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Do you need an enema in labour?

An enema is the injection of fluid into the lower bowel by way of the rectum. The most frequent use of an enema is to relieve constipation or for bowel cleansing before a medical examination or procedure.

Giving women enemas during labour has been routine practice in delivery wards of many countries and settings. Occasionally women leak from their back passage whilst giving birth and it was thought an enema in early labour would reduce this soiling and the consequent embarrassment for women. It was also thought that emptying the back passage would give more room for the baby to be born, would reduce the length of labour and would reduce the chance of infection for both the mother and the baby. It was also suggested it would reduce bowel movements after birth which often cause women concern.

A study in 1981 suggested that when preparing for normal labour the enema should be reserved for women who have not had their bowels open in the past 24 hours and have an obviously loaded rectum on initial pelvic examination.

In a Cochrane Database Review in 2013, the Selection criteria being randomised controlled trials (RCTs) in which an enema was administered during the first stage of labour and which included assessment of possible neonatal or puerperal morbidity or mortality were reviewed. Following meta‐analysis of two trials the authors’ conclusion was – “These findings speak against the routine use of enemas during labour, therefore, such practice should be discouraged”.

Enema versus no-enema in pregnant women on admission in labour: A randomized controlled trial Journal of the Medical Association of Thailand = 88(12):1763-7 · December 2005 

Abstract
To compare the maternal and neonatal outcomes between enema and no-enema in pregnant women on admission in labour. One thousand and one hundred term pregnant women with labour pain were selected randomly on admission to be assigned into two groups at Rajavithi Hospital from 1 February 2002 to 15 June 2002. Five -hundred and thirty-nine cases received enema and five-hundred and sixty one cases received no enema. Seventy three women (39 and 34 cases from the enema and no-enema groups, respectively) were excluded because of caesarean section due to obstetric indications. Five hundred cases received enema and five-hundred and twenty -seven cases received no-enema. All cases were delivered vaginally. There was no statistical significant difference between the two groups with regards to maternal age, gestational age, gravidity, parity, mode of delivery, type of episiotomy and degree of perineal tear. Faecal contamination rate during the second stage of labour was significantly higher in the women who received no-enema (34.9%) in comparison with those receiving enema (22.8% (p < 0.001). No neonatal infection occurred in both groups. Duration of labour was significantly longer in the women who received no-enema (459.8 min) compared with those who received enema (409.4 min) (p < 0.001). No-enema methods on admission in labour had significantly more increase in faecal contamination in the second stage of labour and longer duration of labour than the enema method but there was no difference in perineal wound infection and neonatal infection between both groups.

There continues to be advocates both for and against, particularly amongst midwives and nurses involved in daily deliveries but also with women themselves. There are also marked regional differences.

A survey of maternity practices in Croatia in 2015 found that 78 % of women were given an enema in labour.

References
Reveiz L, Gaitán HG, Cuervo LG. Enemas during labour. Cochrane Database of Systematic Reviews 2013, Issue 7.
Clarke NT, Jenkins TR. Randomized prospective trial of the effects of an enema during labor [abstract]. Obstetrics & Gynecology 2007;109(4 Suppl):7S.
Cuervo LG, Bernal MP, Mendoza N. Effects of high volume saline enemas vs no enema during labour – the N-Ma randomised controlled trial. BMC Pregnancy and Childbirth 2006;6:8.
Br Med J (Clin Res Ed) 1981;282:1269
Kovavisarach E, Sringamvong W. Enema versus no-enema in pregnant women on admission in labor: a randomized controlled trial. Journal of the Medical Association of Thailand 2005;88(12):1763-7.
Lurie S, Baider C, Glickman H, Golan A, Sadan O. Are enemas given before cesarean section useful? A prospective randomized controlled study. European Journal of Obstetrics & Gynecology and Reproductive Biology 2012;163(11):27-9.
Romney ML, Gordon H. Is your enema really necessary?. British Medical Journal 1981;282(6272):1269-71.

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Episiotomy

Episiotomy, is a surgical incision of the perineum and the posterior vaginal wall generally done by a midwife or obstetrician during second stage of labour to quickly enlarge the opening for the baby to pass through.
The incision, which can be done at a 90 degree angle from the vulva towards the anus or at an angle from the posterior end of the vulva (medio-lateral episiotomy), is performed under local anaesthetic and is sutured after delivery.

The use of a surgical incision of the perineum during childbirth was first described in 1742. It was introduced into the USA in the mid-19th Century. In 1920, at a meeting of the American Gynaecological Society in Chicago, USA, Joseph DeLee first publicly advocated the routine adoption of Medio lateral episiotomy for all deliveries in nulliparous women.

They became common practice during the 20th century, the main reason being to reduce the risk of severe perineal tears. 85% of women who have a vaginal delivery, will have some degree of perineal trauma, the majority of which will require suturing. By 1979, episiotomy was performed in approximately 63% of all deliveries in the USA, with higher rates among nulliparous women. In the UK in the same era, episiotomy rates ranged from 14 to 96% among nulliparous women and 16–71% among multiparous women. In recent years opposition to the use of episiotomy as a standard procedure has reduced the rate and its routine use is no longer recommended. Despite this, it is one of the most common medical procedures performed on women, though there is now considerable variation between countries. A review was published in JAMA in 2005. By this time the practice had declined in the USA from of over 60% to 30–35% of vaginal deliveries though the rate was as high as 99% in Eastern Europe.

In 2009, a Cochrane meta-analysis based on studies with over 5,000 women concluded that: “Restrictive episiotomy policies appear to have a number of benefits compared to policies based on routine episiotomy. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy”.

Levine EM et al in 2015 noted – The average episiotomy rate steadily declined from 1996-1998, 2003-2005 and 2012-2014. The rate of advanced perineal lacerations coincidentally rose during these time period comparisons. Levine EM, Bannon K, Fernandez CM, Locher S (2015) Impact of Episiotomy at Vaginal Delivery. J Preg Child Health 2:181.

It has been suggested that perineal massage during the second stage of labour can reduce the need for episiotomy.
Infrared lamp therapy is an effective method of treatment on healing of episiotomy wound among post-natal mothers.
In a study by Sabzaligol M et al. Aloe Vera gel not only relieved the pain but also increased the rate of wound healing in episiotomy.

References
1. Practice Bulletin No. 165: Prevention and Management of Obstetric Lacerations at Vaginal Delivery”. Obstetrics and Gynecology. 128 (1): e1–e15. July 2016.
2. Chang,S-R; Chen,K-H; Lin,H-H; Chao,Y-M Y.; Lai,Y-H (April 2011). “Comparison of the effects of episiotomy and no episiotomy on pain, urinary incontinence, and sexual function 3 months postpartum: A prospective follow-up study”. International Journal of Nursing Studies. 48 (4): 409–418.
3. Graham,I.D.; Carroli,G.; Davies,C.; Medves,J.M. (August 2005). “Episiotomy Rates Around the World: An Update”. Birth. 32 (3): 219–223.
4. Carroli, G, Mignini, L. “Episiotomy for vaginal birth”. Cochrane Database Syst Rev. 2009 Jan 21; (1):
5. Jiang, Hong; Qian, Xu; Carroli, Guillermo; Garner, Paul; Jiang, Hong (2017). “Selective versus routine use of episiotomy for vaginal birth”.
6. American College of Obstetricians-Gynecologists (2006). “ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Number 71, April 2006” Obstetrics & Gynecology. 107 (4): 956–62
7. Levine EM, Bannon K, Fernandez CM, Locher S (2015) Impact of Episiotomy at Vaginal Delivery. J Preg Child Health 2:181.
8. Sabzaligol M, Safari N, Baghcjeghi N, Latifi M, Koohestani H R, Bekhradi R, et al . The effect of Aloevera gel on prineal pain & wound healing after episiotomy. cmja. 2014; 4 (2) :766-775

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Water Birth

Water birth is childbirth that occurs in water. During the 1970s Michel Odent in France and Igor Tcharkovsky in Russia pioneered the use of water in labour. Proponents believe water birth results in a more relaxed, less painful experience. It is best to enter the pool after the cervix has dilated to 5cm. Before this the relaxing effect of water may reduce the power of contractions. Critics argue that the safety of water birth has not been scientifically proven and that a wide range of adverse neonatal outcomes have been documented, including increased mother or child infections and the possibility of infant drowning. A 2009 Cochrane Review of water immersion during the first stage of labour found that it reduces the use of epidural/spinal analgesia and duration of the first stage of labour. There is limited information for other outcomes related to water use during the first and second stages of labour, due to intervention and outcome variability. There is no specific evidence of increased adverse effects to the baby or woman from labouring in water or water birth. (Elizabeth R Cluett, and Ethel Burns Cochrane Pregnancy and Childbirth Group 2009).

Baby doesn’t usually draw breath until there is contact with the cooler air above the water – the dive reflex. There is a small risk of inhaling water where there is foetal distress, so it is important for normal foetal monitoring of heart rate during labour.

It has been suggested that neonatal infection may occur due to cross-contamination from the water and pool, and from the woman. However, several comparative studies, report no increased risk of infection for the baby (Zanetti-Daellenbach RA, Tschudin S, Zhong XZ, Holzgreve W, Lapaire O, Hösli I. Maternal and neonatal infection and obstetrical outcome in water birth. European Journal of Obstetrics & Gynecology and Reproductive Biology 2007;134(1):37-43.). As with all maternity care it is necessary to adhere to cleaning protocols for labour and birthing pools, and employ usual precautions.

As with any labouring woman, it is important to avoid her becoming pyrexial. Therefore, the water temperature of a pool should not exceed the maternal body temperature, as immersing a woman in water above her natural core temperature will result in foetal hyperthermia and associated cardiovascular and metabolic disturbances. High temperatures have been identified as a safety issue by several authors as being associated with foetal mortality and morbidity, based on individual case studies. (Deans AC, Steer PH. Temperature of pool is important. BMJ 1995;311:390-1.).

References:

Reid-Campion M. Hydrotherapy: Principles and Practice. 2nd Edition. Oxford: Butterworth Heineman, 1997.

Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, et al. Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2011, Issue 7

Mammas IN, Thiagarajan P. Water aspiration syndrome at birth – report of two cases. Journal of Maternal-Fetal and Neonatal Medicine 2009;22(4):365-7.

Department of Health. Changing Childbirth. HMSO, 1993.

Thoeni A, Zech N, Moroder L, Ploner F. Review of 600 water births. Does water birth increase the risk of neonatal infection?. Journal of Maternal-Fetal and Neonatal Medicine 2005;17(5):357-61.