Risk factors for obstetric anal sphincter injuries in twin deliveries: a retrospective review

Is there still an indication for episiotomy? Results from a French national database analysis

OBJECTIVE

To assess the link between mediolateral episiotomy and the occurrence of obstetrical anal sphincter injury (OASIS).

METHODS

Data were collected from the national database (PMSI; Programme de Médicalisation des Systèmes d'Information). Women between 18 and 50 years old, undergoing a vaginal delivery in France in 2018 were included. The main outcome was factors associated with a higher adjusted OASIS rate after a vaginal delivery.

RESULTS

Of 623 003 women with a vaginal delivery, 239 949 were primiparous (38.5%), 62 310 experienced mediolateral episiotomy (10.0%) and 7077 had a third- or fourth-degree perineal tear (1.14%). Risk factors for OASIS were primiparity (adjusted odds ratio [OR] 2.97), shoulder dystocia (aOR 2.57), instrumental delivery (aOR 2.81), gestational diabetes (aOR 1.20), and post-term delivery (aOR 1.53). Mediolateral episiotomy increased the occurrence of OASIS for women without an instrumental delivery, either for parous (OR 1.32, 95% confidence interval [CI] 1.07-1.62) or primiparous (OR 1.26, 95% CI 1.13-1.39) women. In contrast, episiotomy among primiparous women with episiotomy and a vacuum or forceps delivery significantly decreased the risk for OASIS (OR 0.62, 95% CI 0.56-0.67).

CONCLUSIONS

The practice of routine episiotomy should be discouraged. Selective mediolateral episiotomy should be considered with extreme caution and mainly for primiparous women during instrumental vaginal delivery. Further randomized trial may confirm such results.

Anal Sphincter Injury Associated with Vaginal Twin Delivery

OBJECTIVE

Obstetric anal sphincter injury remains the most common cause of fecal incontinence in women, and research in twin pregnancies is sparse. This study aimed to examine risk factors for sphincter injury in twin deliveries over a 10-year period.

STUDY DESIGN

This was a retrospective study of twin vaginal deliveries in a tertiary-level hospital over 10 years. We examined the demographics of women who had a vaginal delivery of at least one twin. Logistic regression analysis was used to examine risk factors.

RESULTS

There were 1,783 (2.1%) twin pregnancies, of which 556 (31%) had a vaginal delivery of at least one twin. Sphincter injury occurred in 1.1% (6/556) women with twins compared with 2.9% (1720/59,944) singleton vaginal deliveries. Women with sphincter injury had more instrumental deliveries (83.3 vs. 27.6%; p = 0.008). On univariate analysis, only instrumental delivery was a significant risk factor (odds ratio: 2.93; p = 0.019).

CONCLUSION

Sphincter injury occurs at a lower rate in vaginal twin pregnancies than in singletons. No twin-specific risk factors were identified. Discussion of the risk of sphincter injury should form part of patient counseling with regard to the mode of delivery.

Vaginal delivery of the second twin in unengaged cephalic presentation

In accordance with women's preferences guidelines, referring to population-based and randomized trials, which recommends counseling women with vertex-first twins to attempt a vaginal delivery. Yet, the rising rates of twin caesareans are associated with the decline in skills of senior and junior obstetricians. Although noncephalic second twins have been in the focus of interest, prompt delivery of cephalic second twins can be trickier when the head does not engage. We illustrate how to avoid complications during instrumental delivery or internal podalic version and breech extraction of the second twin encouraging to start when membranes are still intact.

Non-surgical acute traumatic perianal injuries

Objectives

The diagnosis of fecal incontinence is challenging and complex. One of the most significant causes of fecal incontinence is trauma in the perianal area. The most important cause of such trauma is birth trauma. It is hard to evaluate patients and plan treatment. Surgical method is determined by the severity of sphincter damage and injuries formed in the organs in the perianal area. The aim of this study, therefore, was to analyze the cases of patients who had undergone sphincter repair because of acute injuries in the perianal area.

Material and Methods

The cases of 15 patients with perianal area injuries who had presented to Necmettin Erbakan University Meram Medical School's General Surgery Clinic between 2010 and 2015 were retrospectively analyzed. Data on age, sex, form of injury, severity of injury, time of first response, form of repair, injury problems, and post-operative complications of the patients were investigated. The patients' long-term results were analyzed.

Results

While 5 of the patients were male, 10 were female. 9 of the female patients had birth trauma, while one had injury during sexual intercourse. While all of the patients received sphincteroplasty, 10 had levatoroplasty. All the female patients received vaginoplasty.

Conclusion

We are of the opinion that it is significant to have surgical intervention before tissue edema develops.