Pratique libérale versus restrictive de l’épisiotomie : existe-t-il des indications obstétricales spécifiques de l’épisiotomie?

Evaluation of Suzor forceps training by studying obstetric anal sphincter injuries: a retrospective study

BACKGROUND

Instrumental deliveries are an unavoidable part of obstetric practice. Dedicated training is needed for each instrument. To identify when a trainee resident can be entrusted with instrumental deliveries by Suzor forceps by studying obstetric anal sphincter injuries.

METHODS

A French retrospective observational study of obstetric anal sphincter injuries due to Suzor forceps deliveries performed by trainee residents was conducted from November 2008 to November 2016 at Limoges University Hospital. Perineal lesion risk factors were studied. Sequential use of a vacuum extractor and then forceps was also analyzed.

RESULTS

Twenty-one residents performed 1530 instrumental deliveries, which included 1164 (76.1%) using forceps and 89 (5.8%) with sequential use of a vacuum extractor and then forceps. Third and fourth degree perineal tears were diagnosed in 82 patients (6.5%). Residents caused fewer obstetric anal sphincter injuries after 23.82 (+/- 0.8) deliveries by forceps (p = 0.0041), or after 2.36 (+/- 0.7) semesters of obstetrical experience (p = 0.0007). No obese patient (body mass index> 30) presented obstetric anal sphincter injuries (p = 0.0013). There were significantly fewer obstetric anal sphincter injuries after performance of episiotomy (p <  0.0001), and more lesions in the case of the occipito-sacral position (p = 0.028). Analysis of sequential instrumentation did not find any additional associated risk.

CONCLUSION

Training in the use of Suzor forceps requires extended mentoring in order to reduce obstetric anal sphincter injuries. A stable level of competence was found after the execution of at least 24 forceps deliveries or after 3 semesters (18 months) of obstetrical experience.

[Mode of delivery in spontaneous preterm birth]

OBJECTIVE

To evaluate the benefit/risk balance of way of birth according to fetal presentation, to assess monitoring during preterm labor, to discuss method of delivery and practice of delayed cord clamping in case of spontaneous preterm birth.

METHODS

Bibliographic research from the Pubmed database and recommendations issued by the main scientific societies, and assignment of a level of evidence and a recommendation grade.

RESULTS

In case of vertex presentation, no studies suggest that cesarean section improve neonatal outcome during spontaneous preterm birth (LE4). Nevertheless, cesarean is associated with higher maternal morbidity than vaginal delivery. Thus, routine cesarean is not recommended simply because of a spontaneous preterm labor (professional consensus). The available data do not allow specific recommendations about the choice of mode of delivery for preterm breech presentation in view of the low levels of proof (Professional consensus). Fetal rate monitoring is necessary during preterm labor (Professional consensus). Current data about second lines method for fetal surveillance (fetal scalp blood for pH or lactates) are insufficient to recommend their use before 34 WG (Professional consensus). Systematic assisted vaginal delivery is not recommended during preterm birth (Professional consensus). Use of vacuum is possible after 34 WG when cranial vertex ossification is considered satisfactory (Professional consensus). Systematic use of episiotomy in case of preterm birth is not recommended (Professional consensus). A delayed cord clamping is possible if the neonatal or maternal state so permits (Professional consensus). The available data are insufficient to recommend a systematic use of this procedure (LE3).

CONCLUSION

In case of preterm delivery, the available data do not allow specific recommendations about the choice of mode of delivery regardless of fetal presentation.

[Assessment of restrictive episiotomy use and impact on perineal tears in the Burgundy's Perinatal Network]

OBJECTIVES

To analyse episiotomy and perineal tears rates in Burgundy after French National College of Obstetricians and Gynecologists (CNGOF) guidelines in 2005.

MATERIALS AND METHOD

Multicenter retrospective study, between 2003-2005 (period 1) et 2012-2014 (period 2), conducted on singletons vaginal deliveries, in cephalic presentation from 37 weeks. We compared the episiotomy rate (ER), and perineal lesions in normal deliveries (ND) and instrumental deliveries (ID) between the two periods.

RESULTS

A total of 74,268 women were included. The overall ER significantly decreased from 35.8 to 16.7% (P<0.01), without increasing third degree perineal tears (0.73% vs. 0.66%) or fourth degree (0.14% vs 0.14%). First degree perineal tears rose (42.1% vs 17.6%, P<0.001), second degree decreased (13.5% vs 20.5%, P<0.001). ER decreased whatever the level of motherhood, healthcare ward, vaginal delivery type, or the instrument used.

CONCLUSION

Our study found a strong impact in Burgundy of the French guidelines for the practice of restrictive episiotomy for both ND and for ID without increasing sphincter tears and in decreasing spontaneous morbidity.

[Delivery of premature infants]

Prematurity is a frequent event and clearly raises an issue concerning how these fetuses with multiple weaknesses should be delivered. Although, a systematic abdominal approach has no scientific basis, there are cases where the caesarean is chosen because of other factors associated to prematurity such as any maternal or fetal indication to terminate the pregnancy while labour induction remains impossible. However, in case of breech presentation, which is often delivered by caesarean, the literature does recommend neither the vaginal nor the abdominal approach. Caesarean in case of prematurity is more difficult because of the absence of any inferior segment and implies making a large incision so as to easily extract these weak fetuses. Increased maternal morbidity related to preterm caesarean sections has been reported through out literature. The viability gestational age limit represents a confounding factor in most studies since caesarean is rarely chosen for these fetuses because of a very low expected survival rate, while it is probably in this situation that the abdominal approach could provide a real benefit. Larger studies are required to show potential advantages. Systematic use of episiotomies or instrumental deliveries in case of vaginal births is not recommended in case of prematurity. Protecting the fetal head with spatulas still requires further evaluations.

[What is new about obstetrical interventions during labor and normal delivery?]

This systematic review of the literature reports studies published over the last five years (2008-2013) about interventions during labor and normal delivery. The points made concerning active management of labor, interventions aimed at improving maternal comfort, management of occiput posterior fetal presentations, management of second stage of labor and prevention techniques for perineal lesions. Although obstetrics remains an "art" to which training is mainly based on experience and clinical expertise, this "art" at present cannot live without the evidence-based medicine. Numerous randomized trials published and in process, demonstrate awareness of this reality in our specialty.

[From the impact of French guidelines to reduce episiotomy's rate]

OBJECTIVES

Following the publication of the French Guidelines on episiotomy in 2005 by the French National College of Gynaecologists and Obstetricians (CNGOF), our unit decided to adopt a restrictive politics to replace the former liberal one. The goal of this study was to evaluate the impact of this modification of trend in the Unit of Gynaecology and Obstetrics of the teaching hospital from Caen. This was the start point of an internal audit with the objective of an enhancement of the care during delivery.

PATIENTS AND METHODS

It was a retrospective study concerning the period going from January, 2004 till December, 2009, measuring the impact of the guidelines on the episiotomy rates and perineal tears. The totality of the population of the women naturally delivered at a term superior or equal to 37 weeks of gestation and a cephalic presentation was included. To modify the practices, after diffusion of the guidelines by some obstetrical leaders, we imposed to notify the indication of the episiotomy in the computerized obstetrical files. Moreover, we published monthly screenboards with all the detailed results to all the practioners acting in the delivery room (obstetricians, midwives).

RESULTS

Between 2004 and 2009, we observed a dramatic decline of the episiotomy rates from 55.7 to 13.3%. This trend was the same for primiparae and multiparae, as wall as for spontaneous or assisted delivery (mostly vacuum extraction in our unit). We noticed a slight increased in minor perineal tears without functional consequences. There was no statistically significant difference between severe perineal tear (1.3% vs. 1.1%). By contrary, the rate of intact perineum significantly raised (17.6% vs. 21.7%, p<0.001), especially in vacuum extractions.

DISCUSSION

Our results are in accordance with those of the national guidelines. However, our rate does not decrease in 2007 and 2008 (20%), contrary to some results obtained in the literature. Some reports mentioned the weak impact of the publication of national guidelines to modify the usual practice. However, we believe that retro-information to practitioners has a real impact on their daily current practice. Hence we insisted again on the importance of these national guidelines at the end of 2008 and we could demonstrate a real decline of the rate of episiotomy. Our efforts have to be continued, especially for instrumental delivery.

[Evaluating a policy of restrictive episiotomy before and after practice guidelines by the French College of Obstetricians and Gynecologists]

AIM

To evaluate our practice following Clinical Practice Guidelines (CPG) of the French College of Obstetricians and Gynecologists (CNGOF) in 2005 advocating a policy of restrictive episiotomy and to show that a significative decrease in the rate of episiotomy does not increase the number of third and fourth degree perineal tears.

MATERIAL AND METHODS

A retrospective study of episiotomies and third/fourth degree perineal tears of the year 2003 (before the CPG) was compared with the year 2007 (after the CPG). We analyzed the indications of episiotomies and compared the rate of episiotomies and severe perineal tears between the two periods.

RESULTS

In 2003, the rate of episiotomies was 18.8% (upon 1755 vaginal deliveries). We observed 16 (9 per thousand) third-degree perineal tears, five of which was associated with episiotomies; and two (1 per thousand) fourth-degree perineal tears. In 2007, the rate of episiotomies was 3.4% (upon 1940 vaginal deliveries). There were eight (4 per thousand) third-degree and four (2 per thousand) fourth-degree perineal tears. The two periods of study were similar in terms of age, parity, gestational age, birthweight, rate of spontaneous deliveries, breech and instrumental deliveries. There were a difference regarding deliveries in the occipitoposterior position (5.8% vs 13.8% ; p=0.02). No significant difference was found between the rates of third degree (9 per thousand vs 4 per thousand ; p=0.059) and fourth degree perineal tears (1 per thousand vs 2 per thousand ; p=0.487). However, there was a significant decrease in the rate of episiotomies between the two periods (18.8% vs 3.4% ; p<0.001).

CONCLUSION

An episiotomy rate of 3.4% is much lower than the threshold rate of 30% recommanded. A policy of restrictive episiotomy is possible without increasing the rate of severe perineal tears. Aknowledging the risks and benefits of each obstetrical procedure might decrease the number of episiotomies, whose practice should be evaluated in every labour ward.

[Immediate fetal-maternal morbidity of first instrumental vaginal delivery using Thierry's spatulas. A prospective continuous study of 195 fetal extractions]

OBJECTIVES

To investigate the immediate fetal-maternal morbidity related to Thierry's spatula for first instrumental vaginal delivery.

PATIENTS AND METHODS

We conducted a prospective observational study in Toulouse university hospital, including primiparas who vaginally delivered a live singleton cephalic infant>36 WG, between December 2005 and June 2006. Instrumental deliveries were performed using short spatulas in all cases. Outcome measures were: perineal complications (episiotomy, laceration and associated lesions, urinary retention, pain at H48), neonatal morbidity (cutaneous injuries, neonatal transfer, cord pH, Apgar score). Instrumental deliveries were compared with spontaneous vaginal deliveries (SVD).

RESULTS

Six hundred and eight primiparas were included, distributed in 195 extractions (32%) and 413 SVD (68%). Spatulas allowed fetal extraction in all cases. Main differences between the two groups were: length of labour, occiput posterior position (12.8% for spatulas vs 1.7% for SVD; p<0.0001), episiotomy rate (97.9% vs 51.3%; p<0.0001), severe perineal lacerations (3.6% vs 0.2%; p=0.0007), post-partum morbidity (pain, hematoma, and urinary retention). No case of early severe neonatal complication was related to the use of the spatulas.

DISCUSSION AND CONCLUSIONS

Perineal complications (severe lacerations) associated with spatulas are increased with regard to SVD, but comparable to that reported with forceps. The main disadvantage is the high frequency of episiotomy, which should not be systematic. Neonatal morbidity is reduced. Comparative studies (spatulas vs. other procedures) are needed to confirm these data, but spatulas remain a multipurpose instrument which should continue to be taught.

[Instrumental extractions using Thierry's spatulas: evaluation of the risk of perineal laceration according to occiput position in operative deliveries]

OBJECTIVE

Risk factors for severe perineal lacerations are nowadays well-known and they include operative vaginal deliveries and extractions in occiput posterior (OP) positions. The aim of this study was to assess whether OP position increases the risk for anal sphincter injury when compared with occiput anterior (OA) positions in operative deliveries using Thierry's spatulas.

METHODS

Retrospective study of 163 extractions with Thierry's spatulas over a five-year period (January 2000 to December 2005) performed in a general hospital. Singleton cephalic pregnancies at term were studied and the incidence of severe perineal lacerations was noted in deliveries in OP and OA positions.

RESULTS

In these 163 cases, the varieties of presentation obtained by vaginal examination were 129 in anterior and 34 in posterior positions. Eleven posterior positions rotated anteriorly on delivery and 23 remained in a posterior position. The OA group (n=140) and the OP group (n=23) were constituted. Anal sphincter injury occurred significantly more often in the OP group compared with the OA group (17.4% versus 2.9%, p=0.014) with an odds ratio of 7.1 (95% CI 1.6-31). Only one fourth-degree laceration was noted. Within the OP group, the incidence of vaginal lacerations was increased compared to the OA group, but without any significant difference (43.5% versus 27.9%, p=0.20). In a logistic regression model, the OP position was 6.4 times (95% CI 1.3-31.5) more likely to be associated with anal sphincter injury than OA position. The incidence of OP position was 14.1% within the whole population studied and Thierry's spatulas permit anterior rotations of occipito posterior presentation in only 32.4% of cases.

CONCLUSION

The efficiency of Thierry's spatulas is proven. As with forceps and vacuum extractors, extraction with Thierry's spatulas is a risk factor for perineal laceration compared to a spontaneous delivery. In deliveries with spatulas, OP head positions further increase this perineal risk against OA positions. OP positions before fetal extractions do not seem to be an ideal situation for using spatulas, even if an anterior rotation is achieved in one-third of cases.