Proportions and determinants of successful surgical repair of obstetric fistula in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Obstetric fistula is a serious and debilitating problem resulting from tissue necrosis on the reproductive and urinary and/or lower gastrointestinal tract organs due to prolonged labor. Primary studies of the treatment of obstetric fistulae report significantly variable treatment outcomes following surgical repair. However, no systematic review and meta-analysis has yet estimated the pooled proportion and identified the determinants of successful obstetric fistula surgical repair.

OBJECTIVE

To estimate the proportion and identify the determinants of successful surgical repair of obstetric fistulae in low- and middle-income countries.

METHODS

The protocol was developed and registered at the International Prospective Register of Systematic Reviews (ID CRD42022323630). Searches of PubMed, Embase, CINAHL, Scopus databases, and gray literature sources were performed. All the accessed studies were selected with Covidence, and the quality of the studies was examined. Finally, the data were extracted using Excel and analyzed with R software.

RESULTS

This review included 79 studies out of 9337 following the screening process. The analysis reveals that 77.85% (95%CI: 75.14%; 80.56%) of surgical repairs in low and middle-income countries are successful. Women who attain primary education and above, are married, and have alive neonatal outcomes are more likely to have successful repair outcomes. In contrast, women with female genital mutilation, primiparity, a large fistula size, a fistula classification of II and above, urethral damage, vaginal scarring, a circumferential defect, multiple fistulae, prior repair and postoperative complications are less likely to have successful repair outcomes.

CONCLUSION

The proportion of successful surgical repairs of obstetric fistula in low and middle-income countries remains suboptimal. Hence, stakeholders and policymakers must design and implement policies promoting women's education. In addition, fistula care providers need to reach and manage obstetric fistula cases early before complications, like vaginal fibrosis, occur.

Irritable bowel syndrome worsens faecal incontinence after primary repair of major obstetric anal sphincter injuries

AIM

Obstetric anal sphincter injuries (OASIS) occur in approximately 3%-6% of vaginal deliveries and are the leading risk factor for late-onset faecal incontinence, which is an underdiagnosed pathology. The aim of this work was to use a validated scoring system to quantify the effect of irritable bowel syndrome (IBS) on the severity of faecal incontinence symptoms after primary repair of major OASIS (Grade IIIb-IV).

METHOD

A prospective cohort study was performed on all women who underwent primary repair of major OASIS over a 6-year period. They were assessed with ultrasonography within 12 weeks. Two control groups (who did not have OASIS) were women who underwent elective caesarean section and primigravid women. Questionnaires were sent at least 12 months after delivery, or at first consultation for primigravids, which generated the main outcome measures: Cleveland Clinic faecal incontinence severity scores and the presence of IBS based on Rome III criteria.

RESULTS

There was a total of 211 patients included in the three groups and the mean follow-up time was 26 months after sphincter repair. Ultrasonographic sphincter defects were detected in 37% but did not affect the faecal incontinence score (p = 0.47), except in patients with IBS. Within each group, patients with IBS had significantly worse faecal incontinence than those without. Women with both OASIS and IBS had the most severe faecal incontinence scores.

CONCLUSION

OASIS has a limited negative effect on faecal incontinence, independent of whether residual ultrasonographic sphincter defects are present. However, the presence of IBS has a significant compounding effect on faecal incontinence in OASIS patients. The effect of IBS on faecal incontinence is also notable in caesarean section patients and primigravids, suggesting that IBS is an independent risk-factor that should have its place in predelivery assessment and counselling.

UK survey of colorectal surgeons on the management of acute obstetric anal sphincter injuries

AIM

The role of colorectal surgeons in the management of acute obstetric anal sphincter injury (OASI) is an ongoing debate. Their expertise in operating in the anorectal region lends itself to assisting in OASI repair. The aim of this study was to establish the current involvement and recommended management of acute OASI by colorectal surgeons.

METHOD

An online survey of consultant colorectal surgeons was sent to members of the Pelvic Floor Society to assess current involvement in acute OASI management and repair.

RESULTS

Forty completed surveys were collated and analysed. Sixty-five per cent of respondents had seen an acute OASI since being a consultant and 50% stated they were involved in the repair of OASI less than once per year. 37.5% felt that a de-functioning stoma was still necessary sometimes. Many agreed with current guidelines for OASI repair in terms of antibiotics, laxatives and follow-up.

CONCLUSIONS

Colorectal surgeons have varied opinions on the management of OASI. We suggest that multidisciplinary training of obstetricians and colorectal surgeons could lead to more collaboration regarding the management of women with acute OASI.

Conservative management versus systematic suture of isolated vaginal or first-degree perineal tears after delivery: A preliminary randomized efficacy trial

BACKGROUND

The objective of this study was to assess the preliminary efficacy and safety of conservative management compared with systematic suture in isolated vaginal or first-degree perineal tears after birth.

METHODS

We conducted a preliminary efficacy, open-label, randomized, controlled, and prospective trial. This study implemented Simon's 2-step plan (interim analysis and final analysis) to test the success rate of the digital compression strategy group. Primiparous women aged ≥18 years with isolated vaginal or first-degree perineal tears after spontaneous vaginal birth of a cephalic presenting term (≥37 weeks) neonate were randomly allocated to the conservative management (CM) group (digital compression if bleeding followed by suture if persistent bleeding) or a systematic suture (SS) group. The primary outcome was the success of the intervention 10 days after delivery, defined by pain as evaluated using a visual analog scale < 3, satisfactory healing defined by a REEDA score ≤ 2, and no bleeding or infection. Sexual well-being was assessed at 2 and 6 months postpartum.

RESULTS

Among 861/2209 eligible women, 143 consenting women with a superficial perineal tear were randomized: 72 in the systematic suture group and 71 in the conservative management group. Success rate was 87.8% (90% CI [70.5-93.54]) (42/55) in the systematic suture group vs 90% (90% CI [78.3-93.8]) (53/61) in the conservative management group. The REEDA score was significantly higher in the systematic suture group (1.4 vs 0.9; P = 0.036). Perineal pain was significantly higher at day 1 in the systematic suture group (2.38 vs 1.69; P = 0.034). For the Female Sexual Functional Index score, no significant difference was found between the two groups at inclusion or at 2 and 6 months postpartum.

CONCLUSIONS

Conservative management of superficial perineal tears shows an efficacy rate ≥90%. Women in the conservative management group had less pain at the 1st day follow-up and lower REEDA scores at the 10th day follow-up.

Reasons for delay in accessing free treatment of obstetric fistula in South-East Nigeria - A qualitative study

Obstetric fistula continues to be a menace in Nigeria and other low- and middle-income countries. The national policy for its elimination makes surgical repair free in dedicated national centres. However, the majority of the clients present late for repair. The aim of the study was to explore the reasons for this delay in seeking treatment. It was a qualitative (exploratory) study carried out at the National Obstetric Fistula Centre (NOFIC), Abakaliki, Nigeria among obstetric fistula patients who presented for treatment with a duration of leakage of over six months. A consecutive sampling technique was used for patient recruitment. Data was collected from twenty patients using in-depth interviews. Thematic analysis of the responses and recurring patterns was done, with themes illustrated using the word cloud. The mean age of the participants was 37.1 years (range = 21-75 years) while the mean duration of leakage was 64.3 months (range = 8-564 months). Reasons for delay in accessing treatment of obstetric fistula were lack of awareness of the availability of free treatment in a specialized centre, delay in referral from index health care facilities, wrong information from health care workers, failed repairs at other health facilities, secondary delay due to transportation challenges, cultural beliefs and other issues peculiar to the patients. The commonest reason for the delay in accessing treatment for obstetric fistula is a lack of awareness on the part of patients, the public, and health workers. We recommend improved campaigns, advocacy, and community mobilization.

Maternal and fetal characteristics for predicting risk of Cesarean section following induction of labor: pooled analysis of PROBAAT trials

OBJECTIVE

Induction of labor (IOL) is one of the most widely used obstetric interventions. However, one-fifth of IOLs result in Cesarean section (CS). We aimed to assess maternal and fetal characteristics that influence the likelihood of CS following IOL, according to the indication for CS.

METHODS

This was a secondary analysis of pooled data from four randomized controlled trials, including women undergoing IOL at term who had a singleton pregnancy and an unfavorable cervix, intact membranes and the fetus in cephalic presentation. The main outcomes of this analysis were CS for failure to progress (FTP) and CS for suspected fetal compromise (SFC). Restricted cubic splines were used to determine whether continuous maternal and fetal characteristics had a non-linear relationship with outcome. Optimal cut-offs for those characteristics with a non-linear pattern were determined based on the maximum area under the receiver-operating-characteristics curve. Adjusted odds ratios (aOR) were computed, using multivariable logistic regression analysis, for the associations between optimally categorized characteristics and outcome.

RESULTS

Of a total of 2990 women undergoing IOL, 313 (10.5%) had CS for FTP and 227 (7.6%) had CS for SFC. The risk of CS for FTP was increased in women aged 31-35 years compared with younger women (aOR, 1.51 (95% CI, 1.15-1.99)), in nulliparous compared with parous women (aOR, 8.07 (95% CI, 5.34-12.18)) and in Sub-Saharan African compared with Caucasian women (aOR, 2.09 (95% CI, 1.33-3.28)). Higher body mass index (BMI) increased incrementally the risk of CS for FTP (aOR, 1.06 (95% CI, 1.04-1.08)). High birth-weight percentile was also associated with an increased risk of CS due to FTP (aOR, 2.66 (95% CI, 1.74-4.07) for birth weight between the 80.0^th and 89.9^th percentiles and aOR, 4.08 (95% CI, 2.75-6.05) for birth weight ≥ 90^th percentile, as compared with birth weight between the 20.0^th and 49.9^th percentiles). For CS due to SFC, higher maternal age (aOR, 1.09 (95% CI, 1.05-1.12)) and BMI (aOR, 1.05 (95% CI, 1.03-1.08)) were associated with an incremental increase in risk. The risk of CS for SFC was increased in nulliparous compared with parous women (aOR, 5.91 (95% CI, 3.76-9.28)) and in South Asian compared with Caucasian women (aOR, 2.50 (95% CI, 1.23-5.10)). Birth weight < 10.0^th percentile increased significantly the risk of CS due to SFC (aOR, 1.93 (95% CI, 1.22-3.05)), as compared with birth weight between the 20.0^th and 49.9^th percentiles. Bishop score did not demonstrate a significant association with the risk of CS for FTP or for SFC.

CONCLUSIONS

In women undergoing IOL, maternal age, BMI, parity, ethnicity and birth-weight percentile are predictors of CS due to FTP and of CS due to SFC, but the direction and magnitude of the associations differ according to the indication for CS. These characteristics should be considered in combination with the Bishop score to stratify the risk of CS for different indications in women undergoing IOL. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Amniotic fluid embolism - implementation of international diagnosis criteria and subsequent pregnancy recurrence risk

OBJECTIVES

An international diagnostic criterion for amniotic fluid embolism (AFE) diagnosis has recently been published. Data regarding subsequent pregnancies is scarce. We sought to implement recent diagnostic criteria and detail subsequent pregnancies in survivors.

METHODS

A case series of all suspected AFE cases at a tertiary medical center between 2003 and 2018 is presented. Cases meeting the diagnostic criteria for AFE were included. Clinical presentation, treatment, and outcomes described. Pregnancy outcomes in subsequent pregnancies in AFE survivors detailed.

RESULTS

Between 2003 and 2018 14 women were clinically suspected with AFE and 12 of them (85.71%) met the diagnostic criteria for AFE. Three cases occurred during midtrimester dilation and evacuation procedures, and the remaining occurred in the antepartum period. Of the antepartum cases, mode of delivery was cesarean delivery or vacuum extraction for expedited delivery due to presentation of AFE in 8/9 cases (88.88%). Clinical presentation included cardiovascular collapse, respiratory distress and disseminated intravascular coagulopathy (DIC). Heart failure of varying severity was diagnosed in 75% (9/12) cases. Composite maternal morbidity was 5/12 (41.66%), without cases of maternal mortality. 11 subsequent pregnancies occurred in four AFE survivors. Pregnant women were followed by a high-risk pregnancy specialist and multidisciplinary team if pregnancy continued beyond the early second trimester. Six pregnancies resulted in a term delivery. No recurrences of AFE were documented.

CONCLUSIONS

Use of a diagnostic criterion for diagnosis of AFE results in a more precise diagnosis of AFE. Nevertheless, the accuracy of clinical diagnosis is still high. Subsequent pregnancies were not associated with AFE recurrence.

Early secondary repair of obstetric anal sphincter injuries (OASIs): experience and a review of the literature

INTRODUCTION AND HYPOTHESIS

Secondary anal sphincter repair for a dehisced obstetric anal sphincter injury (OASI) is required following 2.6% of primary repairs. There is growing evidence that instead of delaying repair for 3-6 months, early secondary repair of the anal sphincter can be completed within 14 days. Our aims were to review the literature and to describe experiences in our unit.

METHODS

This is a narrative review of all published cases reporting outcomes of early secondary repair of dehisced OASIs. In addition, we report a series from Croydon University Hospital (CUH) between 2010 and 2019.

RESULTS

Ninety patients from five studies were identified on literature search. Six patients from CUH were included in the case series. Overall, the most common complications following secondary repair included skin dehiscence [10.3% (n = 10)], infection [5.2% (n = 5)] and fistula formation [8.2% (n = 8)]. In our case series, following secondary repair, normal manometric incremental squeeze pressure was found in five women (83%). Also, on endoanal ultrasound, internal anal sphincter (IAS) defects were found in 75% with a history of IAS injury (n = 4). There were no full-thickness external anal sphincter defects. Compared to those requiring primary repair alone, residual defects were significantly larger in those who also underwent secondary repair (Starck score 2.1 vs. 5.7, p = 0.01).

CONCLUSION

Early secondary repair is a feasible surgical procedure for the reconstruction of dehisced OASIs. This case series and review of the literature can be used to support clinicians in the management of primary OASI repair dehiscence.

Retained Products of Conception Fed by the Inferior Mesenteric Artery: A Case Report

Retained products of conception (RPOC) refer to the persistence of placental or fetal tissue in the uterus following delivery or miscarriage. RPOC may cause massive postpartum or post-abortion hemorrhage. Arterial embolization (AE) is an effective choice of management for postpartum hemorrhage including RPOC. We report a case of hemorrhagic RPOC, in which uterine artery embolization with transcervical resection did not achieve hemostasis, and laparotomy with uterine compression sutures was subsequently required. The RPOC was apparently fed by an aberrant branch derived from the inferior mesenteric artery (IMA). AE of IMA was not performed because of possible necrosis of the descending colon and rectum. A physician should be aware that AE is not an all-encompassing hemostatic technique for postpartum bleeding, such as with RPOC, and should keep alternatives in mind.

Risk of obstetric anal sphincter injuries (OASIS) and anal incontinence: A meta-analysis

BACKGROUND

Obstetric anal sphincter injuries (OASIS) are the commonest cause of anal incontinence in women of reproductive age. We determined the risk of anal sphincter defects diagnosed by ultrasound, and the risk of anal incontinence in (i) all women who deliver vaginally, (ii) in women without clinical suspicion of OASIS, and (iii) after primary repair of sphincter injury, by systematic review.

METHODS

We searched major databases until June 2018, without language restrictions. Random effects meta-analysis was used to obtain pooled estimates of ultrasound diagnosed OASIS and risk of anal incontinence symptoms at various time points after delivery, and of persistent sphincter defects after primary repair. We reported the association between ultrasound diagnosed OASIS and anal incontinence symptoms using relative risk (RR) with 95 % CI.

RESULTS

We included 103 studies involving 16,110 women. Of all women who delivered vaginally, OASIS were diagnosed on ultrasound in 26 % (95 %CI, 21-30, I² = 91 %), and 19 % experienced anal incontinence (95 %CI, 14-25, I² = 92 %). In women without clinical suspicion of OASIS (n = 3688), sphincter defects were observed in 13 % (10-17, I² = 89 %) and anal incontinence experienced by 14 % (95 % CI: 6-24, I² = 95 %). Following primary repair of OASIS, 55 % (46-63, I² = 98 %) of 7549 women had persistent sphincter defect with 38 % experiencing anal incontinence (33-43, I² = 92 %). There was a significant association between ultrasound diagnosed OASIS and anal incontinence (RR 3.74, 2.17-6.45, I² = 98 %).

INTERPRETATION

Women and clinicians should be aware of the high risk for sphincter defects following vaginal delivery even when clinically unsuspected. This underlines the need of careful and systematic perineal assessment after birth to mitigate the risk of missing OASIS. We also noted a high rate of persistent defects and symptoms following primary repair of OASIS. This dictates the need for provision of robust training for clinicians to achieve proficiency and sustain competency in repairing OASIS.

Accurate diagnosis and repair of obstetric anal sphincter injuries: why and how

Obstetric anal sphincter injuries represent the minority of obstetric lacerations, but can have a significant long-term impact on urinary and fecal continence, as well as pelvic organ support. Accurate diagnosis of lacerations, appropriate repair, and close follow-up are essential to healthy healing and to improve outcomes for women. The infrequency of these injuries has resulted in a lack of familiarity with laceration repair and postpartum care of this population at all levels of practice. As such, continuing education strategies aimed at simulation, increased clinical exposure to anal sphincter injuries, and evidence-based repair techniques are important for mitigating the deficits in the current obstetric environment. Ensuring that patients have access to timely multidisciplinary postpartum care and education on the laceration incurred is essential to promote healthy healing and to optimize pelvic floor outcomes.

Risk factors for Cesarean delivery in pregnancy with small-for-gestational-age fetus undergoing induction of labor

OBJECTIVES

To identify risk factors for Cesarean delivery and non-reassuring fetal heart tracing (NRFHT) in pregnancies with a small-for-gestational-age (SGA) fetus undergoing induction of labor and to design and validate a prediction model, combining antenatal and intrapartum variables known at the time of labor induction, to identify pregnancies at increased risk of Cesarean delivery.

METHODS

This was a retrospective cohort study of non-anomalous, singleton gestations with a SGA fetus that underwent induction of labor, delivered in a single tertiary referral center between January 2011 and December 2016. SGA was defined as estimated fetal weight (EFW) < 10^th percentile. The primary outcome was to identify risk factors associated with Cesarean delivery. The secondary outcome was to identify risk factors associated with NRFHT. Univariate and multivariate analyses were used to determine which clinical characteristics, available at the time of admission, had the strongest association with Cesarean delivery and NRFHT during labor induction. The predictive value of the final models was assessed by the area under the receiver-operating-characteristics curve (AUC). Sensitivity and specificity of the models were also assessed. Internal validation of the models was performed using 10 000 bootstrap replicates of the original cohort. The adequacy of the models was evaluated using the Hosmer-Lemeshow goodness-of-fit test.

RESULTS

A total of 594 pregnancies were included. Cesarean delivery was performed in 243 (40.9%) pregnancies. Significant risk factors associated with Cesarean delivery, and included in the final model, were maternal age, gestational age at delivery and initial method of labor induction. The bootstrap estimate of the AUC of the final prediction model for Cesarean delivery was 0.82 (95% CI, 0.78-0.86). The model had sensitivity of 64.2%, specificity of 86.9%, positive likelihood ratio (LR) of 4.9 and negative LR of 0.41. The model had good fit (P = 0.617). NRFHT complicated 117 (19.7%) pregnancies. Significant risk factors for NRFHT included EFW < 5^th percentile, abnormal umbilical artery Doppler studies (pulsatility index > 95^th percentile or absent/reversed end-diastolic flow) and gestational age at delivery. The final prediction model for NRFHT had an AUC of 0.69 (95% CI, 0.63-0.75) and specificity of 97.0%.

CONCLUSION

We identified several significant risk factors for Cesarean delivery and NRFHT among SGA pregnancies undergoing induction of labor. Clinicians may use these risk factors to guide patient counseling and to help anticipate the potential need for operative delivery. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Impact of a selective use of episiotomy combined with Couder's maneuver for the perineal protection

PURPOSE

To evaluate the impact of a selective use of episiotomy combined with Couder's maneuver on the incidence of perineal tears in spontaneous term deliveries.

METHODS

A comparative, retrospective, mono-centric study in a university maternity unit was designed and included all primiparous women who delivered spontaneously after 37 weeks of gestation in cephalic presentation. Two cohorts were studied, before and after the practice of Couder's maneuver. In the first cohort, the ''OSE cohort'' only selective episiotomies were performed from January 2009 to December 2010. In the second cohort, from January 2016 to December 2017, the ''SEC cohort'' selective episiotomies combined with Couder's maneuver were performed by midwives and obstetricians. The primary outcome was the type of perineal tears, according to the Royal College of Obstetricians and Gynaecologists (RCOG) classification.

RESULTS

A total of 2081 patients were included: 909 patients in the OSE cohort and 1172 patients in the SEC cohort. Couder's maneuver was performed in 59% of the SEC cohort. In the SEC cohort, there were an increase in the number of intact perinea (55% versus 63%, p < 0.001), a decrease in second-degree perineal tears (18% versus 11%, p < 0.001) and a decrease in labia minora tears (48% versus 37%, p < 0.001). The rate of obstetrical anal sphincter injuries was less than 1% in both cohorts (0.3% versus 0.5%, p = 0.7).

CONCLUSION

A selective use of episiotomy combined with Couder's maneuver could reduce the incidence of perineal tears, particularly second-degree perineal tears, without increasing the rate of obstetrical anal sphincter injuries.

Follow-up of postpartum anal sphincter injuries

BACKGROUND

A number of women who incur anal sphincter injuries during childbirth develop severe anal incontinence. The purpose of our study was to survey the follow-up and treatment of anal sphincter injuries in the first two years postpartum.

MATERIAL AND METHOD

Data on all women who have undergone vaginal birth with the diagnosis code third or fourth degree perineal rupture in Norway in the period 1.1.2012-31.12.2013 were obtained from the Medical Birth Registry of Norway. These data were linked to the Norwegian Patient Registry to chart any treatment with sacral neuromodulation or sphincteroplasty up to two years postpartum. A questionnaire survey of procedures for following up patients with perineal rupture was also conducted among maternity departments in Norway.

RESULTS

1 999 women had suffered third or fourth degree perineal rupture during childbirth during the study period. Twelve (0.6 %) of them had undergone sphincteroplasty, while none had been treated with sacral neuromodulation. Almost all of them were followed up by the hospital 6-12 months after giving birth, but few hospitals used a validated scoring system to assess the degree of anal incontinence.

INTERPRETATION

Very few women with third or fourth degree perineal rupture were treated for severe anal incontinence with sphincteroplasty or sacral neuromodulation within two years of giving birth.

Continuous versus discontinuous suture in perineal injuries produced during delivery in primiparous women: a randomized controlled trial

BACKGROUND

The technique used in the repair of a perineal injury resulting from childbirth could avoid discomfort and morbidity during the postpartum period. Recent studies show inconsistent results and support the need for new research with the inclusion of new health parameters not yet studied. Therefore, this study aims to evaluate if the suture technique (continuous or interrupted) has an effect on pain and other postpartum problems, incidence of incontinence (urinary and/or fecal), and the restart of sexual relations.

METHODS

A single-blind randomized clinical trial was conducted in five hospitals in south-east Spain. The participants were primiparous women who had experienced a perineal injury during delivery (second-degree tear or episiotomy). Data was collected on sociodemographic variables, variables associated with pregnancy, labor and delivery, and the postpartum period, and outcomes during the 3 months after delivery: pain, incontinence, and restart of sexual relations. Odds ratios (OR) were calculated by binary logistic regression to assess the influence of the suture type on binary outcomes and t-test used for comparing continuous outcomes. Multivariate analyses (using logistic regression -adjusted (aOR)- and analysis of covariance) were carried out to adjust for unbalanced variables after randomization.

RESULTS

A total of 70 women were included in the intervention group (continuous suture) and 64 in the reference group (interrupted sutures). A negative association was observed (aOR = 0.39; 95% CI = 0.18-0.86) between a continuous suture and the need for analgesia at 24 h postpartum. Pain experienced by the women at 24 h postpartum was assessed as 4.4 ± 0.3 compared with a score of 3.4 ± 0.3 in the group with continuous sutures (p = 0.011). At 15 days postpartum, women in the intervention group experienced less pain (aOR = 0.38; 95% CI = 0.18-0.80) (p = 0.019). Urinary sphincter incontinence was also evaluated at 15 days, with 4.3% (n = 3) of the women in the intervention group presenting with urinary incontinence compared with 18.8% (n = 12) in the control group (aOR = 0.11; 95% CI = 0.03-0.47) (P = 0.003).

CONCLUSIONS

The women who had a continuous suture repair showed lower levels of pain from delivery to 3 months after delivery and had a lower incidence of urinary incontinence at 15 days postpartum.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03825211 posted January 31, 2019 (retrospectively registered).

Surgical management of critical congenital malformations in the delivery room

Newborn emergencies that occur in the delivery room are frequently the result of life-threatening congenital anomalies that can result in death or severe disability if not treated in the immediate postnatal period. Prompt recognition and treatment of such disorders are paramount to ensuring the wellbeing of the infant. As congenital anomalies are frequently being diagnosed earlier due to improved prenatal detection, the coordination of planned interventions for life-threatening malformations is also becoming more common. This article serves as a guide for the presentation and initial management of the most common non-cardiac, newborn surgical emergencies.

Rehabilitation and reintegration programming adjunct to female genital fistula surgery: a scoping review protocol

INTRODUCTION

Female genital fistula is a debilitating traumatic injury, largely birth-associated, globally affecting up to 2 million women, mostly in sub-Saharan Africa. Fistula has significant physical, psychological and economic consequences. Women often face challenges in reintegrating and resuming prior roles despite successful surgery. Synthesising the evidence on services adjunct to fistula surgery and their outcomes is important for developing the evidence base for best practices and identifying research priorities. This scoping review seeks to examine the range of rehabilitation and reintegration services provided as adjunct to genital fistula surgery, map the existing programming and outcomes, and identify areas for additional research.

METHODS AND ANALYSIS

Our scoping review is informed by existing methodological frameworks and will be conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses-ScR guidelines. The search strategy will be applied to nine biomedical, public health and social science databases. The initial search was completed on 27 September 2018. Grey literature will be identified through targeted Google searches and from organisational websites identified as relevant by the United Nations Population Fund (UNFPA) Campaign to End Fistula. We will iteratively build our search strategy through term harvesting and review, and search reference lists of reports and articles to identify additional studies. Two reviewers will independently screen titles and abstracts, followed by full-text screening of all potentially relevant articles and standardised data extraction. Articles eligible for inclusion will discuss research or programmatic efforts around service provision in adjunct to surgery among females with genital fistula. Data will be presented in summary tables accompanied by narrative description.

ETHICS AND DISSEMINATION

Ethics approval is not required for a scoping review. Our results can be used to inform policy, serve as support for funding and development of reintegration programmes and highlight areas for subsequent research. Results will be disseminated at relevant conferences and published in a peer-reviewed journal.

Adherence to guidelines and suboptimal practice in term breech delivery with perinatal death- a population-based case-control study in Norway

BACKGROUND

In a recent population-based study we reported excess risk of neonatal mortality associated with vaginal breech delivery. In this case-control study we examine whether deviations from Norwegian guidelines are more common in breech deliveries resulting in intrapartum or neonatal deaths than in breech deliveries where the offspring survives, and if these deaths are potentially avoidable.

MATERIAL AND METHODS

Case-control study completed as a perinatal audit including term breech deliveries of singleton without congenital anomalies in Norway from 1999 to 2015. Deliveries where the child died intrapartum or in the neonatal period were case deliveries. For each case, two control deliveries who survived were identified. All the included deliveries were reviewed by four obstetricians independently assessing if the deaths in the case group might have been avoided and if the management of the deviations from Norwegian guidelines were more common in case than in control deliveries.

RESULTS

Thirty-one case and 62 control deliveries were identified by the Medical Birth Registry of Norway. After exclusion of non-eligible deliveries, 22 case and 31 control deliveries were studied. Three case and two control deliveries were unplanned home deliveries, while all in-hospital deliveries were in line with national guidelines. Antenatal care and/or management of in-hospital deliveries was assessed as suboptimal in seven (37%) case and two (7%) control deliveries (p = 0.020). Three case deliveries were completed as planned caesarean delivery and 12 (75%) of the remaining 16 deaths were considered potentially avoidable had planned caesarean delivery been done. In seven of these 16 deliveries, death was associated with cord prolapse or difficult delivery of the head.

CONCLUSION

All in-hospital breech deliveries were in line with Norwegian guidelines. Seven of twelve potentially avoidable deaths were associated with birth complications related to breech presentation. However, suboptimal care was more common in case than control deliveries. Further improvement of intrapartum care may be obtained through continuous rigorous training and feedback from repeated perinatal audits.

Lateral episiotomy versus no episiotomy to reduce obstetric anal sphincter injury in vacuum-assisted delivery in nulliparous women: study protocol on a randomised controlled trial

INTRODUCTION

Obstetric anal sphincter injury (OASIS) occurs in 5%-7% of normal deliveries and increases with vacuum extraction (VE) to 12%-14% in nulliparous women in Sweden. Lateral/mediolateral episiotomy may reduce the prevalence of OASIS at VE in nulliparous women. The current use of episiotomy is restrictive. The protective effect and consequences are uncertain. This trial will investigate if lateral episiotomy can reduce the prevalence of OASIS and assess short-term and long-term effects.

METHODS AND ANALYSIS

This is a multicentre randomised controlled trial of lateral episiotomy versus no episiotomy in nulliparous women with a singleton, live fetus, after gestational week 34+0 with indication for VE. A lateral episiotomy of 4 cm is cut at crowning, 1-3 cm from the midline, at a 60° angle. The primary outcome is OASIS by clinical diagnosis analysed according to intention to treat. To demonstrate a 50% reduction in OASIS prevalence (from 12.4% to 6.2%), 710 women will be randomised at a 1:1 ratio. Secondary outcomes are pain, blood loss, other perineal injuries, perineal complications, Apgar score, cord pH and neonatal complications. Web-based questionnaires at baseline, 2 months, 1 and 5 years will be used to assess pain, incontinence, prolapse, sexual function, quality of life and childbirth experience. A subset of women will receive follow-up by pelvic floor sonography and pelvic examination. Mode of delivery and recurrence of OASIS/episiotomy in subsequent pregnancies will be assessed at 5 and 10 years using register data.

ETHICS AND DISSEMINATION

The trial is open for enrolment. The trial has received ethical approval from the Regional Ethical Review Board of Stockholm and full funding from the Swedish Research Council. Women are interested in participation. The predominant restrictive view on episiotomy may limit recruitment. Results are of global interest and will be disseminated in peer-reviewed journals and at international congresses.

TRIAL REGISTRATION NUMBER

NCT02643108; Pre-results.

'Safe', yet violent? Women's experiences with obstetric violence during hospital births in rural Northeast India

The majority of maternal health interventions in India focus on increasing institutional deliveries to reduce maternal mortality, typically by incentivising village health workers to register births and making conditional cash transfers to mothers for hospital births. Based on over 15 months of ethnographically informed fieldwork conducted between 2015 and 2017 in rural Assam, the Indian state with the highest recorded rate of maternal deaths, we find that while there has been an expansion in institutional deliveries, the experience of childbirth in government facilities is characterised by obstetric violence. Poor and indigenous women who disproportionately use state facilities report both tangible and symbolic violence including iatrogenic procedures such as episiotomies, in some instances done without anaesthesia, improper pelvic examinations, beating and verbal abuse during labour, with sometimes the shouting directed at accompanying relatives. While the expansion of institutional deliveries and access to emergency obstetric care is likely to reduce maternal mortality, in the absence of humane care during labour, institutional deliveries will continue to be characterised by the paradox of "safe" births (defined as simply reducing maternal deaths) and the deployment of violent practices during labour, underscoring the unequal and complex relationship between the bodies of the poor and reproductive governance.

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.

Too Long to Wait: Obstetric Fistula and the Sociopolitical Dynamics of the Fourth Delay in Soroti, Uganda

Uganda has one of the highest obstetric fistula rates in the world with approximately 200,000 women currently suffering. Surgical closure successfully treats fistula in the majority of cases, yet there is a severe shortage of facilities and trained surgeons in low-resource countries. The purpose of this study was to examine Ugandan women's experiences of obstetric fistula with the aim of adding narrative depth to the clinical literature on this devastating birth injury. Data were collected through semistructured interviews, focus groups, and participant observation. Resulting narratives were consensus coded, and key themes were member-checked using reciprocal ethnography. Women who suffered from fistula described barriers in accessing essential obstetric care during labor-barriers that are consistent with the three delays framework developed by Thaddeus and Maine. In this article, we extend this scholarship to discuss a fourth, critical delay experienced by fistula survivors-the delay in the diagnosis and treatment of their birth injury.

Pubovesical sling for residual incontinence after successful vesicovaginal fistula closure: a new approach to an old procedure

INTRODUCTION AND HYPOTHESIS

For decades, the pubovesical (PV) sling has been in the armamentarium of the fistula surgeon for treating persistent urinary incontinence after successful fistula closure. We report our early experience with slings, and then also introduce a new "tight" PV sling technique for management of post-fistula urethral leak. Our hypothesis is that performance of tight slings might result in improved continence for women with persistent urinary incontinence after obstetric fistula closure.

METHODS

Data from 120 patients in whom some type of sling procedure had been performed between 1996 and 2012 were extracted and labeled as "early slings." Beginning in October 2014, more complete data were recorded and a more uniform approach was undertaken in 40 patients. Data were extracted from their charts and recorded as "tight slings." This information was analyzed using Chi-squared analysis.

RESULTS

Tight slings were more successful in patients who had less severe fibrosis and who had a shorter time since initial injury. Thirty percent of women who underwent tight slings had improved continence at follow-up.

CONCLUSION

Persistent urinary incontinence despite successful surgical closure of obstetrical fistula remains a difficult problem. Tight slings may be warranted in an attempt to avoid urinary diversion.

Indications and Fetal Outcomes of Caesarean Section in Sindhu Sadabahar Hospital, Sindhupalchok

Background There has been a sustained increase in the rate of caesarean section in the last few years around the world. Caesarean section (CS) Audit which plays an important role in the analysis of rate, indications and outcomes of caesarean section, helps to modify the trend of caesarean delivery. Objective This study was done to know the indications and outcomes of caesarean section in Sindhu Sadabahar Hospital, Khadichaur, Sindhupalchok. Method A hospital based descriptive study was conducted in gynaecological department of Sindhu Sadabahar hospital, Sindhupalchok over 14 months period from 1st Baisakh 2070 to 30thAshad 2071 (14th April 2013 to 14th July 2014) among 218 women who underwent caesarean section. Result The foetal distress was the leading indication of caesarean section (34%, n=74). Non-progress of labour and prolonged second stage of labour were seen in 15.6% (n=34) women respectively. There was 3.2% (n=7) fresh still birth and 1.8% (n=4) early neonatal death. Total perinatal death was 5% (n=11). There were 12.1% (n=27) low birth weight baby and 9.9% (n=22) macrosomic baby. ≤ 5/10 Appearance, Pulse, Grimace, Activity and Respiration (APGAR) score at five minutes was seen in 35.5% (n=79) neonates. Conclusion This study showed that majority of patients had an emergency cesarean section for foetal distress, nonprogress of labour and prolonged second stage of labour. Prevalence of caesarean section was higher than the caesarean rate (15%) recommended by World Health Organization (WHO). Cesarean sections performed for appropriate medical or obstetric indications are life saving for both the mother as well as the new born.