Suturing versus non-suturing of spontaneous perineal tears following normal birth: Factors that influence the practice of New Zealand/Aotearoa midwives
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Rationale: Perineal trauma following birth can have a profound effect on a woman's biological, psychological, and emotional health. There is debate on whether or not to suture perineal tears. Research is limited relating to midwifery decision making on the topic and is sparse from a New Zealand context. Study aim: The aim of this study is to describe the degree of influence of specific factors on midwives' decisions to either suture or not suture spontaneous perineal tears following normal birth. Design: This descriptive study used survey methodology. A randomly selected sample of 400 midwives from the New Zealand College of Midwives was sent a postal survey over a seven week period in May 2009. Analysis was performed using Statistical Package for the Social Sciences (SPSS, version 17, Chicago). Results: 216/400 (54%) questionnaires were completed and returned. Three clinical characteristics, the depth of the tear, amount of bleeding and alignment/apposition of the tear, had a considerable influence on both midwives decision to suture or not to suture, as did the midwives own practice experience confidence in identification of the tear, confidence in repair technique, evidence from research, previous perineal outcome and woman's general health and wellbeing. Woman's choice also had considerable influence on the midwives decision not to suture. Time restraints, peer pressure and place of birth had little influence on either decision. Years in practice impacted on the influence of many factors: confidence in the repair technique on the decision to suture (p=0.04) and not to suture (p=0.03); midwives' reported confidence levels in the repair of a first degree (p=0.01), second degree (p=0.04), branching/complex (p=0.03), or labial tear (p=0.05); time restraints on the decision to suture (p=0.05); and practice experience on the decision not to suture (p=0.04). Main work types impacted on the influence that hospital policies had on the decision to suture (p=0.02) and not to suture the perineal tear (p=<0.001), the woman's previous perineal outcome on the decision not to suture (p=0.05) and the midwives reported confidence levels in the repair of a second degree tears (p=0.03) and branching/complex tear (p=0.002). Conclusion: New Zealand midwives were primarily influenced by the clinical characteristics of a spontaneous perineal tear in their decision to suture or not to suture, but factors such as practice experience, confidence in identification and repair, evidence from research, the women's health and wellbeing and the woman's choice also impacted on decisions and were commonly part of the decision-making process. Years in practice and main work type of the midwife had an impact on some but not all factors. Environmental factors such as place of birth, time and peer pressure were not important influences. This study demonstrates that New Zealand midwives view their decisions as their own professional responsibility suggesting autonomous decision-making. Importantly, midwives used a holistic approach to navigate their way through the complexity of the decision-making process. Professional development or education on the topic needs to provide opportunities for midwives to explore the complexity of factors that may influence decisions regarding suturing or non-suturing of spontaneous perineal tears.
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