Introduction

Midwife skills and experiences play an important role in the maintenance of maternal health during childbirth (1). During labor, the soft tissues of the birth canal and adjacent organs are injured. These injuries are more common among primiparous women due to the relatively thick tissues and more resistance to the baby's exit during birth (2). Episiotomy means the cut of the perineal area which is regarded as the most common surgery among the female population after cutting the umbilical cord (3-5).

Yee et al. (2014) reported the rate of episiotomy in 2500 cases as 7.5% in Chicago (7). However, over 90% of primiparous women underwent episiotomy in developing countries (8).

The prevalence rates of episiotomy were 97.3% and 88.3% in Tehran (2009) and Mashhad (2005) at Umm al-Banin Hospital, respectively (10-12).

According to a study conducted by Golmakani (2003), only 50% of all 50 patients in the selective episiotomy group and 100% of the cases in the common episiotomy group underwent episiotomy (2). One of the reasons for the acceptance of episiotomy was the replacement of a direct surgical incision with easier repair rather than rippling tears caused by episiotomy (13).

However, the World Health Organization and the American College of Obstetricians and Gynecologists do not recommend the routine utilization of episiotomy (14,15). The midwife will only have to perform episiotomy if mothers or infants are indicative of performing an episiotomy. This is called selective episiotomy. The midwives can properly manage these situations if they have the appropriate manual and psychological skills (5.7). The influential factors affecting the routine use of episiotomy include five general concepts, such as labor factors (including personal experience, skill level, the ability to communicate with mothers and the role of labor), maternal factors (including anatomical differences and lack of co-operation), fetal factors, legal problems, fear of being reproached, as well as labor management (including lack of implementation of new methods of delivery and lack of maternal preparation) (5).

The decision on whether or not to perform episiotomy is ultimately made by those who are responsible for conducting the birth. Stress, time constraints, worries about undesirable performance, lack of experience, and adherence to interventional patterns as well as conventions are among the factors that put the labor process under pressure and avoid the midwives to perform based on her observation (5, 15).

The factors hindering midwives to perform episiotomy include the occurrence of unexpected events, acceptance of responsibility in case of failure, high workload, fear of being reproached by the authorities and decisions which are non-adaptive to work environment. These factors lead to decreased levels of midwife's self-confidence and passive behaviors instead of initiative ones. Midwives perform episiotomy due to higher levels of calmness, fewer levels of stress, and familiarity with episiotomy conditions (15). In addition, they need individual skills, human relationships, and the development of coping strategies with stressful situations in order to meet the needs of the clients (17). Occupational stress and job burnout among midwives result from the traumas that occur during delivery to the clients. The midwives who are stressed lose face lower levels of job quality and cannot say "No" (17).

An individual who uses a collaborative approach to solving interpersonal conflicts also has problem-solving skills (18). Several studies have identified problem-solving skill training as a suitable way to cope with interpersonal problems. This skill is useful in improving interpersonal relationships and preventing as well as reducing physical and psychological damage in stressful situations (19).

Solving conflicts using problem-solving skills make the two sides of the conflict feel as winners. This skill is a systematic process which analyzes stressful situations leading to proper decision making. Problem-solving skills can be very helpful in difficult situations which require critical thinking (20). Problem-solving skill is a part of decision-making skill. This skill solves the problems while taking into account the position of the person involved in stressful situations (20). Problem-solving skill is a cognitive process by which an individual tries to find the right solution for a problem.

In solving the problem, it is not necessary to find a particular solution for a particular problem. However, it is essential to find an abstract principle or law applicable to other situations using problem-solving skill (20). The founders of this approach emphasized the need for problem-solving skills training in social skills training. People who use problem-solving skills have the ability to overcome unpredictable situations and do not need to rely on others. This skill increases the use of effective coping strategies, increased collaboration, and self-control.

According to the literature, individuals use this skill in an interpersonal situation after training (19). Yee et al. (2014) reported that coping strategies and being more tolerant of physicians' ambiguity are associated with a decreased rate of episiotomy. They also suggested that more research is required on the effect of cognitive skills training on the decision of those who are responsible for conducting childbirth to perform episiotomy (7).

According to a study conducted by Abdullah Hossein et al. (2012) in Jordan, there were many barriers to perform selective episiotomy by midwives including obedience to the physician orders, fear of being reproached by the authorities, and care center policies (21).

According to the results of several studies, this skill is learnable and can affect performance as well as cognitive skills (22, 23). Shiroudi et al. (2011) stated that problem-solving skill training increased the level of adaptation of high school female students and reduced their aggressiveness (22). Ghalyli et al. (2007) concluded that problem-solving skill training improved marital conflicts and also increased the cooperative approach in couples (23). Furthermore, problem solving skill is an issue that is involved in the decision-making process and the correct decision on the selective episiotomy will eventually lead to the enhancement of safe delivery.

Given the high prevalence of episiotomy, the fewer number of selective episiotomy, and the effect of midwife decisions on this technique, this study aimed to determine the effect of problem-solving skill training on the number of selective episiotomy in primiparous women.

Materials and Methods

This randomized clinical trial with two groups was conducted on 60 midwives working at Imam Hadi, 17 Shahrivar, and Shahid Hasheminejad hospitals in Mashhad during 2015. The study protocol was approved by the Ethics Committee of Mashhad University of Medical Sciences, Mashhad, Iran. Subsequently, the researcher referred to the abovementioned hospitals and explained the research objectives to the authorities to take the required permission for sampling.  In the next step, the researcher referred to the maternity wards to identify the midwives who met the inclusion criteria for participation in the study. Written informed consents were obtained from participants and they were all informed of the research objectives and procedure as well as the confidentiality of their information.

The inclusion criteria were: 1) BSc in midwifery, 2) lack of experience of being in stressful situations, 3) lack of being under psychotherapy in the last six months, 4) lack of use of psychotropic medication at the onset of the intervention, 5) minimum of 6-month work experience in the maternity ward, 6) no systematic education regarding problem solving, 7) lack of completion of years of service during the study, and 8) no conflict with colleagues or supervisor in the past six months.

On the other hand, the participants who had experiences of being in stressful situations and those who did not participate in the pre- or post-test, and did not attend the training workshop for more than two hours were excluded from the study.

The data were collected using a demographic form asked for midwives' personal and occupational information and Baron's problem-solving questionnaire. The personal characteristics of mothers were also collected through forms (including information about pregnancy, delivery stages, neonate, as well as episiotomy), a checklist for indications for episiotomy measurements, and a scale to measure pelvic floor muscle strength. This scale is utilized to determine the muscle strength of the pelvic floor. The scores within the range of 3-12 indicate degrees of muscle strength in the pelvic floor. Baron's problem-solving questionnaire consists of five questions that are measured based on a five-point Likert scale (from fully agree, agree, to some extent agree, disagree to completely disagree). Some questions are scored in reverse order. The minimum and maximum scores on this scale are 6 and 30, respectively. A score of 6 is the minimum score indicating the lowest level of skill in problem-solving and a score of 30 is the maximum score indicating the highest level of ability in this skill. The score of 18 is also defined as the median and mean level of problem-solving skills.

This questionnaire has been standardized in Iran by Samui et al. Moreover, its validity and reliability have been confirmed in numerous studies (24). The reliability of this questionnaire was estimated at 0.987 using Cronbach's alpha coefficient. Moreover, the content validity of the interview forms, observation checklists, and the scale for pelvic floor muscle strength measurements was confirmed in this study. The inter-rater reliability of the pelvic floor muscle strength measurements was determined at 0.1. The samples included four postpartum mothers before (n=2) and after the intervention (n=2).

In total, four postpartum mothers were under control by each midwife. The sampling was performed according to convenient accessibility and inclusion and exclusion criteria. The participants were then asked to pick one envelop out of 60 closed envelopes which were either intervention (n=30) or control (n=30). Subsequently, the midwives were randomly assigned into two groups of intervention or control groups. The midwives were initially asked to complete the demographic forms and Baron's problem-solving questionnaire. Subsequently, each midwife conducted two primiparous births (singleton, cephalic, term, and without anomaly) under the supervision of the researcher.

The deliveries after posttest were checked in the control group to avoid the interference of data obtained from the intervention group.  The midwives in the control group conducted four births (i.e. two births were conducted on pretest and the two others were performed on posttest). Afterwards, the training session were held and two births were evaluated in the intervention group. Subsequently, all participants were asked to complete the questionnaire. The researcher determined perineum length and pelvic floor muscle strength using the scale for pelvic floor muscle strength measurement

Fetal heart rate, volume as well as the dose of oxytocin, and uterine contractions were controlled and determined in terms of distance, duration and severity during the first and second stages of labor. During delivery, the researcher checked the checklist for episiotomy indications and decided whether the postpartum mothers required episiotomy or not. The researcher then waited for the midwife decision. If the midwife decided to perform an episiotomy, the researcher asked for the reason behind it.

The researcher then completed the forms related to delivery, episiotomy as well as the neonate. Subsequently, the researcher determined the selective or non-selective episiotomy indications based on the checklist. In case of observing any exclusion criteria (i.e., labor dysfunction, abnormal vaginal bleeding, manual pressure to the uppermost part of the uterus during labor, and lack of pregnant women cooperation during labor) the postpartum mothers were excluded from the study. After the pre-test, two problem-solving training workshops were held for four hours by a researcher accompanied by a psychologist as an observer.

The purpose of the workshop was to make midwives familiar with the overall problem-solving skill as a key social skill. The first session was a brainstorming session to generate general ideas about problem-solving skills. Subsequently, the problem-solving skill was explained in the form of the lecture using presentation aids like Power Point slides.

Considering the situations requiring problem-solving skills, the midwives went through step-by-step problem-solving skill for the scenario under consideration. Following the teamwork, one person as a reporter presented the results to everyone and answered the scenario questions. After the results were quoted, the researcher discussed the problem-solving stages; meanwhile, the feedback was given on the results of the teamwork.

Subsequently, another scenario was presented to the teams, and the participants were asked to list the most important problems they faced in the last month in the workplace and at home. They were also required to use the learned skills to solve the problems as homework. The homework was checked on the second training session. Eventually, a general summary of the two-session workshop was presented.

On the second session, the researcher initially checked the participants’ homework. Following this, the second session was held focusing on the problem-oriented solutions and its difference with compatible and incompatible excitement-based solutions. Then, brainstorming was made and a lecture was given by the researcher. In the next stage, two unreal scenarios were presented and the groups began discussing on the solutions.

During the meeting, the midwives were asked to discuss their experiences regarding the need for this skill in interpersonal situations. The concluding remarks were drawn after the two-session workshop. An associate advisor provided the researcher with the training manual developed by Ladan Fata and Mehrdad Kazemzade Atofi. Moreover, the researcher participated in the problem-solving training workshop and was qualified by the research advisor.

Two weeks after the training sessions, the posttest (completion of the questionnaire, forms and control of two deliveries) was held similar to the pretest. A total of 240 deliveries were controlled before (n=120) and after the intervention (n=120). The sample attrition in the population of midwives were from 64 to 60 cases due to the unwillingness to continue the study or lack of attendance at one of the training sessions. Regarding the group of postpartum mothers, no sample attrition was observed. In case of exclusion, another woman was replaced immediately. The data were analyzed in SPSS software (version. 16) through the Chi-square, Mann-Whitney U, Fisher's exact, and Wilcoxon tests. P-value less than 0.05 was considered statistically significant.

Results

According to the obtained results, there was no difference between the two groups of midwives regarding work experience, employment status, and career interest. The mean age of the midwives was obtained at 29.3±0.6. The results of Mann-Whitney U test showed no significant difference between the two groups regarding age (P=0.694) and work experience (P=0.917, Table 1).

Regarding the employment status, most midwives in the intervention (40.0%) and control (56.6%) groups were contractor employees. The Chi-square test results showed no significant difference between the intervention and control groups regarding the employment status of midwives which was not statistically significant (P=0.619, Table 2). The majority of the midwives in the intervention (43.4%) and control groups (56.7%) reported moderate level of career interest. According to the results of the Mann-Whitney U test, there were no significant differences between the two groups regarding the career interests (P=0.120, Table 2). 

Mann-Whitney U test results showed no significant differences between the intervention and control groups regarding the mean age of postpartum mothers before (P=0.200) and after the intervention (P=0.893, Table 3). Moreover, no significant difference was observed between the two groups regarding perineum length and pelvic floor muscle strength score (Table 3).

According to the Chi-square test results, there was no significant difference between the two groups regarding the neonate's gender before (P=0.361) and after the intervention (P=0.715, Table 4). Based on Fisher's exact test results, there was no significant difference between the two groups in terms of assisted delivery before the intervention (P=1.000). In addition, according to the Chi-square test results, no significant difference was observed between the two groups in terms of assisted delivery after the intervention (P=1.000, Table 4).

Furthermore, the Chi-square test results showed no significant difference between the two groups in terms of shoulder dystocia before the intervention (P=1.000). Moreover, according to Fisher's exact test, there was no statistically significant difference between the two groups in terms of shoulder dystocia after the intervention (P=1.000, Table 4).

Regarding the problem-solving ability, the mean score of midwives' problem-solving ability was obtained at 23.2±2.2 before the intervention. However, the Mann-Whitney U test revealed no significant differences between the two groups regarding problem-solving ability before the intervention (P=0.320). The mean score of midwives’ problem-solving ability was 23.1±2.5 after the intervention.

The Mann-Whitney U test results did not show any significant differences between the intervention and control groups regarding the mean score of problem-solving ability after the intervention (P=0.537). With respect to the results of within-group comparison obtained from Wilcoxon test, there was no significant difference between the mean scores of the problem-solving ability before and after the intervention in the intervention group (P=0.375). Moreover, no significant difference was observed between the mean scores of the problem-solving ability before and after intervention in the control group (P=0.196, Table 5).

Furthermore, Fisher's exact test results showed no significant difference between the two groups regarding the need for episiotomy before and after the intervention in the groups with and without episiotomy (Table 6).