies3. Research by Jenny McLeish revealed first-time mothers’ satisfaction with postnatal care and their confidence as new mothers were primarily influenced not by the extent to which their expectations were met but the varied extent to which their postnatal needs were met’1.

    Ultimately, McLeish concludes that rapid and responsive assessment of needs both antenatally and postnatally is the best possible course of action for mum and baby alike. Raising concerns with our senior colleagues and questioning processes that may not supporting mums is important. Our voices matter and we have a profound impact on new mothers’ lives.

    As care providers we need to bring focus back to postnatal care, to offer solutions and push to promote and define postnatal care pathways. Let’s start here in the UK and put postnatal care back into the spotlight where it belongs.

    References 

    1. First-Time Mothers’ Expectations and Experiences of Postnatal Care in England, Jenny McLeishMerryl HarveyMaggie Redshaw, … First Published September 17, 2020 Research Article in PubMed https://doi.org/10.1177/1049732320944141
    2. Demott, K., Bick, D., Norman, R., Ritchie, G., Turnbull, N., Adams, C., Barry, C., Byrom, S., Elliman, D., Marchant, S., Mccandlish, R., Mellows, H., Neale, C., Parkar, M., Tait, P., Taylor, C. (Eds.). (2006). Clinical guidelines and evidence review for postnatal care: Routine postnatal care of recently delivered women and their babies. National Collaborating Centre for Primary Care and Royal College of General Practitioners.
    3. Barclay, L., Everitt, L., Rogan, F., Schmied, V., Wyllie, A. (1997). Becoming a mother— An analysis of women’s experience of early motherhood. Journal of Advanced Nursing, 25(4), 719–728. https://doi.org/10.1046/j.1365-2648.1997.t01-1-1997025719.x

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