Does the Finnish intervention prevent obstetric anal sphincter injuries? A systematic review of the literature

The prevention of perineal trauma during vaginal birth

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.

Prevention of obstetric anal sphincter injuries with perineal support and lateral episiotomy: A historical cohort study

INTRODUCTION

There are many risk factors for obstetric anal sphincter injury (OASIS) and the interaction between these risk factors is complex and understudied. The many observational studies that have shown a reduction of OASIS rates after implementation of perineal support have short follow-up time. We aimed to study the effect of integration of active perineal support and lateral episiotomy on OASIS rates over a 15-year period and to study interactions between risk factors known before delivery.

MATERIAL AND METHODS

We performed a historical cohort study over the periods 1999-2006 and 2007-2021 at Stavanger University Hospital, Norway. The main outcome was OASIS rates. Women without a previous cesarean section and a live singleton fetus in cephalic presentation at term were eligible. The department implemented in 2007 the Finnish concept of active perineal protection, which includes support of perineum, control of fetal expulsion, good communication with the mother and observation of perineal stretching. The practice of mediolateral episiotomy was replaced with lateral episiotomy when indicated. We analyzed the OASIS rates in groups with and without episiotomy stratified for delivery mode, fetal position at delivery and for parity, and adjusted for possible confounders (maternal age, gestational age, oxytocin augmentation and epidural analgesia).

RESULTS

We observed a long-lasting reduction in OASIS rates from 4.9% to 1.9% and an increase in episiotomy rates from 14.4% to 21.8%. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with instrumental vaginal deliveries and occiput anterior (OA) position; 3.4% vs 10.1% (OR 0.31; 95% CI: 0.24-0.40) and 6.1 vs 13.9% (OR 0.40; 95% CI: 0.19-0.82) in women with occiput posterior (OP) position. Lateral episiotomy was also associated with lower OASIS rates in nulliparous women with spontaneous deliveries and OA position; 2.1% vs 3.2% (OR 0.62; 95% CI: 0.49-0.80). The possible confounders had little confounding effects on the risk of OASIS in groups with and without episiotomy.

CONCLUSIONS

We observed a long-lasting reduction in OASIS rates after implementation of preventive procedures. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with an instrumental delivery. Special attention should be paid to deliveries with persistent OP position.

A pre-post implementation study of a care bundle to reduce perineal trauma in unassisted births conducted by midwives

PROBLEM

The perineal-bundle is a complex intervention widely implemented in Australian maternity care facilities.

BACKGROUND

Most bundle components have limited or conflicting evidence and the implementation required many midwives to change their usual practice for preventing perineal trauma.

AIM

To measure the effect of perineal bundle implementation on perineal injury for women having unassisted births with midwives.

METHODS

A retrospective pre-post implementation study design to determine rates of second degree, severe perineal trauma, and episiotomy. Women who had an unassisted, singleton, cephalic vaginal birth at term between two time periods: January 2011 - November 2017 and August 2018 - August 2020 with a midwife or midwifery student accoucheur. We conducted logistic regression on the primary outcomes to control for confounding variables.

FINDINGS

data from 20,155 births (pre-implementation) and 6273 (post-implementation) were analysed. After implementation, no significant difference in likelihood of severe perineal trauma was demonstrated (aOR 0.86, 95% CI 0.71-1.04, p = 0.124). Nulliparous women were more likely to receive an episiotomy (aOR 1.49 95% CI 1.31-1.70 p < 0.001) and multiparous women to suffer a second degree tear (aOR 1.18 95% CI 1.09-1.27 p < 0.001).

DISCUSSION

This study adds to the growing body of literature which suggests a number of bundle components are ineffective, and some potentially harmful. Why, and how, the bundle was introduced at scale without a research framework to test efficacy and safety is a key concern.

CONCLUSION

Suitably designed trials should be undertaken on all proposed individual or grouped perineal protection strategies prior to broad adoption.

The impact of a perineal care bundle on women's birth experiences in Queensland, Australia: A qualitative thematic analysis

A care bundle was introduced into 28 Australian hospitals in 2018 with the aim of reducing severe perineal tears. There has been limited research regarding the impact of this bundle on women's birth experiences.

QUESTION

How does the introduction of a perineal care bundle impact on women's birth experiences in Queensland maternity hospitals?

METHODS

We recruited 18 women who had birthed in five Queensland hospitals where the bundle had been implemented. Semi-structured, individual interviews were analysed using reflexive thematic analysis.

FINDINGS

Three descriptive themes were generated: 1) Lack of information and consent to bundle elements, 2) Other non-consented and disrespectful treatment and 3) Recommendations for hospitals and clinicians. Two analytic themes were generated: 1) Default-position: Prioritising policies over women's autonomy and 2) Counter-position: Women asserting their rights to autonomy and respect.

DISCUSSION

None of the women interviewed could recall having received information about the perineal care bundle from clinicians during pregnancy. While many women accepted that its elements were in their or their baby's best interests, this was not the case for all women. Some women reported coercive and non-consented application of bundle elements, which they found distressing.

CONCLUSION

Given the broader institutional context in which the perineal bundle was implemented, the impact on information provision, informed consent and the detrimental emotional consequences for some women arising from the bundle's implementation were largely foreseeable. The potential for bundled care initiatives to impinge on women's human rights to autonomy and respectful care should be given greater preventative attention prior to implementation.

Modifiable and non-modifiable risk factors for obstetric anal sphincter injury in a Norwegian Region: a case-control study

Background

Obstetric anal sphincter injury (OASI) is a common and severe complication of vaginal delivery and may have short- and long-term consequences, including anal incontinence, sexual dysfunction and reduced quality of life. The rate of OASI varies substantially between studies and national birth statistics, and a recent meta-analysis concluded that there is a need to identify unrecognized risk factors. Our aim was therefore to explore both potential modifiable and non-modifiable risk factors for OASI.

Methods

We performed a case–control study in a single center maternity clinic in South-Eastern Norway. Data were extracted retrospectively from an institutional birth registry. The main outcome measure was the occurrence of the woman’s first-time 3^rd or 4^th degree perineal lesion (OASI) following singleton vaginal birth after 30 weeks’ gestation. For each woman with OASI the first subsequent vaginal singleton delivery matched for parity was elected as control. The study population included 421 women with OASI and 421 matched controls who gave birth during 1990–2002. Potential risk factors for OASI were assessed by conditional logistic regression analyses.

Results

The mean incidence of OASI was 3.4% of vaginal deliveries, but it increased from 1.9% to 5.8% during the study period. In the final multivariate regression model, higher maternal age and birthweight for primiparous women, and higher birthweight for the multiparous women, were the only non-modifiable variables associated with OASI. Amniotomy was the strongest modifiable risk factor for OASI in both primi- (odds ratio [OR] 4.84; 95% confidence interval [CI] 2.60–9.02) and multiparous (OR 3.76; 95% CI 1.45–9.76) women, followed by augmentation with oxytocin (primiparous: OR 1.63; 95% CI 1.08–2.46, multiparous: OR 3.70; 95% CI 1.79–7.67). Vacuum extraction and forceps delivery were only significant risk factors in primiparous women (vacuum: OR 1.91; 95% CI 1.03–3.57, forceps: OR 2.37; 95% CI 1.14–4.92), and episiotomy in multiparous women (OR 2.64; 95% CI 1.36–5.14).

Conclusions

Amniotomy may be an unrecognized independent modifiable risk factor for OASI and should be further investigated for its potential role in preventive strategies.

Perineal Lacerations: A Retrospective Study in a Habitual-Risk Public Maternity

OBJECTIVE

 In around 85% of vaginal births, the parturients undergo perineal lacerations and/or episiotomy. The present study aimed to determine the incidence of lacerations and episiotomies among parturients in 2018 in a habitual-risk public maternity hospital in southern Brazil, and to determine the risk and protective factors for such events.

METHODOLOGY

 A retrospective cross-sectional study. Data were obtained from medical records and analyzed using the Stata software. Univariate and multivariate logistic regressions were performed. Values of p < 0.05 were considered significant.

RESULTS

 In 2018, there were 525 vaginal births, 27.8% of which were attended by obstetricians, 70.7% by obstetric nurses, and 1.5% evolved without assistance. Overall, 55.2% of the parturients had some degree of laceration. The professional who attended the birth was a significant variable: a greater number of first- and second-degree lacerations, as well as more severe cases, occurred in births attended by nurses (odds ratio [OR]: 2,95; 95% confidence interval [95%CI]: 1,74 to 5,03). Positions at birth that did not enable perineal protection techniques (expulsive period with the "hands-off" method), when analyzed in isolation, determined the risk; however, in the final regression model, this relationship was not confirmed. Although reported in the literature, there were no associations between the occurrence of laceration and age, skin color, or birth weight. In 24% of the births, episiotomy was performed, and doctors performed 63.5% of them.

CONCLUSION

 Births attended by nurses resulted in an increased risk of perineal lacerations, of varying degrees. In turn, those assisted by physicians had a higher occurrence of episiotomy.

How a perineal care bundle impacts midwifery practice in Australian maternity hospitals: A critical, reflexive thematic analysis

BACKGROUND

A care bundle to reduce severe perineal trauma (the bundle) was introduced in 28 Australian maternity hospitals in 2018. The bundle includes five components of which only one - warm perineal compresses - has highest level evidence. There is scant published research about the impact of implementation of perineal bundles.

QUESTION

How does a perineal care bundle impact midwifery practice in Australian maternity hospitals?

METHODS

Purposively sampled midwives who worked in hospitals where the bundle had been implemented. Interested midwives were recruited to participate in one-to-one, semi-structured interviews. The researchers conducted critical, reflexive thematic analysis informed by Foucauldian concepts of power.

FINDINGS

We interviewed 12 midwives from five hospitals in one state of Australia. Participants varied by age, clinical role, experience, and education. Three themes were generated: 1) bundle design and implementation 2) changing midwifery practice: obedience, subversion, and compliance; and 3) obstetric dominance and midwifery submission.

DISCUSSION

The bundle exemplifies tensions between obstetric and midwifery constructs of safety in normal birth. Participants' responses appear consistent with oppressed group behaviour previously reported in nurses and midwives. Women expect midwives to facilitate maternal autonomy yet decision-making in maternity care is commonly geared towards obtaining consent. In our study midwives encouraged women to consent or decline depending on their personal preferences.

CONCLUSION

The introduction of the perineal bundle acts as an exemplar of obstetric dominance in Australian maternity care. We recommend midwives advocate autonomy - women's and their own - by using clinical judgement, evidence, and woman-centred care.

Risk factors for perineal and vaginal tears in primiparous women - the prospective POPRACT-cohort study

Background

The aim of this study was to estimate the incidence of second-degree perineal tears, obstetric anal sphincter injuries (OASI), and high vaginal tears in primiparous women, and to examine how sociodemographic and pregnancy characteristics, hereditary factors, obstetric management and the delivery process are associated with the incidence of these tears.

Methods

All nulliparous women registering at the maternity health care in Region Örebro County, Sweden, in early pregnancy between 1 October 2014 and 1 October 2017 were invited to participate in a prospective cohort study. Data on maternal and obstetric characteristics were extracted from questionnaires completed in early and late pregnancy, from a study-specific delivery protocol, and from the obstetric record system. These data were analyzed using unadjusted and adjusted multinomial and logistic regression models.

Results

A total of 644 women were included in the study sample. Fetal weight exceeding 4000 g and vacuum extraction were found to be independent risk factors for both second-degree perineal tears (aOR 2.22 (95% CI: 1.17, 4.22) and 2.41 (95% CI: 1.24, 4.68) respectively) and OASI (aOR 6.02 (95% CI: 2.32, 15.6) and 3.91 (95% CI: 1.32, 11.6) respectively). Post-term delivery significantly increased the risk for second-degree perineal tear (aOR 2.44 (95% CI: 1.03, 5.77), whereas, maternal birth positions with reduced sacrum flexibility significantly decreased the risk of second-degree perineal tear (aOR 0.53 (95% CI 0.32, 0.90)). Heredity of pelvic floor dysfunction and/or connective tissue deficiency, induced labor, vacuum extraction and fetal head circumference exceeding 35 cm were independent risk factors for high vaginal tears (aOR 2.32 (95% CI 1.09, 4.97), 3.16 (95% CI 1.31, 7.62), 2.53 (95% CI: 1.07, 5.98) and 3.07 (95% CI 1.5, 6.3) respectively).

Conclusion

The present study corroborates previous findings of vacuum extraction and fetal weight exceeding 4000 g as risk factors of OASI. We found that vacuum extraction is a risk factor for second-degree tear, and vacuum extraction, fetal head circumference exceeding 35 cm and heredity of pelvic floor dysfunction and/or connective tissue deficiency were associated with increased risk of high vaginal tears. These findings have not been documented previously and should be confirmed by additional studies.

Regional variations in childbirth interventions and their correlations with adverse outcomes, birthplace and care provider: A nationwide explorative study

BACKGROUND

Variations in childbirth interventions may indicate inappropriate use. Most variation studies are limited by the lack of adjustments for maternal characteristics and do not investigate variations in adverse outcomes. This study aims to explore regional variations in the Netherlands and their correlations with referral rates, birthplace, interventions, and adverse outcomes, adjusted for maternal characteristics.

METHODS

In this nationwide retrospective cohort study, using a national data register, intervention rates were analysed between twelve regions among single childbirths after 37 weeks' gestation in 2010-2013 (n = 614,730). These were adjusted for maternal characteristics using multivariable logistic regression. Primary outcomes were intrapartum referral, birthplace, and interventions used in midwife- and obstetrician-led care. Correlations both between primary outcomes and between adverse outcomes were calculated with Spearman's rank correlations.

FINDINGS

Intrapartum referral rates varied between 55-68% (nulliparous) and 20-32% (multiparous women), with a negative correlation with receiving midwife-led care at the onset of labour in two-thirds of the regions. Regions with higher referral rates had higher rates of severe postpartum haemorrhages. Rates of home birth varied between 6-16% (nulliparous) and 16-31% (multiparous), and was negatively correlated with episiotomy and postpartum oxytocin rates. Among midwife-led births, episiotomy rates varied between 14-42% (nulliparous) and 3-13% (multiparous) and in obstetrician-led births from 46-67% and 14-28% respectively. Rates of postpartum oxytocin varied between 59-88% (nulliparous) and 50-85% (multiparous) and artificial rupture of membranes between 43-52% and 54-61% respectively. A north-south gradient was visible with regard to birthplace, episiotomy, and oxytocin.

CONCLUSIONS

Our study suggests that attitudes towards interventions vary, independent of maternal characteristics. Care providers and policy makers need to be aware of reducing unwarranted variation in birthplace, episiotomy and the postpartum use of oxytocin. Further research is needed to identify explanations and explore ways to reduce unwarranted intervention rates.

Third- and fourth-degree tears: A review of the current evidence for prevention and management

BACKGROUND

Third- and fourth-degree tears are associated with significant pain, discomfort and impact on quality of life and intimate relationships. Australian women experience comparatively higher rates of third- and fourth-degree tears relative to countries of similar economic development.

AIMS

We aimed to conduct a comprehensive review of the literature, published over the past five years, to identify the best ways to prevent and manage third- and fourth-degree perineal tears in Australian maternity centres.

MATERIALS AND METHODS

We searched the literature using the Cochrane Database of Systematic Reviews, EMBASE, MEDLINE, Maternity and Infant Care Database and Google Scholar for articles published since 2013 using key search terms. A review of reviews was undertaken given the extensive amount of literature on this topic.

RESULTS

Twenty-six systematic reviews were identified. The most common risk factors reported in the literature for third- and fourth-degree tears included primiparity, mother's ethnicity, large for gestational age infants and certain interventions used in labour and birth, such as instrumental deliveries. Preventive practices with varying degrees of effectiveness and often dependant on parity included: antenatal perineal massage, different maternal birthing positions, water births, warm compresses, protection of the perineum and episiotomy for instrumental births.

CONCLUSIONS

Third- and fourth-degree perineal tears are associated with immediate and long-term implications for women and health systems. Evidence-based approaches can reduce the number of women who sustain a severe perineal tear and alleviate the associated disease burden for those who do.

The effects of a severe perineal trauma prevention program in an Australian tertiary hospital: An observational study

BACKGROUND

Severe perineal trauma during childbirth is associated with significant morbidity and rates internationally, are on the rise.

AIMS

To determine the impact of a prevention program on severe perineal trauma in a nulliparous population at a tertiary hospital in Australia.

METHODS

Routinely collected maternity data were used comparing outcomes in two time periods; two years before and two years after the introduction of the program. Categorical data were compared using the Chi Squared statistic and continuous data Student's t-test. Logistic regression examined the association between independent and dependent variables using unadjusted and adjusted odds ratios, with 95% confidence intervals and p -values with significance set at 0.05. The main outcome of interest is severe perineal trauma.

RESULTS

The proportion of women in this nulliparous population experiencing severe perineal trauma during vaginal birth decreased from 8.8% in the first time period to 5.6% in the second. Reductions were achieved in all modes of vaginal birth but were most pronounced in vacuum births. Rates of episiotomy increased between time periods and further analysis found that this was protective of severe perineal trauma in all modes of birth for women of Asian country of birth and only in forceps birth for non-Asian women. Factors found to contribute to severe perineal trauma in this population were Asian country of birth, neonatal weight ≥4000gm, forceps birth and maternal age.

CONCLUSIONS

The prevention program is associated with reduced rates of severe perineal trauma. The challenge for the service is to maintain this positive change.

Incidence and risk factors for obstetric anal sphincter ruptures, OASIS, following the introduction of preventive interventions. A retrospective cohort study from a Norwegian hospital 2012-2017

OBJECTIVE

A decrease of obstetric anal sphincter injuries (OASIS) was observed after preventive interventions were implemented at a Norwegian university hospital. The aim was to investigate whether the improvement had sustained over the following years.

MATERIALS AND METHODS

We performed a retrospective cohort study of 18 258 singleton vaginal cephalic births, ≥37 + 0 weeks of gestation during 2012-2017, examining data from the hospital's birth journals and separate registration forms. Interventions to prevent OASIS were implemented in 2011, and training in practical skills was repeated each year.

MAIN OUTCOME MEASURES

The main outcome was OASIS (n = 377).

RESULTS

Frequency of OASIS overall decreased from 3.6% prior to 2011 to 2.1% after the intervention and sustained at that level throughout the study period. A trend of fewer OASIS among spontaneous deliveries, decreasing from 2.1% to 1.2% (p = 0.01) was observed, but no trend was seen for instrumental deliveries (p = 0.37), where the incidence fluctuated between 4.0% and 9.3% with an average of 6.5%. Primiparity, increased maternal age and increased fetal head circumference were associated with more OASIS in spontaneous deliveries. In instrumental deliveries, primiparity, occiput posterior position and increased fetal head circumference were associated with more OASIS, whilst episiotomy was associated with fewer OASIS.

CONCLUSION

The incidence of obstetric anal sphincter injuries maintained at a similar level of around 2.1% during the six following years after introducing preventive interventions. Regularly repetition and practical training seemed to be effective.

Severe perineal trauma among women undergoing vaginal birth after cesarean delivery: A population-based cohort study

BACKGROUND

To examine risk of severe perineal trauma among nulliparous women and those undergoing vaginal birth after cesarean delivery (VBAC).

METHODS

This is a population-based cohort study of all births to women with their two first consecutive singleton pregnancies in Stockholm-Gotland Sweden between 2008 and 2014. Risk of severe perineal trauma was compared between nulliparous women and those undergoing VBAC with severe perineal trauma being the main outcome measure. Associations between indication and timing of primary cesarean delivery and risk of severe perineal trauma in subsequent vaginal birth were analyzed using Poisson regression analysis.

RESULTS

The rate of severe perineal trauma among nulliparous women and those undergoing VBAC was 7.0% and 12.3%, respectively. Compared with nulliparous women, those undergoing VBAC were significantly older, had a shorter stature, and gave birth in a non-upright position to heavier infants with larger head circumferences. The rate of instrumental vaginal delivery among nulliparous women and those undergoing VBAC was 19.3% and 20.2%, respectively (P = 0.331). An increased risk of severe perineal trauma remained after adjustments among those undergoing VBAC (adjusted risk ratio 1.42, 95% CI 1.23-1.63). Level of risk was not associated with indication (dystocia or signs of fetal distress) of primary cesarean delivery, nor how far the woman had progressed in labor (fully dilated versus planned cesarean delivery) before delivering by cesarean.

CONCLUSIONS

Compared with nulliparous women, those undergoing VBAC are at increased risk of severe perineal trauma, irrespective of indication and timing of primary cesarean delivery.

Effects of an intervention program for reducing severe perineal trauma during the second stage of labor

BACKGROUND

Obstetric anal sphincter injuries lead frequently to short- and long-term consequences for the mother, including perineal pain, genital prolapse, and sexual problems. The aim of the study was to evaluate whether the implementation of an intervention program in the second stage of labor involving altered perineal support techniques reduced severe perineal trauma.

METHODS

All women reaching the second stage of labor and giving birth vaginally to singleton babies at Landspítali University Hospital (comprising 76% of births in Iceland in 2013) were enrolled in a cohort study. Data were recorded retrospectively for 2008-2010 and prospectively in 2012-2014, for a total of 16 336 births. During 2011, an intervention program was implemented, involving all midwives and obstetricians working in the labor wards. Two professionals assessed and agreed on classification of every perineal tear.

RESULTS

The prevalence of obstetric anal sphincter injuries decreased from 5.9% to 3.7% after the implementation (P < 0.001). Third-degree tears decreased by 40%, and fourth-degree tears decreased by 56% (P < 0.001). The prevalence of first-degree tears increased from 25.8% to 33.1%, whereas second-degree tears decreased from 44.7% to 36.6% between the before and after study periods. Severe perineal trauma was linked to birthweight, and this did not change despite the new intervention.

CONCLUSIONS

Active intervention to reduce perineal trauma was associated with an overall significant decrease in obstetric anal sphincter injuries. Good perineal visualization, manual perineal support, and controlled delivery of the fetal head were essential components for reducing perineal trauma.

Coaching a slow birth with the woman in an empowered position may be less harmful than routine hands-on practice to protect against severe tears in birth - A discussion paper

BACKGROUND

Different hands-on interventions to protect women from severe perineal tears after birth have been widely implemented. Evidence to support the routine use of hands-on interventions to reduce severe tears is mainly based on aggregated data from observational studies.

AIM

To critically discuss the current evidence for the implementation of hands-on intervention as a routine practice to protect women from severe tears after birth.

DISCUSSION

Observational studies have been used to justify the routine use of hands-on intervention to protect women from severe perineal tears despite randomized controlled trials and systematic reviews showing lack of benefit. There is strong evidence supporting the slow speed at the time of birth to prevent severe perineal tears. While hands-on intervention does reduce the speed of birth, it may have a negative effect on the birth process, on neonatal outcomes and women's agency.

CONCLUSION

Evidence-based practice requires sufficient evaluation of interventions before being implemented in clinical practice as well as valuing the level of evidence when making clinical decisions. Evaluation of hands-on interventions to protect women from severe perineal tears must include not just one outcome of interest, but also an assessment of how the intervention interferes with the normal mechanism of birth, and how it affects neonatal outcomes and the autonomy of women.

"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

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.

[Fetal expulsion: Which interventions for perineal prevention? CNGOF Perineal Prevention and Protection in Obstetrics Guidelines]

OBJECTIVE

The objective for all obstetricians and midwifes who intervene during the release of the fetal presentation is to prevent at best the perineal lesions. This work consisted in analyzing the literature, researching and evaluating interventions that reduce this perineal risk during the release.

METHODS

A keyword search for each medical intervention during the expulsion phase was conducted by selecting studies assessing perineal risk. Interventions during pregnancy and during delivery before the expulsion phase were specifically addressed in other sections of the recommendations.

RESULTS

Firstly, the degree of perineal stretching during the second stage of labour does not appear to be a risk factor for OASIS, postpartum incontinence, or sexual disorders (LE3) and that a substantial stretching of the perineum is not an indication of episiotomy (Professional consensus). Then, manual control of the expulsion of the fetus at the end of the second stage of labour and support of the posterior perineum during this time appear to reduce the rate of OASIS (LE3). The crowning of the baby's head should be manually controlled and the posterior perineum manually supported manually to reduce the risk of OASIS (GradeC). There is no recognised benefit to episiotomy in normal deliveries (LE1); the liberal practice of episiotomy results in fewer intact perineums than its restrictive practice, and the latter does not result in increasing the number of cases of OASIS. No evidence indicates that an episiotomy for women with a breech presentation, twin pregnancy, or posterior position prevents OASIS (LE3). Indication for episiotomy during delivery depends on individual risk factors and obstetric conditions (Professional consensus). It is recommended that the indication for episiotomy be explained and the woman's consent received before its performance. The performance of an episiotomy during normal deliveries is not recommended to reduce the risk of OASIS (Grade A). The liberal practice of episiotomy to prevent OASIS is not recommended for women with a breech presentation, twin pregnancy, or posterior position (GradeC). Episiotomy during an instrumental delivery appears to be associated with a reduction of the risk of OASIS (LE3). The vacuum extractor appears to induce fewer cases of OASIS than other instruments (LE3). Episiotomy may be indicated in instrumental deliveries to avoid OASIS (GradeC). Training in perineal protection in obstetrics is recommended (Grade B). In operative vaginal deliveries when several instruments can be used, a vacuum extractor is preferentially recommended to reduce the risk of OASIS (GradeC). When forceps or spatulas are used, it is preferable that they be withdrawn just before cephalic deflexion so that the fetal head is not "capped" with these instruments at birth (Professional consensus). Couder's maneuver, which consists of lowering the forearm during the release of the fetal shoulders, appears to decrease the rate of second-degree perineal tears and increase the rate of intact perineum (LE3).

CONCLUSION

Manual control of the expulsion and perineal support reduce the risk of perineal injury. There is no benefit to episiotomy in normal delivery, nor in special cases such the breech presentation for example. On the other hand, in case of instrumental delivery, an episiotomy may be indicated to avoid OASIS (GradeC), and it is recommended if it is possible to use the ventouse preferentially. The Couder's maneuver seems to reduce the rate of 2^nd degree perineal lesions (LE3). Finally, training in perineal obstetric protection is recommended (Grade B).

Long-term outcomes of the Stop Traumatic OASI Morbidity Project (STOMP)

OBJECTIVE

To evaluate long-term sustainability of the Stop Traumatic OASI Morbidity Project (STOMP) in reducing the incidence of obstetric anal sphincter injury (OASI).

METHODS

A prospective observational study of women undergoing vaginal delivery at a UK district general hospital between September 1, 2014, and February 28, 2017. The principles of STOMP involve encouraging upright positioning, verbal coaching to avoid expulsive pushing and to slow down delivery, and tactile support to the vertex to judge speed and slow down delivery. After a training period, STOMP was implemented for all vaginal deliveries. Clinical and demographic data on women affected by OASI were collected across a 30-month period. The primary outcome measure was the incidence of OASI.

RESULTS

There were 8782 vaginal deliveries during the 30-month period after implementation of STOMP. There was a significant decrease in the mean incidence of OASI relative to the 9 months before implementation (P<0.001). There was a significant decrease in the incidence of OASI for both spontaneous vaginal and instrumental deliveries (both P<0.05). There was no change in the frequency of episiotomy.

CONCLUSIONS

Implementation of STOMP led to a significant decrease in OASI, confirming the sustainability of this approach to improve outcomes.

A qualitative exploration of techniques used by expert midwives to preserve the perineum intact

BACKGROUND

The perineum stretches during birth to allow passage of the baby, but 85% of women sustain some degree of perineal trauma during childbirth, which is painful post-partum. Episiotomy rates vary significantly, with some countries having rates of >60%. Recent Irish and New Zealand studies showed lower severe perineal trauma and episiotomy rates than other countries.

AIM

To explore expert Irish and New Zealand midwives' views of the skills that they employ in preserving the perineum intact during spontaneous vaginal birth.

METHODS

Following ethical approval a qualitative, descriptive study was undertaken. Semi-structured, recorded, interviews were transcribed and analysed using the constant comparative method. Expert midwives employed in New Zealand and one setting in Ireland, were invited to join the study. "Expert" was defined as achieving, in the preceding 3.5 years, an episiotomy rate for nulliparous women of <11.8%, a 'no suture' rate of 40% or greater, and a severe perineal tear rate of <3.2%. Twenty-one midwives consented to join the study.

RESULTS

Four core themes emerged: 'Calm, controlled birth', 'Position and techniques in early second stage', 'Hands on or off?' and 'Slow, blow and breathe the baby out.' Using the techniques described enabled these midwives to achieve rates, in nulliparous women, of 3.91% for episiotomy, 59.24% for 'no sutures', and 1.08% for serious lacerations.

CONCLUSIONS

This study provides further understanding of the techniques used by expert midwives at birth. These findings, combined with existing quantitative research, increases the evidence on how to preserve the perineum intact during spontaneous birth.

Factors associated with obstetric anal sphincter injuries in midwife-led birth: A cross sectional study

INTRODUCTION

Obstetric anal sphincter injurie (OASI) in vaginal births are a serious complication, and are associated with maternal morbidity. Focus on modifiable factors in midwives clinical skills and competences contributing to prevent the occurrence of OASI are essential. The objective of this study was to investigate the association between OASI and factors related to midwife-led birth such as manual support of perineum, active delivery of baby's shoulders, maternal birth position, and pushing and breathing techniques in second stage of labour.

METHODS

A prospective cross sectional study including primiparous (n = 129) and multiparous (n = 628) women in midwife-led non-instrumental deliveries with OASI (n = 96) or intact perineum (n = 661). Data were collected in a university hospital in Norway with two different birth settings: an alongside midwife-led unit with approximately 1500 births per year and an obstetrical unit with approximately 3500 births per year. In midwife-led births, there were a total of 2.6% OASI and 18.9% intact perineum.

RESULTS

The sample consisted of 757 women, 12.7% suffered OASI and 87.3% of participating women had an intact perineum. This selected sample compares the most serious outcome (OASI), and the optimal outcome (intact perineum).In primiparous women, 61 women suffered OASI and 68 women had intact perineum, while for multipara women, 35 women suffered OASI and 593 women had intact perineum. There was an increased risk of OASI if women actively pushed when the head was crowning compared to breathing the head out (adjusted OR: 3.10; 95% CI: 1.75 to 5.47). The maternal birth position associated with the lowest risk of OASI was kneeling position (adjusted OR: 0.15; 95% CI: 0.03 to 0.70), supine maternal birth position (adjusted OR: 2.52; 95% CI: 1.04 to 4.90) and oxytocin augmentation more than 30 min in second stage (OR: 1.93; 95% CI: 1.68 to 15.63) were associated with an increased risk of OASI, when adjusting for maternal, foetal, and obstetric factors.

CONCLUSION

Our study suggests that actively pushing when the baby's head is crowning, a supine maternal birth position and oxytocin augmentation more than 30 min in second stage, were associated with increased risk of OASI when compared to intact perineum. A kneeling maternal birth position was associated with a decreased risk of OASI.

Modified Ritgen Maneuver in Perineal Protection - Sixty-Year Experience

SUMMARY – The aim is to present the 60-year experience in modified Ritgen maneuver according to perineal injuries. This retrospective clinical observational study (1950-2010) analyzed the impact of modified Ritgen maneuver delivery technique (controlled fetal head deflexion with left hand and synchronous reduction of perineal strain with extended right hand thumb along the right side of the vulva and perineum without pushing) on peripartum perineal tears at the Maternity Ward, Bjelovar General Hospital in Bjelovar, Croatia, divided into five-year intervals. The rate of perineal tear in general was less than 5% until 2000. The rate of perineal tear grade I was very low until 1995, then increased to 8.6% in 2010, yet never exceeding 10%. The rate of perineal tear grade II never exceeded 2%, whereas perineal tear grade III was a sporadic event never exceeding 0.4% of the study material with a single case of grade IV tear. The rate of intact perineum in vaginal deliveries without episiotomy ranged from 96.2% to 100% in the 1950-1960 period, with a decrease to 46% in 2010. The study revealed the modification of Ritgen maneuver described to have resulted in significant reduction of all grades of perineal tear over decades.

[Anal incontinence and obstetrical anal sphincter injuries, epidemiology and prevention]

Our main objectives were to identify risk factors, methods for early diagnosis, and prevention of obstetric anal sphincter injuries (OASIs), using a literature review. The main risk factors for OASIs are nulliparity, instrumental delivery, posterior presentation, median episiotomy, prolonged second phase of labor and fetal macrosomia. Asian origin, short ano-vulvar distance, ligamentous hyperlaxity, lack of expulsion control, non-visualization of the perineum or maneuvers for shoulder dystocia also appear to be risk factors. There is a risk of under-diagnosis of OASIs in the labor ward. Experience of the accoucheur is a protective factor. Secondary prevention is based on the training of birth professionals in recognition and repair of OASIs. Primary prevention of OASIs is based on training in the maneuvers of the second phase of labor; if possible, instrumental extractions should be avoided. Mediolateral episiotomy may have a preventive role in high-risk OASIs deliveries. A robust predictive model is still lacking to allow a selective use of episiotomy.

Teaching childbirth with high-fidelity simulation. Is it better observing the scenario during the briefing session?

The design of optimal courses for obstetric undergraduate teaching is a relevant question. This study evaluates two different designs of simulator-based learning activity on childbirth with regard to respect to the patient, obstetric manoeuvres, interpretation of cardiotocography tracings (CTG) and infection prevention. This randomised experimental study which differs in the content of their briefing sessions consisted of two groups of undergraduate students, who performed two simulator-based learning activities on childbirth. The first briefing session included the observations of a properly performed scenario according to Spanish clinical practice guidelines on care in normal childbirth by the teachers whereas the second group did not include the observations of a properly performed scenario, and the students observed it only after the simulation process. The group that observed a properly performed scenario after the simulation obtained worse grades during the simulation, but better grades during the debriefing and evaluation. Simulator use in childbirth may be more fruitful when the medical students observe correct performance at the completion of the scenario compared to that at the start of the scenario. Impact statement What is already known on this subject? There is a scarcity of literature about the design of optimal high-fidelity simulation training in childbirth. It is known that preparing simulator-based learning activities is a complex process. Simulator-based learning includes the following steps: briefing, simulation, debriefing and evaluation. The most important part of high-fidelity simulations is the debriefing. A good briefing and simulation are of high relevance in order to have a fruitful debriefing session. What do the results of this study add? Our study describes a full simulator-based learning activity on childbirth that can be reproduced in similar facilities. The findings of this study add that high-fidelity simulation training in childbirth is favoured by a short briefing session and an abrupt start to the scenario, rather than a long briefing session that includes direct instruction in the scenario. What are the implications of these findings for clinical practice and/or further research? The findings of this study reveal what to include in the briefing of simulator-based learning activities on childbirth. These findings have implications in medical teaching and in medical practice.

Risk of obstetric anal sphincter injury increases with maternal age irrespective of parity: a population-based register study

Background

Obstetric anal sphincter injury (OASI) is a rare but serious outcome of vaginal birth. Based on concerns about the increasing number of women who commence childbearing later than previous generation, this study aimed at investigating age-related risk of OASI in women of different parity.

Methods

A population-based register study including 959,559 live singleton vaginal births recorded in the Swedish Medical Birth Register 1999 to 2011. In each parity group risks of OASI at age 25–29 years, 30–34 years, and ≥35 years compared with age < 25 years were investigated by logistic regression analyses, adjusted for year of birth, education, region of birth, smoking, Body Mass Index, infant birthweight and fetal presentation; and in parous women, history of OASI and cesarean section. Additional analyses also adjusted for mediating factors, such as epidural analgesia, episiotomy, and instrumental delivery, and maternal age-related morbidity.

Results

Rates of OASI were 6.6%, 2.3% and 0.9% in first, second and third births respectively. Age-related risk increased from 25-29 years in first births (Adjusted OR 1.66; 95% CI 1.59–1.72) and second births (Adjusted OR 1.78; 95% CI 1.58–2.01), and from 30-34 years in third births (Adjusted OR 1.60; 95% CI 1.00–2.56). In all parity groups the risk was doubled at age ≥ 35 years, compared with the respective reference group of women under 25 years. Adding mediating factors and maternal age-related morbidity only marginally reduced these risk estimates.

Conclusion

Maternal age is an independent risk factor for OASI in first, second and third births. Although age-related risks by parity are relatively similar, more nulliparous than parous women will be exposed to OASI due to the higher baseline rate.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1473-7) contains supplementary material, which is available to authorized users.

Risk factors for obstetric anal sphincter injuries (OASI) at a tertiary centre in south India

INTRODUCTION AND HYPOTHESIS

Despite several studies that have reported risk factors for obstetric anal sphincter injuries (OASI), data from the Indian subcontinent are scarce. The purpose of this study was to identify risk factors for these sphincter injuries in an Indian population.

METHODS

This was a case-control study within a retrospective cohort of vaginal deliveries at a tertiary care facility. All vaginal births beyond 24 completed weeks of gestation and birth weight ≥500 g from January 2008 to December 2012 were identified from the hospital electronic database. Cases were women with OASI sustained during vaginal delivery; the rest constituted controls. Potential risk factors for occurrence and severity of OASI were assessed initially using bivariate analysis and then a logistic regression model.

RESULTS

The incidence of sphincter injury was 2.1% of vaginal births and 1.1% of all deliveries, and major-degree (3c and 4th-degree) tears constituted 20.9% of tears. After adjusted analysis, significant predictors for injury included primiparity, delivery at or beyond 41 weeks of gestation, epidural analgesia, instrumental delivery, shoulder dystocia, birth weight ≥4000 g, and head circumference ≥35 cm. Episiotomy protected against sphincter injuries, particularly in forceps and ventouse deliveries. Shoulder dystocia was significantly associated with major-degree tears, while episiotomy appeared to be protective.

CONCLUSION

Risk factors are similar to those in other population groups; however, primiparity appears to be associated with lesser risk and forceps delivery with greater risk of sphincter trauma than previously reported.

Midwives' Management during the Second Stage of Labor in Relation to Second-Degree Tears-An Experimental Study

INTRODUCTION

Most women who give birth for the first time experience some form of perineal trauma. Second-degree tears contribute to long-term consequences for women and are a risk factor for occult anal sphincter injuries. The objective of this study was to evaluate a multifaceted midwifery intervention designed to reduce second-degree tears among primiparous women.

METHODS

An experimental cohort study where a multifaceted intervention consisting of 1) spontaneous pushing, 2) all birth positions with flexibility in the sacro-iliac joints, and 3) a two-step head-to-body delivery was compared with standard care. Crude and Adjusted OR (95% CI) were calculated between the intervention and the standard care group, for the various explanatory variables.

RESULTS

A total of 597 primiparous women participated in the study, 296 in the intervention group and 301 in the standard care group. The prevalence of second-degree tears was lower in the intervention group: [Adj. OR 0.53 (95% CI 0.33-0.84)]. A low prevalence of episiotomy was found in both groups (1.7 and 3.0%). The prevalence of epidural analgesia was 61.1 percent. Despite the high use of epidural analgesia, the midwives in the intervention group managed to use the intervention.

CONCLUSION

It is possible to reduce second-degree tears among primiparous women with the use of a multifaceted midwifery intervention without increasing the prevalence of episiotomy. Furthermore, the intervention is possible to employ in larger maternity wards with midwives caring for women with both low- and high-risk pregnancies.