The impact of antenatal education on wound-healing rates for women who have given birth in a hospital

What is the issue?

In hospitals, a large majority of women who give birth vaginally suffer from an injury to their perineum, the area of skin and muscle between the anus and the vagina. This injury may be bruising or tearing, or occur as a result of a deliberate cut to assist with childbirth. As women are often discharged from hospital very shortly after childbirth, they may be left to care for this wound themselves, without healthcare supervision. The type and extent of the injury varies, as does the treatment for these wounds. They might have stitches, need cold packs and analgesics or anti-inflammatories for pain relief; or salt baths, wound packing, and antibiotics to help with healing. Many women are not warned of the likelihood or prepared for a perineal wound. They do not know how to manage and care for the wound. This may result in complications such as increased pain and discomfort, distress, risk of infection, and difficulty with urination and having sexual intercourse. This review aimed to examine whether providing education to women before childbirth, about the expectation and management of a perineal wound, made a difference to wound healing after childbirth.

Why is this important?

Perineal wounds that do not heal well impact poorly on women's health, on the relationship between the mother and her baby, and on family relationships. Healthcare professionals are in the unique position of being able to provide up-to-date and accurate advice, and can play a key role in educating women in this important aspect of their personal care. Appropriate formal education provided before childbirth might lessen the shock and distress associated with a perineal wound, and empower the mother to manage the treatment of the wound, thereby reducing the risk of complications. This review aimed to examine whether providing education to women before childbirth, either as part of antenatal education or during visits to their healthcare provider, made a difference to wound healing after childbirth.

What evidence did we find?

We searched for evidence in September 2017 but did not find any randomised controlled studies relating to our area of interest. We excluded one study and one other study is not yet complete.

What does this mean?

We cannot say whether or not antenatal education has an effect on perineal wound healing after childbirth among women who have birthed in a hospital setting. We do not know from randomised controlled trials what the benefits and harms of this education might be. More research is this area is needed to determine the impact of education delivered before childbirth on perineal wound healing in women who have birthed in a hospital setting. Trials may also examine the outcome on related issues including infection rate, re-attendance or re-admission to hospital, pain, health-related quality of life, maternal bonding, and negative emotional experiences relating to a perineal wound. A large proportion of childbearing women experience a perineal wound in childbirth, and these wounds are known to have a significant physical, psychological and economic impact. Future research could examine the potential benefits of a tailor-made education package to be delivered to this cohort of women, as there is currently no evidence to support this.

Authors' conclusions: 

We set out to evaluate the RCT evidence pertaining to the impact of antenatal education on perineal wound healing in postnatal women who have birthed in a hospital setting, and who experienced a break in the skin of the perineum as a result of a tear or episiotomy, or both. However, no studies met the inclusion criteria. There is a lack of evidence concerning whether or not antenatal education relating to perineal wound healing in this cohort of women will change the outcome for these women in relation to wound healing, infection rate, re-attendance or re-admission to hospital, pain, health-related quality of life, maternal bonding, and negative emotional experiences. Further study is warranted in this area given the significant physical, psychological and economic impact of perineal wounds, and the large proportion of childbearing women who have experienced a postnatal wound. The benefits of any future research in this field would be maximised by incorporating women in a range of socio-economic groups, and with a range of healthcare options. This research could take both a qualitative and a quantitative approach and examine the outcomes identified in this review in order to assess fully the potential benefits of a tailored antenatal package, and to make recommendations for future practice. There is currently no evidence to inform practice in this regard.

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Background: 

The female perineum becomes suffused and stretched during pregnancy, and further strain during vaginal childbirth contributes to approximately 85% of women experiencing some degree of trauma to the perineal region. Multiple factors play a role in the type and severity of trauma experienced, including parity, delivery method, and local practices. There is ongoing debate about best midwifery practice to reduce perineal trauma. Once perineal trauma has occurred, treatment also varies greatly, depending on its degree and severity, local practice and customs, and personal preference. In order to optimise wound-healing outcomes, it is important that wounds are assessed and managed in an appropriate and timely manner. A perineal wound may cause significant physical and/or psychological impact in the short or long term, however little evidence is available on this subject.

Antenatal education serves to prepare women and their partners for pregnancy, delivery and the postpartum period. The delivery of this education varies widely in type, content, and nature. This review examined antenatal education which is specifically tailored towards perineal care and wound healing in the postnatal period via formal channels. Appropriate patient education positively impacts on wound-healing rates and compliance with wound care. Risk factors that contribute to the breakdown of wounds and poor healing rates may be addressed antenatally in order to optimise postnatal wound healing. It is important to assess whether or not antenatal wound-care education positively affects perineal healing, in order to empower women to incorporate best practice, evidence-based treatment with this important aspect of self-care in the immediate postnatal period.

Objectives: 

To evaluate the effects of antenatal education on perineal wound healing in postnatal women who have birthed in a hospital setting, and who have experienced a break in the skin of the perineum as a result of a tear or episiotomy, or both.

Search strategy: 

We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2017), ClinicalTrials.gov (8th September 2017), the WHO International Clinical Trials Registry Platform (ICTRP) (8th September 2017) and reference lists of retrieved studies.

Selection criteria: 

We considered randomised controlled trials (RCTs) which referred to all formal methods of antenatal education and addressed care of a potential perineal wound as a result of a tear or episiotomy, which was experienced by pregnant women who planned to give birth within a hospital setting.

Trials using a cluster-RCT and a quasi-randomised design would have been eligible for inclusion in this review but none were identified. Cross-over trials were not eligible for inclusion in this review. Studies published in abstract form would have been eligible for inclusion in this review, but none were identified.

We planned to consider all formal methods of antenatal education which addressed care of a perineal wound. We also planned to consider all contact points where there was an opportunity for formal education, including midwifery appointments, antenatal education classes, obstetrician appointments, general practitioner appointments and physiotherapist appointments.

Data collection and analysis: 

Two review authors independently assessed titles and abstracts of the studies identified by the search strategy for their eligibility.

Main results: 

No studies met the inclusion criteria for this review. We excluded one study and one other study is ongoing.

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