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Macedo MD, Risløkken J, Halle T, Ellström Engh M, Siafarikas F. Occurrence and risk factors for second-degree perineal tears: A prospective cohort study using a detailed classification system. Birth 2024. [PMID: 38305584 DOI: 10.1111/birt.12817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 10/17/2023] [Accepted: 01/12/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND The amount of tissue trauma within second-degree perineal tears varies widely. Therefore, subcategorization of second-degree tears and a better understanding of their occurrence and risk factors are needed. The aim of this study was to assess the occurrence of perineal tears when second-degree tears were subcategorized. Furthermore, we aimed to assess the association between variables related to perineal anatomy and other potential risk factors, with second-degree tear subcategories. METHODS This prospective cohort study included 880 primiparous and multiparous women giving birth to one child vaginally. Perineal tears were categorized using the classification system recommended by the Royal College of Obstetricians and Gynaecologists. In addition, second-degree tears were subcategorized as 2A, 2B, or 2C according to the percentage of damage to the perineal body. Selected variables related to perineal anatomy were as follows: length of genital hiatus; perineal body length; and previous perineal trauma. Risk factors for second-degree tear subcategories were analyzed using a multinominal regression model. RESULTS Perineal tears occurred as follows: first-degree: 35.6% (n = 313), 2A: 16.3% (n = 143), 2B: 9.1% (n = 80), 2C: 6.6% (n = 58), and third- or fourth-degree: 1.6% (n = 14). In total, 169/880 participants underwent an episiotomy. When episiotomies were excluded, the risk for 2B, or 2C tears increased with smaller genital hiatus, larger perineal body, previous perineal trauma, primiparity, higher gestational age, instrumental vaginal delivery and fetal presentation other than occiput anterior. CONCLUSION The occurrence of second-degree tear subcategories was 16.3% for 2A tears, 9.1% for 2B tears, and 6.6% for 2C tears. Factors related to perineal anatomy increased the odds for experiencing a second-degree tear in a more severe subcategory.
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Affiliation(s)
- Marthe D Macedo
- Division Akershus University Hospital, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway
| | - Jeanette Risløkken
- Division Akershus University Hospital, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway
| | - Tuva Halle
- Division Akershus University Hospital, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Marie Ellström Engh
- Division Akershus University Hospital, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway
| | - Franziska Siafarikas
- Division Akershus University Hospital, Faculty of Medicine, University of Oslo, Oslo, Norway
- Department of Obstetrics and Gynecology, Akershus University Hospital, Lørenskog, Norway
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van Bavel J, Ravelli ACJ, Roovers JPWR, Abu-Hanna A, Mol BW, de Leeuw JW. Risk indicators for obstetrical anal sphincter injury in vaginal birth after caesarean section compared to first vaginal delivery. Eur J Obstet Gynecol Reprod Biol 2023; 288:198-203. [PMID: 37572448 DOI: 10.1016/j.ejogrb.2023.07.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/02/2023] [Accepted: 07/27/2023] [Indexed: 08/14/2023]
Abstract
OBJECTIVES Comparison of the rate of obstetric anal sphincter injury (OASI) between women having their first vaginal birth after caesarean section (CS) and true nulliparous women with a vaginal delivery. Assessment of risk indicators for OASI in women with vaginal birth after one CS (VBAC). STUDY DESIGN 28 535 women with their first VBAC and a cohort of 275 439 nulliparous women with a vaginal delivery of a liveborn infant in a cephalic position from the Dutch perinatal registry were analyzed. We compared the OASI rate with univariate and multivariate analysis. In women with VBAC possible risk indicators for OASI were assessed using univariate and multivariate logistic regression analysis. RESULTS The rate of OASI was 5.2% in women with vaginal birth after CS and 4.0% in women with a first vaginal delivery. The adjusted OR (aOR) for vaginal birth after an elective CS was higher (aOR 1.34, 95% CI 1.23-1.47) compared to vaginal birth after an emergency CS (aOR 1.16, 95% CI 1.08-1.25). In women with vaginal birth after emergency CS, the aOR for the indication non-progressive labor was 1.18 (95% CI 1.08-1.29), whereas CS for suspected fetal distress was not significantly associated with obstetric anal sphincter injury in VBAC. In the 28 535 women with a VBAC, mediolateral episiotomy (MLE), birth weight < 3000 g and maternal age < 25 years were associated with a significantly lower rate of OASI. A gestational age of 42 weeks, birth weight ≥ 3500 g, operative vaginal delivery and duration of the 2nd stage of labour of ≥ 60 min were associated with a significantly higher rate of OASI. CONCLUSIONS Women with a VBAC have a higher rate of OASI in comparison with women with a first vaginal delivery, with the exception of women with a vaginal birth after an emergency CS for suspected fetal distress. Factors associated with a significantly lower rate for OASI were MLE, maternal age < 25 and birth weight < 3000 g. A gestational age of 42 weeks, birth weight between 3500 and 4000 g and ≥ 4000 g, operative vaginal delivery and duration of the 2nd stage of delivery longer dan 60 min were associated with a significantly higher rate of OASI.
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Affiliation(s)
- J van Bavel
- Department of Obstetrics and Gynaecology, Amphia Hospital Breda, The Netherlands.
| | - A C J Ravelli
- Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands; Amsterdam Public Health, Amsterdam, The Netherlands; Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, location AMC, Amsterdam, The Netherlands.
| | - J P W R Roovers
- Department of Obstetrics and Gynaecology, Amsterdam University Medical Center, location AMC, Amsterdam, The Netherlands.
| | - A Abu-Hanna
- Department of Medical Informatics, Academic Medical Center, Amsterdam, The Netherlands; Amsterdam Public Health, Amsterdam, The Netherlands.
| | - B W Mol
- Department of Obstetrics and Gynaecology, Monash University, Clayton, Victoria, Australia; Aberdeen Centre for Women's Health Research, School of Medicine, University of Aberdeen, Aberdeen, UK.
| | - J W de Leeuw
- Department of Obstetrics and Gynaecology, Ikazia Hospital, Rotterdam, the Netherlands.
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Mathieu L, Legendre G, Rebmann E, Hamel JF, Venara A. Obstetrical anal sphincter injury and unnecessary episiotomy are both associated with anal incontinence 8 years after childbirth: A nationwide database analysis. Int J Gynaecol Obstet 2022; 159:284-289. [PMID: 35044683 DOI: 10.1002/ijgo.14101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/04/2022] [Accepted: 01/12/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE to assess the relationship between anal incontinence (AI) 8 years after childbirth and the occurrence of Obstetrical Anal Sphincter Injury (OASI) and/or performance of an episiotomy during childbirth. METHODS This is a nationwide database analysis performed on two national medico-administrative databases, including all the women aged ≥18 years who delivered infants in France in 2012. The main outcome measure was AI in the 8-years after delivery. RESULTS Of the 163,443 perineal tears reported, 0.47% were grade-3 and 0.08% were grade-4; 8,938 women experienced AI (1.33%) and 261 women experienced severe AI (0.04%). Episiotomies performed in the absence of risk factors for OASI were significantly associated with an increased risk of AI (Odds Ratio (OR)=1.59; 95% Confidence Interval (CI):1.49-1.69;p<0.001). Grade 3 and 4 OASI also significantly increased the risk of AI and severe AI. Mediolateral episiotomy was preventative of OASI when performed in subjects at risk (OR=0.26; 95% CI:0.23-0.30; p<0.001) but contributed to OASI in the absence of risk (OR=2.18; 95% CI:1.98-2.40; p<0.001). CONCLUSIONS OASI is a risk factor for AI. Episiotomies could reduce the occurrence of OASI, but they could also have a increase the risk of long-term AI in the absence of risk factors for OASI.
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Affiliation(s)
- Levaillant Mathieu
- Faculty of Health, Angers, France.,Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, F-59000, Lille, France.,Department of Biostatistics, CHU Angers, 4 rue Larrey, 49933, Angers, France
| | - Guillaume Legendre
- Faculty of Health, Angers, France.,Department of Gynaecology-obstetrics, CHU Angers, 4 rue Larrey, 49933, Angers, France
| | - Emeline Rebmann
- Faculty of Health, Angers, France.,Department of Visceral Surgery, CHU Angers, 4 rue Larrey, 49933, Angers, France
| | - Jean-François Hamel
- Faculty of Health, Angers, France.,Univ. Lille, CHU Lille, ULR 2694 - METRICS : Évaluation des technologies de santé et des pratiques médicales, F-59000, Lille, France.,Ester
- Irset Inserm UMR 1085
| | - Aurélien Venara
- Faculty of Health, Angers, France.,Department of Visceral Surgery, CHU Angers, 4 rue Larrey, 49933, Angers, France.,IHFIH, UPRES EA 3859, University of Angers, Angers, France
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Laine K, Yli BM, Cole V, Schwarz C, Kwee A, Ayres-de-Campos D, Vayssiere C, Roth E, Gliozheni E, Savochkina Y, Ivanisevic M, Kalis V, Timonen S, Verspyck E, Anstaklis P, Beke A, Eriksen BH, Santo S, Kavsek G, Duvekot H, Dadak C. European guidelines on perinatal care- Peripartum care Episiotomy. J Matern Fetal Neonatal Med 2021; 35:8797-8802. [PMID: 34895000 DOI: 10.1080/14767058.2021.2005022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OF RECOMMENDATIONS1. Episiotomy should be performed by indication only, and not routinely (Moderate quality evidence +++-; Strong recommendation). Accepted indications for episiotomy are to shorten the second stage of labor when there is suspected fetal hypoxia (Low quality evidence ++-; Weak recommendation); to prevent obstetric anal sphincter injury in vaginal operative deliveries, or when obstetric sphincter injury occurred in previous deliveries (Moderate quality evidence +++-; Strong recommendation)2. Mediolateral or lateral episiotomy technique should be used (Moderate quality evidence +++-; Strong recommendation). Labor ward staff should be offered regular training in correct episiotomy techniques (Moderate quality evidence +++-; Strong recommendation).3. Pain relief needs to be considered before episiotomy is performed, and epidural analgesia may be insufficient. The perineal skin needs to be tested for pain before an episiotomy is performed, even when an epidural is in place. Local anesthetics or pudendal block need to be considered as isolated or additional pain relief methods (Low quality evidence ++-; Strong recommendation).4. After childbirth the perineum should be carefully inspected, and the anal sphincter palpated to identify possible injury (Moderate quality evidence +++-; Strong recommendation). Primary suturing immediately after childbirth should be offered and a continuous suturing technique should be used when repairing an uncomplicated episiotomy (High quality evidence ++++; Strong recommendation).
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Affiliation(s)
- Katariina Laine
- Norwegian Research Centre for Women's Health, Oslo University Hospital, Oslo, Norway.,Clinical Medicine, University of Oslo Faculty of Medicine, Oslo, Norway
| | | | - Vanessa Cole
- Kingston Hospital NHS Foundation Trust, Kingston upon Thames, United Kingdom of Great Britain and Northern Ireland
| | | | | | | | | | | | | | | | | | - Vladimir Kalis
- Czech Society of Perinatology and Feto-Maternal Medicine
| | | | | | | | - Artur Beke
- Hungarian Society of Perinatology and Obstetric Anesthesiology
| | | | - Susana Santo
- Portuguese Society of Obstetrics and Maternal-Fetal Medicine
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Dakin A, Eogan M. Birth preferences and delivery outcomes after previous obstetric anal sphincter injury. Eur J Obstet Gynecol Reprod Biol 2021; 266:125. [PMID: 34634670 DOI: 10.1016/j.ejogrb.2021.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2021] [Accepted: 09/17/2021] [Indexed: 11/16/2022]
Affiliation(s)
- A Dakin
- Rotunda Hospital, Dublin, Ireland.
| | - M Eogan
- Rotunda Hospital, Dublin, Ireland
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Recognition and Management of Pelvic Floor Disorders in Pregnancy and the Postpartum Period. Obstet Gynecol Clin North Am 2021; 48:571-584. [PMID: 34416938 DOI: 10.1016/j.ogc.2021.05.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Often considered a condition of aging women, pelvic floor disorders may initially present in pregnancy and postpartum, having a negative impact on quality of life during this important time in a woman's life. This review outlines the clinical approach to implementing pelvic health into obstetric care through education and promotion of pelvic health in pregnancy, screening for pelvic floor disorders routinely, and providing support through resources, treatment, and referrals if pelvic floor disorders develop during pregnancy and postpartum.
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