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Stevens L, Masteling M, Raju KS, Mastrovito S, Ashton-Miller JA, DeLancey JOL. Comparison of the Vaginal and Labial Dimensions of Ethnic Chinese and Western Nullipara. Int Urogynecol J 2024; 35:1921-1926. [PMID: 39222263 DOI: 10.1007/s00192-024-05912-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 08/06/2024] [Indexed: 09/04/2024]
Abstract
INTRODUCTION AND HYPOTHESIS Vaginal dimensions have clinical and surgical implications. We sought to quantify the differences between vaginal and labial dimensions in healthy ethnic Chinese and Western women with normal pelvic organ support. METHODS This is a cross-sectional study of a convenience sample of ethnic Chinese nulliparas (n = 33) and Western nulliparas (n = 33) recruited for research purposes. For each subject, magnetic resonance imaging was used to quantify the vaginal and labial dimensions. Specifically, we identified the anterior and posterior vaginal wall, the outline of the cervix in the mid-sagittal and coronal planes, and the distance from the labia majora to the hymenal ring at the urethral meatus. RESULTS There were significant differences in age and weight between groups. Substantial variation in vaginal and labial dimensions was found within each group. The vaginal and labial dimensions of ethnic Chinese women ranged from 9-21% smaller than those of Western women; In the ethnic Chinese group, increasing weight and BMI correlated with greater labial distance (r = 0.66 and r = 0.63 respectively); as did height and the distance from the vaginal opening to the cervical os (r = 0.5). In the Western group, only weight correlated with the labial distance (r = 0.51). CONCLUSIONS Significant group differences in vaginal and labial dimensions were found, with the dimensions of Chinese nulliparas being up to 21% smaller than those of Western nulliparas.
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Affiliation(s)
- Lisa Stevens
- Biomechanics Research Laboratory, University of Michigan, G.G. Brown Building, 2350 Hayward St, Ann Arbor, MI, 48109, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, 48109, USA
| | - Mariana Masteling
- Biomechanics Research Laboratory, University of Michigan, G.G. Brown Building, 2350 Hayward St, Ann Arbor, MI, 48109, USA.
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, 48109, USA.
| | - Kruthi Srinivasa Raju
- Biomechanics Research Laboratory, University of Michigan, G.G. Brown Building, 2350 Hayward St, Ann Arbor, MI, 48109, USA
| | - Sara Mastrovito
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, 48109, USA
| | - James A Ashton-Miller
- Biomechanics Research Laboratory, University of Michigan, G.G. Brown Building, 2350 Hayward St, Ann Arbor, MI, 48109, USA
- Department of Biomedical Engineering, University of Michigan, Ann Arbor, MI, 48109, USA
- Department of Mechanical Engineering, University of Michigan, Ann Arbor, MI, 48109, USA
| | - John O L DeLancey
- Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, 48109, USA
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2
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Okeahialam NA, Sultan AH, Thakar R. The prevention of perineal trauma during vaginal birth. Am J Obstet Gynecol 2024; 230:S991-S1004. [PMID: 37635056 DOI: 10.1016/j.ajog.2022.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 06/08/2022] [Accepted: 06/12/2022] [Indexed: 08/29/2023]
Abstract
Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%. The incidence of obstetrical anal sphincter injury is approximately 3%, with a significantly higher rate in primiparous than in multiparous women (6% vs 2%). Obstetrical anal sphincter injury is a significant risk factor for the development of anal incontinence, with approximately 10% of women developing symptoms within a year following vaginal birth. Obstetrical anal sphincter injuries have significant medicolegal implications and contribute greatly to healthcare costs. For example, in 2013 and 2014, the economic burden of obstetrical anal sphincter injuries in the United Kingdom ranged between £3.7 million (with assisted vaginal birth) and £9.8 million (with spontaneous vaginal birth). In the United States, complications associated with trauma to the perineum incurred costs of approximately $83 million between 2007 and 2011. It is therefore crucial to focus on improvements in clinical care to reduce this risk and minimize the development of perineal trauma, particularly obstetrical anal sphincter injuries. Identification of risk factors allows modification of obstetrical practice with the aim of reducing the rate of perineal trauma and its attendant associated morbidity. Risk factors associated with second-degree perineal trauma include increased fetal birthweight, operative vaginal birth, prolonged second stage of labor, maternal birth position, and advanced maternal age. With obstetrical anal sphincter injury, risk factors include induction of labor, augmentation of labor, epidural, increased fetal birthweight, fetal malposition (occiput posterior), midline episiotomy, operative vaginal birth, Asian ethnicity, and primiparity. Obstetrical practice can be modified both antenatally and intrapartum. The evidence suggests that in the antenatal period, perineal massage can be commenced in the third trimester of pregnancy to increase muscle elasticity and allow stretching of the perineum during birth, thereby reducing the risk of tearing or need for episiotomy. With regard to the intrapartum period, there is a growing body of evidence from the United Kingdom, Norway, and Denmark suggesting that the implementation of quality improvement initiatives including the training of clinicians in manual perineal protection and mediolateral episiotomy can reduce the incidence of obstetrical anal sphincter injury. With episiotomy, the International Federation of Gynecology and Obstetrics recommends restrictive rather than routine use of episiotomy. This is particularly the case with unassisted vaginal births. However, there is a role for episiotomy, specifically mediolateral or lateral, with assisted vaginal births. This is specifically the case with nulliparous vacuum and forceps births, given that the use of mediolateral or lateral episiotomy has been shown to significantly reduce the incidence of obstetrical anal sphincter injury in these groups by 43% and 68%, respectively. However, the complications associated with episiotomy including perineal pain, dyspareunia, and sexual dysfunction should be acknowledged. Despite considerable research, interventions for reducing the risk of perineal trauma remain a subject of controversy. In this review article, we present the available data on the prevention of perineal trauma by describing the risk factors associated with perineal trauma and interventions that can be implemented to prevent perineal trauma, in particular obstetrical anal sphincter injury.
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Affiliation(s)
| | - Abdul H Sultan
- Croydon University Hospital, London, United Kingdom; St George's University of London
| | - Ranee Thakar
- Croydon University Hospital, London, United Kingdom; St George's University of London.
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3
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Maher GM, O'Byrne LJ, McKernan J, Corcoran P, Greene RA, Khashan AS, McCarthy FP. Predicting perineal trauma during childbirth using data from a general obstetric population. HRB Open Res 2023; 5:79. [PMID: 37928404 PMCID: PMC10624951 DOI: 10.12688/hrbopenres.13656.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/04/2023] [Indexed: 11/07/2023] Open
Abstract
Background Perineal trauma is a common complication of childbirth and can have serious impacts on long-term health. Few studies have examined the combined effect of multiple risk factors. We developed and internally validated a risk prediction model to predict third and fourth degree perineal tears using data from a general obstetric population. Methods Risk prediction model using data from all singleton vaginal deliveries at Cork University Maternity Hospital (CUMH), Ireland during 2019 and 2020. Third/fourth degree tears were diagnosed by an obstetrician or midwife at time of birth and defined as tears that extended into the anal sphincter complex or involved both the anal sphincter complex and anorectal mucosa. We used univariable and multivariable logistic regression with backward stepwise selection to develop the models. Candidate predictors included infant sex, maternal age, maternal body mass index, parity, mode of delivery, birthweight, post-term delivery, induction of labour and public/private antenatal care. We used the receiver operating characteristic (ROC) curve C-statistic to assess discrimination, and bootstrapping techniques were used to assess internal validation. Results Of 8,403 singleton vaginal deliveries, 8,367 (99.54%) had complete data on predictors for model development. A total of 128 women (1.53%) had a third/fourth degree tear. Three variables remained in the final model: nulliparity, mode of delivery (specifically forceps delivery or ventouse delivery) and increasing birthweight (per 100 gram increase) (C-statistic: 0.75, 95% CI: 0.71, 0.79). We developed a nomogram to calculate individualised risk of third/fourth degree tears using these predictors. Bootstrapping indicated good internal performance. Conclusions Use of our nomogram can provide an individualised risk assessment of third/fourth degree tears and potentially aid counselling of women on their potential risk.
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Affiliation(s)
- Gillian M. Maher
- INFANT Research Centre, University College Cork, Cork, T12YE02, Ireland
- School of Public Health, University College Cork, Cork, T12XF62, Ireland
| | - Laura J. O'Byrne
- INFANT Research Centre, University College Cork, Cork, T12YE02, Ireland
- Department of Obstetrics and Gynaecology, University College Cork, Cork, T12YE02, Ireland
- National Perinatal Epidemiology Centre, University College Cork, Cork, T12YE02, Ireland
| | - Joye McKernan
- National Perinatal Epidemiology Centre, University College Cork, Cork, T12YE02, Ireland
| | - Paul Corcoran
- National Perinatal Epidemiology Centre, University College Cork, Cork, T12YE02, Ireland
| | - Richard A. Greene
- Department of Obstetrics and Gynaecology, University College Cork, Cork, T12YE02, Ireland
- National Perinatal Epidemiology Centre, University College Cork, Cork, T12YE02, Ireland
| | - Ali S. Khashan
- INFANT Research Centre, University College Cork, Cork, T12YE02, Ireland
- School of Public Health, University College Cork, Cork, T12XF62, Ireland
| | - Fergus P. McCarthy
- INFANT Research Centre, University College Cork, Cork, T12YE02, Ireland
- Department of Obstetrics and Gynaecology, University College Cork, Cork, T12YE02, Ireland
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4
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Hu Y, Lu H, Ren L, Yang M, Shen M, Huang J, Huang Q, Fu L. Prediction models for perineal lacerations during childbirth: A systematic review and critical appraisal. Int J Nurs Stud 2023; 145:104546. [PMID: 37423201 DOI: 10.1016/j.ijnurstu.2023.104546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 06/06/2023] [Accepted: 06/08/2023] [Indexed: 07/11/2023]
Abstract
BACKGROUND Perineal lacerations could lead to substantial morbidities for women. A reliable prediction model for perineal lacerations has the potential to guide the prevention. Although several prediction models have been developed to estimate the risk of perineal lacerations, especially third- and fourth-degree perineal lacerations, the evidence about the model quality and clinical applicability is scarce. OBJECTIVES To systematically review and critically appraise the existing prediction models for perineal lacerations. METHODS Seven databases (PubMed, Embase, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, SinoMed, China National Knowledge Infrastructure, and Wanfang Data) were systematically searched from inception to July 2022. Studies that developed prediction models for perineal lacerations or performed external validation of existing models were considered eligible to include in the systematic review. Two reviewers independently conducted data extraction according to the Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies. The risk of bias and the applicability of the included models were assessed with the Prediction Model Risk of Bias Assessment Tool. A narrative synthesis was performed to summarize the characteristics, risk of bias, and performance of existing models. RESULTS Of 4345 retrieved studies, 14 studies with 22 prediction models for perineal lacerations were included. The included models mainly aimed to estimate the risk of third- and fourth-degree perineal lacerations. The top five predictors used were operative vaginal birth (72.7 %), parity/previous vaginal birth (63.6 %), race/ethnicity (59.1 %), maternal age (50.0 %), and episiotomy (40.1 %). Internal and external validation was performed in 12 (54.5 %) and seven (31.8 %) models, respectively. 13 studies (92.9 %) assessed model discrimination, with the c-index ranging from 0.636 to 0.830. Seven studies (50.0 %) evaluated the model calibration using the Hosmer-Lemeshow test, Brier score, or calibration curve. The results indicated that most of the models had fairly good calibration. All the included models were at higher risk of bias mainly due to unclear or inappropriate methods for handling missing data and continuous predictors, external validation, and model performance evaluation. Six models (27.3 %) showed low concerns about applicability. CONCLUSIONS The existing models for perineal lacerations were poorly validated and evaluated, among which only two have the potential for clinical use: one for women undergoing vaginal birth after cesarean delivery, and the other one for all women undergoing vaginal birth. Future studies should focus on robust external validation of existing models and the development of novel models for second-degree perineal laceration. PROSPERO REGISTRATION NUMBER CRD42022349786. TWEETABLE ABSTRACT The existing models for perineal lacerations during childbirth need external validation and updating. Tools are needed for second-degree perineal laceration.
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Affiliation(s)
- Yinchu Hu
- School of Nursing, Peking University, Beijing 100191, China.
| | - Hong Lu
- School of Nursing, Peking University, Beijing 100191, China.
| | - Lihua Ren
- School of Nursing, Peking University, Beijing 100191, China.
| | - Minghui Yang
- Department of Obstetrics and Gynecology, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Meidi Shen
- School of Nursing, Peking University, Beijing 100191, China
| | - Jing Huang
- School of Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom
| | - Qifang Huang
- School of Nursing, Peking University, Beijing 100191, China
| | - Li Fu
- School of Nursing, Peking University, Beijing 100191, China
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5
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Fruscalzo A, Novak A, Somma C, Xholli A, Michelerio V, Prefumo F, Londero AP, Cagnacci A. Anthropometric Features and Third-Fourth Degree Perineal Tears. J Pers Med 2023; 13:jpm13030545. [PMID: 36983727 PMCID: PMC10053975 DOI: 10.3390/jpm13030545] [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: 01/05/2023] [Revised: 03/11/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
The main objective of this study was to evaluate the association between maternal and fetal anthropometric characteristics and third- and fourth-degree perineal tears. This retrospective cohort study considered all consecutive pregnancies from 2011 to 2017 at a single Institution. The inclusion criteria were: singletons who delivered vaginally during the study period, the presence of information on maternal pre-pregnancy weight, maternal height, and weight of the newborn. The feto-maternal body-mass index (BMI) was calculated as neonatal weight in kg on maternal height in squared meters (kg/m2). In total, 5397 singleton-term pregnancies were included; the prevalence of third-fourth-degree perineal tears was 0.47%. The most predictive factors were: nulliparity, feto-maternal BMI, neonatal weight, gestational age at delivery, and neonatal head circumference. After adjustment in multivariate analysis, the only independent predictors were nulliparity and fetomaternal BMI. The AUC of the final multivariate model was 73.54% (95% CI 65.65-81.42). Furthermore, feto-maternal BMI and gestational age had a significant direct correlation. Nulliparity and feto-maternal BMI are the two best predictors for third and fourth-degree perineal tears in our setting. Confirming this association in future research and integrating it into a decision algorithm on delivery timing could reduce obstetric damage to the anal sphincter.
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Affiliation(s)
- Arrigo Fruscalzo
- Clinic of Obstetrics and Gynecology, University Hospital of Fribourg, 1752 Fribourg, Switzerland
| | - Alice Novak
- Clinic of Obstetrics and Gynecology, DAME, Academic Hospital of Udine, 33100 Udine, Italy
| | - Camilla Somma
- Clinic of Obstetrics and Gynecology, DAME, Academic Hospital of Udine, 33100 Udine, Italy
| | - Anjeza Xholli
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale San Martino, 16132 Genoa, Italy
| | - Virginia Michelerio
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale San Martino, 16132 Genoa, Italy
| | - Federico Prefumo
- Obstetrics and Gynecology Unit, IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy
| | - Ambrogio P Londero
- Obstetrics and Gynecology Unit, IRCCS Istituto Giannina Gaslini, 16147 Genova, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health, University of Genoa, 16132 Genova, Italy
| | - Angelo Cagnacci
- Academic Unit of Obstetrics and Gynecology, IRCCS Ospedale San Martino, 16132 Genoa, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics, Maternal and Infant Health, University of Genoa, 16132 Genova, Italy
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6
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Maher GM, O'Byrne L, McKernan J, Corcoran P, Greene RA, Khashan AS, McCarthy FP. Predicting perineal trauma during childbirth using data from a general obstetric population. HRB Open Res 2022. [DOI: 10.12688/hrbopenres.13656.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: Perineal trauma is a common complication of childbirth and can have serious impacts on long-term health. Few studies have examined the combined effect of multiple risk factors. We developed and internally validated a risk prediction model to predict third and fourth degree perineal tears using data from a general obstetric population. Methods: Risk prediction model using data from all singleton vaginal deliveries at Cork University Maternity Hospital (CUMH), Ireland during 2019 and 2020. Third/fourth degree tears were diagnosed by an obstetrician or midwife at time of birth and defined as tears that extended into the anal sphincter complex or involved both the anal sphincter complex and anorectal mucosa. We used univariable and multivariable logistic regression with backward stepwise selection to develop the models. Candidate predictors included infant sex, maternal age, maternal body mass index, parity, mode of delivery, birthweight, post-term delivery, induction of labour and public/private antenatal care. We used the receiver operating characteristic (ROC) curve C-statistic to assess discrimination, and bootstrapping techniques were used to assess internal validation. Results: Of 8,403 singleton vaginal deliveries, 8,367 (99.54%) had complete data on predictors for model development. A total of 128 women (1.53%) had a third/fourth degree tear. Three variables remained in the final model: nulliparity, mode of delivery (specifically forceps delivery or ventouse delivery) and increasing birthweight (per 100 gram increase) (C-statistic: 0.75, 95% CI: 0.71, 0.79). We developed a nomogram to calculate individualised risk of third/fourth degree tears using these predictors. Bootstrapping indicated good internal performance. Conclusions: Use of our nomogram can provide an individualised risk assessment of third/fourth degree tears and potentially aid counselling of women on their potential risk.
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7
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Hu Y, Lu H, Huang Q, Ren L, Wang N, Huang J, Yang M, Cao L. Risk factors for severe perineal lacerations during childbirth: A systematic review and meta‐analysis of cohort studies. J Clin Nurs 2022. [PMID: 35791260 DOI: 10.1111/jocn.16438] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 05/24/2022] [Accepted: 06/20/2022] [Indexed: 12/28/2022]
Affiliation(s)
- Yinchu Hu
- School of Nursing Peking University Beijing China
| | - Hong Lu
- School of Nursing Peking University Beijing China
| | - Qifang Huang
- School of Nursing Peking University Beijing China
| | - Lihua Ren
- School of Nursing Peking University Beijing China
| | - Na Wang
- School of Nursing Capital Medical University Beijing China
| | - Jing Huang
- School of Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care King's College London London UK
| | - Minghui Yang
- Department of Obstetrics and Gynecology First Affiliated Hospital of Kunming Medical University Kunming China
| | - Linlin Cao
- Department of Obstetrics and Gynecology Peking University Third Hospital Beijing China
- National Clinical Research Center for Obstetrics and Gynecology (Peking University Third Hospital) Beijing China
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Naqvi M, Jaffe EF, Goldfarb IT, Bryant AS, Wylie BJ, Kaimal AJ. Prolonged Second Stage of Labor and Anal Sphincter Injury in a Contemporary Cohort of Term Nulliparas. Am J Perinatol 2022; 39:937-943. [PMID: 33080634 DOI: 10.1055/s-0040-1718878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE This study aimed to assess whether a prolonged second stage of labor is an independent predictor of obstetric anal sphincter injury (OASI) in a contemporary cohort of nulliparous and term parturients, and to evaluate whether predelivery factors can accurately predict OASI. STUDY DESIGN This was a nested case-control study within a cohort of consecutive nulliparous term parturients with a singleton gestation who underwent a vaginal delivery at a single institution between January 2014 and January 2015. Cases were defined as women with a third- or fourth-degree laceration at the time of delivery, and controls were women without a third- or fourth-degree laceration. A prolonged second stage was defined as a second stage of ≥3 hours. Univariable and multivariable regression analyses were performed to examine the relationship between prolonged second stage of labor and third- or fourth-degree lacerations. Receiver operator curves were developed to assess the predictive capacity of predelivery information for third- and fourth-degree lacerations. RESULTS Of 1,197 births, 63 women had third- or fourth-degree lacerations (5.3%). With each additional hour of the second stage, the rate of OASI increased, with 2.9% of women with a second stage of <1 hour with OASI, 3.5% between 1 and 2 hours, 5.7% between 2 and 3 hours, 7.8% between 3 and 4 hours, 16.1% between 4 and 5 hours, and 28.6% among women with a second stage length >5 hours (p < 0.001). In multivariable regression analysis, operative vaginal delivery (adjusted odds ratio [aOR] = 5.92, 95% confidence interval [CI]: 3.17-11.07) and a prolonged second stage (aOR = 1.92, 95% CI: 1.06-3.51) were independent predictors of third- and fourth-degree lacerations. A predictive model was developed from these results (area under the curve [AUC] = 0.75, 95% CI: 0.68-0.81). CONCLUSION Prolonged second stage of labor is a predictor of OASI, after adjustment for operative vaginal delivery. A model using predelivery risk factors has a reasonable prediction of OASI. KEY POINTS · Prolonged second stage labor is associated with obstetric anal sphincter injury in term nulliparas.. · Predelivery risk factors reasonably predict obstetric anal sphincter injury in term nulliparas.. · Improved models are needed for clinical risk-stratification..
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Affiliation(s)
- Mariam Naqvi
- Division of Maternal Fetal Medicine Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, California.,Division of Maternal Fetal Medicine Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
| | - Elana F Jaffe
- Department of Maternal, Child, and Family Health, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina.,Department of Social Medicine, Center for Bioethics, University of North Carolina, Chapel Hill, North Carolina
| | - Ilona T Goldfarb
- Division of Maternal Fetal Medicine Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
| | - Allison S Bryant
- Division of Maternal Fetal Medicine Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
| | - Blair J Wylie
- Division of Maternal Fetal Medicine Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts.,Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Anjali J Kaimal
- Division of Maternal Fetal Medicine Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, Massachusetts
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9
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Luchristt D, Meekins AR, Zhao C, Grotegut C, Siddiqui NY, Alhanti B, Jelovsek JE. Risk of obstetric anal sphincter injuries at the time of admission for delivery: A clinical prediction model. BJOG 2022; 129:2062-2069. [PMID: 35621030 DOI: 10.1111/1471-0528.17239] [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: 01/07/2022] [Revised: 04/18/2022] [Accepted: 05/19/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To develop and validate a model to predict obstetric anal sphincter injuries (OASIS) using only information available at the time of admission for labour. DESIGN A clinical predictive model using a retrospective cohort. SETTING A US health system containing one community and one tertiary hospital. SAMPLE A total of 22 873 pregnancy episodes with in-hospital delivery at or beyond 21 weeks of gestation. METHODS Thirty antepartum risk factors were identified as candidate variables, and a prediction model was built using logistic regression predicting OASIS versus no OASIS. Models were fit using the overall study population and separately using hospital-specific cohorts. Bootstrapping was used for internal validation and external cross-validation was performed between the two hospital cohorts. MAIN OUTCOME MEASURES Model performance was estimated using the bias-corrected concordance index (c-index), calibration plots and decision curves. RESULTS Fifteen risk factors were retained in the final model. Decreasing parity, previous caesarean birth and cardiovascular disease increased risk of OASIS, whereas tobacco use and black race decreased risk. The final model from the total study population had good discrimination (c-index 0.77, 95% confidence interval [CI] 0.75-0.78) and was able to accurately predict risks between 0 and 35%, where average risk for OASIS was 3%. The site-specific model fit using patients only from the tertiary hospital had c-stat 0.74 (95% CI 0.72-0.77) on community hospital patients, and the community hospital model was 0.77 (95%CI 0.76-0.80) on the tertiary hospital patients. CONCLUSIONS OASIS can be accurately predicted based on variables known at the time of admission for labour. These predictions could be useful for selectively implementing OASIS prevention strategies.
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Affiliation(s)
- Douglas Luchristt
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
| | - Ana Rebecca Meekins
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA.,Department of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Congwen Zhao
- Department of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Chad Grotegut
- Department of Obstetrics and Gynecology Wake Forest Baptist Health, Winston-Salem, NC, USA
| | - Nazema Y Siddiqui
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA.,Department of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Brooke Alhanti
- Department of Biostatistics & Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - John Eric Jelovsek
- Department of Obstetrics and Gynecology, Duke University Medical Center, Durham, North Carolina, USA
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10
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Luchristt D, Brown O, Pidaparti M, Kenton K, Lewicky-Gaupp C, Miller ES. Predicting obstetrical anal sphincter injuries in patients who undergo vaginal birth after cesarean delivery. Am J Obstet Gynecol 2021; 225:173.e1-173.e8. [PMID: 33617798 DOI: 10.1016/j.ajog.2021.02.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/31/2021] [Accepted: 02/12/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND Women with a history of previous cesarean delivery must weigh the numerous potential risks and benefits of elective repeat cesarean delivery or trial of labor after cesarean delivery. Notably, 1 important risk of vaginal delivery is obstetrical anal sphincter injuries. Furthermore, the rate of obstetrical anal sphincter injuries is high among women undergoing vaginal birth after cesarean delivery. However, the risk of obstetrical anal sphincter injuries is not routinely included in the trial of labor after cesarean delivery counseling, and there is no tool available to risk stratify obstetrical anal sphincter injuries among women undergoing vaginal birth after cesarean delivery. OBJECTIVE This study aimed to develop and validate a predictive model to estimate the risk of obstetrical anal sphincter injuries in the setting of vaginal birth after cesarean delivery population to improve antenatal counseling of patients regarding risks of trial of labor after cesarean delivery. STUDY DESIGN This study was a secondary subgroup analysis of the Maternal-Fetal Medicine Units Network Trial of Labor After Cesarean Delivery prospective cohort (1999-2002). We identified women within the Maternal-Fetal Medicine Units Network cohort with 1 previous cesarean delivery followed by a term vaginal birth after cesarean delivery. This Maternal-Fetal Medicine Units Network Vaginal Birth After Cesarean Delivery cohort was stratified into 2 groups based on the presence of obstetrical anal sphincter injuries, and baseline characteristics were compared with bivariate analysis. Significant covariates in bivariate testing were included in a backward stepwise logistic regression model to identify independent risk factors for obstetrical anal sphincter injuries and generate a predictive model for obstetrical anal sphincter injuries in the setting of vaginal birth after cesarean delivery. Internal validation was performed using bootstrapped bias-corrected estimates of model concordance indices, Brier scores, Hosmer-Lemeshow chi-squared values, and calibration plots. External validation was performed using data from a single-site retrospective cohort of women with a singleton vaginal birth after cesarean delivery from January 2011 to December 2016. RESULTS In this study, 10,697 women in the Maternal-Fetal Medicine Units Network Trial of Labor After Cesarean Delivery cohort met the inclusion criteria, and 669 women (6.3%) experienced obstetrical anal sphincter injuries. In the model, factors independently associated with obstetrical anal sphincter injuries included use of forceps (adjusted odds ratio, 5.08; 95% confidence interval, 4.10-6.31) and vacuum assistance (adjusted odds ratio, 2.64; 95% confidence interval, 2.02-3.44), along with increasing maternal age (adjusted odds ratio, 1.05; 95% confidence interval, 1.04-1.07 per year), body mass index (adjusted odds ratio, 0.99; 95% confidence interval, 0.97-1.00 per unit kg/m2), previous vaginal delivery (adjusted odds ratio, 0.19; 95% confidence interval, 0.15-0.23), and tobacco use during pregnancy (adjusted odds ratio, 0.59; 95% confidence interval, 0.43-0.82). Internal validation demonstrated appropriate discrimination (concordance index, 0.790; 95% confidence interval, 0.771-0.808) and calibration (Brier score, 0.047). External validation used data from 1266 women who delivered at a tertiary healthcare system, with appropriate model discrimination (concordance index, 0.791; 95% confidence interval, 0.735-0.846) and calibration (Brier score, 0.046). The model can be accessed at oasisriskscore.xyz. CONCLUSION Our model provided a robust, validated estimate of the probability of obstetrical anal sphincter injuries during vaginal birth after cesarean delivery using known antenatal risk factors and 1 modifiable intrapartum risk factor and can be used to counsel patients regarding risks of trial of labor after cesarean delivery compared with risks of elective repeat cesarean delivery.
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Roper JC, Amber N, Wan OYK, Sultan AH, Thakar R. Review of available national guidelines for obstetric anal sphincter injury. Int Urogynecol J 2020; 31:2247-2259. [PMID: 32789813 PMCID: PMC7561538 DOI: 10.1007/s00192-020-04464-5] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 07/23/2020] [Indexed: 12/21/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Obstetric anal sphincter injuries (OASIs) are the most severe form of perineal trauma with potentially devastating effects on a mother's quality of life. There are various national guidelines available for their management. The aim of this study was to review and compare recommendations from published national guidelines regarding management and prevention of OASI. METHODS We searched the PUBMED, EMBASE, MEDLINE, CINAHL and COCHRANE databases from January 2008 till October 2019 using relevant Medical Subject Headings (MeSH), including all subheadings. The guideline characteristics were mapped and methodological quality assessed with the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool by three independent reviewers. To compare the methodological quality of the guidelines, the interpretation of the six domain scores were taken into consideration. By consensus of the authors, a score of 70% was taken as a cut-off, and scores above this were considered 'high quality'. RESULTS Thirteen national guidelines on perineal trauma were included and analysed. Nine of these were specific to OASI. There is wide variation in methodological quality and evidence used for recommendations. AGREE scores for overall guideline assessment were > 70% in eight of the guidelines, with Australia-Queensland, Canada, the UK and USA scoring highest. CONCLUSIONS The wide variation in methodological quality and evidence used for recommendations suggests that there is a need for an agreed international guideline. This will enable healthcare practitioners to follow the same recommendations, with the most recent evidence, and provide evidence-based care to all women globally.
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Affiliation(s)
- Joanna C Roper
- Obstetrics and Gynaecology department, Croydon University Hospital, London Road, Croydon, CR7 7YE, UK
| | | | - Osanna Yee Ki Wan
- Department of Obstetrics and Gynaecology, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong, SAR, Hong Kong
| | - Abdul H Sultan
- Obstetrics and Gynaecology department, Croydon University Hospital, London Road, Croydon, CR7 7YE, UK.,St George's University of London, London, UK
| | - Ranee Thakar
- Obstetrics and Gynaecology department, Croydon University Hospital, London Road, Croydon, CR7 7YE, UK. .,St George's University of London, London, UK.
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