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Regional and clinical guidelines for prevention and care of obstetric anal sphincter injuries - A critical frame analysis. Midwifery 2023; 119:103608. [PMID: 36739637 DOI: 10.1016/j.midw.2023.103608] [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: 05/27/2022] [Revised: 01/26/2023] [Accepted: 01/29/2023] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Policy documents govern how the prevention and care of obstetric anal sphincter injuries (OASIS) are implemented. Thus, in the absence of Swedish national guidelines on OASIS, differing views may be visible in the regional and local policy documents. Therefore, we aimed to analyse regional and local policies, guidelines, and care programs on the prevention of OASIS and care for OASIS-affected women in a Swedish context by applying a critical frame analysis inspired by Verloo. DESIGN AND SETTING A cross-sectional study of existing policy documents from Swedish healthcare regions was performed. The documents were analysed using Verloo's critical frame analysis. FINDINGS We found that OASIS was framed as a preventable problem addressed by skilled protective manoeuvres of the healthcare staff. Education, communication, and teamwork were three frames of crucial solutions to minimise the prevalence of OASIS. However, complicating power dimensions between professional groups and between professionals and birthing women were identified. Furthermore, several discursive struggles were found, predominantly regarding the scientific evidence for the suggested prevention and care. CONCLUSION The policy documents emphasised that OASIS is preventable, and improved education, communication, and teamwork could diminish the OASIS prevalence. Nevertheless, power dimensions and discursive struggles may challenge the preventive efforts. Furthermore, each Swedish region has the sovereignty to develop its policies, which was reflected in our findings and may imply inequities in care provision. Thus, there is an urgent need to develop comprehensive national high-quality guidelines of high quality for OASIS prevention and care so that all women giving birth have access to equal care and treatment in Sweden.
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Chang SD, Hsieh WC, Chiu SYH, Ng KL, Liang CC. Factors determining the persistence of prenatal stress urinary incontinence 12 months postpartum. Taiwan J Obstet Gynecol 2023; 62:40-44. [PMID: 36720548 DOI: 10.1016/j.tjog.2022.10.003] [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] [Accepted: 10/25/2022] [Indexed: 01/30/2023] Open
Abstract
OBJECTIVE Whilst many studies have explored the mechanisms of stress urinary incontinence (SUI) following various modes of delivery, few have examined outcomes of postpartum SUI in women who experienced new-onset SUI during their pregnancy. Our primary objective was to investigate the risk factors for persistent postpartum SUI in women with new-onset SUI during pregnancy at 1-year follow-up following vaginal delivery. MATERIALS AND METHODS 303 women with new-onset SUI during pregnancy who underwent vaginal delivery in a university hospital between 2014 and 2015 were included. In-person interviews were conducted for all participants on the second postpartum day, followed by phone interviews at 12 months postpartum, with completion of structured questionnaires, including Urogenital Distress Inventory Short Form (UDI-6) and Incontinence Impact Questionnaire Short Form (IIQ-7). Demographic, obstetrics and questionnaire scores were analyzed and compared between the group of women who experienced persistent postpartum SUI and the group who did not. RESULTS At 12 months postpartum, 16.5% (n = 50) of women had persistent postpartum SUI, with 83.5% (n = 253) experiencing resolution of SUI symptoms. Maternal age ≥35 years (aOR = 2.62; 95% CI, 1.40-4.87, P = 0.002), gestational age at birth ≥40 weeks (aOR = 2.21; 95% CI, 1.12-4.37, P = 0.022), and severe perineal lacerations (aOR = 2.32; 95% CI, 1.27-4.45, P = 0.013) were independent risk factors for persistent postpartum SUI for women following vaginal delivery at 1-year follow-up. CONCLUSION The prevalence of persistent postpartum SUI at 1-year following vaginal delivery is 16.5%, with advanced maternal age, gestational age at birth ≥40 weeks and severe perineal lacerations being independent risk factors.
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Affiliation(s)
- Shuenn-Dhy Chang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Wu-Chiao Hsieh
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Sherry Yueh-Hsia Chiu
- Department of Health Care Management, College of Management, Chang Gung University, Tao-Yuan, Taiwan; Division of Hepatogastroenterology, Department of Internal Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan
| | - Kai-Lyn Ng
- Department of Obstetrics and Gynecology, Mount Elizabeth Novena Hospital, Singapore; Division of Urogynaecology, National University Hospital, Singapore
| | - Ching-Chung Liang
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital, Linkou Branch, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Relationship between Perineal Body Length and Degree of Perineal Tears in Primigravidas Undergoing Vaginal Delivery with Episiotomy. Obstet Gynecol Int 2021; 2021:2621872. [PMID: 34567127 PMCID: PMC8460378 DOI: 10.1155/2021/2621872] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 11/13/2020] [Accepted: 02/12/2021] [Indexed: 11/18/2022] Open
Abstract
Background Perineal tears are one of the most common complications of vaginal delivery. Severe perineal tears can cause various morbidities. There are many factors that affect the occurrence of perineal tears. One of the major factors related to the occurrence of perineal tears is the length of the perineal body. However, until now, no research in Indonesia has concluded that the length of perineal body can predict the perineal tears. Objective To find the relationship between perineal body length and perineal tears, so it can provide a reference on the use of perineal body length to predict severe perineal tears in vaginal delivery with episiotomy. Methods This nested case-control study was conducted at RSUD Tangerang and RSUD Karawang in Indonesia from February to September 2017. A total of 126 primigravida patients participated in the study consecutively. The length of the perineal body was then measured and followed until the start of the second stage of labor. Afterwards, the perineal length and degree of perineal tears were assessed using unpaired T-test for bivariate analysis, multivariate analysis, and scoring test to predict the occurrence of third- and fourth-degree of perineal tears with power calculation (β) 80% and Zβ 0.842. Results There was a significant difference in mean length of the perineal body between the group with first- and second-degree perineal tears and the group with third- and fourth-degree perineal tears (p < 0.001). From the multivariate analysis, adjusted OR was 5.26 (95% CI 1.52-18.17). Score test was performed to predict the occurrence of third- and fourth-grade perineal tears. Perineal body length and head circumference could be used as predicting factors of perineal tears. Perineum length ≤ 3.0 cm and head circumference ≥ 33.5 cm posed a risk of perineal tears of third and fourth degrees (70.52%). Conclusion The length of the perineal body has a good ability to predict the occurrence of perineal tears.
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Borycka-Kiciak K, Młyńczak M, Kiciak A, Pietrzak P, Dziki A. Non-invasive obstetric anal sphincter injury diagnostics using impedance spectroscopy. Sci Rep 2019; 9:7097. [PMID: 31068631 PMCID: PMC6506466 DOI: 10.1038/s41598-019-43637-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 04/29/2019] [Indexed: 12/04/2022] Open
Abstract
Obstetric anal sphincter injuries are the most common cause of fecal incontinence in women yet remain under-diagnosed. The aim of this study was to assess the suitability of impedance spectroscopy for diagnosing sphincter injuries arising during delivery. This was a prospective single-center study. 22 female patients were included: 10 with symptoms of sphincter dysfunction, in the early postpartum period, and 12 unaffected, in the distant period of more than 2 years after natural delivery. The presence, extent and severity of anal sphincters injury was assessed by measuring the sphincter parameters in physical examination, the degree of sphincter damage in endoanal ultrasound imaging and the sphincters function parameters in anorectal manometry. All measurements were used as references and compared with the outcomes from the impedance spectroscopy models. Impedance spectroscopy showed the highest precision (with mean accuracy of 83.9%) in relation to transanal ultrasonography. 74.1% of its results corresponded to the results of rectal physical examination and 76.7% - to those of anorectal manometry. The method showed the highest accuracy in the assessment of the sphincter's parameters, both anatomically and functionally. New impedance spectroscopy techniques hold promise for detecting obstetric anal sphincter injuries.
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Affiliation(s)
- Katarzyna Borycka-Kiciak
- Department of General, Oncological and Gastrointestinal Surgery, Orlowski Hospital, Centre of Postgraduate Medical Education, Warsaw, Poland.
| | - Marcel Młyńczak
- Warsaw University of Technology, Faculty of Mechatronics, Institute of Metrology and Biomedical, Warsaw, Poland
| | - Adam Kiciak
- Department of General, Oncological and Gastrointestinal Surgery, Orlowski Hospital, Centre of Postgraduate Medical Education, Warsaw, Poland
| | - Piotr Pietrzak
- Department of Physiological Sciences, Faculty of Veterinary Medicine, Warsaw University of Life Sciences, Warsaw, Poland
| | - Adam Dziki
- Department of General and Colorectal Surgery, Medical University of Łódź, Łódź, Poland
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"Struggling to settle with a damaged body" - A Swedish qualitative study of women's experiences one year after obstetric anal sphincter muscle injury (OASIS) at childbirth. SEXUAL & REPRODUCTIVE HEALTHCARE 2018; 19:36-41. [PMID: 30928133 DOI: 10.1016/j.srhc.2018.11.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 11/14/2018] [Accepted: 11/19/2018] [Indexed: 11/23/2022]
Abstract
OBJECTIVE This study aimed to explore women's experiences related to recovery from obstetric anal sphincter muscle injuries (OASIS) one year after childbirth. METHOD This is a qualitative study based on written responses from 625 women approximately one year after childbirth in which OASIS occurred. Data was obtained from a questionnaire distributed by the national Perineal Laceration Register (PLR) in Sweden. Inductive qualitative content analysis was applied for analysis. RESULTS The theme "Struggling to settle with a damaged body" indicated that the first year after OASIS involved a struggle to settle to and accept living with a changed and sometimes still-wounded body. Many participants described problems related to a non-functional sexual life, physical and psychological problems that left them feeling used and broken, and increased worries for their future health and pregnancies. However, some women had adjusted to their situation, had moved on with their lives, and felt recovered and strong. Encountering a supportive and helpful health care professional was emphasized as vital for recovery after OASIS. CONCLUSION This study provides important insights on how women experience their recovery approximately one year after having had OASIS at childbirth, wherein many women still struggled to settle into their damaged bodies. Clear pathways are needed within health care organizations to appropriate health care services that address both physical and psychological health problems of women with prolonged recovery after OASIS.
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Lindqvist M, Persson M, Nilsson M, Uustal E, Lindberg I. ‘A worse nightmare than expected’ - a Swedish qualitative study of women's experiences two months after obstetric anal sphincter muscle injury. Midwifery 2018. [DOI: 10.1016/j.midw.2018.02.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Aasheim V, Nilsen ABV, Reinar LM, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 2017; 6:CD006672. [PMID: 28608597 PMCID: PMC6481402 DOI: 10.1002/14651858.cd006672.pub3] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Most vaginal births are associated with trauma to the genital tract. The morbidity associated with perineal trauma can be significant, especially when it comes to third- and fourth-degree tears. Different interventions including perineal massage, warm or cold compresses, and perineal management techniques have been used to prevent trauma. This is an update of a Cochrane review that was first published in 2011. OBJECTIVES To assess the effect of perineal techniques during the second stage of labour on the incidence and morbidity associated with perineal trauma. SEARCH METHODS We searched Cochrane Pregnancy and Childbirth's Trials Register (26 September 2016) and reference lists of retrieved studies. SELECTION CRITERIA Published and unpublished randomised and quasi-randomised controlled trials evaluating perineal techniques during the second stage of labour. Cross-over trials were not eligible for inclusion. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. We checked data for accuracy. MAIN RESULTS Twenty-two trials were eligible for inclusion (with 20 trials involving 15,181 women providing data). Overall, trials were at moderate to high risk of bias; none had adequate blinding, and most were unclear for both allocation concealment and incomplete outcome data. Interventions compared included the use of perineal massage, warm and cold compresses, and other perineal management techniques.Most studies did not report data on our secondary outcomes. We downgraded evidence for risk of bias, inconsistency, and imprecision for all comparisons. Hands off (or poised) compared to hands onHands on or hands off the perineum made no clear difference in incidence of intact perineum (average risk ratio (RR) 1.03, 95% confidence interval (CI) 0.95 to 1.12, two studies, Tau² 0.00, I² 37%, 6547 women; moderate-quality evidence), first-degree perineal tears (average RR 1.32, 95% CI 0.99 to 1.77, two studies, 700 women; low-quality evidence), second-degree tears (average RR 0.77, 95% CI 0.47 to 1.28, two studies, 700 women; low-quality evidence), or third- or fourth-degree tears (average RR 0.68, 95% CI 0.21 to 2.26, five studies, Tau² 0.92, I² 72%, 7317 women; very low-quality evidence). Substantial heterogeneity for third- or fourth-degree tears means these data should be interpreted with caution. Episiotomy was more frequent in the hands-on group (average RR 0.58, 95% CI 0.43 to 0.79, Tau² 0.07, I² 74%, four studies, 7247 women; low-quality evidence), but there was considerable heterogeneity between the four included studies.There were no data for perineal trauma requiring suturing. Warm compresses versus control (hands off or no warm compress)A warm compress did not have any clear effect on the incidence of intact perineum (average RR 1.02, 95% CI 0.85 to 1.21; 1799 women; four studies; moderate-quality evidence), perineal trauma requiring suturing (average RR 1.14, 95% CI 0.79 to 1.66; 76 women; one study; very low-quality evidence), second-degree tears (average RR 0.95, 95% CI 0.58 to 1.56; 274 women; two studies; very low-quality evidence), or episiotomy (average RR 0.86, 95% CI 0.60 to 1.23; 1799 women; four studies; low-quality evidence). It is uncertain whether warm compress increases or reduces the incidence of first-degree tears (average RR 1.19, 95% CI 0.38 to 3.79; 274 women; two studies; I² 88%; very low-quality evidence).Fewer third- or fourth-degree perineal tears were reported in the warm-compress group (average RR 0.46, 95% CI 0.27 to 0.79; 1799 women; four studies; moderate-quality evidence). Massage versus control (hands off or routine care)The incidence of intact perineum was increased in the perineal-massage group (average RR 1.74, 95% CI 1.11 to 2.73, six studies, 2618 women; I² 83% low-quality evidence) but there was substantial heterogeneity between studies). This group experienced fewer third- or fourth-degree tears (average RR 0.49, 95% CI 0.25 to 0.94, five studies, 2477 women; moderate-quality evidence).There were no clear differences between groups for perineal trauma requiring suturing (average RR 1.10, 95% CI 0.75 to 1.61, one study, 76 women; very low-quality evidence), first-degree tears (average RR 1.55, 95% CI 0.79 to 3.05, five studies, Tau² 0.47, I² 85%, 537 women; very low-quality evidence), or second-degree tears (average RR 1.08, 95% CI 0.55 to 2.12, five studies, Tau² 0.32, I² 62%, 537 women; very low-quality evidence). Perineal massage may reduce episiotomy although there was considerable uncertainty around the effect estimate (average RR 0.55, 95% CI 0.29 to 1.03, seven studies, Tau² 0.43, I² 92%, 2684 women; very low-quality evidence). Heterogeneity was high for first-degree tear, second-degree tear and for episiotomy - these data should be interpreted with caution. Ritgen's manoeuvre versus standard careOne study (66 women) found that women receiving Ritgen's manoeuvre were less likely to have a first-degree tear (RR 0.32, 95% CI 0.14 to 0.69; very low-quality evidence), more likely to have a second-degree tear (RR 3.25, 95% CI 1.73 to 6.09; very low-quality evidence), and neither more nor less likely to have an intact perineum (RR 0.17, 95% CI 0.02 to 1.31; very low-quality evidence). One larger study reported that Ritgen's manoeuvre did not have an effect on incidence of third- or fourth-degree tears (RR 1.24, 95% CI 0.78 to 1.96,1423 women; low-quality evidence). Episiotomy was not clearly different between groups (RR 0.81, 95% CI 0.63 to 1.03, two studies, 1489 women; low-quality evidence). Other comparisonsThe delivery of posterior versus anterior shoulder first, use of a perineal protection device, different oils/wax, and cold compresses did not show any effects on perineal outcomes. Only one study contributed to each of these comparisons, so data were insufficient to draw conclusions. AUTHORS' CONCLUSIONS Moderate-quality evidence suggests that warm compresses, and massage, may reduce third- and fourth-degree tears but the impact of these techniques on other outcomes was unclear or inconsistent. Poor-quality evidence suggests hands-off techniques may reduce episiotomy, but this technique had no clear impact on other outcomes. There were insufficient data to show whether other perineal techniques result in improved outcomes.Further research could be performed evaluating perineal techniques, warm compresses and massage, and how different types of oil used during massage affect women and their babies. It is important for any future research to collect information on women's views.
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Affiliation(s)
- Vigdis Aasheim
- Western Norway University of Applied SciencesFaculty of Health and Social SciencesBergenNorway
| | - Anne Britt Vika Nilsen
- Western Norway University of Applied SciencesFaculty of Health and Social SciencesBergenNorway
| | - Liv Merete Reinar
- Norwegian Institute of Public HealthDivision for Health ServicesPO Box 4404NydalenOsloNorway0403
| | - Mirjam Lukasse
- University College of Southeast NorwayFaculty of Health and Social SciencesOsloNorway
- Oslo and Akershus University CollegeFaculty of Health SciencesPB4St.Olavs plassOsloNorwayN‐0130
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Menzies R, Leung M, Chandrasekaran N, Lausman A, Geary M. Episiotomy Technique and Management of Anal Sphincter Tears-A Survey of Clinical Practice and Education. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2016; 38:1091-1099.e2. [PMID: 27986182 DOI: 10.1016/j.jogc.2016.09.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 09/01/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE To ascertain current techniques of episiotomy used by obstetrics and gynaecology faculty members and residents in an academic department and to determine the current management strategies for third and fourth degree tears. METHOD A 14-question anonymous online survey was circulated to all faculty members and residents in the University of Toronto Department of Obstetrics and Gynaecology between October 2015 and March 2016. Results were analyzed descriptively or with Fisher exact test. RESULTS The survey response rate was 65.5% (169/258) among 108 faculty members and 61 residents. A history of clinical teaching regarding episiotomy was reported by 87% of faculty members and 75.4% of residents. Right mediolateral episiotomy was the most frequently used method among faculty members (88.0%) and residents (95.1%). The majority of respondents indicated that they would use an end-to-end technique for repair in the labour and delivery room under regional anaesthesia. Prophylactic antibiotics were never prescribed by 18.5% of faculty members and 13.1% of residents for third or fourth degree tears. In analysis by type of training, respondents who had taken a workshop or formal class were significantly more likely to prescribe physiotherapy postpartum (P = 0.001). CONCLUSION The most common reported method of learning episiotomy was clinical experience. A substantial number of responses differed from current SOGC guidelines for episiotomy technique and repair and management of anal sphincter injury. We propose developing a workshop and/or simulation-based method of instruction for episiotomy technique and repair.
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Affiliation(s)
- Rebecca Menzies
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto ON
| | - Marian Leung
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto ON
| | | | - Andrea Lausman
- Department of Obstetrics and Gynaecology, University of Toronto, Toronto ON
| | - Michael Geary
- Department of Obstetrics and Gynecology, St. Michael's Hospital, Toronto ON
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Soligo M, Livio S, De Ponti E, Scebba I, Carpentieri F, Serati M, Ferrazzi E. Pelvic floor assessment after delivery: how should women be selected? Eur J Obstet Gynecol Reprod Biol 2016; 206:153-157. [PMID: 27693937 DOI: 10.1016/j.ejogrb.2016.09.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 08/18/2016] [Accepted: 09/13/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Pelvic floor dysfunction after delivery is quite common. New mothers deserve to receive targeted care for pelvic floor dysfunction, but how should women who are at risk be identified and selected for treatment? This study investigated risk factors and puerperal health-seeking behaviours to develop a restrictive patient selection model for postpartum pelvic floor dysfunction assessment. STUDY DESIGN This prospective observational study involved women who were at ≥32 weeks gestational age when they delivered in a tertiary referral maternity hospital in Milan, Italy, between July and December 2014. Eligible women were scheduled for a 3-month postnatal pelvic floor clinic. The adherence rate to the pelvic floor clinic and the prevalence of pelvic floor dysfunctions at 3 months postpartum were recorded. Univariable and logistic multivariable analyses were performed to select risk factors for pelvic floor dysfunctions. Risk factors were then tested for sensitivity and specificity for 3-month postpartum pelvic floor dysfunctions. RESULTS Of 1606 eligible women, 1293 (80.5%) were included in the analysis; 685 puerperal women (53.0%) adhered to the 3-month postnatal pelvic floor clinic; pelvic floor dysfunctions were detected in 238 women (34.7%). Four elements emerged as risk factors: symptoms before pregnancy (OR 1.72, 95% CI 1.15-2.56; p=0.008), symptoms during pregnancy (OR 2.13, 95% CI 1.49-3.06; p<0.0001), vacuum extractor use (OR 1.62, 95% CI 1.04-2.54; p=0.034), and severe perineal tears (OR 19.45, 95% CI 2.42-156.15; p=0.005). The combined sensitivity and specificity for the 4 risk factors were 82% and 39%, respectively. CONCLUSION Internal risk factors analysis offers the potential to efficiently restrict patient selection for follow-up.
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Affiliation(s)
- Marco Soligo
- Department of Women, Mothers and Neonates, Buzzi Children's Hospital, ASST Fatebenefratelli Sacco, University of Milan, Milan, Italy.
| | - Stefania Livio
- Department of Women, Mothers and Neonates, Buzzi Children's Hospital, ASST Fatebenefratelli Sacco, University of Milan, Milan, Italy
| | | | - Ileana Scebba
- Department of Women, Mothers and Neonates, Buzzi Children's Hospital, ASST Fatebenefratelli Sacco, University of Milan, Milan, Italy
| | - Federica Carpentieri
- Department of Women, Mothers and Neonates, Buzzi Children's Hospital, ASST Fatebenefratelli Sacco, University of Milan, Milan, Italy
| | - Maurizio Serati
- Department of Obstetrics and Gynaecology, Del Ponte Hospital, University of Insubria, Varese, Italy
| | - Enrico Ferrazzi
- Department of Women, Mothers and Neonates, Buzzi Children's Hospital, ASST Fatebenefratelli Sacco, University of Milan, Milan, Italy
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Early pelvic floor muscle training after obstetrical anal sphincter injuries for the reduction of anal incontinence. Eur J Obstet Gynecol Reprod Biol 2016; 199:201-6. [PMID: 26963793 DOI: 10.1016/j.ejogrb.2016.01.025] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 01/11/2016] [Accepted: 01/29/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Between 0.5 and 5% of vaginal deliveries involve obstetrical anal sphincter injuries (OASIS). Thirty to forty percent of patients with OASIS will suffer from anal incontinence in the subacute postpartum period. The aim of the present study was to assess the effectiveness of early pelvic floor muscle training (PFMT) combined with standard rehabilitation on anal incontinence after vaginal deliveries complicated by OASIS. STUDY DESIGN The present work was a retrospective quantitative study performed in a tertiary-level maternity hospital. Women with 3rd or 4th degree obstetric tears were included. Women who gave birth between January 1st, 2011 and December 31st, 2012 underwent standard pelvic-perineal rehabilitation within 6-8 weeks postpartum. Women who gave birth between January 1st, 2013 and July 1st, 2014 had early rehabilitation (within 30 days after delivery) followed by the same standard rehabilitation received by the other group. Rehabilitation was performed by physiotherapists specialized in perineology. No electrostimulation was done in early rehabilitation. An in-house-validated modification of the Jorge and Wexner questionnaire was sent by mail to the patients to assess symptoms. The main judgment criterion was anal incontinence to gas, loose stools and/or solid stool. RESULTS Two hundred and thirty patients were diagnosed with OASIS. Nineteen women (8.3%) were lost to follow-up. The intention-to-treat analysis included 211 patients, 109 of whom underwent standard rehabilitation and 102 early rehabilitation plus standard rehabilitation. The two groups were comparable in terms of parity, birth weight, assisted delivery, epidural anesthesia and rates of mediolateral episiotomy. Multivariate analyses adjusted for type of perineal lesion were performed. Early rehabilitation significantly reduced gas leakage: OR 0.51 [0.29-0.90] (p=0.02), liquid stool leakage: OR 0.22 [0.08-0.58] (p=0.02) and urinary stress incontinence: OR 0.43 [0.24-0.77] (p=0.004). CONCLUSIONS We recommend early (during the first month postpartum) PFMT after vaginal deliveries associated with OASIS. Rehabilitation should be carried out by a physiotherapist specialized in perineology in order to prevent medium-term functional consequences. A longer follow-up may be necessary to confirm the stability of results.
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Karmarkar R, Bhide A, Digesu A, Khullar V, Fernando R. Mode of delivery after obstetric anal sphincter injury. Eur J Obstet Gynecol Reprod Biol 2015; 194:7-10. [PMID: 26311280 DOI: 10.1016/j.ejogrb.2015.07.019] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 07/24/2015] [Accepted: 07/28/2015] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess the effect of vaginal delivery and caesarean section on faecal symptoms and structure and function of anal sphincter in women who sustained obstetric anal sphincter injuries (OASIS) in their previous pregnancy and were advised about the mode of delivery based on faecal incontinence symptoms, anal manometry and endoanal ultrasound. STUDY DESIGN It is a descriptive study on a cohort of women who had OASIS from 2006 to 2013. They were assessed after OASIS and during subsequent pregnancy with a questionnaire, endoanal ultrasound and anal manometry. Vaginal delivery was recommended to asymptomatic women with normal investigations. Elective caesarean section was recommended to women with faecal symptoms, anal sphincter defects of more than 30° or low resting or incremental anal pressures. All women were reassessed after subsequent delivery. RESULTS Fifty women who had pregnancies after OASIS, were seen after OASIS, during subsequent pregnancy and after the second delivery. 15 women had faecal symptoms after OASIS. The external, internal and combined anal sphincter defects were seen in 13, 11 and 9 women respectively. Low resting and incremental pressure were seen in 15 and 11 women respectively. Caesarean section was done in 22 women and 28 women delivered vaginally. Worsening of faecal symptoms and reduction in anal pressures were not observed in planned vaginal delivery or elective caesarean section groups. Faecal symptoms were worse with reduced anal pressures in three women from the planned caesarean section group. One of the women had a vaginal delivery and two women had emergency caesarean section at 7cm and 10cm dilatation. There were no new sphincter defects or recurrent OASIS in any of the women in the study group. CONCLUSION Decision about the mode of delivery of pregnancy after OASIS based on symptoms, anal manometry and endoanal ultrasound helps in preserving the anal sphincter function and avoiding unnecessary caesarean sections. Further follow-up of these patients is essential to evaluate the long-term effects of this decision.
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Affiliation(s)
- Roopali Karmarkar
- Department of Urogynaecology, Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London W2 1NY, United Kingdom.
| | - Alka Bhide
- Department of Urogynaecology, Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London W2 1NY, United Kingdom
| | - Alex Digesu
- Department of Urogynaecology, Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London W2 1NY, United Kingdom
| | - Vik Khullar
- Department of Urogynaecology, Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London W2 1NY, United Kingdom
| | - Ruwan Fernando
- Department of Urogynaecology, Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London W2 1NY, United Kingdom
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Bulchandani S, Watts E, Sucharitha A, Yates D, Ismail KM. Manual perineal support at the time of childbirth: a systematic review and meta-analysis. BJOG 2015; 122:1157-65. [DOI: 10.1111/1471-0528.13431] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/02/2015] [Indexed: 12/24/2022]
Affiliation(s)
- S Bulchandani
- Birmingham Women's NHS Foundation Trust; Birmingham UK
| | - E Watts
- Medical School; University of Birmingham; Birmingham UK
| | - A Sucharitha
- The Royal Wolverhampton NHS Trust; Wolverhampton West Midlands UK
| | - D Yates
- Birmingham Women's NHS Foundation Trust; Birmingham UK
| | - KM Ismail
- Birmingham Women's NHS Foundation Trust; Birmingham UK
- The Birmingham Centre of Women's and Children's Health; School of Clinical and Experimental Medicine; College of Medical and Dental Sciences; University of Birmingham; Birmingham UK
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Ampt AJ, Roberts CL, Morris JM, Ford JB. The impact of first birth obstetric anal sphincter injury on the subsequent birth: a population-based linkage study. BMC Pregnancy Childbirth 2015; 15:31. [PMID: 25879873 PMCID: PMC4339080 DOI: 10.1186/s12884-015-0469-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 02/03/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With rising obstetric anal sphincter injury (OASI) rates, the number of women at risk of OASI recurrence is in turn increasing. Decisions regarding mode of subsequent birth following an OASI are complex, and depend on a variety of factors. We sought to identify the risk factors for OASI recurrence from first and subsequent births, and to investigate the effect of OASI birth factors on planned caesarean for the second birth. METHODS Using two linked population datasets from New South Wales, Australia, we selected women giving birth between 2001 and 2011 with a first birth OASI and a subsequent birth. Multivariable logistic regression was used to identify the association of first and second birth factors with OASI recurrence, and to determine which factors were associated with a planned pre-labour caesarean at the second birth. RESULTS Of 6,380 women with a first birth OASI who proceeded to a subsequent birth, 75.4% had a vaginal second birth, 19.4% a pre-labour caesarean, and 5.2% an intrapartum caesarean. Although the OASI recurrence rate of 5.7% was significantly higher than the first birth OASI rate of 4.5% (p < 0.01), this may not reflect a clinically significant increase. Following adjustment for first and second birth factors, first birth diabetes and second birthweight ≥3.5 kg were associated with increased likelihood of OASI recurrence, while first birthweight ≥4.0 kg and second gestation at 37-38 weeks were associated with decreased likelihood. A fourth degree tear at the first birth was the strongest factor associated with planned caesarean at the second birth, with other factors including epidural, spinal or general anaesthetic, birthweight, gestation, country of birth and maternal age. CONCLUSIONS Compared with previous reports, the low OASI recurrence rate (approximately one in twenty) may reflect appropriate decision-making about subsequent mode of delivery following first birth OASI. This assertion is supported by evidence of different risk profiles for women who have planned caesareans compared with planned vaginal births.
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Affiliation(s)
- Amanda J Ampt
- Clinical and Population Perinatal Health Research, Kolling Institute, University of Sydney, Royal North Shore Hospital, Building 52, St Leonards, NSW, 2065, Australia.
| | - Christine L Roberts
- Clinical and Population Perinatal Health Research, Kolling Institute, University of Sydney, Royal North Shore Hospital, Building 52, St Leonards, NSW, 2065, Australia.
| | - Jonathan M Morris
- Clinical and Population Perinatal Health Research, Kolling Institute, University of Sydney, Royal North Shore Hospital, Building 52, St Leonards, NSW, 2065, Australia.
| | - Jane B Ford
- Clinical and Population Perinatal Health Research, Kolling Institute, University of Sydney, Royal North Shore Hospital, Building 52, St Leonards, NSW, 2065, Australia.
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14
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Hsieh WC, Liang CC, Wu D, Chang SD, Chueh HY, Chao AS. Prevalence and contributing factors of severe perineal damage following episiotomy-assisted vaginal delivery. Taiwan J Obstet Gynecol 2014; 53:481-5. [DOI: 10.1016/j.tjog.2013.07.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2013] [Indexed: 11/30/2022] Open
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El-Din ASS, Kamal MM, Amin MA. Comparison between two incision angles of mediolateral episiotomy in primiparous women: A randomized controlled trial. J Obstet Gynaecol Res 2014; 40:1877-82. [DOI: 10.1111/jog.12432] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 02/10/2014] [Indexed: 11/29/2022]
Affiliation(s)
- Adel S. S. El-Din
- Department of Obstetrics and Gynecology; Faculty of Medicine; Ain Shams University; Abbasiya Cairo Egypt
| | - Magdy M. Kamal
- Department of Obstetrics and Gynecology; Faculty of Medicine; Ain Shams University; Abbasiya Cairo Egypt
| | - Malaka A. Amin
- Department of Obstetrics and Gynecology; Faculty of Medicine; Ain Shams University; Abbasiya Cairo Egypt
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Priddis HS, Schmied V, Kettle C, Sneddon A, Dahlen HG. "A patchwork of services"--caring for women who sustain severe perineal trauma in New South Wales--from the perspective of women and midwives. BMC Pregnancy Childbirth 2014; 14:236. [PMID: 25034120 PMCID: PMC4223519 DOI: 10.1186/1471-2393-14-236] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 07/11/2014] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Current research into severe perineal trauma (3rd and 4th degree) focuses upon identification of risk factors, preventative practices and methods of repair, with little focus on women's experiences of, and interactions with, health professionals following severe perineal trauma (SPT). The aim of this study is to describe current health services provided to women in New South Wales (NSW) who have experienced SPT from the perspective of Clinical Midwifery Consultants (CMC) and women. METHODS This study used a descriptive qualitative design and reports on the findings of a component of a larger mixed methods study. Data were collected through a semi-structured discussion group using a variety of non-directive, open-ended questions leading CMCs of NSW. A survey was distributed prior to the discussion group to collect further information and enable a more comprehensive understanding of services provided. Data from individual interviews with twelve women who had experienced SPT during vaginal birth is used to provide greater insight into their interactions with, and ease of access to, health service providers in NSW. An integrative approach was undertaken in reporting the findings which involved comparing and analysing findings from the three sets of data. RESULTS One overarching theme was identified: A Patchwork of Policy and Process which identified that current health services operate in a 'patchwork' manner when caring for women who sustain SPT. They are characterised by lack of consistency in practice and standardisation of care. Within the overarching theme, four subthemes were identified: Falling through the gaps; Qualifications, skills and attitudes of health professionals; Caring for women who have sustained SPT; and Gold standard care: how would it look? CONCLUSION The findings from this study suggest that current health services in NSW represent a 'patchwork' of service provision for women who have sustained SPT. It appeared that women seek compassionate and supportive care based upon a clear exchange of information, and this should be considered when reflecting upon health service design. This study highlights the benefits of establishing multi-disciplinary collaborative specialist clinics to support women who experience SPT and associated morbidities, with the aim of providing comprehensive physiological and psychological support.
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Affiliation(s)
- Holly S Priddis
- School of Nursing and Midwifery, University of Western Sydney, Building EB, Parramatta Campus, Locked Bag 1797, Penrith South DC NSW 2751, Australia
| | - Virginia Schmied
- School of Nursing and Midwifery, University of Western Sydney, Building EB, Parramatta Campus, Locked Bag 1797, Penrith South DC NSW 2751, Australia
| | - Christine Kettle
- Staffordshire University, Blackheath Lane, Stafford, Staffordshire ST18 0AD, UK
| | - Anne Sneddon
- Obstetrics and Gynaecology Gold Coast, Griffith University, Gold Coast, Australia
| | - Hannah G Dahlen
- School of Nursing and Midwifery, University of Western Sydney, Building EB, Parramatta Campus, Locked Bag 1797, Penrith South DC NSW 2751, Australia
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Long-term outcome of obstetric anal sphincter injury repaired by experienced obstetricians. Int J Gynaecol Obstet 2014; 126:130-5. [PMID: 24866049 DOI: 10.1016/j.ijgo.2014.03.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 03/03/2014] [Accepted: 04/22/2014] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To examine the long-term outcomes of women with obstetric anal sphincter injury (OASI) repaired by obstetricians without the involvement of colorectal surgeons. METHODS A retrospective cohort study was undertaken of women who had been admitted for delivery between 2004 and 2012. All OASIs had been repaired by experienced obstetricians using the end-to-end technique. An unexposed group (no OASI) was matched at a ratio of 1:1. Fecal incontinence was graded using a modified Wexner questionnaire. RESULTS Overall, 113 OASIs were recorded. Sixty-seven (59.3%) and 71 (62.8%) women from the exposed and unexposed groups, respectively, agreed to participate in the study (P=0.9). Continence to both stool and gas was reported by 48 (71.6%) and 64 (90.1%) women in the exposed and unexposed groups, respectively (P=0.03). The incidence of urgency, dyspareunia, and use of a pad or constipating agents was the same in both groups. CONCLUSION The long-term outcome of OASI repair performed by experienced obstetricians is comparable to that reported in the literature. Some women who did not sustain an OASI reported fecal incontinence, which suggests that only a proportion of fecal incontinence can be attributed to OASI.
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Evans C, Archer R, Forrest A, Barrington J. Management of obstetric anal sphincter injuries (OASIS) in subsequent pregnancy. J OBSTET GYNAECOL 2014; 34:486-8. [PMID: 24800795 DOI: 10.3109/01443615.2014.911835] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Obstetric anal sphincter injuries (OASIS) are common and may greatly affect a patient's quality of life. There is very little information regarding optimum management in future pregnancies. Based upon anecdotal experience, this study describes the recommendations of a cohort of consultant obstetricians in the UK, in this clinical situation. There is limited adherence to the available national guidelines due to the absence of available equipment and expertise to perform endo-anal ultrasound and manometry. Elective episiotomy is still recommended by a small number of obstetricians but the majority of patients are routinely followed-up. Caesarean section is only advised for asymptomatic patients with a previous stage 4 tear, and for any symptomatic patient with a previous stage 3 or 4 tear, irrespective of subgrade. A request for elective caesarean section is likely to be granted, irrespective of OASIS grade. The use of postpartum endo-anal ultrasound would help identify those women in whom a further vaginal delivery is unlikely to exacerbate any symptoms of faecal incontinence.
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Affiliation(s)
- C Evans
- Department of Obstetrics and Gynaecology, Torbay Hospital , Torquay , UK
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Abstract
BACKGROUND Perineal hyaluronidase (HAase) injection was widely used to reduce the occurrence of perineal trauma, pain and need for episiotomy in the 1950s to 1960s. Reports suggested that the administration of HAase was a simple, low risk, low cost and effective way to decrease perineal trauma without adverse effects. OBJECTIVES The objective of this review was to assess the effectiveness and safety of perineal HAase injection for reducing spontaneous perineal trauma, episiotomy and perineal pain in vaginal deliveries. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 October 2013), the International Clinical Trials Registry Platform (ICTRP) and the Networked Digital Library of Theses and Dissertations (both on 1 April 2013), and reference lists of retrieved studies. We also contacted relevant organisations. SELECTION CRITERIA Published and unpublished randomised and quasi-randomised controlled trials comparing perineal HAase injection with placebo injection or no intervention in vaginal deliveries. DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, extracted data and evaluated methodological quality. Data were checked for accuracy. MAIN RESULTS The search strategy identified six potentially eligible studies. Two studies were excluded. We included four randomised controlled trials that randomised a total of 599 women (data were available for 595 women).Two trials (283 women) compared the effects of perineal HAase injection during the second stage of labour with placebo injection and were at low risk of bias. Three trials (one three-armed trial was analysed twice) (373 women) compared the effects of perineal HAase injection during second stage of labour with no intervention and two out of the three trials were at high risk of bias. Data from four trials involving 599 women suggested that perineal HAase injection during second stage of labour had a lower incidence of perineal trauma (average risk ratio (RR) 0.69, 95% confidence interval (CI) 0.50 to 0.95,Tau² = 0.08, I² = 82% compared with women in the control group, but there was no clear evidence of a reduction in the incidence of episiotomy (average RR 0.74, 95% CI 0.43 to 1.29, Tau² = 0.17, I² = 66%), first and second degree perineal lacerations (average RR 0.54, 95% CI 0.38 to 1.33, Tau² = 0.30 , I² = 85%) and third and fourth degree perineal lacerations (RR 0.12, 95% CI 0.01 to 2.13). Data from two trials involving 283 women indicated that there was no clear evidence of a reduction in the incidence of perineal trauma (RR 0.90, 95% CI 0.77 to 1.06, Tau²=1.07, I² = 7%), episiotomy (RR 0.77, 95% CI 0.32 to 1.89, Tau² = 0.27, I² = 54%), first and second degree perineal lacerations (RR 1.08, 95% CI 0.83 to 1.40, Tau² = 1.11, I² = 10%) and third and fourth degree perineal lacerations (RR 0.12, 95% CI 0.01 to 2.13) with perineal HAase injection. Data from three trials involving 373 women suggested that perineal HAase injection during second stage of labour had a lower incidence of perineal trauma (RR 0.61, 95% CI 0.42 to 0.88, Tau² = 0.08, I² = 78%) compared with no intervention, but had no clear effect on in the incidence of episiotomy (RR 0.79, 95% CI 0.44 to 1.42, Tau² = 0.16, I² = 70%) and first and second degree perineal lacerations (RR 0.58, 95% CI 0.31 to 1.10, Tau² = 0.18, I² = 59%). No side effects were reported in the included trials.No included trials reported on perineal pain and other pre-specified secondary outcomes: perineal trauma requiring suturing; blood loss; dyspareunia; urinary incontinence; faecal incontinence; assisted delivery rate; women's satisfaction; Apgar score less than seven at five minutes and need for admission to special care baby unit. AUTHORS' CONCLUSIONS Perineal HAase injection during second stage of labour had a lower incidence of perineal trauma compared with control or no intervention, but there was no clear evidence of benefit compared with placebo injection. The difference in incidence of perineal trauma may probably be due to bias and confounding in the non-placebo controlled comparison, this result should be interpreted cautiously. The potential use of perineal HAase injection as a method to reduce perineal trauma were yet to be determined as there was no appropriate established dose for HAase, no evidence of follow up, and the number of high-quality trials and outcomes reported were too limited to draw conclusions on its effectiveness and safety. Further rigorous randomised controlled trials are required to evaluate the role of perineal HAase injection in vaginal deliveries.
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Affiliation(s)
- Fan Zhou
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynaecologyRenmin Nan RoadChengduSichuanChina610041
| | - Xiao Dong Wang
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynaecologyRenmin Nan RoadChengduSichuanChina610041
| | - Jing Li
- West China Hospital, Sichuan UniversityChinese Cochrane CentreNo. 37, Guo Xue XiangChengduSichuanChina610041
| | - Gui Qiong Huang
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynaecologyRenmin Nan RoadChengduSichuanChina610041
| | - Bing Xin Gao
- West China Second University Hospital, Sichuan UniversityDepartment of Obstetrics and GynaecologyRenmin Nan RoadChengduSichuanChina610041
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Seijmonsbergen-Schermers AE, Geerts CC, Prins M, van Diem MT, Klomp T, Lagro-Janssen ALM, de Jonge A. The use of episiotomy in a low-risk population in the Netherlands: a secondary analysis. Birth 2013; 40:247-55. [PMID: 24344705 DOI: 10.1111/birt.12060] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/02/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND To examine the episiotomy incidence and determinants and outcomes associated with its use in primary care midwifery practices. METHODS Secondary analysis of two prospective cohort studies (n = 3,404). RESULTS The episiotomy incidence was 10.8 percent (20.9% for nulliparous and 6.3% for parous women). Episiotomy was associated with prolonged second stage of labor (adj. OR 12.09 [95% CI 6.0-24.2] for nulliparous and adj. OR 2.79 [1.7-4.6] for parous women) and hospital birth (adj. OR 1.75 [1.2-2.5] for parous women). Compared with episiotomy, perineal tears were associated with a lower rate of postpartum hemorrhage in parous women (adj. OR 0.58 [0.4-0.9]). Fewer women with perineal tears reported perineal discomfort (adj. OR 0.35 [0.2-0.6] for nulliparous and adj. OR 0.22 [0.1-0.3] for parous women). Among nulliparous women episiotomy was performed most frequently for prolonged second stage of labor (38.8%) and among parous women for history of episiotomy or prevention of major perineal trauma (21.1%). CONCLUSIONS The incidence of episiotomy is high compared with some low-risk settings in other Western countries. Episiotomy was associated with higher rates of adverse maternal outcomes. Restricted use of episiotomy is likely to be beneficial for women.
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Affiliation(s)
- A E Seijmonsbergen-Schermers
- Department of Midwifery Science, AVAG and the EMGO Institute of Health and Care Research, VU University Medical Centre, Amsterdam, The Netherlands
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Ampt AJ, Ford JB, Roberts CL, Morris JM. Trends in obstetric anal sphincter injuries and associated risk factors for vaginal singleton term births in New South Wales 2001-2009. Aust N Z J Obstet Gynaecol 2013; 53:9-16. [PMID: 23405994 DOI: 10.1111/ajo.12038] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2012] [Accepted: 11/15/2012] [Indexed: 11/28/2022]
Abstract
BACKGROUND Changes in clinical practice and in the characteristics of childbearing women have the potential to influence the rate of obstetric anal sphincter injuries (OASIS). To date, little investigation has been undertaken to assess the effect of risk factor trends for the Australian population on OASIS rates. AIMS To ascertain the OASIS rates amongst singleton vaginal births ≥37 weeks gestation in NSW, 2001 - 2009; to determine risk factor effect sizes and trends; and to compare predicted with observed OASIS rates. METHODS Using two linked population-based data sets, risk factors for OASIS were determined by logistic regression. Contingency tables and predictive modelling were used to determine trends and predicted rates of OASIS, respectively. RESULTS The OASIS rate increased from 2.2% in 2001 to 2.9% in 2009. Highest risks were for forceps deliveries without episiotomy (primiparas aOR 6.10, multiparas aOR 6.15), followed by multiparas with no previous vaginal birth (aOR 5.61). High birthweight, vacuum delivery and Asian country of birth posed risks for all women. The greatest risk factor trends were increases in Asian country of birth and vacuum delivery, while the greatest trend amongst protective factors was an increase in maternal age ≥35 years for primiparas. Predicted OASIS rates were lower than observed rates. CONCLUSION In an environment of changing demographic and clinical risk factors, the OASIS rate has increased. This increase is only minimally explained by the identified risk factors and may be related to other unmeasured risk factors or a possible increase in clinical ascertainment and/or documentation of OASIS.
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Affiliation(s)
- Amanda J Ampt
- Clinical and Population Perinatal Health Research, Kolling Institute of Medical Research, University of Sydney, St Leonards, New South Wales, Australia.
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Affiliation(s)
- Inger Lindberg
- Inger Lindberg Assistant Professor Division of Nursing, Luleå University of Technology, Norrbotten, Sweden
| | - Ellinor Mella
- Ellinor Mella Midwife Maternity services, Björknäs Primary Healthcare Centre, Norrbotten County Council, Sweden
| | - Jessica Johansson
- Jessica Johansson Midwife Department of Maternity care, Sunderby Hospital, Norrbotten County Council, Sweden
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Karaçam Z, Ekmen H, Çalişir H. The Use of Perineal Massage in the Second Stage of Labor and Follow-Up of Postpartum Perineal Outcomes. Health Care Women Int 2012; 33:697-718. [DOI: 10.1080/07399332.2012.655385] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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de Vogel J, van der Leeuw-van Beek A, Gietelink D, Vujkovic M, de Leeuw JW, van Bavel J, Papatsonis D. The effect of a mediolateral episiotomy during operative vaginal delivery on the risk of developing obstetrical anal sphincter injuries. Am J Obstet Gynecol 2012; 206:404.e1-5. [PMID: 22425401 DOI: 10.1016/j.ajog.2012.02.008] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2011] [Revised: 01/26/2012] [Accepted: 02/13/2012] [Indexed: 11/18/2022]
Abstract
OBJECTIVE The objective of the study was to evaluate the frequency of obstetrical anal sphincter injuries (OASIS) in women undergoing operative vaginal deliveries (OVD) and to assess whether a mediolateral episiotomy is protective for developing OASIS in these deliveries. STUDY DESIGN We performed a retrospective cohort study. Maternal and obstetrical characteristics of the 2861 women who delivered liveborn infants by an OVD at term in the years 2001-2009 were extracted from a clinical obstetrics database and were analyzed in a logistic regression model. RESULTS The frequency of OASIS was 5.7%. Women with a mediolateral episiotomy were at significantly lower risk for OASIS compared with the women without a mediolateral episiotomy in case of an OVD (adjusted odds ratio, 0.17; 95% confidence interval, 0.12-0.24). CONCLUSION We found a 6-fold decreased odds for developing OASIS when a mediolateral episiotomy was performed in OVD. Therefore, we advocate the use of a mediolateral episiotomy in all operative vaginal deliveries to reduce the incidence of OASIS.
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Affiliation(s)
- Joey de Vogel
- Department of Obstetrics and Gynaecology, Amphia Hospital Breda, Breda, The Netherlands.
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Aasheim V, Nilsen ABV, Lukasse M, Reinar LM. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 2011:CD006672. [PMID: 22161407 DOI: 10.1002/14651858.cd006672.pub2] [Citation(s) in RCA: 73] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Most vaginal births are associated with some form of trauma to the genital tract. The morbidity associated with perineal trauma is significant, especially when it comes to third- and fourth-degree tears. Different perineal techniques and interventions are being used to prevent perineal trauma. These interventions include perineal massage, warm compresses and perineal management techniques. OBJECTIVES The objective of this review was to assess the effect of perineal techniques during the second stage of labour on the incidence of perineal trauma. SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (20 May 2011), the Cochrane Central Register of ControlledTrials (The Cochrane Library 2011, Issue 2 of 4), MEDLINE (January 1966 to 20 May 2011) and CINAHL (January 1983 to 20 May 2011). SELECTION CRITERIA Published and unpublished randomised and quasi-randomised controlled trials evaluating any described perineal techniques during the second stage. DATA COLLECTION AND ANALYSIS Three review authors independently assessed trails for inclusion, extracted data and evaluated methodological quality. Data were checked for accuracy. MAIN RESULTS We included eight trials involving 11,651 randomised women. There was a significant effect of warm compresses on reduction of third- and fourth-degree tears (risk ratio (RR) 0.48, 95% confidence interval (CI) 0.28 to 0.84 (two studies, 1525 women)). There was also a significant effect towards favouring massage versus hands off to reduce third- and fourth-degree tears (RR 0.52, 95% CI 0.29 to 0.94 (two studies, 2147 women)). Hands off (or poised) versus hand on showed no effect on third- and fourth-degree tears, but we observed a significant effect of hands off on reduced rate of episiotomy (RR 0.69, 95% CI 0.50 to 0.96 (two studies, 6547 women)). AUTHORS' CONCLUSIONS The use of warm compresses on the perineum is associated with a decreased occurrence of perineal trauma. The procedure has shown to be acceptable to women and midwives. This procedure may therefore be offered to women.
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Affiliation(s)
- Vigdis Aasheim
- Department of Postgraduate Studies, Bergen University College, Møllendalsveien 6, PO Box7030, Bergen, Norway, 5020
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Groutz A, Cohen A, Gold R, Hasson J, Wengier A, Lessing JB, Gordon D. Risk factors for severe perineal injury during childbirth: a case-control study of 60 consecutive cases. Colorectal Dis 2011; 13:e216-9. [PMID: 21689311 DOI: 10.1111/j.1463-1318.2011.02620.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM The study aimed to evaluate the current risk factors for severe perineal tears in a single university-affiliated maternity hospital. METHOD An obstetric database of 31 784 consecutive women who delivered from January 2007 to December 2009 was screened for cases of third-degree or fourth-degree perineal tears. Four controls, matched by time of delivery, were selected for each case of third- or fourth-degree perineal tear. Maternal and obstetric parameters were analyzed and compared between the study and control groups. RESULTS Sixty women (0.25% of all vaginal deliveries) had a third-degree (53 women) or a fourth-degree (seven women) perineal tear. The control group comprised 240 matched vaginal deliveries without severe tears. Primiparity, younger maternal age, Asian ethnicity, longer duration of second stage of labour, vacuum-assisted delivery and heavier newborn birth weight were significantly more common among women who had third- or fourth-degree perineal tears. Of the variables that were found to be statistically significant in the univariate analysis, only primiparity (OR = 2.809, 95% CI: 1.336-5.905), vacuum delivery (OR = 10.104, 95% CI: 3.542-28.827) and heavier newborn birth weight (OR = 1.002, 95% CI: 1.001-1.003) were found to be statistically significant independent risk factors for severe perineal trauma. CONCLUSION Identification of women at risk may facilitate the use, or avoidance, of certain obstetric interventions to minimize the occurrence of childbirth-associated perineal trauma.
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Affiliation(s)
- A Groutz
- Urogynaecology and Pelvic Floor Unit, Department of Obstetrics and Gynaecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical Centre, Sackler Faculty of Medicine, Tel Aviv University, Israel.
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Kumar R, Ooi C, Nicoll A. Anal incontinence and quality of life following obstetric anal sphincter injury. Arch Gynecol Obstet 2011; 285:591-7. [PMID: 21800085 DOI: 10.1007/s00404-011-2003-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2011] [Accepted: 07/08/2011] [Indexed: 11/28/2022]
Abstract
PURPOSE The objective of our study was to identify the number of women who have long-term ano-rectal symptoms following primary repair of obstetric anal sphincter injury (OASI) and the effect on their quality of life. We also wished to determine the impact of the injury on decision for future pregnancies and mode of delivery in subsequent pregnancies. METHODS A cohort of women who sustained OASI in 2004 in Ninewells Hospital were contacted (minimum 4 years post-repair). They were sent a questionnaire about incontinence of flatus, solid stools, liquid stools, severity of incontinence, quality of life, decision for future pregnancy and mode of delivery in subsequent pregnancy. RESULTS 70/4,245 (1.7%) women sustained OASI. 42/70 (60%) women responded to the questionnaire. 15/41 (37%) experienced anal incontinence. 8/15 (53%) women had to alter their lifestyle due to their symptoms. Women who were asymptomatic had a median visual analogue score of 0.5 (range 0-4) and women who were symptomatic had a median score of 3.5 (range 2-8). 12/41 (29%) decided against further pregnancies and 8 of them were symptomatic (p 0.015). 16/41 women (39%) did not have any further pregnancy following OASI and 9 of them (56%) had anal incontinence. Of the 25 women who did have further pregnancies, 6 women (24%) had anal incontinence. 19 of them were asymptomatic. (p = 0.03). 5 out of the 6 symptomatic women had elective caesarean sections. CONCLUSIONS Long-term outcomes following OASI are not encouraging. A significant number of women decided against further pregnancy and most symptomatic women that have further pregnancy opt to deliver by caesarean section.
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Affiliation(s)
- Ranitha Kumar
- Obstetrics & Gynaecology, Wishaw General Hospital, 40, The Fairways, Bothwell, Lanarkshire G71 8PA, UK.
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Groutz A, Hasson J, Wengier A, Gold R, Skornick-Rapaport A, Lessing JB, Gordon D. Third- and fourth-degree perineal tears: prevalence and risk factors in the third millennium. Am J Obstet Gynecol 2011; 204:347.e1-4. [PMID: 21183150 DOI: 10.1016/j.ajog.2010.11.019] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2010] [Revised: 10/21/2010] [Accepted: 11/09/2010] [Indexed: 10/18/2022]
Abstract
OBJECTIVE We sought to assess the modern prevalence and risk factors for third- and fourth-degree perineal tears. STUDY DESIGN The study population comprised 38,252 women who delivered in one medical center, from January 2005 through December 2009, and met the following inclusion criteria: singleton pregnancy, vertex presentation, and vaginal delivery. Of these, 96 women (0.25%) sustained third- or fourth-degree perineal tears. Maternal and obstetric variables were compared between women with vs without severe perineal tears. RESULTS Five variables were found to be statistically significant independent risk factors: Asian ethnicity (odds ratio [OR], 8.9; 95% confidence interval [CI], 4.2-18.9), primiparity (OR, 2.4; 95% CI, 1.5-3.7), persistent occipito posterior (OR, 2.1; 95% CI, 1-4.5), vacuum delivery (OR, 2.7; 95% CI, 1.6-4.6), and heavier birthweight (OR, 1.001; 95% CI, 1-1.001). CONCLUSION Severe perineal tears are uncommon in modern obstetric practice. Significant risk factors are Asian ethnicity, primiparity, persistent occipito posterior, vacuum delivery, and heavier birthweight.
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Affiliation(s)
- Mary Steen
- Midwifery Department, Faculty of Health and Social Care, University of Chester
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Viswanathan M. Tailoring systematic reviews to meet critical priorities in maternal health in the intrapartum period. Paediatr Perinat Epidemiol 2008; 22 Suppl 1:10-7. [PMID: 18237347 DOI: 10.1111/j.1365-3016.2007.00907.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Health care practitioners and researchers commonly call for greater reliance on evidence as a means to achieve improvement in quality of care. Systematic reviews provide a means to accelerate the use of evidence-based clinical interventions and public health practices. The extent to which these time- and resource-intensive systematic reviews currently address critical maternal health priorities in the intrapartum period is unclear. This analysis summarises key maternal health and research priorities, maps these priorities to existing reviews, identifies gaps in the literature that can be addressed with systematic reviews, and highlights key methodological concerns in conducting systematic reviews. The analysis draws on published data on maternal morbidities and an overview of 108 systematic reviews in Medline in the past 5 years using the MeSH terms 'Delivery, Obstetric,' to draw the links between health priorities, research priorities, existing evidence and missing evidence. Key causes of morbidity during labour and delivery in the United States include haemorrhage, pre-eclampsia and eclampsia, obstetric trauma and infection. Analyses of maternal morbidity and mortality suggest that key concerns include racial and ethnic disparities in health outcomes and the prevention of adverse events. Systematic reviews, however, generally tend to focus on the reduction of harms associated with interventions, are frequently limited to randomised designs, and do not address issues of health disparities. The results suggest that advances in evidence-based care in maternal health require that systematic reviews address issues of prevention of adverse events, include a larger variety of study designs when necessary and pay closer attention to health disparities.
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Affiliation(s)
- Meera Viswanathan
- Research Triangle Institute International, Research Triangle Park, NC 27709-2194, USA.
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Huang WC, Yang SH, Yang JM. Three-dimensional transperineal sonographic characteristics of the anal sphincter complex in nulliparous women. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2007; 30:210-20. [PMID: 17659660 DOI: 10.1002/uog.4083] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVE To explore the morphological characteristics and normal biometry of the anal sphincter complex in nulliparous Chinese women using three-dimensional (3D) transperineal ultrasound. METHODS 3D sonographic data from 55 nulliparous Chinese women (aged 19-38 years) who had no pelvic organ prolapse and no symptoms of pelvic floor dysfunction were retrieved from an image dataset and analyzed by offline post-processing. The morphological characteristics of the external and internal anal sphincters, puborectalis muscle and perineal body were assessed in the sagittal, coronal and axial views. RESULTS The external anal sphincter had three sonographic components: the circular main body, a subcutaneous part and an extension portion. It was significantly thinner at 12 o'clock than at the 3, 6 and 9 o'clock positions. The internal anal sphincter was seen as dark echolucent strips of equal thickness. In the mid-sagittal view, it started from the anal verge and ended at the anorectal junction. The perineal body was an ovoid structure covering the upper margin of the external sphincter, while the puborectalis muscle was banana-shaped in the sagittal view and was located behind the anorectal junction, extending downward along the inferior margin of the posterior external sphincter extension. Sonographic characteristics of the anal sphincter complex did not vary with age, weight, height or body mass index. CONCLUSIONS 3D transperineal ultrasound clearly demonstrates the spatial relationships of each component of the anal sphincter complex. This should allow standardized measurement of the complex for investigations of its function.
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Affiliation(s)
- W-C Huang
- Department of Obstetrics and Gynecology, Cathay General Hospital, Taipei, Taiwan
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Aasheim V, Nilsen ABV, Lukasse M, Reinar LM. Perineal techniques during the second stage of labour for reducing perineal trauma. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2007. [DOI: 10.1002/14651858.cd006672] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Yagel S, Valsky DV. Three-dimensional transperineal ultrasonography for evaluation of the anal sphincter complex: another dimension in understanding peripartum sphincter trauma. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2006; 27:119-23. [PMID: 16435322 DOI: 10.1002/uog.2714] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
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