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Boudry T, Lallemant M, Ramanah R, Mottet N. Influence of in utero fetal death on perineal tears in vaginal deliveries. Sci Rep 2023; 13:7484. [PMID: 37160998 PMCID: PMC10170066 DOI: 10.1038/s41598-023-34185-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Accepted: 04/25/2023] [Indexed: 05/11/2023] Open
Abstract
The aim of this work was to evaluate and compare the incidence of perineal tears and Obstetrical anal sphincter injuries (OASIS) after vaginal delivery following a in utero fetal death (IUFD) compared with those with a live-birth. We conducted a single-center, retrospective cohort study using a database of all women who underwent a spontaneous vaginal delivery in the level III maternity ward. Exclusion criteria were breech presentation, cesarean section birth, instrumental delivery, multiple pregnancy, delivery before 24 + 6 weeks of gestation (WG) and termination of pregnancy for medical reasons. Women from the database were divided into two groups: an "in utero fetal death" (IUFD) group and a control group. Women were included in the IUFD group if they had a spontaneous vaginal delivery following a fetal demise after 24 + 6 WG in cephalic presentation between January 2006 and June 2020. Women in the "control" group were selected from the same database and were included if they underwent a spontaneous vaginal delivery of a live fetus in cephalic presentation, after 24 + 6 WG, during the same period. Each woman in the "IUFD" group was matched to two women (ratio 1:2) in the control group for parity, maternal age, body mass index, gestation and birth weight. The primary outcome was the presence of a sutured or unsutured perineal tear. During the study period, 31,208 patients delivered at a level III maternity hospital. Among them, 215 and 430 women were included in the IUFD group and the control group respectively. The two groups were comparable for all demographic and clinical characteristics except for an epidural analgesia (92% versus 70% in the control group, p < 0.01) and labor induction (86% versus 17% in the control group, p < 0.01). The incidence of any perineal tears was 13% (28/15) in the IUFD group versus 16% (70/430) in the control group. Relative risk of any perineal tears was non significative (RR = 0.8 IC95% [0.5-1.2]). The incidence of first-degree perineal tears was 10% in the IUFD group and 11% in the control group. The incidence of second-degree perineal tears was 18% in the IUFD group and 28% in the control group. Relative risk of first-degree perineal tears (RR = 0.88 95% CI [0.5-1.4]) and second-degree tears (RR = 0.51 95% CI [0.2-1.4]) were non significative. No obstetrical anal sphincter injury was found in either group. Vaginal delivery following a fetal demise did not appear to be either a risk factor or a protective factor for perineal tears. But there as a trend toward a lower incidence of second degree perineal tears in this context.
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Affiliation(s)
- Thibaud Boudry
- Department of Obstetrics and Gynecology, University Medical Center of Besancon, University of Franche-Comte, Alexander Fleming Boulevard, 25000, Besançon, France
| | - Marine Lallemant
- Department of Obstetrics and Gynecology, University Medical Center of Besancon, University of Franche-Comte, Alexander Fleming Boulevard, 25000, Besançon, France
- Université de Franche-Comté, FEMTO-ST Institute, UMR CNRS 6174, Department of Applied Mechanics, Besançon, France
| | - Rajeev Ramanah
- Department of Obstetrics and Gynecology, University Medical Center of Besancon, University of Franche-Comte, Alexander Fleming Boulevard, 25000, Besançon, France
- Nanomedicine Laboratory, INSERM EA4662, University of Franche-Comte, 25000, Besancon, France
| | - Nicolas Mottet
- Department of Obstetrics and Gynecology, University Medical Center of Besancon, University of Franche-Comte, Alexander Fleming Boulevard, 25000, Besançon, France.
- Nanomedicine Laboratory, INSERM EA4662, University of Franche-Comte, 25000, Besancon, France.
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Leborne P, de Tayrac R, Zemmache Z, Serrand C, Fabbro-Peray P, Allegre L, Vintejoux E. Incidence of obstetric anal sphincter injuries following breech compared to cephalic vaginal births. BMC Pregnancy Childbirth 2023; 23:317. [PMID: 37142944 PMCID: PMC10161470 DOI: 10.1186/s12884-023-05595-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 04/11/2023] [Indexed: 05/06/2023] Open
Abstract
INTRODUCTION Obstetric anal sphincter injuries (OASIs) at the time of childbirth can lead to serious consequences including anal incontinence, dyspareunia, pain and rectovaginal fistula. These types of lesions and their incidence have been well studied after cephalic presentation deliveries, but no publications have specifically addressed this issue in the context of vaginal breech delivery. The goal of our study was to evaluate the incidence of OASIs following breech deliveries and compare it with cephalic presentation births. METHODS This was a retrospective cohort study involving 670 women. Of these, 224 and 446 had a vaginal birth of a fetus in the breech (breech group) and cephalic (cephalic group) presentations respectively. Both groups were matched for birthweight (± 200 g), date of delivery (± 2 years) and vaginal parity. Main outcome of interest was to evaluate the incidence of OASIs following breech vaginal birth compared to cephalic vaginal births. Secondary endpoints were the incidence of intact perineum or first-degree tear, second-degree perineal tear and rates of episiotomies in each group. RESULTS There was no statistically significant difference in OASIs incidence between the breech and cephalic groups (0.9% vs. 1.1%; RR 0.802 (0.157; 4.101); p = 0.31). There were more episiotomies in the breech group (12.5% vs. 5.4%, p = 0.0012) and the rate of intact or first-degree perineum was similar in both groups (74.1% vs. 75.3%, p = 0.7291). A sub-analysis excluding patients with episiotomy and history of OASIs did not show any statistically significant difference either. CONCLUSION We did not demonstrate a significant difference in the incidence of obstetric anal sphincter injuries between women who had a breech vaginal birth compared to cephalic.
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Affiliation(s)
- Perrine Leborne
- Department of Obstetric Gynecology, University Hospital Arnaud de Villeneuve, 371 avenue du Doyen Gaston Giraud - 34000, Montpellier, 34000, France.
| | - Renaud de Tayrac
- Department of Obstetric Gynecology, University Hospital of Nimes, Place du Pr R. Debré, NIMES CEDEX9, 30029, France
| | - Zakarya Zemmache
- Statistics department (BESPIM), University Hospital of Nimes, Place du Pr R. Debré, NIMES CEDEX9, 30029, France
| | - Chris Serrand
- Statistics department (BESPIM), University Hospital of Nimes, Place du Pr R. Debré, NIMES CEDEX9, 30029, France
| | - Pascale Fabbro-Peray
- Statistics department (BESPIM), University Hospital of Nimes, Place du Pr R. Debré, NIMES CEDEX9, 30029, France
| | - Lucie Allegre
- Department of Obstetric Gynecology, University Hospital of Nimes, Place du Pr R. Debré, NIMES CEDEX9, 30029, France
| | - Emmanuelle Vintejoux
- Department of Obstetric Gynecology, University Hospital Arnaud de Villeneuve, 371 avenue du Doyen Gaston Giraud - 34000, Montpellier, 34000, France
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Perrin A, Korb D, Morgan R, Sibony O. Effectiveness of episiotomy to prevent OASIS in nulliparous women at term. Int J Gynaecol Obstet 2023. [PMID: 36728572 DOI: 10.1002/ijgo.14706] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 01/26/2023] [Accepted: 02/01/2023] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess the association between episiotomy and severe obstetric anal sphincter injury (OASIS) in nulliparous women at term according to the use of an instrument for delivery with control confounding by indication. METHODS This was an observational retrospective cohort study including 12 346 women from 2004 to 2020. All nulliparous women with a cephalic singleton pregnancy were included. The primary outcome was the occurrence of OASIS. Association between episiotomy and OASIS was assessed by multivariate logistic regression with adjustment for confounding factors and stratification on the use of an instrument at delivery. Propensity score matching was used to account for indication bias. RESULTS Among 12 346 women included, 7803 (63.2%) had an episiotomy and 4543 (36.8%) did not have an episiotomy; the rate of OASIS was similar in both groups (0.7%). After stratification on use of instrument, an association between episiotomy and OASIS was shown in the case of instrumental delivery (odds ratio [OR] 0.46, 95% confidence interval [CI] 0.26-0.80) but not if the delivery was spontaneous (OR 0.76, 95% CI 0.29-1.98). The result was similar after matching on propensity score (in the case of operative vaginal delivery: OR 0.20, 95% CI 0.10-0.75). CONCLUSION Episiotomy seems to be a protective factor for OASIS in nulliparous woman at term only in the case of operative vaginal delivery.
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Affiliation(s)
- Antoine Perrin
- Department of Obstetrics and Gynecology, Robert Debré Hospital, APHP, Paris, France
| | - Diane Korb
- Department of Obstetrics and Gynecology, Robert Debré Hospital, APHP, Paris, France.,Center for Epidemiology and Statistics Sorbonne Paris Cité (CRESS), Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, University Paris Cité, Paris, France
| | - Rosemary Morgan
- Department of Obstetrics and Gynecology, Robert Debré Hospital, APHP, Paris, France
| | - Olivier Sibony
- Department of Obstetrics and Gynecology, Robert Debré Hospital, APHP, Paris, France
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Mathieu L, Legendre G, Rebmann E, Hamel JF, Venara A. Obstetrical anal sphincter injury and unnecessary episiotomy are both associated with anal incontinence 8 years after childbirth: A nationwide database analysis. Int J Gynaecol Obstet 2022; 159:284-289. [PMID: 35044683 DOI: 10.1002/ijgo.14101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/04/2022] [Accepted: 01/12/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE to assess the relationship between anal incontinence (AI) 8 years after childbirth and the occurrence of Obstetrical Anal Sphincter Injury (OASI) and/or performance of an episiotomy during childbirth. METHODS This is a nationwide database analysis performed on two national medico-administrative databases, including all the women aged ≥18 years who delivered infants in France in 2012. The main outcome measure was AI in the 8-years after delivery. RESULTS Of the 163,443 perineal tears reported, 0.47% were grade-3 and 0.08% were grade-4; 8,938 women experienced AI (1.33%) and 261 women experienced severe AI (0.04%). Episiotomies performed in the absence of risk factors for OASI were significantly associated with an increased risk of AI (Odds Ratio (OR)=1.59; 95% Confidence Interval (CI):1.49-1.69;p<0.001). Grade 3 and 4 OASI also significantly increased the risk of AI and severe AI. Mediolateral episiotomy was preventative of OASI when performed in subjects at risk (OR=0.26; 95% CI:0.23-0.30; p<0.001) but contributed to OASI in the absence of risk (OR=2.18; 95% CI:1.98-2.40; p<0.001). CONCLUSIONS OASI is a risk factor for AI. Episiotomies could reduce the occurrence of OASI, but they could also have a increase the risk of long-term AI in the absence of risk factors for OASI.
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Affiliation(s)
- Levaillant Mathieu
- Faculty of Health, Angers, France.,Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, F-59000, Lille, France.,Department of Biostatistics, CHU Angers, 4 rue Larrey, 49933, Angers, France
| | - Guillaume Legendre
- Faculty of Health, Angers, France.,Department of Gynaecology-obstetrics, CHU Angers, 4 rue Larrey, 49933, Angers, France
| | - Emeline Rebmann
- Faculty of Health, Angers, France.,Department of Visceral Surgery, CHU Angers, 4 rue Larrey, 49933, Angers, France
| | - Jean-François Hamel
- Faculty of Health, Angers, France.,Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, F-59000, Lille, France.,Ester
- Irset Inserm UMR 1085
| | - Aurélien Venara
- Faculty of Health, Angers, France.,Department of Visceral Surgery, CHU Angers, 4 rue Larrey, 49933, Angers, France.,IHFIH, UPRES EA 3859, University of Angers, Angers, France
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Forey PL, Lallemant M, Bourtembourg-Matras A, Eckman-Lacroix A, Ramanah R, Riethmuller D, Mottet N. Impact of a selective use of episiotomy combined with Couder's maneuver for the perineal protection. Arch Gynecol Obstet 2020; 302:77-83. [PMID: 32388778 DOI: 10.1007/s00404-020-05572-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Accepted: 04/25/2020] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the impact of a selective use of episiotomy combined with Couder's maneuver on the incidence of perineal tears in spontaneous term deliveries. METHODS A comparative, retrospective, mono-centric study in a university maternity unit was designed and included all primiparous women who delivered spontaneously after 37 weeks of gestation in cephalic presentation. Two cohorts were studied, before and after the practice of Couder's maneuver. In the first cohort, the ''OSE cohort'' only selective episiotomies were performed from January 2009 to December 2010. In the second cohort, from January 2016 to December 2017, the ''SEC cohort'' selective episiotomies combined with Couder's maneuver were performed by midwives and obstetricians. The primary outcome was the type of perineal tears, according to the Royal College of Obstetricians and Gynaecologists (RCOG) classification. RESULTS A total of 2081 patients were included: 909 patients in the OSE cohort and 1172 patients in the SEC cohort. Couder's maneuver was performed in 59% of the SEC cohort. In the SEC cohort, there were an increase in the number of intact perinea (55% versus 63%, p < 0.001), a decrease in second-degree perineal tears (18% versus 11%, p < 0.001) and a decrease in labia minora tears (48% versus 37%, p < 0.001). The rate of obstetrical anal sphincter injuries was less than 1% in both cohorts (0.3% versus 0.5%, p = 0.7). CONCLUSION A selective use of episiotomy combined with Couder's maneuver could reduce the incidence of perineal tears, particularly second-degree perineal tears, without increasing the rate of obstetrical anal sphincter injuries.
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Affiliation(s)
- Pierre-Louis Forey
- Department of Obstetrics and Gynecology, University Hospital Jean Minjoz, University of Franche-Comté, 25000, Besançon, France
| | - Marine Lallemant
- Department of Obstetrics and Gynecology, University Hospital Jean Minjoz, University of Franche-Comté, 25000, Besançon, France
| | - Aude Bourtembourg-Matras
- Department of Obstetrics and Gynecology, University Hospital Jean Minjoz, University of Franche-Comté, 25000, Besançon, France
| | - Astrid Eckman-Lacroix
- Department of Obstetrics and Gynecology, University Hospital Jean Minjoz, University of Franche-Comté, 25000, Besançon, France
| | - Rajeev Ramanah
- Department of Obstetrics and Gynecology, University Hospital Jean Minjoz, University of Franche-Comté, 25000, Besançon, France
- Nanomedecine Laboratory, Imagery and Therapeutics, INSERM EA 4662, University of Franche-Comté, 25000, Besançon, France
| | - Didier Riethmuller
- Department of Obstetrics and Gynecology, University Hospital Jean Minjoz, University of Franche-Comté, 25000, Besançon, France
| | - Nicolas Mottet
- Department of Obstetrics and Gynecology, University Hospital Jean Minjoz, University of Franche-Comté, 25000, Besançon, France.
- Nanomedecine Laboratory, Imagery and Therapeutics, INSERM EA 4662, University of Franche-Comté, 25000, Besançon, France.
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Desplanches T, Szczepanski E, Cottenet J, Semama D, Quantin C, Sagot P. A novel classification for evaluating episiotomy practices: application to the Burgundy perinatal network. BMC Pregnancy Childbirth 2019; 19:300. [PMID: 31419953 PMCID: PMC6698013 DOI: 10.1186/s12884-019-2424-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 07/24/2019] [Indexed: 11/24/2022] Open
Abstract
Background Though the rate of episiotomy has decreased in France, the overall episiotomy rate was 20% in the 2016 national perinatal survey. We aimed to develop a classification to facilitate the analysis of episiotomy practices and to evaluate whether episiotomy is associated with a reduction in the rate of obstetric anal sphincter injuries (OASIS) for each subgroup. Methods This population-based study included all the deliveries that occurred in the Burgundy Perinatal Network from 2011 to 2016. The main outcome was episiotomy, which was identified thanks to the French Common Classification of Medical Procedures. An ascending hierarchical cluster analysis was performed to build the classification. A clinical audit using the classification was conducted yearly in all obstetric units. The episiotomy rates were described throughout the study period for each subgroup of the classification. The OASIS rates were evaluated by subgroup and the association between mediolateral episiotomy and OASIS was investigated for each subgroup. Results Our analyses included 81,290 pregnant women. The classification comprised 7 subgroups: (1) nulliparous single cephalic at term, (2) nulliparous single cephalic at term with instrumental delivery, (3) multiparous single cephalic at term, (4) multiparous single cephalic at term with instrumental delivery, (5) all preterm deliveries (< 37 weeks gestation), (6) all breech deliveries, (7) all multiple deliveries. Episiotomy rates ranged from 6.2% in Group 3 to 40.9% in Group 2. From 2011 to 2016, every group except breech deliveries experienced a significant decrease in episiotomy rates, ranging from − 28.1 to − 61.0%. The prevalence of OASIS was the highest in Groups 2 (3.0%) and 4 (2.2%). Overall OASIS rates did not significantly differ with episiotomy use (P = 0.25). However, we found that the use of episiotomy was associated with a reduction in OASIS rates in Groups 1 and 2 (odds ratio 0.6 [95% CI 0.4–0.9] and 0.4 [0.3–0.5], respectively). This reduction was only observed in Group 4 with forceps delivery (odds ratio 0.4 [0.1–0.9]). Conclusion We developed the first classification for the evaluation of episiotomy practices based on 7 clinically relevant subgroups. This easy-to-use tool can help obstetricians and midwives improve their practices through self-assessment. Electronic supplementary material The online version of this article (10.1186/s12884-019-2424-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas Desplanches
- CHRU Dijon, Department of gynecology, obstetrics, fetal medicine and infertility, Dijon, France. .,Obstetrical, Perinatal, and Pediatric Epidemiology Team, Epidemiology and Biostatistics Sorbonne Paris Cité Research Center (U1153), INSERM, Paris, France, Paris Descartes University, Paris, France.
| | - Emilie Szczepanski
- CHRU Dijon, Department of gynecology, obstetrics, fetal medicine and infertility, Dijon, France
| | - Jonathan Cottenet
- Service de Biostatistique et d'Informatique Médicale (DIM), Dijon University Hospital, F-21000, Dijon, France.,Inserm, CIC 1432, Clinical Epidemiology Unit Dijon, France; Clinical Investigation Center, Clinical Epidemiology Unit, Dijon University Hospital, Dijon, France
| | - Denis Semama
- CHRU Dijon, Department of Neonatal Pediatrics, Dijon University Hospital, Dijon, France
| | - Catherine Quantin
- Service de Biostatistique et d'Informatique Médicale (DIM), Dijon University Hospital, F-21000, Dijon, France.,Inserm, CIC 1432, Clinical Epidemiology Unit Dijon, France; Clinical Investigation Center, Clinical Epidemiology Unit, Dijon University Hospital, Dijon, France.,Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases (B2PHI), INSERM, UVSQ, Institut Pasteur, Université Paris-Saclay, Paris, France
| | - Paul Sagot
- CHRU Dijon, Department of gynecology, obstetrics, fetal medicine and infertility, Dijon, France.,University of Burgundy, Dijon, France
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