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

Duration of the active first stage of labour and severe perineal lacerations and maternal postpartum complications: a population-based cohort study

OBJECTIVE

The impact of first stage labour duration on maternal outcomes is sparsely investigated. We aimed to study the association between a longer active first stage and maternal complications in the early postpartum period.

DESIGN

A population-based cohort study.

SETTING

Regions of Stockholm and Gotland, Sweden, 2008-2020.

POPULATION

A cohort of 159 459 term, singleton, vertex pregnancies, stratified by parity groups.

METHODS

The exposure was active first stage duration, categorised in percentiles. Poisson regression analysis was performed to estimate the adjusted relative risk (aRR) and the 95% confidence interval (95% CI). To investigate the effect of second stage duration on the outcome, mediation analysis was performed.

MAIN OUTCOME MEASURES

Severe perineal lacerations (third or fourth degree), postpartum infection, urinary retention and haematoma in the birth canal or ruptured sutures.

RESULTS

The risks of severe perineal laceration, postpartum infection and urinary retention increased with a longer active first stage, both overall and stratified by parity group. The aRR increased with a longer active first stage, using duration of <50th percentile as the reference. In the ≥90th percentile category, the aRR for postpartum infection was 1.64 (95% CI 1.46-1.84) in primiparous women, 2.43 (95% CI 1.98-2.98) in parous women with no previous caesarean delivery (CD) and 2.33 (95% CI 1.65-3.28) in parous women with a previous CD. The proportion mediated by second stage duration was 33.4% to 36.9% for the different outcomes in primiparous women. The risk of haematoma or ruptured sutures did not increased with a longer active first stage.

CONCLUSIONS

Increasing active first stage duration is associated with maternal complications in the early postpartum period.

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.

The prevention of perineal trauma during vaginal birth

Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%. The incidence of obstetrical anal sphincter injury is approximately 3%, with a significantly higher rate in primiparous than in multiparous women (6% vs 2%). Obstetrical anal sphincter injury is a significant risk factor for the development of anal incontinence, with approximately 10% of women developing symptoms within a year following vaginal birth. Obstetrical anal sphincter injuries have significant medicolegal implications and contribute greatly to healthcare costs. For example, in 2013 and 2014, the economic burden of obstetrical anal sphincter injuries in the United Kingdom ranged between £3.7 million (with assisted vaginal birth) and £9.8 million (with spontaneous vaginal birth). In the United States, complications associated with trauma to the perineum incurred costs of approximately $83 million between 2007 and 2011. It is therefore crucial to focus on improvements in clinical care to reduce this risk and minimize the development of perineal trauma, particularly obstetrical anal sphincter injuries. Identification of risk factors allows modification of obstetrical practice with the aim of reducing the rate of perineal trauma and its attendant associated morbidity. Risk factors associated with second-degree perineal trauma include increased fetal birthweight, operative vaginal birth, prolonged second stage of labor, maternal birth position, and advanced maternal age. With obstetrical anal sphincter injury, risk factors include induction of labor, augmentation of labor, epidural, increased fetal birthweight, fetal malposition (occiput posterior), midline episiotomy, operative vaginal birth, Asian ethnicity, and primiparity. Obstetrical practice can be modified both antenatally and intrapartum. The evidence suggests that in the antenatal period, perineal massage can be commenced in the third trimester of pregnancy to increase muscle elasticity and allow stretching of the perineum during birth, thereby reducing the risk of tearing or need for episiotomy. With regard to the intrapartum period, there is a growing body of evidence from the United Kingdom, Norway, and Denmark suggesting that the implementation of quality improvement initiatives including the training of clinicians in manual perineal protection and mediolateral episiotomy can reduce the incidence of obstetrical anal sphincter injury. With episiotomy, the International Federation of Gynecology and Obstetrics recommends restrictive rather than routine use of episiotomy. This is particularly the case with unassisted vaginal births. However, there is a role for episiotomy, specifically mediolateral or lateral, with assisted vaginal births. This is specifically the case with nulliparous vacuum and forceps births, given that the use of mediolateral or lateral episiotomy has been shown to significantly reduce the incidence of obstetrical anal sphincter injury in these groups by 43% and 68%, respectively. However, the complications associated with episiotomy including perineal pain, dyspareunia, and sexual dysfunction should be acknowledged. Despite considerable research, interventions for reducing the risk of perineal trauma remain a subject of controversy. In this review article, we present the available data on the prevention of perineal trauma by describing the risk factors associated with perineal trauma and interventions that can be implemented to prevent perineal trauma, in particular obstetrical anal sphincter injury.

Anal incontinence after obstetrical anal sphincter injury significantly impacts quality of life for women: a cohort study

PURPOSE

To assess the prevalence of anal incontinence (AI) after obstetrical anal sphincter injuries (OASIS) and its severity, as well as the risk factors for AI and AI episodes ≥ 6 months.

METHODS

This prospective and observational monocentric cohort study included all the women who had an OASIS between 1 January 2005 and 31 December 2019. Information was collected by using a letter informing for the fecal incontinence quality of life (FIQL) questionnaire and by a phone interview. The main outcome measure was "1 passed or ongoing episode of AI".

RESULTS

Among the 227 patients included, 19.8% had ongoing AI, and 35.2% had AI passed or ongoing episodes. A total of 46.7% of women with AI reported a change in their quality of life in all fields of the FIQL. Excluding a history of inflammatory bowel disease, no factor was associated with the incidence of an AI episode. Post-obstetrical AI ≥ 6 months (POAI ≥ 6) represented 63.7% of AI cases. This incontinence began with significant incidence in the immediate postpartum period but increased over time, unlike AI < 6 months, which appeared primarily in the immediate postpartum period. Instrumental birth was a protective factor for POAI ≥ 6 (OR = 0.24; CI 95% [0.08-0.78]; p = 0.016), while an increase in parity and BMI were risk factors for POAI ≥ 6 (OR = 4.21; CI 95% [1.01-17.71]; p = 0.05 and OR = 1.15; CI 95% [1.03-1.30]; p = 0.016, respectively).

CONCLUSION

The prevalence of AI after OASIS is not underestimated. Despite the fact that women do not seek care, the impact of AI on the quality of life is significant. A case of AI that lasts for 6 months after giving birth risks becoming chronic. Therefore, specialist advice should be recommended in this case.

CLINICAL TRIAL REGISTRY

NCT04940494.

Neglected medium-term and long-term consequences of labour and childbirth: a systematic analysis of the burden, recommended practices, and a way forward

Over the past three decades, substantial progress has been made in reducing maternal mortality worldwide. However, the historical focus on mortality reduction has been accompanied by comparative neglect of labour and birth complications that can emerge or persist months or years postnatally. This paper addresses these overlooked conditions, arguing that their absence from the global health agenda and national action plans has led to the misconception that they are uncommon or unimportant. The historical limitation of postnatal care services to the 6 weeks after birth is also a contributing factor. We reviewed epidemiological data on medium-term and long-term complications arising from labour and childbirth beyond 6 weeks, along with high-quality clinical guidelines for their prevention, identification, and treatment. We explore the complex interplay of human evolution, maternal physiology, and inherent predispositions that contribute to these complications. We offer actionable recommendations to change the current trajectories of these neglected conditions and help achieve the targets of Sustainable Development Goal 3. This paper is the third in a Series of four papers about maternal health in the perinatal period and beyond.

A systematic review and a meta-analysis on the incidence of obstetric anal sphincter injuries during vaginal delivery

AIM

The incidence of obstetric anal sphincter injuries (OASIS) has increased in the past two decades despite improved awareness of the risk factors. This study aimed to define the incidence of OASIS in women with different features (instrumental delivery or other variables).

METHODS

A systematic review was conducted on articles reporting the incidence of OASIS. This review aims to examine the association of instrumentation and OASIS by performing a formal systematic review of the published literature. Databases used for the research were MEDLINE, Embase, CINAHL and 'Maternity and infant care' databases.

RESULTS

Two independent reviewers screened the selected articles. 2326 duplicates were removed from the total of 4907 articles. The remaining 2581 articles were screened for title and abstract. 1913 articles were excluded due to irrelevance. The remaining 300 were screened as full text. Primiparity associated with the use of forceps were the features associated with the highest incidence of OASIS in the selected articles (19.4%). OASIS in all women had an overall incidence of 3.8%. The incidence of OASIS in all women by geographical region was the highest (6.5%) in North America.

CONCLUSIONS

There are various factors that impact on the incidence of OASIS and the combination of some of these, such as the use of forceps in primiparas, resulted in the highest incidence of OASIS. The lack of international consensus is limiting the improvements that can be done to reduce OASIS rates and improve best clinical practice.

A sensorised surgical glove to improve training and detection of obstetric anal sphincter injury: A preclinical study on a pig model

OBJECTIVE

To create a sensorised surgical glove that can accurately identify obstetric anal sphincter injury to facilitate timely repair, reduce complications and aid training.

DESIGN

Proof-of-concept.

SETTING

Laboratory.

SAMPLE

Pig models.

METHODS

Flexible triboelectric pressure/force sensors were mounted onto the fingertips of a routine surgical glove. The sensors produce a current when rubbed on materials of different characteristics which can be analysed. A per rectum examination was performed on the intact sphincter of pig cadavers, analogous to routine examination for obstetric anal sphincter injuries postpartum. An anal sphincter defect was created by cutting through the vaginal mucosa and into the external anal sphincter using a scalpel. The sphincter was then re-examined. Data and signals were interpreted.

MAIN OUTCOME MEASURES

Sensitivity and specificity of the glove in detecting anal sphincter injury.

RESULTS

In all, 200 examinations were performed. The sensors detected anal sphincter injuries in a pig model with sensitivities between 98% and 100% and a specificity of 100%. The current produced when examining an intact sphincter and sphincter with a defect was significantly different (p < 0.001).

CONCLUSION

In this preliminary study, the sensorised glove accurately detected anal sphincter injury in a pig model. Future plans include its clinical translation, starting with an in-human study on postpartum women, to determine whether it can accurately detect different types of obstetric anal sphincter injury in vivo.

Three-Dimensional Transperineal Ultrasound Guiding Early Secondary Repair of Obstetric Anal Sphincter Injury in an Incontinent Patient without Suture Dehiscence

We present the case of a 36-year-old primigravida who gave birth to a 3200 g baby by vacuum-assisted (Kiwi OmniCup™) operative vaginal delivery with mediolateral episiotomy. A "y"-shaped perineal tear with a grade IIIC obstetric anal sphincter injury (OASI) was diagnosed and repaired. Two days after delivery, in the absence of suture dehiscence, she started experiencing complete anal incontinence. A decision was made in association with a proctologic surgeon for an early secondary repair. Before surgery, a Three-dimensional transperineal ultrasound (TPUS) was performed. The exam revealed a major defect of the external anal sphincter at the 11 o'clock position. This allowed for the reopening of only a circumscribed area of the perineal suture and repair of the sphincters using the end-to-end technique. The symptoms regressed completely, and follow-up TPUS demonstrated the gradual wound healing process. Anal incontinence, secondary to obstetric anal sphincter injury (OASI), has a severe negative impact on women's quality of life. TPUS is an effective method to detect sphincter defects and monitor the healing process. This report investigates the feasibility of identifying the sphincter tear in an incontinent puerperal patient without suture dehiscence in order to target early secondary repair while minimizing its extent. TPUS has proven a safe and effective tool to guide early secondary repair of symptomatic OASI complications while minimizing the invasiveness of the procedure. Multidisciplinary management is crucial to ensure the adequate standard of care.

Clinical, ultrasonographic, and functional outcomes after obstetric anal sphincter injury primary repair: A single-center experience

OBJECTIVE

To present clinical and instrumental sequelae after obstetric anal sphincter injuries (OASIS), evaluating correlations between intrapartum severity of lesions, postpartum symptoms, and sonographic and manometric findings; outcomes during subsequent deliveries were also evaluated.

METHODS

This retrospective study evaluated all consecutive women who sustained an OASIS between 2015 and 2020. Postpartum symptoms, anorectal manometry (ARM), and three-dimensional endoanal ultrasonography (3D-EAUS) were analyzed.

RESULTS

A total of 107 women underwent OASIS primary repair; 84 (78.5%) of them were asymptomatic after 1 month. The presence and severity of symptoms showed a great correlation with instrumental outcomes in terms of maximum resting pressure, squeeze pressure increment (SPI), circumferential extension of defect for both external anal sphincter (EAS) and internal anal sphincter (IAS), and EAS, IAS and total Starck scores. There was a significant correlation between ARM and 3D-EAUS findings, with the exception of SPI, for which the abnormalities were not predictable based on EAUS results.

CONCLUSION

Both ARM and EAUS findings after OASIS are directly related to each other, and associated with symptoms. These instrumental tools may be useful for OASIS assessment and counseling.

Predictive factors for obstetric anal sphincter injury in primiparous women: systematic review and meta-analysis

OBJECTIVES

The primary objective was to perform a systematic review of predictive factors for obstetric anal sphincter injury (OASI) occurrence at first vaginal delivery, with the diagnosis made by ultrasound (US-OASI). The secondary objective was to report on incidence rates of sonographic anal sphincter (AS) trauma, including trauma that was not clinically reported at childbirth, among the studies providing data for our primary objective.

METHODS

We conducted a systematic search of MEDLINE, EMBASE, Web of Science, CINAHL, The Cochrane Library and ClinicalTrials.gov databases. Both observational cohort studies and interventional trials were eligible for inclusion. Study eligibility was assessed independently by two authors. Random-effects meta-analyses were performed to pool effect estimates from studies reporting on similar predictive factors. Summary odds ratio (OR) or mean difference (MD) is reported with 95% CI. Heterogeneity was assessed using the I2 statistic. Methodological quality was assessed using the Quality in Prognosis Studies tool.

RESULTS

A total of 2805 records were screened and 21 met the inclusion criteria (16 prospective cohort studies, three retrospective cohort studies and two interventional non-randomized trials). Increasing gestational age at delivery (MD, 0.34 (95% CI, 0.04-0.64) weeks), shorter antepartum perineal body length (MD, -0.60 (95% CI, -1.09 to -0.11) cm), labor augmentation (OR, 1.81 (95% CI, 1.21-2.71)), instrumental delivery (OR, 2.13 (95% CI, 1.13-4.01)), in particular forceps extraction (OR, 3.56 (95% CI, 1.31-9.67)), shoulder dystocia (OR, 12.07 (95% CI, 1.06-137.60)), episiotomy use (OR, 1.85 (95% CI, 1.11-3.06)) and shorter episiotomy length (MD, -0.40 (95% CI, -0.75 to -0.05) cm) were associated with US-OASI. When pooling incidence rates, 26% (95% CI, 20-32%) of women who had a first vaginal delivery had US-OASI (20 studies; I2  = 88%). In studies reporting on both clinical and US-OASI rates, 20% (95% CI, 14-28%) of women had AS trauma on ultrasound that was not reported clinically at childbirth (16 studies; I2  = 90%). No differences were found in maternal age, body mass index, weight, subpubic arch angle, induction of labor, epidural analgesia, episiotomy angle, duration of first/second/active-second stages of labor, vacuum extraction, neonatal birth weight or head circumference between cases with and those without US-OASI. Antenatal perineal massage and use of an intrapartum pelvic floor muscle dilator did not affect the odds of US-OASI. Most (81%) studies were judged to be at high risk of bias in at least one domain and only four (19%) studies had an overall low risk of bias.

CONCLUSION

Given the ultrasound evidence of structural damage to the AS in 26% of women following a first vaginal delivery, clinicians should have a low threshold of suspicion for the condition. This systematic review identified several predictive factors for this. © 2023 International Society of Ultrasound in Obstetrics and Gynecology.

Predictive value of the Oxford Acute Severity of Illness Score in acute stroke patients with stroke-associated pneumonia

Background

Stroke-associated pneumonia (SAP) is associated with a poor prognosis and a high mortality rate in stroke patients. However, the accuracy of early prediction of SAP is insufficient, and there is a lack of effective prognostic evaluation methods. Therefore, in this study, we investigated the predictive value of the Oxford Acute Severity of Illness Score (OASIS) in SAP to provide a potential reference index for the incidence and prognosis of SAP.

Methods

We recruited a total of 280 patients with acute ischemic stroke who had been diagnosed and treated in the Zhumadian Central Hospital between January 2021 and January 2023. These patients were divided into an SAP group (86 cases) and a non-SAP group (194 cases) according to SAP diagnostic criteria by expert consensus on the diagnosis and treatment of SAP. We collated general and clinical data from all patients, including the survival of SAP patients during the follow-up period. Multivariate logistic regression was used to analyze the risk factors for SAP. Kaplan-Meier and multivariate COX regression analyses were used to investigate the relationship between OASIS and the prognosis of SAP, and a receiver operating characteristic (ROC) curve was drawn to analyze the predictive value of OASIS for SAP.

Results

Our analyses identified body temperature, C-reactive protein, procalcitonin, OASIS, and a prolonged length of intensive care unit (ICU) stay as the main risk factors for SAP (all Ps < 0.05). Advanced age and an elevated OASIS were identified as the main risk factors for death in SAP patients (all Ps < 0.05). The risk of death in patients with OASIS of 31-42 points was significantly higher than that in patients with OASIS of 12-20 points (HR = 5.588, 95% CI = 1.531-20.401, P = 0.009). ROC curve analysis further showed that OASIS had a high predictive value for morbidity and the incidence of death in SAP patients.

Conclusion

OASIS can effectively predict the onset and death of SAP patients and provides a potential reference index for early diagnosis and the prediction of prognosis in patients with SAP. Our findings should be considered in clinical practice.

Neonatal head circumference as a risk factor for obstetric anal sphincter injuries: a systematic review and meta-analysis

OBJECTIVE

Between 53% and 79% of women will sustain some degree of perineal laceration during vaginal delivery. Third- and fourth-degree perineal lacerations are known as obstetric anal sphincter injuries. Timely diagnosis and prompt treatment of obstetric anal sphincter injuries can help to prevent the development of severe consequences like fecal incontinence, urinary incontinence, and rectovaginal fistula. Neonatal head circumference is routinely measured postpartum but is often not mentioned as a risk factor for obstetric anal sphincter injuries in clinical guidelines. Thus far, no review article on the risk factors for obstetric anal sphincter injuries has discussed the role of neonatal head circumference. This study aimed to review and analyze the relationship between head circumference and the occurrence of obstetric anal sphincter injuries among previous studies to conclude whether head circumference should be recognized as an important risk factor.

DATA SOURCES

Through study screening on Google Scholar, PubMed, Scopus, and Science Direct for articles published between 2013 to 2023, followed by assessment of eligibility, this study ended up reviewing 25 studies, 17 of which were included in the meta-analysis.

STUDY ELIGIBILITY CRITERIA

Only studies that reported both the neonatal head circumference and the occurrence of obstetric anal sphincter injuries were included in this review.

METHODS

The included studies were appraised using the Dartmouth Library risk of bias assessment checklist. Qualitative synthesis was based on the study population, findings, adjusted confounding factors, and suggested causative links in each study. Quantitative synthesis was conducted using calculation and pooling of odds ratios and inverse variance using Review Manager 5.4.1.

RESULTS

A statistically significant association between head circumference and obstetric anal sphincter injuries was reported in 21 of 25 studies; 4 studies reported that head circumference was a true independent risk factor. A meta-analysis of the studies that reported neonatal head circumference as a dichotomous categorical variable with a cutoff point of 35±1 cm yielded statistically significant pooled results (odds ratio, 1.92; 95% confidence interval, 1.80-2.04).

CONCLUSION

The risk for obstetric anal sphincter injuries increased as the neonatal head circumference increased-this should be considered in decision-making during labor and postpartum management to attain the best outcome.

Women's experiences of anal incontinence following vaginal birth: A qualitative study of missed opportunities in routine care contacts

OBJECTIVES

This study aimed to explore experiences of women with anal incontinence following a childbirth injury, and to identify areas of missed opportunities within care they received.

DESIGN

This is a qualitative study involving semi-structured interviews.

SETTING

Participants were recruited via five hospitals in the UK, and via social media adverts and communication from charity organisations.

PARTICIPANTS

Women who have experienced anal incontinence following a childbirth injury, either within 7 years of sustaining the injury, or if they identified new, or worsening symptoms of AI at the time of menopause.

MAIN OUTCOME MEASURES

Main outcomes are experiences of women with anal incontinence following childbirth injury, and missed opportunities within the care they received.

RESULTS

The following main themes were identified: opportunities for diagnosis missed, missed opportunities for information sharing and continuity and timeliness of care.

CONCLUSIONS

Anal Incontinence following a childbirth injury has a profound impact on women. Lack of information and awareness both amongst women and healthcare professionals contributes to delays in accurate diagnosis and appropriate treatment.

Follow up of women after obstetric anal sphincter injuries (OASI)-What is the role of anorectal testing?

AIMS

To evaluate the benefit of performing anorectal studies on all women following primary obstetric anal sphincter injury (OASI) repair over performing them on symptomatic women only.

METHODS

Women who attended perineal clinic between 2007 and 2020 underwent symptom assessment and anorectal studies at 6 weeks and 6 months postpartum. Anorectal studies including endo anal ultrasound (EAUS) and anal manometry (AM) were performed. The anorectal studies of symptomatic women who were the case group, were compared with asymptomatic women who were the control group.

RESULTS

A total of 1348 women were seen in the perineal clinic over 13 years. A total of 454 (33.7%) women were symptomatic. A total of 894 (66.3%) women were asymptomatic. A total of 313 (35%) asymptomatic women had two abnormal anorectal studies, 274 (31%) had abnormal AM alone, and 86 (9.6%) had abnormal EAUS alone. A total of 221 (24.7%) asymptomatic women had normal anorectal studies.

CONCLUSION

Almost 70% of women were asymptomatic 6 months following primary OASI repair. Most had at least one abnormal anorectal study result. Selectively performing anorectal tests on symptomatic women would not identify asymptomatic women at risk of future faecal incontinence following further vaginal birth. Without anorectal study results, women would not receive accurate counseling about the risks of vaginal birth. Anorectal studies should be offered to all women following OASI where resources allow.

The incidence of anal incontinence following obstetric anal sphincter injury graded using the Sultan classification: a network meta-analysis

OBJECTIVE

This study aimed to systematically determine and compare the incidence of anal incontinence between those with different grades of obstetric anal sphincter injury.

DATA SOURCES

Ovid MEDLINE, Embase, and the Cochrane Library were searched from January 2000 to April 2021.

STUDY ELIGIBILITY CRITERIA

Observational studies investigating the incidence of anal incontinence following an obstetric anal sphincter injury that was graded using the Sultan classification were eligible for inclusion. To allow comparison between individual tear grades (3a, 3b, 3c, fourth), a network meta-analysis was performed using Stata (version 15.1).

METHODS

For binary outcomes, odds ratios with corresponding 95% confidence intervals were reported. Obstetric anal sphincter injury grades were ranked from the best clinical outcome to the worst clinical outcome. The percentage chance of each grade taking each rank with regards to outcome was calculated. Study quality and risk of bias was assessed using the relevant tool from the Joanna Briggs Institute.

RESULTS

Of the 696 studies identified, 10 were eligible for inclusion and were included in the network meta-analysis (n=2467 women). The mean incidence of anal incontinence among those with 3a tears was 22.4% (range, 6.1%-51.2%), 24.9% (range, 6.9%-46.7%) among those with 3b tears, 26.8% (range, 0%-55.6%) among those with 3c tears, and 28.6% (0%-71.4%) among those with fourth-degree tears. Anal incontinence incidence was found to be significantly higher among those with 3c (odds ratio, 1.79; 95% confidence interval, 1.09-2.94) and fourth-degree tears (odds ratio, 2.37; 95% confidence interval, 1.40-4.02) than among those with 3a tears. In addition, anal incontinence incidence was significantly higher among those with fourth-degree tears (odds ratio, 1.89; 95% confidence interval, 1.10-3.22) than among those with 3b tears. Those with 3a tears had the highest probability of having the best clinical outcome; those with 3b; second-, 3c; third- and fourth-degree tears had the highest probability of having the worst clinical outcome. Overall, all studies had a high or unclear risk of bias across 1 or more assessed element.

CONCLUSION

This was a network meta-analysis comparing the incidence of anal incontinence among those with different grades of obstetric anal sphincter injury. Increasing tear-grade severity is associated with worse clinical outcomes. This study provides useful, clinically applicable information that can assist clinicians in the counseling of women following an obstetric anal sphincter injury. In addition, it highlights the importance of accurately diagnosing the obstetric anal sphincter injury grade and subsequently performing the appropriate repair.

Postpartum perineal wound infection and its effect on anal sphincter integrity: Results of a prospective observational study

INTRODUCTION

Perineal wound infection can affect tissues at superficial, deep, and organ space levels. Women with obstetric anal sphincter injuries (OASIS) are at risk of infection; however, no study to date has investigated if infection can extend to affect the anal sphincter integrity. The aim of this study was to evaluate the clinical progression of perineal wound infection and its effect on the anal sphincter in women with or without OASIS using three-dimensional endoanal ultrasound (3D-EAUS).

MATERIAL AND METHODS

Women were recruited into the Prospective Observational Study Evaluating the Sonographic Appearance of the Anal Sphincter in Women With Perineal Wound Infection Following Vaginal Delivery (PERINEAL Study) between August 2020 and August 2021 (NCT04480684). 3D-EAUS was performed weekly until complete wound healing. Significant bacterial colonization was diagnosed using the MolecuLight i:X camera. The primary study outcome was a change in a sphincter defect angle from baseline (wound infection) until wound healing. A robust Poisson regression model was used to analyze the effect of significant bacterial loads on the anal sphincter.

RESULTS

Seventy-three women were included. A median of two ultrasound scans were performed in each patient (range 1-16). Five women (6.8%) had an OASI clinically diagnosed at delivery. In total, 250 EAUS were performed. An external anal sphincter defect was found on EAUS in 55 (22.0%) scans (n = 10 women). An external anal sphincter and internal anal sphincter defect was found in 26 scans (10.4%) (n = 3 women). During the course of the wound healing process, there was no significant change in defect size in wounds with or without significant bacterial colonization. In cases of an intact anal sphincter, wound infection did not disrupt its integrity.

CONCLUSIONS

We found that perineal wound infection does not disrupt an intact anal sphincter or OASIS. This new information can provide important information for clinicians and patients. As there are myths frequently encountered in cases of litigation when disruption of sphincter integrity is attributed to perineal infection, the findings of this study should be tested in larger studies in the future.

Effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women: A systematic review and meta-analysis

BACKGROUND

Perineal massage during childbirth has been recommended as an effective measure to prevent perineal injury. However, the overall effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women remain inconclusive. Particularly, the effects of perineal massage begun during different stages of labor need to be further investigated.

OBJECTIVES

To comprehensively review the effects of perineal massage during childbirth on primiparous health outcomes, including perineal-related outcomes, duration of labor, hemorrhage and postpartum perineal pain, and neonatal outcomes, including Apgar scores and neonatal complications, and to further explore the effects of perineal massage begun during different stages of labor.

DESIGN

A systematic review and meta-analysis following the Cochrane Handbook guidelines and PRISMA2020.

METHODS

A systematic search strategy was developed following the three-phase search approach, and the literature search was conducted in electronic databases and clinical trial registers from inception to 7th January 2022. Study selection and data extraction were completed independently by two researchers. The updated Cochrane risk of bias 2.0 tool for randomized trials was chosen to evaluate the quality of included studies. Data analyses were conducted using the Revman5.4 software, and subgroup analyses were performed based on the different start times of perineal massage. Furthermore, the certainty of body of evidence for each outcome was assessed utilizing the GRADEpro online tool.

RESULTS

Seventeen randomized controlled trials involving 3248 primiparous women were included in the review. The pooled results of meta-analyses indicated that perineal massage begun during the second stage of labor significantly increased the occurrence of intact perineum (RR = 2.78, 95 % CI: [1.52, 5.05], P < 0.001), reduced the rate of second- and third-degree perineal lacerations (P < 0.05), and decreased the incidence of episiotomy (RR = 0.63, 95 % CI: [0.50, 0.79], P < 0.001), while perineal massage during the first stage of labor effectively shortened the duration of the first and second stages of labor (P < 0.05). The available evidence also suggests the potential role of perineal massage on hemorrhage and long-term postpartum perineal pain (P < 0.05). However, the aggregated results failed to demonstrate the beneficial effects of perineal massage on neonatal outcomes (P > 0.05).

CONCLUSIONS

Perineal massage begun during the second stage of labor effectively improves the perineal-related outcomes in primiparous women, while perineal massage during the first stage of labor significantly shortens the duration of labor. High-quality studies exploring the standardized procedure for perineal massage and the short- and long-term effects of perineal massage are warranted.

REGISTRATION NUMBER

CRD42022302336 (PROSPERO).

The role of anal manometry in the follow-up of women with obstetric anal sphincter injuries (OASI)

INTRODUCTION AND HYPOTHESIS

Mode of birth (MOB) following OASI is determined by choice, symptoms and anorectal study results in asymptomatic women. Endoanal ultrasound (EAUS) is the gold-standard imaging modality. EAUS use in MOB counselling is supported by strong evidence. Less is understood about how anal manometry (AM) influences MOB counselling.

METHODS

A retrospective observational study was conducted from 2007 to 2020. Women underwent symptom assessment using validated ePAQ and St Mark's incontinence score (SMIS). Anorectal studies using EAUS and AM were performed. The case group was the normal ultrasound group and the control group was the abnormal ultrasound group. Both groups were compared with normal and abnormal AM result groups.

RESULTS

A total of 1348 women were included over 13 years. Among these, 454 women were symptomatic, 894 were asymptomatic; 274 (31%) asymptomatic women had isolated abnormal AM results, 313 (35%) had two abnormal anorectal results and 221 (24.7%) had normal anorectal results. Eighty-six asymptomatic women (10.4%) had isolated abnormal EAUS results, 138 (30.4%) symptomatic women had isolated abnormal AM, 221 (48.7%) had two abnormal anorectal results and 57 (12.6%) had normal anorectal results. Thirty-eight symptomatic women (8.4%) had an isolated abnormal EAUS result.

CONCLUSIONS

AM identifies more women with sphincter function impairment than EAUS alone. Without AM, almost one third of asymptomatic women would not have been identified and could have been inadequately counselled. Performing AM and EAUS together captured most women with compromised anal sphincter function. We conclude that AM should be performed in all women with OASI alongside EAUS to enable accurate MOB counselling.

Incidence and risk factors for secondary failure after acute obstetric sphincter injury repair - an audit of 239 women

AIM

The rate of secondary failure after obstetric sphincter injury repair is unknown, with the literature reporting rates ranging from 0.1% to 53%. We aimed to perform an audit to identify the rate and risk factors for failure of sphincter repair in a cohort of postpartum women using endoanal ultrasound (EAUS) and manometry, assessing the risk factors and impact of these events.

METHOD

Prospective data were collected within a 2 year period from patients who attended the perineal clinic at Eastern Health. Variables of primary repair and presence of postpartum complications were recorded and subsequently analysed.

RESULTS

Of 239 patients with obstetric anal sphincter injury (OASI) included, 100 (41.8%) had EUAS evidence of sphincter defects. Only 20% with secondary repair failure were symptomatic with faecal or flatal incontinence at a mean follow-up of 23.4 months postpartum. Patients with secondary repair failure had lower anal resting (p = 0.006) and maximum squeeze pressures compared with patients with intact repairs (p < 0.001). In terms of variables that were investigated, namely location, operator hierarchy, type of repair and material used, none had a statistically significant correlation with secondary repair failure of OASI. Postpartum complications had an overall incidence of 12.7%, and those with any complication were found to have an increased rate of secondary failure of repair (p = 0.157).

CONCLUSION

Using EAUS to confirm secondary failure of repair, incidence was 41.4% in this cohort. There were no identifiable modifiable variables that reduced the risk of secondary failure of repair. Further prospective research with increased sample size and longer follow-up periods is required to assess the validity of the findings.

When does oasis cause de novo pelvic floor dysfunction? role of the surgeon's skills

INTRODUCTION AND HYPOTHESIS

Minorly skilled gynecologists are less likely to repair obstetric anal sphincter injuries (OASIS), and this can lead to higher rate of de novo onset of pelvic floor dysfunction (PFD). The aim of this study was to understand the impact of surgeon skills in OASIS repair on de novo incidence of PFDs.

METHODS

An observational prospective cohort study performed between January 2019 and December 2020. We included 116 women with OASIS. At 6-weeks from delivery, women were divided into two groups in relation to the onset of PFDs. Characteristics were compared; categorical and continuous variables were assessed with chi-squared test and the Mann-Whitney rank-sum test respectively. Factors involved in PFDs development were analysed with explorative univariate analysis; significant (p<0.05) or approaching significance (p≤0.10) variables were included in multivariable analysis.

RESULTS

Seventy-six women (76/116; 65.5%) reported at least one PFD symptom and anal incontinence was the most prevalent (44.73%; 34/76). OASIS management by a skilled gynaecologist resulted protective for PFDs [aOR 0.33 (0.13-0.61)]. Skilled surgeon reported fewer PFDs than less skilled surgeon (4% vs 82.4%; p<0.0001). Operative delivery was more performed (32.5% vs 15.8%; p= 0.03) and severe OASIS resulted more prevalent (60% vs 17.1%; p<0.0001) among women without PDFs, even if these didn't affect the incidence of de novo PFDs [aOR 1.03 (0.23-1.45) and 0.83 (0.13-1.45), respectively].

CONCLUSIONS

Surgeons skilled in OASIS repair resulted the only protective factor for incidence of de novo PFDs in women with OASIS at 6 weeks of follow up. Improvement of training in OASIS repair is necessary.

Time trends in episiotomy and severe perineal tears in Portugal: a nationwide register-based study

INTRODUCTION

Rates of episiotomy and severe perineal tears (SPT) are indicators of the quality of obstetric care. Time-trends in the reported occurrence of episiotomy and SPT can contribute to understand both, changes in care and in the frequency of risk factors. Therefore, we aimed to estimate time trends in the frequency of SPT in Portugal and its relationship with episiotomy.

METHODS

We conducted a nationwide register-based study using data from the national inpatient database of all Portuguese public hospitals between 2000 and 2015. Time-trend analysis using joinpoint regression models was performed to identify trends (joinpoints) and compare time changes in the prevalence of SPT and risk factors expressed as annual percentage changes (APC) with 95% Confidence Intervals (95% CI). Poisson regression models were fitted to estimate whether time-trends in SPT rates were explained by changes in risk factors and to assess the association between episiotomy and SPT. Adjusted relative risk (aRR) and their respective 95% CI were obtained.

RESULTS

From 908,999 singleton vaginal deliveries, 20.6% were instrumental deliveries, 76.7% with episiotomy and 0.56% were complicated by SPT. Among women with non-instrumental deliveries and no episiotomy SPT decreased from 2009 onwards (1.3% to 0.7%), whereas SPT kept increasing in women with episiotomy for both non-instrumental (0.1% in 2000 to 0.4% in 2015) and instrumental deliveries (0.7% in 2005 to 2.3% in 2015). Time-trends in potential risk factors did not explain the observed increase in SPT. Episiotomy was associated with a decrease in SPT with adjusted RR varying between 2000 and 2015 from 0.18 (95%CI:0.13-0.25) to 0.59 (95%CI:0.44-0.79) for non-instrumental deliveries and from 0.45 (95%CI:0.25-0.81) to 0.50 (95%CI:0.40-0.72) for instrumental deliveries.

CONCLUSIONS

Our findings suggest that episiotomy rate could safely further decrease as the main factor driving SPT rates seems to be an increase in awareness and reporting of SPT particularly among women who underwent an episiotomy.

Validation of new ultrasound algorithm for estimating prevalence of anal sphincter trauma in a urogynecological population

OBJECTIVES

To estimate the prevalence of major perineal trauma in a urogynecological population, to test the predictive value of sonographic tear grading (Gillor algorithm) for anal incontinence (AI), AI bother score and St Mark's score, and to compare the predictive power of the Gillor algorithm with that of the residual-defect method.

METHODS

This was a retrospective study of 721 women attending a tertiary urogynecology unit between February 2019 and May 2021. All women underwent a standardized interview, including determination of St Mark's score and visual analog scale (VAS) bother score for AI, as well as exoanal (translabial) ultrasound with later offline analysis. Results were reported as the presence of a residual defect of the external anal sphincter (EAS), i.e. a discontinuity of ≥ 30° in ≥ 4/6 tomographic slices, and according to the Gillor algorithm (normal, Grade 3a, Grade 3b or Grade 3c/4).

RESULTS

Mean age at assessment was 57 (range, 19-93) years and mean body mass index was 30 (range, 17-57) kg/m² . Six hundred and thirty-six (88.2%) women were vaginally parous and 161 (22.3%) had undergone at least one forceps delivery. AI was reported by 186/721 (25.8%) women, with a median St Mark's score of 10 (interquartile range (IQR), 6-14) and a median VAS score of 6.3 (IQR, 3.9-10). EAS defects were detected in 261 (36.2%) women, with a residual defect diagnosed in 88 (12.2%). On sonographic grading according to the Gillor algorithm, we identified 532 (73.8%) women with a normal sphincter, 66 (9.2%) with Grade-3a tear, 87 (12.1%) with Grade-3b tear and 36 (5.0%) with Grade-3c/4 tear. In total, the Gillor algorithm classified 189 (26.2%) women as having suffered a major perineal tear. The two grading systems were in moderate agreement (κ, 0.537 (95% CI, 0.49-0.56); P < 0.001). There were weak, albeit significant, associations between EAS defects and measures of AI (P = 0.009 to P = 0.047), both for residual defect as well as the Gillor algorithm.

CONCLUSION

Neither the Gillor algorithm nor the residual-defect method of quantifying sphincter trauma on imaging is clearly superior in terms of predicting AI. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.

When to assess residual anal sphincter defect after OASI by ultrasound

OBJECTIVES

Obstetrical anal sphincter injuries (OASIS) are complications of vaginal delivery. Unrepaired anal sphincter after delivery increases the risk of anal incontinence. The aim of our study is to search for residual defect after OASI repair by 4D introital ultrasound (US). We hypothesised that imaging prior to hospital discharge would show the same number of defects as assessment at 3 months.

STUDY DESIGN

This is a retrospective analysis of 138 patients with immediate repair after OASIS. Since 2009, we have been routinely inviting all our patients with OASIS to the perineal clinic for postoperative follow-up. We scheduled the first visit before discharge from hospital and followed up with a second visit after three months. During both visits, patients underwent transperineal 4D ultrasound examination. We provided examination while at rest and during contraction; volumes were saved for further evaluation.

RESULTS

Eighty-one patients (58.7%) completed both exams and were included in the analysis. Residual external anal sphincter defect was found in 17.3% at the first visit versus 13.6% at the second (delayed) visit. We were not able to assess the sphincter in 9.9% at early versus none in the delayed examination. In 9.9%, the residual defect was not confirmed by the second examination, and in 4.9% the residual defect was missed by the first examination.

CONCLUSIONS

In conclusion, we have found that a 3 month scan yields a smaller number of defects than a scan before discharge.

Does the Contractile Capability of Pelvic Floor Muscles Improve with Knowledge Acquisition and Verbal Instructions in Healthy Women? A Systematic Review

Seventy percent of women with pelvic floor dysfunctions (PFDs) are estimated to present deficient consciousness of their pelvic floor muscles (PFMs) and poor ability to contract them. Improving the proprioception of PFMs, defined as the capacity to know the status and position of each body part, and adequately contracting them could be a protective factor to prevent the appearance of PFDs in the general female population. This study aimed to identify the effectiveness of educational interventions and verbal instructions on how to contract and exercise the PFMs to improve the proprioception of the PFMs in women. A systematic search of studies published in the last 20 years until March 2022 was conducted in the PubMed, Cochrane Library, Web of Science, Scopus, PEDro, Lilacs, and Dialnet databases. A meta-analysis could not be performed due to the heterogeneity in the types of studies and included populations. This review followed the PRISMA guidelines for the design, search, and reporting of studies. The methodological quality was analysed via the PEDro and the Newcastle–Ottawa scales in the case of randomised clinical trials and non-randomised studies, respectively, while the quality of evidence was determined using the SIGN grading system for evidence-based guidelines. Descriptive and experimental studies published in English, Spanish, or Portuguese that evaluated the contractile capability of the PFMs in healthy women or women without a previous diagnosis of PFD were included. Seven articles that included a total of 2507 women were found, three of which were clinical trials with PEDro scores between 5 and 9 points out of 10 and four of which were non-randomised studies with NOS scores between 6 and 8 points out of 10. The outcomes were measured through vaginal palpation, visual observation, questionnaires for PFD symptoms, and self-perception reports. This review discriminated between two types of intervention, educational programmes and verbal instructions, and evaluated the changes observed in PFM strength and knowledgeability and the symptoms of PFDs. The findings showed that educational interventions and verbal instructions improve the proprioception of PFMs in women of all ages that are healthy or without a previous diagnosis of PFDs as well as their knowledge about the pelvic floor, healthy lifestyle habits, and symptoms that are potentially indicative of PFDs. Further high-quality randomised clinical trials are warranted to draw definitive conclusions about the effectiveness of educational interventions to improve the proprioception of the PFMs in women considered healthy or with mild symptoms that may be indicative of PFDs.

Risk factors for obstetric anal sphincter injury recurrence: A systematic review and meta-analysis

BACKGROUND

Women with previous obstetric anal sphincter injuries (OASIs) are at a higher risk of recurrence in the subsequent pregnancy, which may lead to the development or worsening of anal incontinence. Due to a lack of evidence, few recommendations can be made about the factors that may affect the risk of OASI recurrence.

OBJECTIVE

We sought to conduct a systematic review and meta-analysis to investigate potential risk factors for recurrent OASIs.

SEARCH STRATEGY

Studies up to May 2019 were identified from PubMed, Scopus, Cochrane Library, and ISI Web of Science.

SELECTION CRITERIA

Studies assessing the impact of risk factors on OASI recurrence in subsequent pregnancies were included. Reviews, letters to the editor, conference abstracts, book chapters, guidelines, Cochrane reviews, and expert opinions were excluded.

DATA COLLECTION AND ANALYSIS

Data were extracted by two independent reviewers. Odds ratio and standardized mean difference were chosen as effect measures. Pooled estimates were calculated using the random-effects model.

MAIN RESULTS

The meta-analysis showed that maternal age, gestational age, occiput posterior presentation, oxytocin augmentation, operative delivery, and shoulder dystocia were associated with the risk of recurrent OASIs in the subsequent delivery.

CONCLUSION

Prenatal and intrapartum risk factors are associated with recurrence of OASI. PROSPERO registration no. CRD42020178125.

[Postpartum fecal incontinence. State of the problem]

A review of the current national and foreign literature is devoted to epidemiology, risk factors, causes, diagnosis and modern treatment approaches for fecal incontinence (FI). Incidence of FI in early and delayed period after childbirth is 30% or more. At the same time, up to 87% of postpartum injuries of anal sphincter remain undiagnosed. Importantly, routine caesarean section does not reduce the risk of incontinence. In addition to typical complaints of spontaneous gas and stool, diagnosis of FI after childbirth includes transrectal ultrasound, MRI, anorectal manometry and pudendal nerve terminal motor latency testing. Survey of proctologists from different regions of Russia revealed a high demand from medical community for educational programs devoted to diagnosis, treatment and rehabilitation of patients with postpartum perineal injuries.

Chemokine therapy for anal sphincter injury in a rat model: a pilot study

INTRODUCTION AND HYPOTHESIS

To determine whether delayed administration of CXCL12 alters anorectal manometric pressures and histology in rats following anal sphincterotomy compared to primary surgical repair alone.

METHODS

Adult female rats were divided into three groups: A, a control group that did not undergo surgery; B, anal sphincterotomy with primary surgical repair; C, anal sphincterotomy with primary surgical repair and intra-sphincteric injection of CXCL12 at 6 weeks post-injury. All rats underwent anal manometry measurements at baseline and at 6 and 12 weeks post-injury. Histologic analysis of the anal sphincters was also performed.

RESULTS

At baseline and 6 weeks, there were no statistically significant differences among D, T_max and P∆ of Groups A, B and C. At 12-week manometry, the total duration of contractions on anal manometry was significantly less in Group C compared to Groups A and B (3.65, 5.5, 5.3 p < 0.01) as was time to peak of contraction at 12 weeks (1.6, 2.1, 3.1, p < 0.01); however, group C had a significantly higher P∆ at 12 weeks compared to Groups A and B (2.25, 1.4, 0.34, p < 0.01). There were no statistically significant differences in the ratio of muscle to collagen at the site of injury; however, muscle fibers were significantly smaller in group C and less per bundle than the other groups.

CONCLUSIONS

Administration of chemokine therapy at 6 weeks post-repair using CXCL12 enhanced the magnitude of anal sphincter contractions in a rat model of anal sphincter injury but decreased overall duration of contraction. Increased anal sphincter contraction magnitude was not explained by histologic differences in explanted specimens.

Immediate postpartum assessment of the anal sphincter by endovaginal ultrasound: An experimental study

INTRODUCTION AND HYPOTHESIS

Obstetric anal sphincter injuries are frequently missed and carry a significant risk for the development of anal incontinence. Immediate postpartum endoanal ultrasound increases identification of these injuries but is rarely employed. We hypothesize that endovaginal ultrasound could be a feasible and easily available alternative sonographic tool to improve early diagnosis of anal sphincter tears.

METHODS

We conducted a prospective experimental study including 160 primiparous women. Shortly after vaginal delivery, patients underwent clinical and sonographic perineal examinations. We analyzed the feasibility of anal sphincter assessment by endovaginal ultrasound and its potential contribution in the early diagnosis of anal sphincter injuries.

RESULTS

Sonographic assessment of the anal sphincter was analyzable for 136 patients (85.0%). Causes of non-analyzability included air artifacts (6.9%), lack of distinction between the external anal sphincter and surrounding tissues (9.4%) and distortion artifacts (9.4%). Patients in the non-analyzable ultrasound subgroup were less likely to have delivered in a dorsal lithotomy position (62.5% vs. 85.3 %) and more likely to have had an episiotomy (33.3% vs. 14.0%), and their risk of sphincter injury was more frequently classified as "improbable" on clinical examination (91.7% vs. 61.0%). Ultrasounds were analyzable for 96.4% of patients clinically reported as having "possible" or "certain" sphincter injuries. The incidence of anal sphincter injury was 16.9% for clinical observation and 20.0% with associated sonographic examination.

CONCLUSIONS

Endovaginal ultrasound could be used as a complementary tool in assessment of the anal sphincter in high-risk patients. Its feasibility and easy availability make this technique a promising tool for improving the management of anal sphincter tears.

Comparison of perineal outcomes in Chinese women adopting lateral positions and lithotomy positions during the passive and active phases of the second stage of labour: An observational study

AIMS

To compare the effects of the adoption of lateral positions and lithotomy positions during the passive and active phases of the second stage of labour on perineal outcomes.

DESIGN

An observational study with prospectively collected data, conducted in three hospitals in China.

METHOD

Attending midwives recorded the perineal outcomes and characteristics of women giving birth between July-November 2020. Binary logistic regression was performed to explore the effects of lateral positions on perineal outcomes during different phases of the second stage of labour. The STROBE guidelines guided the reporting of this study.

RESULTS

Among primiparous women, when compared with those who adopted lateral positions during the passive phase of the second stage of labour and changed to lithotomy positions during the active phase, women who assumed lateral positions during both the passive and active phases had a higher rate of intact perineum/first-degree perineal tears and a reduced risk of episiotomy, and episiotomy/second-degree perineal tears. No significant difference was found in perineal outcomes between those who assumed lithotomy positions during the passive and active phases and those who adopted lateral positions during the passive phase and changed to lithotomy positions during the active phase. No significant difference was found in perineal outcomes among multiparous women, regardless of different positions adopted at the passive and/or the active phase.

CONCLUSION

Lateral positions during the active phase may have protective effects on the perineum in primiparous women. However, adopting lateral positions only during the passive phase did not promote better perineal outcomes, regardless of parity.

RELEVANCE TO CLINICAL PRACTICE

This study will provide a further reference for the use of lateral positions during different phases of the second stage of labour among primiparous and multiparous women in clinical practice, contributing to the perineal protection during childbirth.

Classification and evaluation of episiotomy practices from 2004 to 2020 and association with OASIS

OBJECTIVE

To apply a new classification based on 7 clinically relevant subgroups to accurately describe episiotomy practices and evaluate the association between episiotomy and obstetrical anal sphincter injuries (OASIS) rates according to the classification's subgroups.

METHODS

Observational retrospective cohort study based on a population comprising 39487 women from 01/01/2004 to 31/12/2020 in a level III university maternity unit. The primary outcome was the overall episiotomy rate in the institution, its trend over the time as well as in each subgroup of obstetric population classification. Secondary outcome was the rate of OASIS third and fourth degree, its association with episiotomy practice.

RESULTS

The episiotomy rate decreased significantly from 43,2% to 20% in the total population. The overall OASIS rate was 0,34%, it remained significantly the same during the study period, although the association between OASIS and episiotomy was significant only in group 2 (Nulliparous with instrumental delivery) with a decrease of OASIS rate if using episiotomy (OR 0.5; 95% CI[0,3-0,8]).

CONCLUSION

The episiotomy rate can be decreased without exposing women to an increased risk of OASIS. It encourages restrictive practice of episiotomy, but episiotomy should be considered in case of nulliparous women with instrumental delivery.

Risk of obstetric anal sphincter injury among women who birth vaginally after a prior caesarean section: A state-wide cohort study

OBJECTIVE

Vaginal birth after caesarean (VBAC) has been suggested to be associated with an increased risk of obstetric anal sphincter injury (compared with primiparous women who birth vaginally). However, prior studies have been small, or used outdated methodology. We set out to validate whether the risk of obstetric anal sphincter injury among women having their first VBAC is greater than that among primiparous women having a vaginal birth.

DESIGN

State-wide retrospective cohort study.

SETTING

Victoria, Australia.

POPULATION

All births (455,000) between 2009-2014.

METHODS

The risk of severe perineal injury between first vaginal birth and first vaginal birth after previous caesarean section was compared, after adjustment for potential confounding variables. Covariates were examined using logistic regression for categorical data and Wilcoxon rank-sum test for continuous data. Missing data were handled using multiple imputation; the analysis was performed using regression adjustment and Stata v16 multiple imputation and teffects suites.

RESULTS

Women having a VBAC (n=5,429) were significantly more likely than primiparous women (n=123,353) to sustain a 3^rd or 4^th degree tear during vaginal birth (7.1 vs 5.7%, p<0.001). After adjustment for mode of birth, body mass index, maternal age, infant birthweight, episiotomy and epidural, there was a 21% increased risk of severe perineal injury (relative risk 1.21 (95%CI 1.07 - 1.38)).

CONCLUSIONS

Women having their first vaginal birth after caesarean section have a significant increased risk of sustaining a 3^rd or 4^th degree tear, compared with primiparous women having a vaginal birth. Patient counselling and professional guidelines should reflect this increased risk.

Critical appraisal of international guidelines for the management of fecal incontinence in adults: is it possible to define what to do in different clinical scenarios?

Fecal incontinence (FI) is a complex often multifactorial functional disorder which is associated with a significant impact on patients’ quality of life. There is a broad spectrum of symptoms, and degrees of severity and diverse patient backgrounds. Several treatment algorithms from different professional societies and experts are available in the literature. However, no consensus has been reached on several aspects of FI management. We performed a critical review of the most recently published guidelines on FI, emphasising the lack of consensus, highlighting specific topics mentioned in each of the guidelines that are not covered in the others and defining the treatment proposed in different clinical scenarios.

Postpartum ultrasound for the diagnosis of obstetrical anal sphincter injury

This review presents the available data on the diagnosis of obstetrical anal sphincter injury by postnatal ultrasound imaging. There is increasing evidence that anal sphincter tears are often missed after childbirth and, even when diagnosed, often suboptimally repaired, with a high rate of residual defects after reconstruction. Even after postpartum diagnosis and primary repair, 25% to 50% of patients will have persistent anal incontinence. As clinical diagnosis may fail in the detection and classification of obstetrical anal sphincter injury, the use of imaging has been proposed to improve the detection and treatment of these lacerations. Notably, 3-dimensional endoanal ultrasound is considered the gold standard in the detection of obstetrical anal sphincter injury, and recently, 4-dimensional transperineal ultrasound, commonly available in obstetrical and gynecologic settings, has proven to be effective as well. Avoidance of forceps delivery when possible, performance of a rectal examination after vaginal delivery and before repair of any severe perineal tear, and offering sonographic follow-up at 10 to 12 weeks after vaginal delivery in high-risk women (maternal age of ≥35 years, vaginal birth after cesarean delivery, forceps, prolonged second stage of labor, overt obstetrical anal sphincter injury, shoulder dystocia, and macrosomia) may help reduce morbidity arising from anal sphincter tears.

Fourth degree perineal tears: Surgical repair technique in 10 steps

Obstetrical anal sphincter injury (OASIS) may lead to significant comorbidities, including anal incontinence, rectovaginal fistula, and pain. A correct repair is required to avoid improper healing, as a persistent defect in the external anal sphincter after delivery can increase the risk of complications and worsening of symptoms following subsequent vaginal deliveries. Herein is described the surgical repair technique for a fourth degree perineal tear. Regarding resident education, there are challenges associated with the proper training in OASIS repair. The procedure is illustrated by an instructive video article that standardizes the essential steps to make the technique ergonomic and easy to perform with step-by-step explanations.

Language barrier as a risk factor for obstetric anal sphincter injury - A case-control study

INTRODUCTION

The incidence of grade 3-4 perineal tears, also known as obstetric anal sphincter injury (OASI), is reported to be between 0.5 and 2.5%. Beyond the medico-economic burden, the consequences of OASI on a woman's emotional, psychological, sexual, and physical wellbeing are considerable. Among the various risk factors of OASI, few data are available about the impact of a language barrier on its incidence.

MATERIAL AND METHODS

We conducted a case-control study to evaluate the effect of language barriers on the risk of OASI comparing 171 women with OASI and 163 matched controls. The matched criteria included ethnicity, age, previous vaginal delivery, delivery mode, prophylactic episiotomy and birthweight. Patients' characteristics were compared and crude ORs and 95% CIs estimated using unadjusted logistic models. Multivariate analysis was performed with recognized potential confounders.

RESULTS

All of the cases had grade 3 tears. Language barrier was a determinant factor of OASI with an OR of 3.32 [1.36-8.90], p = 0.01. Other risk factors were occipito-posterior delivery, African origin and prolonged labor duration (OR 6.33, 95% CI: 2.04-27.78, p = 0.004, OR 1.85, 95% CI: 1.08-3.19, p = 0.03 and OR 1.03, 95% CI: 1.01-1.05, p = 0.004, respectively).

CONCLUSION

Our data suggest that language barrier is an independent risk factor of OASI. Physicians and midwives should attempt to identify patients with a language barrier during prenatal visits. Education about simple terms used during delivery could decrease the incidence of this complication.

Establishing a peripartum perineal trauma clinic: a narrative review

INTRODUCTION AND HYPOTHESIS

Obstetric anal sphincter injury (OASI) is not rare, and its consequences are multiple and potentially severe, especially for young women. Some dedicated perineal clinics have been established to improve the management of OASI. Despite their obvious importance, these specific clinics are underrepresented and underdeveloped. The objectives of this review are to explore various options for developing a peripartum perineal clinic and to compare the different practices regarding the mode of delivery for subsequent pregnancies after an OASI.

METHODS

This narrative review covers information from patients' questionnaires specific to anal incontinence, anal physiology assessment, pelvic floor and anal sphincter imaging, and the arguments for choosing the mode of delivery after an OASI.

RESULTS

This review highlights the extensive range of practices regarding the delivery mode after an OASI throughout national professional organizations and experienced perineal clinics.

CONCLUSION

This review summarizes the different choices in developing a perineal clinic to facilitate their development in promoting health care and education specific for peripartum women concerning the perineal consequences of delivery for obstetrician-gynaecologists, family doctors, and residents.

Comparison of maternal and neonatal outcomes after forceps or spatulas-assisted delivery

OBJECTIVE

The aim of this study was to compare the perinatal outcomes associated with spatulas or forceps assisted delivery.

STUDY DESIGN

This is a bicentric retrospective cohort study including all assisted deliveries in cephalic presentation after 37 weeks of gestation, performed on singleton pregnancy with forceps and with spatulas in two tertiary centers. The main outcome was the rate of episiotomy. Secondary outcomes included obstetric anal sphincter injuries (OASIS), maternal outcomes and neonatal parameters.

RESULTS

Out of 37 002 deliveries, the overall rate of assisted delivery was 11.4 %, and 1 041 (2.8 %) assisted deliveries with forceps and 2 462 (6.7 %) spatulas deliveries were included. The rate of episiotomy was 90.3 % after forceps-assisted delivery and 70.9 % for spatulas (p < 0.001). The rate of OASIS was 7.2 % and 5.6 % respectively (p = 0.06). A slight but significant decrease in neonatal trauma after spatulas was observed.

CONCLUSION

In this retrospective cohort study, the episiotomy rate was higher with forceps assisted deliveries than with spatulas. Both instruments have low neonatal morbidity and are similar regarding OASIS.

Effect of a subsequent pregnancy on anal sphincter integrity and function after obstetric anal sphincter injury (OASI)

Introduction and hypothesis

Endoanal ultrasound (EAUS) and anal manometry are used in the assessment women with a history of obstetric anal sphincter injury (OASI), both postpartum and in a subsequent pregnancy, to aid counselling regarding mode of delivery (MOD).

Methods

A prospective observational study between 2012 to 2020 was completed. Women were reviewed 3 months postpartum following OASI and in the second half of a subsequent pregnancy. Anorectal symptoms were measured using the validated St Mark’s Incontinence Score (SMIS: asymptomatic to mild symptoms = ≤ 4). Anal manometry (incremental maximum squeeze pressure [iMSP: normal = > 20 mmHg]) and EAUS (abnormal = sphincter defect > 1 h in size) were performed.

Results

One hundred forty-six women were identified and 67.8% had an anal sphincter defect ≤ 1 h in size postnatally. In those with a defect ≤ 1 h, postpartum mean iMSP and SMIS significantly improved in a subsequent pregnancy (p = 0.04 and p = 0.01, respectively). In women with a defect > 1 h, there was no significant difference between the mean iMSP or SMIS score postnatally compared to a subsequent pregnancy. At both time points, significantly more women had an anal sphincter defect ≤ 1 h and SMIS of ≤ 4 (p = 0.001 and p < 0.001 respectively) compared to those with a defect < 1 h. In addition, significantly more women had an anal sphincter defect ≤ 1 h and iMSP ≥ 20 mmHg (p < 0.001). Overall, out of the 146 women included in this study, 76 (52.1%) with a defect ≤ 1 h also had an iMSP ≥ 20 mmHg and SMIS ≤ 4 at 3 months postpartum.

Conclusions

Women who remain asymptomatic with normal anal manometry and no abnormal sphincter defects on EAUS postnatally do not need to have these investigations repeated in a subsequent pregnancy and can be recommended to have a vaginal delivery. If our protocol was modified, over half of the women in this study could have had their MOD recommendation made in the postnatal period alone.

Obstetric anal sphincter injuries: strategies for prevention, diagnosis, and management

Obstetric anal sphincter injuries (OASIS) are one of the most common causes of anal incontinence (AI) in women of reproductive age and can have a significant impact on quality of life. However, many women do not report symptoms to their physicians because of embarrassment and shame. Therefore, prevention and diagnosis of the tear is essential. Diagnostic strategies have evolved considerably in recent years, with an increase in prevalence of OASIS as a consequence. The use of 3D endoanal (3D-EAUS) and 4D transperineal ultrasound (4D-TPUS), in addition to standard clinical examination have enhanced the detection of OASIS. Once identified, adequate repair by a skilled practitioner and optimal postpartum management should be ensured in order to reduce the risk of anal incontinence. This review presents the available evidence on strategies for prevention, diagnosis, and management of OASIS.