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Bergendahl S, Jonsson M, Hesselman S, Ankarcrona V, Leijonhufvud Å, Wihlbäck AC, Wallström T, Rydström E, Friberg H, Kopp Kallner H, Brismar Wendel S. Lateral episiotomy or no episiotomy in vacuum assisted delivery in nulliparous women (EVA): multicentre, open label, randomised controlled trial. BMJ 2024; 385:e079014. [PMID: 38886011 PMCID: PMC11307825 DOI: 10.1136/bmj-2023-079014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/20/2024]
Abstract
OBJECTIVE To assess the effect of lateral episiotomy, compared with no episiotomy, on obstetric anal sphincter injury in nulliparous women requiring vacuum extraction. DESIGN A multicentre, open label, randomised controlled trial. SETTING Eight hospitals in Sweden, 2017-23. PARTICIPANTS 717 nulliparous women with a single live fetus of 34 gestational weeks or more, requiring vacuum extraction were randomly assigned (1:1) to lateral episiotomy or no episiotomy using sealed opaque envelopes. Randomisation was stratified by study site. INTERVENTION A standardised lateral episiotomy was performed during the vacuum extraction, at crowning of the fetal head, starting 1-3 cm from the posterior fourchette, at a 60° (45-80°) angle from the midline, and 4 cm (3-5 cm) long. The comparison was no episiotomy unless considered indispensable. MAIN OUTCOME MEASURES The primary outcome of the episiotomy in vacuum assisted delivery (EVA) trial was obstetric anal sphincter injury, clinically diagnosed by combined visual inspection and digital rectal and vaginal examination. The primary analysis used a modified intention-to-treat population that included all consenting women with attempted or successful vacuum extraction. As a result of an interim analysis at significance level P<0.01, the primary endpoint was tested at 4% significance level with accompanying 96% confidence interval (CI). RESULTS From 1 July 2017 to 15 February 2023, 717 women were randomly assigned: 354 (49%) to lateral episiotomy and 363 (51%) to no episiotomy. Before vacuum extraction attempt, one woman withdrew consent and 14 had a spontaneous birth, leaving 702 for the primary analysis. In the intervention group, 21 (6%) of 344 women sustained obstetric anal sphincter injury, compared with 47 (13%) of 358 women in the comparison group (P=0.002). The risk difference was -7.0% (96% CI -11.7% to -2.5%). The risk ratio adjusted for site was 0.47 (96% CI 0.23 to 0.97) and unadjusted risk ratio was 0.46 (0.28 to 0.78). No significant differences were noted between groups in postpartum pain, blood loss, neonatal outcomes, or total adverse events, but the intervention group had more wound infections and dehiscence. CONCLUSIONS Lateral episiotomy can be recommended for nulliparous women requiring vacuum extraction to significantly reduce the risk of obstetric anal sphincter injury. TRIAL REGISTRATION ClinicalTrials.gov NCT02643108.
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Affiliation(s)
- Sandra Bergendahl
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Maria Jonsson
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Susanne Hesselman
- Department of Women's and Children's Health, Centre for Clinical Research Dalarna, Falun, Sweden
| | - Victoria Ankarcrona
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Åsa Leijonhufvud
- Department of Clinical Science Helsingborg, Lund University, Helsingborg, Sweden
| | - Anna-Carin Wihlbäck
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, Umeå, Sweden
| | - Tove Wallström
- Department of Clinical Science and Education, South General Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Emmie Rydström
- Department of Obstetrics and Gynecology, Växjö Central Hospital, Växjö, Sweden
| | - Hanna Friberg
- Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Göteborg, Sweden
| | - Helena Kopp Kallner
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | - Sophia Brismar Wendel
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
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Ratiu D, Hayder AQ, Gilman E, Ludwig S, Ratiu J, Mallmann-Gottschalk N, Mallmann P, Gruttner B, Baek S. Shifting Trends in Obstetrics: An 18-year Analysis of Low-risk Births at a German University Hospital. In Vivo 2024; 38:390-398. [PMID: 38148051 PMCID: PMC10756433 DOI: 10.21873/invivo.13451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 08/28/2023] [Accepted: 08/29/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND/AIM At the beginning of the 21st century, obstetric medicine took a turn from interventional to restrictive in low-risk birth. The present study examined the changes in peripartum management over the past 20 years at the Women's University Hospital Cologne. The attitudes of the becoming mother and physicians towards anesthesia, episiotomy, and vaginal-operative deliveries were compared and the factors influencing the duration of birth over the past 20 years were examined. PATIENTS AND METHODS In this retrospective study, the low-risk singleton birth of 955 in 2000/2001 and 944 births in 2018 at the Women's University Hospital Cologne were analyzed. RESULTS The age of women who tended to give birth has significantly increased at present compared to 20 years ago. In 2018, labor was induced significantly more often than in 2000/2001. The rate of vaginal operative deliveries has fluctuated between 15% and 20% in the last 20 years. Forceps are no longer used. The use of episiotomy has taken a fundamental turn in the last 20 years. Prophylactic episiotomy is not performed anymore, most vaginal operative deliveries take place without the episiotomy. The birth duration has been significantly shortened at present compared to 20 years ago. CONCLUSION Pregnancy and childbirth over the last years are not considered as a disease, but as a natural course, and the trend of minimizing interventions in low-risk delivery has a positive effect on childbirth.
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Affiliation(s)
- Dominik Ratiu
- Department of Obstetrics and Gynecology, University Hospital Cologne and Medical Faculty, Cologne, Germany
| | - Al-Qaddo Hayder
- Department of Obstetrics and Gynecology, University Hospital Cologne and Medical Faculty, Cologne, Germany
| | - Elena Gilman
- Department of Obstetrics and Gynecology, University Hospital Cologne and Medical Faculty, Cologne, Germany
| | - Sebastian Ludwig
- Department of Obstetrics and Gynecology, University Hospital Cologne and Medical Faculty, Cologne, Germany
| | - Jessika Ratiu
- Department of Obstetrics and Gynecology, University Hospital Cologne and Medical Faculty, Cologne, Germany
| | - Nina Mallmann-Gottschalk
- Department of Obstetrics and Gynecology, University Hospital Cologne and Medical Faculty, Cologne, Germany
| | - Peter Mallmann
- Department of Obstetrics and Gynecology, University Hospital Cologne and Medical Faculty, Cologne, Germany
| | - Berthold Gruttner
- Department of Obstetrics and Gynecology, University Hospital Cologne and Medical Faculty, Cologne, Germany
| | - Sunhwa Baek
- Department of Obstetrics and Gynecology, University Hospital Cologne and Medical Faculty, Cologne, Germany
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Brismar Wendel S, Liu C, Stephansson O. The association between episiotomy or OASIS at vacuum extraction in nulliparous women and subsequent prelabor cesarean delivery: A nationwide observational study. Acta Obstet Gynecol Scand 2023; 102:378-388. [PMID: 36691864 PMCID: PMC9951312 DOI: 10.1111/aogs.14513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 12/28/2022] [Accepted: 01/02/2023] [Indexed: 01/25/2023]
Abstract
INTRODUCTION Severe perineal injuries at childbirth affect women's postnatal health, including future childbirths. First births with vacuum extraction carry an increased risk of obstetric anal sphincter injuries (OASIS). Lateral or mediolateral episiotomy at vacuum extraction may decrease the risk of OASIS. Our aim was to assess whether lateral or mediolateral episiotomy, or OASIS, at vacuum extraction in nulliparous women is associated with prelabor cesarean delivery in the subsequent childbirth. MATERIAL AND METHODS This is a nationwide observational study using data from the Swedish Medical Birth Register, including women having a first birth with vacuum extraction and a second birth in 2000-2014. Both births were live, single, cephalic, ≥34 gestational weeks without malformations. The association between episiotomy or OASIS in the first birth and prelabor cesarean delivery in the second birth was examined using univariate and multivariate logistic regression with inverse probability of treatment weighting, and interaction analysis. Main outcome measure was prelabor cesarean delivery in the second birth. RESULTS In total, 44 656 women with vacuum extraction at their first birth were included. The rate of prelabor cesarean delivery in the second birth was 5.9% (824 of 13 950) in women with episiotomy, compared with 6.0% (1830 of 30 706) in women without episiotomy. Thus, women with episiotomy did not have an increased risk of prelabor cesarean delivery (adjusted odds ratio [aOR] 1.00, 95% confidence interval [95% CI] 0.83-1.20) compared with women without episiotomy. For comparison, the rate of prelabor cesarean delivery in the second birth was 20.6% (1275 of 6176) in women with OASIS, compared with 3.6% (1379 of 38 480) in women without OASIS (aOR 6.57, 95% CI 5.97-7.23). There was no interaction between episiotomy and OASIS. CONCLUSIONS Lateral or mediolateral episiotomy at vacuum extraction in nulliparous women did not increase the risk of prelabor cesarean delivery in the subsequent childbirth. OASIS increased the odds of prelabor cesarean delivery more than sixfold.
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Affiliation(s)
- Sophia Brismar Wendel
- Department of Clinical SciencesKarolinska Institutet, Danderyd HospitalStockholmSweden,Department of Women's HealthDanderyd HospitalStockholmSweden,Clinical Epidemiology Division, Department of MedicineKarolinska InstitutetStockholmSweden
| | - Can Liu
- Clinical Epidemiology Division, Department of MedicineKarolinska InstitutetStockholmSweden,Department of Public Health SciencesStockholm UniversityStockholmSweden,Centre for Health Equity Studies (CHESS)Stockholm University/Karolinska InstitutetStockholmSweden
| | - Olof Stephansson
- Clinical Epidemiology Division, Department of MedicineKarolinska InstitutetStockholmSweden,Department of Women's Health, Division of ObstetricsKarolinska University HospitalStockholmSweden
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Effect of Dry Heat Application on Perineal Pain and Episiotomy Wound Healing among Primipara Women. Obstet Gynecol Int 2023; 2023:9572354. [PMID: 36643188 PMCID: PMC9833924 DOI: 10.1155/2023/9572354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 10/11/2022] [Accepted: 11/21/2022] [Indexed: 01/06/2023] Open
Abstract
Background Women who undergo perineal episiotomy can be affected by several complications such as bleeding, infection, perineal pain, dyspareunia, reduction of sexual desire, as well as urinary and anal incontinence. Perineal pain related to episiotomy has been reported to interfere with women's daily activities postpartum and can prevent proper breastfeeding, proper rooming-in, and maternal-infant bonding. The purpose of this study was to determine the effect of dry heat application on perineal pain and episiotomy wound Healing among primipara women. Method A quasi-experimental, two-group, pre-post-test research study was conducted at the postnatal inpatient ward and the outpatient clinic of the El-Shatby Maternity University Hospital in Alexandria. A sample of 100 parturient women was divided into the following two groups at random: dry heat and moist (control) heat. Women in the moist heat group were advised to sit in a basin (tub) of warm water for 10 minutes, while those in the dry heat group were instructed to set an infrared light (230 volts) at a distance of 45 cm from the perineum after 12 hours post episiotomy. Both interventions were applied twice a day for ten consecutive days. They evaluated the severity of their perineal pain at baseline and repeated it on the 5th and 10th days after obtaining the interventions while the episiotomy wound healing was assessed on the 5th and 10th days. Results It was discovered that the dry heat group had a significantly improved episiotomy wound healing as regards perineal redness, edema of the perineal area, ecchymosis, wound discharge, and approximation of wound edges on the 5th (P < 0.001, P < 0.001, P < 0.007, P < 0.003, and P < 0.001, respectively) and 10th day after intervention (P < 0.001, P < 0.001, P < 0.001, P < 0.005, and P < 0.001, respectively) than the moist heat group. The primipara women had significantly lower perineal pain intensity in the dry heat group on the 5th and 10th days after intervention than in the moist heat group (MH P < 0.001 for the dry heat group and MH P = 0.004 for the moist heat group). Conclusion The application of dry heat promoted episiotomy wound healing among primipara women and reduced their perineal pain during early postpartum days than moist heat.
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Jia Y, Liu Q, Zeng L, Wang Y. Risk factors accounting for anal incontinence during the first year after vaginal delivery-A case control study in China. Front Med (Lausanne) 2023; 10:1073073. [PMID: 37200962 PMCID: PMC10187753 DOI: 10.3389/fmed.2023.1073073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 04/11/2023] [Indexed: 05/20/2023] Open
Abstract
Introduction and hypothesis Anal incontinence (AI) is a prevalent postpartum disorder. This study aims to investigate and quantify the risk factors for AI in the Chinese population during the first year following vaginal delivery. Methods The case control study was conducted at Peking University Third Hospital, including all women who delivered vaginally between January 1, 2014, and June 30, 2018. Participants were followed up by telephone interviews 1 year after delivery. AI was defined as the involuntary loss of flatus or feces using a retrospective Jorge and Wexner score above 0. Clinical data were retrieved from the medical record system. Univariate and multivariate analyses were applied to identify potential risk factors accounting for AI. Based on the logistic regression model, a nomogram was constructed to predict the probability of AI postpartum. Restricted cubic spline was utilized to explore potential non-linear relationships between birth weight and AI postpartum. Results Among the 140 AI and 421 none AI cases, we observed antepartum factors like every 100 g of birth weight gain (OR 1.39, 95% CI 1.30-1.49), while intrapartum factors like forceps-assisted vaginal delivery (OR 7.11, 95% CI 2.60-19.45), midline episiotomy (OR 13.11, 95% CI 1.71-100.89), second-degree perineal tear (OR 6.51, 95% CI 1.16-36.68), and third to fourth-degree perineal tear were independent risk factors for postpartum AI. Significantly, infant weighing over 3,400 g at birth increased the risk of AI postpartum. Based on logistic regression model, we constructed a nomogram to estimate the risk of AI 1 year after vaginal delivery. Conclusion Our findings indicated that during the first year following vaginal delivery, infant with birth weight of 3,400 g or more, forceps-assisted vaginal delivery, midline episiotomy, and second to fourth-degree perineal tear increased the risk of AI. As a result, it is essential to limit the routine use of forceps and midline episiotomy and to monitor fetal weight during prenatal care.
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Affiliation(s)
- Yang Jia
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Cuigezhuang Community Health Service Center, Beijing, China
| | - Qingao Liu
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
| | - Lin Zeng
- Research Center of Clinical Epidemiology, Peking University Third Hospital, Beijing, China
- *Correspondence: Lin Zeng,
| | - Yan Wang
- Department of Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- National Center for Healthcare Quality Management in Obstetrics, Beijing, China
- National Clinical Research Center for Obstetrics and Gynecology, Peking University Third Hospital, Beijing, China
- Yan Wang,
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Episiotomy in vacuum extraction, do we cut the levator ani muscle? A prospective cohort study. Int Urogynecol J 2022; 33:3391-3399. [PMID: 35467140 DOI: 10.1007/s00192-022-05188-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
INTRODUCTION AND HYPOTHESIS Vaginal delivery may lead to levator ani muscle (LAM) injury or avulsion. Episiotomy may reduce obstetric anal sphincter injury in operative vaginal delivery, but may increase the risk of LAM injury. Our aim was to assess whether lateral episiotomy in vacuum extraction (VE) in primiparous women causes LAM injury. METHODS A prospective cohort study of 58 primiparous women with episiotomy nested within an ongoing multicenter randomized controlled trial of lateral episiotomy versus no episiotomy in VE (EVA trial) was carried out in Sweden. LAM injury was evaluated using 3D endovaginal ultrasound 6-12 months after delivery and Levator Ani Deficiency (LAD) score. Episiotomy scar properties were measured. Characteristics were described and compared using Chi-squared tests. We stipulated that if a lateral episiotomy cuts the LAM, ≥50% would have a LAM injury. Among those, ≥50% would be side specific. We compared the observed prevalence with a test of one proportion. RESULTS Twelve (20.7%, 95% CI 10.9-32.9) of 58 women had a LAD (p < 0.001, compared with the stipulated 50%). Six (50.0%, 95% CI 21.1% to 78.9%) of 12 women had a LAD on the episiotomy side, including those with bilateral LAD (p = 1.00). Two (16.7%, 95% CI 2.1% to 48.4%) of 12 women had a LAD exclusively on the episiotomy side (p = 0.02). CONCLUSIONS There was no excessive risk of cutting the LAM while performing a lateral episiotomy. LAD was not seen in women with episiotomies shorter than 18 mm.
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Xu B, Luo Q, Wu R, Lu Y, Ying H, Xu Y, Lu Z. Perineal stress as a predictor of performing episiotomy in primiparous women: a prospective observational study. BMC Pregnancy Childbirth 2022; 22:793. [PMID: 36289493 PMCID: PMC9608929 DOI: 10.1186/s12884-022-05075-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 09/23/2022] [Indexed: 11/26/2022] Open
Abstract
Background Episiotomy is a surgical solution to relieve perineal stress, resulting in an easily repairable incision, in comparison to the risks of serious vaginal trauma during delivery. The midwife typically adopts such a clinical decision, on experience and subjective judgment. However, the association between perineal stress and episiotomy is poorly characterized. Our aim was to identify a threshold value for perineal stress leading to episiotomy, which eventually may be employed as a clinical tool for assessing whether an episiotomy is required or not. Methods In total, 245 nulliparous women were investigated for perineal stress during non-instrumental vaginal delivery in Ningbo Women & Children’s Hospital. During the second stage of labor, a flexible membrane stress sensor was placed between the fetal head and perineal wall above the anal fissure. Once the entire fetal head pressed against the sensor, real-time perineal stress was measured, and the peak value was recorded. Cases were divided into non-episiotomy group (n = 173) and episiotomy group (n = 72). The correlations between perineal stress and episiotomy was assessed through logistic regression with adjustment for maternal age, estimated birthweight, duration of second stage of labor, maternal body mass index, and presence of analgesia. Midwives were blinded to all stress measurement values. The predictive value of perineal stress on performing episiotomy was evaluated, together with the ideal cut-off perineal stress value for performing episiotomy. A ROC analysis was also performed. Results The episiotomy group had significantly higher levels of perineal stress in comparison to the non-episiotomy group (140.50 ± 16.03 N versus 118.37 ± 19.21 N, p < 0.01). The episiotomy group was linked to significantly higher perineal stress in comparison to the non-episiotomy group (140.50 ± 16.03 VS 118.37 ± 19.21 N, p < 0.01). ROC analysis between perineal stress and episiotomy revealed a high area under the curve (AUC 0.81, 95% CI 0.75–0.86) and a cut-off value for perineal stress of 124.49 N was identified for episiotomy decision. Conclusion The level of perineal stress was an independent predictor of performing episiotomy in nulliparous women during non-instrumental vaginal delivery. Perineal stress exceeding 124.49 N was identified as the cut-off prompting midwives to perform episiotomy.
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Affiliation(s)
- Binbin Xu
- Ningbo Women & Children’s Hospital, NO.339, Liuting Street, Haishu District, 315012 Ningbo City, Zhejiang Province China
| | - Qi Luo
- Ningbo Women & Children’s Hospital, NO.339, Liuting Street, Haishu District, 315012 Ningbo City, Zhejiang Province China
| | - Rongrong Wu
- Ningbo Women & Children’s Hospital, NO.339, Liuting Street, Haishu District, 315012 Ningbo City, Zhejiang Province China
| | - Ying Lu
- Ningbo Women & Children’s Hospital, NO.339, Liuting Street, Haishu District, 315012 Ningbo City, Zhejiang Province China
| | - Hongjun Ying
- Ningbo Women & Children’s Hospital, NO.339, Liuting Street, Haishu District, 315012 Ningbo City, Zhejiang Province China
| | - Yanan Xu
- Ningbo Women & Children’s Hospital, NO.339, Liuting Street, Haishu District, 315012 Ningbo City, Zhejiang Province China
| | - Zhaie Lu
- Ningbo Women & Children’s Hospital, NO.339, Liuting Street, Haishu District, 315012 Ningbo City, Zhejiang Province China
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Anal incontinence after a prolonged second stage of labor in primiparous women. Sci Rep 2022; 12:7315. [PMID: 35513490 PMCID: PMC9072350 DOI: 10.1038/s41598-022-11346-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 04/21/2022] [Indexed: 12/04/2022] Open
Abstract
The objective was to investigate the effect of delivery mode on anal incontinence 1–2 years after delivery in primiparous women with prolonged second stage of labor. This population-based cohort and questionnaire study performed in Stockholm Region, Sweden, included 1302 primiparous women with a second stage ≥ 3 h from December 1st, 2017 through November 30th, 2018. Background characteristics and outcome data were retrieved from computerized records. Questionnaires based on Wexner score were distributed 1–2 years after delivery. Risk of anal incontinence, defined as Wexner score ≥ 2, was calculated using logistic regression and presented as crude and adjusted odds ratios (OR and aOR) with 95% confidence intervals (CI). Compared with cesarean section, vacuum extraction was associated with anal incontinence (aOR 2.25, 95% CI 1.21–4.18) while spontaneous delivery was not (aOR 1.55, 95% CI 0.85–2.84). Anal incontinence was independently associated with obstetric anal sphincter injuries (aOR 2.03, 95% CI 1.17–3.5) and 2nd degree perineal tears (aOR 1.36, 95% CI 1.03–1.81) compared with no or 1st degree perineal tear. Obstetric anal sphincter injury at vacuum extraction inferred the highest risk of anal incontinence (aOR 4.06, 95% CI 1.80–9.14), compared with cesarean section. Increasing duration of the prolonged second stage did not affect the risk.
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Gachon B, Fritel X, Rivière O, Pereira B, Vendittelli F. French guidelines for restrictive episiotomy during instrumental delivery were not followed by an increase in obstetric anal sphincter injury. Sci Rep 2022; 12:6330. [PMID: 35428837 PMCID: PMC9012794 DOI: 10.1038/s41598-022-10379-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 03/14/2022] [Indexed: 11/25/2022] Open
Abstract
The objective was to assess the influence of the French guidelines in favor of a restrictive use of episiotomy on both episiotomy and obstetric anal sphincter injury (OASI) rates during instrumental delivery. It was aulticenter study involving 193 maternities between 2000 and 2016. We included women with a singleton pregnancy, with cephalic presentation at 34 weeks of gestation or more who underwent an instrumental delivery. The study period was divided into three phases: 2000-2005 (reference) 2006-2011, and 2012-2016. We calculated the adjusted relative risk (aRR) of episiotomy and OASI and investigated for changes in episiotomy and OASI rates over time by using Prais-Winsten regression. We considered 96,035 deliveries. The episiotomy's risk was lower in 2006-2011 (69.4%) and 2012-2016 (59.1%) compared to 2000-2005 (81.2%), respectively: aRR 0.93 [0.92-0.95] and 0.89 [0.87-0.90]. The OASI's risk was higher in 2006-2011 (2.5%) and 2012-2016 (3.1%) compared to 2000-2005, respectively: aRR 1.30 [1.10-1.53]) and 1.57 [1.33-1.85]. However, Prais-Winsten regression showed no difference in the OASI rate during the study period. We observed a massive decrease in episiotomy use and a moderate increase in crude OASI's rate but multivariate analysis failed to report an association between these outcomes.
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Affiliation(s)
- Bertrand Gachon
- Service de Gynécologie Obstétrique et Médecine de la Reproduction, Department of Obstetrics & Gynecology, Centre Hospitalier Universitaire de Poitiers, 2 rue de la Miletrie, 86000, Poitiers, France.
- INSERM CIC61402, Université de Poitiers, CHU de Poitiers, Poitiers, France.
| | - Xavier Fritel
- Service de Gynécologie Obstétrique et Médecine de la Reproduction, Department of Obstetrics & Gynecology, Centre Hospitalier Universitaire de Poitiers, 2 rue de la Miletrie, 86000, Poitiers, France
- INSERM CIC61402, Université de Poitiers, CHU de Poitiers, Poitiers, France
| | - Olivier Rivière
- Audipog, Université Claude Bernard Lyon 1-Laennec, Lyon, France
| | - Bruno Pereira
- Centre Hospitalier Universitaire de Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Françoise Vendittelli
- Audipog, Université Claude Bernard Lyon 1-Laennec, Lyon, France
- Institut Pascal, CHU, CNRS, Clermont Auvergne INP, Université Clermont Auvergne, 63000, Clermont-Ferrand, France
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Meyer R, Levin G. Risk factors for obstetric anal sphincter injury among nulliparous of advanced maternal age. J Matern Fetal Neonatal Med 2022; 35:9391-9397. [PMID: 35125063 DOI: 10.1080/14767058.2022.2035714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Data regarding the risk factors for obstetrical anal sphincter injury (OASI) among nulliparous advanced maternal age (AMA) women are scarce. We aimed to evaluate the risk factors and the rate of OASI in this population. METHODS A retrospective case-control study of nulliparous women aged ≥35 who delivered vaginally between March 2011 and August 2021. The study cohort included nulliparous AMA women, aged 35 years or older, delivering vaginally a singleton, vertex neonate. We excluded cases with missing data. Maternal and intrapartum characteristics were compared between OASI and no-OASI groups. We matched groups to the earliest gestational age in which OASI has occurred. RESULTS A total of 3,635 women met inclusion criteria. Mean age of the participants was 38 years (range 35-56, interquartile range 36-39). The oldest age in which an OASI was diagnosed was 45. A total of 55 (1.5%) cases of OASI were diagnosed. Gestational age at delivery was higher in the OASI group compared to the no-OASI group (mean 396/7±12/7 vs. 391/7±23/7 weeks respectively, p=.039). The rate of induction of labor, oxytocin and epidural analgesia, prolonged second stage, mode of delivery, and rate of blood transfusion did not vary between groups. Estimated fetal weight was higher in the OASI group (3,324 ± 308 vs. 3,114 ± 566 g, p<.001). Sonographic abdominal circumference was higher in the OASI group (338 ± 13 vs. 328 ± 28 mm, p<.001). Mean birthweight was higher in the OASI group (3,286 ± 400 vs. 3,059 ± 541 g, p=.002) and the birthweight centile was higher as well (60 ± 26 vs. 52 ± 25, p=.024).In a multivariable regression analysis including birthweight, gestational age, operative vaginal delivery, epidural anesthesia, and hypertensive disorders-birthweight and hypertensive disorder were positively associated with an OASI odds ratio [OR 95% CI 1.6 (1.1-2.32) for every 500 g increase; 2.42 (1.006-5.82), respectively]. Epidural anesthesia was negatively associated with OASI [OR 95% CI 0.49) 0.27-0.87)]. CONCLUSIONS Epidural anesthesia is the only modifiable risk factor and is protective against OASI among nulliparous AMA women. Birthweight and hypertensive disorders are also independent predictors of OASI in this population.
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Affiliation(s)
- Raanan Meyer
- The Department of Obstetrics and Gynecology, the Chaim Sheba Medical Center, Ramat-Gan, Israel.,Faculty of Medicine, The Sheba Talpiot Medical Leadership Program, Tel-Aviv University, Tel-Aviv, Israel
| | - Gabriel Levin
- The Department of Gynecologic Oncology, Hadassah Medical Center, Faculty of Medicine, Hebrew University, Jerusalem, Israel
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11
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Ankarcrona V, Hesselman S, Kopp Kallner H, Brismar Wendel S. Attitudes and knowledge regarding episiotomy use and technique in vacuum extraction: A web-based survey among doctors in Sweden. Eur J Obstet Gynecol Reprod Biol 2021; 269:62-70. [PMID: 34968876 DOI: 10.1016/j.ejogrb.2021.12.017] [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: 09/02/2021] [Revised: 11/19/2021] [Accepted: 12/11/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Correct episiotomy use and technique may prevent obstetric anal sphincter injuries. We aimed to explore the attitudes, use, and technique regarding episiotomy among doctors in Sweden, and their willingness to contribute to a randomized controlled trial of lateral episiotomy or no episiotomy in vacuum extraction in nulliparous women. STUDY DESIGN A web-based survey was sent to members of the Swedish Society of Obstetrics and Gynecology (n = 2140). The survey included 31 questions addressing personal characteristics, use of episiotomy, a two-dimensional picture on which the respondents drew an episiotomy, and questions regarding attitudes towards episiotomy and participation in a randomized controlled trial. We calculated the proportion of supposedly protective episiotomies (fulfilling criteria of a lateral or mediolateral episiotomy and a length ≥ 30 mm). We compared the results between obstetricians, gynecologists, and residents using Chi-square and Kruskal-Wallis tests for differences between groups, and logistic regression to estimate the odds ratio (OR) of drawing a protective episiotomy. RESULTS We received 432 responses. Doctors without a vacuum delivery in the past year were excluded, leaving 384 respondents for further analyses. In all, 222 (57.8%) doctors reported use of episiotomy in<50% of vacuum extractions. We obtained 308 illustrated episiotomies with a median angle of 53°, incision point distance from the midline of 21 mm, and length of 36 mm, corresponding to a lateral episiotomy. Few doctors combined these parameters correctly resulting in 167 (54.2%) incorrectly drawn episiotomies. Residents drew shorter episiotomies than obstetricians and gynecologists. Doctors ranked episiotomy the least important intervention to prevent obstetric anal sphincter injuries in vacuum extraction. Doctors contributing to an ongoing randomized controlled trial of lateral episiotomy or no episiotomy in vacuum extraction were more able to draw a protective episiotomy (OR 3.69, 95% confidence interval 1.94-7.02). CONCLUSIONS Doctors in Sweden reported restrictive use of episiotomy in vacuum extraction and depicted lateral type episiotomies, although the majority were incorrectly drawn. Preventive episiotomy was ranked of low importance. Our results imply a need for education, training, and guidelines to increase uptake of correct episiotomy technique, which could result in improved prevention of obstetric anal sphincter injuries.
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Affiliation(s)
- Victoria Ankarcrona
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet and the Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden.
| | - Susanne Hesselman
- Department of Women's and Children's Health and Centre for Clinical Research Dalarna and Uppsala University, Uppsala, Sweden
| | - Helena Kopp Kallner
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet and the Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden
| | - Sophia Brismar Wendel
- Department of Clinical Sciences at Danderyd Hospital, Karolinska Institutet and the Department of Obstetrics and Gynecology, Danderyd Hospital, Stockholm, Sweden
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12
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Which elements were significant in reducing obstetric anal sphincter injury? A prospective follow-up study. BMC Pregnancy Childbirth 2021; 21:781. [PMID: 34794417 PMCID: PMC8600779 DOI: 10.1186/s12884-021-04260-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 11/09/2021] [Indexed: 11/14/2022] Open
Abstract
Background To examine which elements of an obstetric anal sphincter injury (OASI) care bundle were protective for OASI. Several interventional trials showed that application of a care bundle involving a hands-on approach to perineal protection may reduce the risk of OASI. Previously, we found that only the element “hand on the fetal head” in itself was protective, although the risk of a type 2 error was calculated to be 50%. Methods A prospective follow-up study in an obstetric department in Denmark with 3200 deliveries per year. We included a cohort of 10,383 women giving birth vaginally from gestational week 22 + 0 from 2016 through 2019. We documented on a person-level the five elements of the care bundle together with maternal and obstetrical characteristics. The elements were 1) communication, 2) visible perineum, 3) hand on fetal head, 4) perineal support and 5) certification. Regression analysis was used for analysis of associations. The primary outcome measure was OASI. Results The total rate of OASI in vaginally delivering women was 1.9%. The incidence was 3.2% in nulliparous women giving birth vaginally. The rate of cesarean section was 16.5% and for episiotomy 2.4%. The reduction in the incidence of OASI was sustained since 2013. Hand on the fetal head and perineal support both were protective factors for OASI. In case of a nulliparous woman with a neonate weighing 3500 g giving birth spontaneously, the relative risk (RR) for OASI was 0.50 (95% CI 0.49- 0.51) with use of hand on the fetal head together with perineal support against no use. Similarly, with a nulliparous woman giving birth to a neonate of 3500 g by vacuum extraction, the RR for OASI was 0.65 (95% CI 0.62-0.68) against no use. Conclusions Both hand on the fetal head and perineal support were associated with a reduced risk of OASI.
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13
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Malm MC, Hesselman S, Brismar Wendel S, Ericson J. Episiotomy or not? Midwives' experiences of recruiting to a randomized controlled trial during pregnancy and labor - A qualitative study. SEXUAL & REPRODUCTIVE HEALTHCARE 2021; 30:100674. [PMID: 34741843 DOI: 10.1016/j.srhc.2021.100674] [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: 04/20/2021] [Revised: 10/10/2021] [Accepted: 10/20/2021] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The performance of randomized controlled trials (RCTs) is dependent on recruitment. Recruiting women to RCTs regarding interventions during childbirth may be difficult due to time constraints and their vulnerable situation. Midwives play a major role in such recruitment. Few studies have investigated the views and experiences of recruiters. The aim of this study was to describe midwives' experiences of recruiting pregnant women regarding an RCT of lateral episiotomy or no episiotomy in vacuum-assisted delivery. METHODS In this qualitative study, 19 midwives were interviewed regarding their experiences. The midwives worked at antenatal health care centers or labor wards. The transcribed interviews were analyzed using content analysis. RESULTS Four categories appeared during the analysis, including "experiences and perceptions of providing trial information" and "the right timing in providing trial information," which varied among the midwives. Midwives' perceptions of how the women provided consent or declined participation, and the women's views and questions about the randomization and intervention, were summarized as "experiences of how the trial information was received by the women." In the final category, "perceived trial apprehensions and concerns," some midwives described ethical concerns related to the intervention and financial compensation to the staff involved. CONCLUSIONS Midwives as recruiters would benefit from education and training in incorporating basic and advanced details of trial design and research methods, as well as training and support in recruitment. Awareness and management of the variation among potential recruiters is important when designing and performing an RCT.
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Affiliation(s)
| | - Susanne Hesselman
- Centre for Clinical Research Dalarna, Uppsala University, Falun, Sweden; Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Sophia Brismar Wendel
- Sweden School of Education, Health and Social Studies, Dalarna University, Falun, Sweden
| | - Jenny Ericson
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden; Department of Paediatrics, Falu Hospital, Falun, Sweden; Department of Paediatrics, Falu Hospital, Falun, Sweden
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14
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Ericson J, Anagrius C, Rygaard A, Guntram L, Wendel SB, Hesselman S. Women's experiences of receiving information about and consenting or declining to participate in a randomized controlled trial involving episiotomy in vacuum-assisted delivery: a qualitative study. Trials 2021; 22:658. [PMID: 34565424 PMCID: PMC8474868 DOI: 10.1186/s13063-021-05624-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 09/14/2021] [Indexed: 11/24/2022] Open
Abstract
Background Information about and invitation to participate in a clinical trial involving an intervention during childbirth may cause fear or worry in pregnant women. The aim of this study was to describe nulliparous women’s experiences of receiving an invitation to participate in a randomized controlled trial (RCT) of lateral episiotomy versus no episiotomy in vacuum-assisted delivery (EVA trial). Methods This qualitative study was nested in the ongoing EVA trial. Data were collected through semistructured telephone interviews with 23 women regarding their experiences of the information and invitation to participate in the EVA trial. Interviews were audio-recorded and transcribed verbatim. A qualitative content analysis was used to analyse the interview contents. Results Three main experience categories were identified among the participants. “Timing of trial information and understanding” revealed that women preferred to obtain information about the trial early on during pregnancy. “Reasons to consent to or decline participation in the trial” encompassed a variety of reasons for women to consent, such as goodwill for science or personal benefits, or to decline, such as not wanting to be randomized or fear of increased risk of having a vacuum-assisted delivery. “Thoughts evoked regarding childbirth” were diverse, ranging from not being affected at all to having increased anxiety. Conclusions The women’s experience of receiving an invitation to participate in an RCT of episiotomy in vacuum-assisted delivery varied widely, from immediately giving consent without further worries to increased anxiety or declining participation. Early and personal information with time for reflection was considered most satisfactory. Trial registration ClinicalTrials.govNCT02643108. Registered on December 28, 2015. The Lateral Episiotomy or Not in Vacuum Assisted Delivery in Non-parous Women (EVA) trial was registered at www.clinicaltrials.gov.
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Affiliation(s)
- Jenny Ericson
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden. .,Center for Clinical Research Dalarna, Uppsala University, Falun, Sweden. .,Department of Pediatrics, Falu Hospital, Falun, Sweden.
| | - Cecilia Anagrius
- Department of Gynecology and Obstetrics, Falu Hospital, Falun, Sweden
| | - Agnes Rygaard
- Department of Gynecology and Obstetrics, Falu Hospital, Falun, Sweden
| | - Lisa Guntram
- Department of Thematic Studies - Technology and Social Change, Linköping University, Linköping, Sweden
| | - Sophia Brismar Wendel
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Susanne Hesselman
- Center for Clinical Research Dalarna, Uppsala University, Falun, Sweden.,Department of Gynecology and Obstetrics, Falu Hospital, Falun, Sweden.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
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15
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Gyhagen M, Ellström Engh M, Husslein H, Koelbl H, Nilsson IEK, Schulz J, Wagg A, Milsom I. Temporal trends in obstetric anal sphincter injury from the first vaginal delivery in Austria, Canada, Norway, and Sweden. Acta Obstet Gynecol Scand 2021; 100:1969-1976. [PMID: 34435349 DOI: 10.1111/aogs.14244] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 08/06/2021] [Accepted: 08/08/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Obstetric anal sphincter injuries (OASI) are severe complications that can cause considerable short- and long-term morbidity. Austria, Canada, Norway, and Sweden have similar socio-economic characteristics, and all four countries have access to national birth registers. In this study, we hypothesized that the incidence of OASI should be very similar for different obstetric scenarios in these four countries. Therefore, the aim was to compare the incidence of OASI in these four countries in primiparous women, with spontaneous or instrumental delivery (vacuum or forceps), and in women with a first vaginal birth after cesarean section (VBAC). MATERIAL AND METHODS Aggregated data on 1 933 930 vaginally delivered primiparous women and women with VBAC were retrieved from the birth registers gathered in Austria, Canada, Norway, and Sweden. The annual rate of OASI (ICD-10 codes O70.2-O70.3) was presented as the percentage of women with a spontaneous delivery, vacuum or forceps delivery, and a VBAC during the period 2004-2016. RESULTS The incidence of OASI varied considerably between countries and over time. Canada and Sweden had the highest rates, and Austria and Norway the lowest. In Norway, the rate of OASI decreased consistently for all types of deliveries after introducing a perineal protection program in 2004 (p < 0.001). During vacuum delivery, the incidence of OASI varied between countries from 4.1% to 15.5% across the study period. In Canada and Norway, the rate of OASI after a forceps delivery was similar in 2004 at ~20% and with differing trajectories to 24.3% (β 0.49) and 6.2% (β -1.15) (trend, all p < 0.001) in 2016. CONCLUSIONS This comparative register study suggests that there may be considerable potential for lowering the incidence of OASI. The perineal protection program implemented by Norway has been successful. Each country should critically, without prejudice, analyze their current clinical practices and rate of OASI and consider the best preventive strategy.
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Affiliation(s)
- Maria Gyhagen
- Gothenburg Continence Research Center, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden
| | - Marie Ellström Engh
- Department of Obstetrics and Gynecology, Akershus University Hospital, and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Heinrich Husslein
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Heinz Koelbl
- Department of Obstetrics and Gynecology, Medical University of Vienna, Vienna, Austria
| | - Ida E K Nilsson
- Gothenburg Continence Research Center, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Södra Älvsborgs Hospital, Borås, Sweden
| | - Jane Schulz
- Department of Obstetrics and Gynecology, University of Alberta, Edmonton, Alberta, Canada
| | - Adrian Wagg
- Gothenburg Continence Research Center, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Ian Milsom
- Gothenburg Continence Research Center, Institute of Clinical Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden.,Department of Obstetrics and Gynecology, Sahlgrenska University Hospital, Gothenburg, Sweden
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16
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Huber M, Malers E, Tunón K. Pelvic floor dysfunction one year after first childbirth in relation to perineal tear severity. Sci Rep 2021; 11:12560. [PMID: 34131194 PMCID: PMC8206367 DOI: 10.1038/s41598-021-91799-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 05/26/2021] [Indexed: 11/09/2022] Open
Abstract
The aims of this study were to evaluate pelvic floor dysfunction symptoms one year after delivery and investigate whether adverse functional outcomes after childbirth were related to the degree of perineal injury. A prospective cohort of 776 primiparas were included. Self-reported pelvic floor function data were obtained using a web-based questionnaire. Women with no/first-degree injuries, second-degree injuries, third-/fourth-degree injuries (obstetric anal sphincter injury, OASI) and cesarean section were compared. A total of 511 women (66%) responded. Second-degree tears were a risk factor for stress incontinence (aOR 2.6 (95% CI 1.3–5.1)). Cesarean section was protective against stress incontinence (aOR 0.2 (95% CI 0.1–0.9)). OASI was a risk factor for urge incontinence (aOR 4.8 (95% CI 1.6–15)), prolapse (aOR 7.7 (95% CI 2.1–29)) and pelvic pain (OR 3.3 (95% CI 1.1–10)). Dyspareunia was reported by 38% of women, 63% of women in the OASI group (aOR 3.1 (95% CI 1.1–9.0)). Women with OASI reported that the injury affected daily life (OR 18 (95% CI 5.1–59)). Pelvic floor dysfunction is common after childbirth, even in women with moderate injury. Women with OASI had significantly higher risks of symptoms of prolapse, urge urinary incontinence, pain, dyspareunia and impacts on daily life.
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Affiliation(s)
- Malin Huber
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, 901 87, Umeå, Sweden.
| | - Ellen Malers
- Department of Clinical Sciences, Obstetrics and Gynecology, Unit of Obstetrics and Gynecology-Östersund, Umeå University, Umeå, Sweden
| | - Katarina Tunón
- Department of Clinical Sciences, Obstetrics and Gynecology, Umeå University, 901 87, Umeå, Sweden
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17
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Ankarcrona V, Zhao H, Jacobsson B, Brismar Wendel S. Authors' response to: "Re: obstetric anal sphincter injury after episiotomy in vacuum extraction: an epidemiological study using an emulated randomised trial approach: robustness and external validity of different practices": Reply: Episiotomy in vacuum extraction. BJOG 2021; 128:1891-1892. [PMID: 34114321 DOI: 10.1111/1471-0528.16763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/23/2021] [Indexed: 11/30/2022]
Affiliation(s)
- Victoria Ankarcrona
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.,Department of Women's Health, Danderyd Hospital, Stockholm, Sweden
| | - Hongwei Zhao
- Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M University, College Station, TX, USA
| | - Bo Jacobsson
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Department of Genetics and Bioinformatics, Domain of Health Data and Digitalization, Institute of Public Health, Oslo, Norway
| | - Sophia Brismar Wendel
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.,Department of Women's Health, Danderyd Hospital, Stockholm, Sweden.,Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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18
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Maphanga CM, Naidoo TD. The perception and knowledge about episiotomy: A cross-sectional survey involving healthcare workers in a low- and middle-income country. Afr J Prim Health Care Fam Med 2021; 13:e1-e6. [PMID: 33970009 PMCID: PMC8111667 DOI: 10.4102/phcfm.v13i1.2424] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 02/02/2021] [Accepted: 02/04/2021] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Episiotomy was introduced into clinical practice without clear evidence of its benefits.The knowledge and understanding of episiotomy guidelines and practice by healthcare workers is substandard in our setting; hence, the injudicious use of this procedure have led to high rates. AIM To assess the knowledge, perception and practice of episiotomy by healthcare workers. SETTING Research was conducted in a Pietermaritzburg complex, South AfricaMethods: A questionnaire-based survey was conducted amongst healthcare workers regarding episiotomy practice. In addition to providing demographic data, the participants were requested to respond to 35 proposed statements regarding episiotomy practice. Data were analysed using SPSS (Statistical Package for the Social Sciences) software. RESULTS One hundred and forty-two midwives and 66 medical practitioners completed the questionnaires. There were variations in responses to several statements on episiotomy practice by medical practitioners and nurses based on their level of experience. This study found that the majority of HCWs did not have access to a protocol or policy on episiotomy practice in their units; furthermore, nor knowledge of the South African guidelines for maternity care on episiotomy practice. Significantly, more medical practitioners felt a need for more in-service training and an increase in the number of episiotomies performed under supervision. The commonly reported reason for performing an episiotomy by both medical practitioners and midwives was to reduce 3rd - 4th degree perineal tears. CONCLUSION Healthcare workers in our setting displayed poor knowledge about the practice of episiotomy and were not aware of existing national guidelines on episiotomy practice.
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Affiliation(s)
- Cyprian M Maphanga
- Department Obstetrics and Gynaecology, Greys Hospital, Pietermaritzburg, South Africa; and, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, Pietermaritzburg.
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Ankarcrona V, Zhao H, Jacobsson B, Brismar Wendel S. Obstetric anal sphincter injury after episiotomy in vacuum extraction: an epidemiological study using an emulated randomised trial approach. BJOG 2021; 128:1663-1671. [PMID: 33539612 DOI: 10.1111/1471-0528.16663] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To emulate a randomised controlled trial investigating whether lateral or mediolateral episiotomy compared with no episiotomy reduces the prevalence of obstetric anal sphincter injury (OASIS) in nulliparous women delivered with vacuum extraction. DESIGN A population-based observational study. SETTING Sweden. POPULATION 63 654 nulliparous women delivered with vacuum extraction derived from the Swedish Medical Birth Register 2000-2011, with a live singleton baby with no known malformations in cephalic presentation in gestational week ≥34+0 , and subject to lateral or mediolateral episiotomy or no episiotomy. METHODS The effect of episiotomy was calculated using a causal doubly robust estimation method based on propensity scores. Results are presented as the average treatment effect and numbers needed to treat (NNT). MAIN OUTCOME MEASURES OASIS (third- and fourth-degree perineal injury) in nulliparous women delivered with vacuum extraction. RESULTS Episiotomy was associated with a reduction in OASIS from 15.5% to 11.8%, average treatment effect of -3.66% (95% CI -4.31 to -3.01) and NNT 27. Third-degree perineal injuries were reduced from 14.0% to 10.9% (-3.08, 95% CI -3.71 to -2.42) with NNT 32. Fourth-degree perineal injuries were reduced from 1.6% to 1.0 % (-0.58%, 95% CI -0.79 to -0.37) with NNT 172. CONCLUSIONS Lateral or mediolateral episiotomy reduced the prevalence of OASIS in nulliparous women delivered with vacuum extraction, compared to women with no episiotomy. TWEETABLE ABSTRACT To prevent one case of OASIS in first-time mothers delivered with vacuum, 27 episiotomies had to be performed.
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Affiliation(s)
- V Ankarcrona
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.,Department of Women's Health, Danderyd Hospital, Stockholm, Sweden
| | - H Zhao
- Department of Epidemiology and Biostatistics, School of Public Health, Texas A&M University, College Station, TX, USA
| | - B Jacobsson
- Department of Obstetrics and Gynecology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Department of Genetics and Bioinformatics, Domain of Health Data and Digitalization, Institute of Public Health, Oslo, Norway
| | - S Brismar Wendel
- Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden.,Department of Women's Health, Danderyd Hospital, Stockholm, Sweden.,Clinical Epidemiology Division, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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20
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Levin G, Rottenstreich A, Cahan T, Ilan H, Shai D, Tsur A, Meyer R. Does birthweight have a role in the effect of episiotomy on anal sphincter injury? Arch Gynecol Obstet 2020; 301:171-177. [DOI: 10.1007/s00404-020-05444-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 01/13/2020] [Indexed: 01/21/2023]
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21
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Levin G, Rottenstreich A. Letter: The Type of Episiotomy Should Be Studied Carefully. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2019; 41:1548. [PMID: 31640862 DOI: 10.1016/j.jogc.2019.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 05/27/2019] [Indexed: 11/16/2022]
Affiliation(s)
- Gabriel Levin
- Department of Obstetrics and Gynecology Hadassah University Medical Center Jerusalem, Israel
| | - Amihai Rottenstreich
- Department of Obstetrics and Gynecology Hadassah University Medical Center Jerusalem, Israel
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22
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Jangö H, Westergaard HB, Kjærbye‐Thygesen A, Langhoff‐Roos J, Lauenborg J. Changing incidence of obstetric anal sphincter injuries—A result of formal prevention programs? Acta Obstet Gynecol Scand 2019; 98:1455-1463. [DOI: 10.1111/aogs.13672] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/27/2019] [Accepted: 05/29/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Hanna Jangö
- Department of Obstetrics and Gynecology Copenhagen University Hospital Hillerød Denmark
- Department of Obstetrics and Gynecology Copenhagen University Hospital Herlev Denmark
| | - Hanne B. Westergaard
- Department of Obstetrics and Gynecology Copenhagen University Hospital Hillerød Denmark
| | | | - Jens Langhoff‐Roos
- Department of Obstetrics Copenhagen University Hospital Rigshospitalet Copenhagen Denmark
| | - Jeannet Lauenborg
- Department of Obstetrics and Gynecology Copenhagen University Hospital Herlev Denmark
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