Long-term outcome after obstetric injury: a retrospective study

Evolution of Episiotomy Incidence and Obstetric Anal Sphincter Injury Over 10 Years: A Mixed-Methods Study

OBJECTIVE

To assess the association between the decrease in the use of episiotomy and the incidence of obstetric anal sphincter injuries (OASIS) over a 10-year period and understand their reasons by interviewing obstetricians and midwives.

DESIGN

Mixed-methods study.

SETTING

A tertiary university public maternity hospital, Paris, France.

POPULATION

All patients who delivered vaginally between January 2012 and December 2021 in the maternity hospital and 20 interviews with obstetrician-gynaecologists and midwives.

METHODS

Quantitative data analysis using a multivariate logistic regression model, stratifying on the mode of delivery. Semi-structured interview with 20 obstetricians and midwives, with an interview guide.

MAIN OUTCOME MEASURES

Obstetric anal sphincter injuries.

RESULTS

The quantitative study of 37 942 women (16.1% of whom had an episiotomy and 1.4% OASIS) shows that, the incidence of episiotomy decreased from 25% to 7.6% over this 10-year period. Allow on the known risk factors for OASIS, we demonstrate that its incidence rose (adjusted odds ratio 1.35, 95% confidence interval 1.09-1.67) for the years in which the episiotomy incidence fell below 10% for the overall population. The interviews showed professionals' apparent awareness that the decreased incidence in episiotomy (achieved by changes in departmental policy, redefining its benefit/risk balance and acquiring new skills to manage the expulsion phase) could lead to an increased incidence of OASIS.

CONCLUSIONS

Decreasing the episiotomy incidence appears to be associated with a rising incidence of OASIS. The optimal incidence of episiotomy remains controversial in the literature and among professionals.

The Impact of Pelvic Floor Muscle Strengthening on the Functional State of Women Who Have Experienced OASIS After Childbirth

Background and Objectives: The primary objective of this study was to assess the impact of pelvic floor muscle (PFM) strengthening on the pelvic floor function in women who have experienced OASIS two years after delivery, and the secondary objective was to educate women about PFM strengthening and instruct them on the correct way to exercise. Methods and Materials: A prospective case-control study was conducted. The participants were divided into two groups: the case group (women who experienced OASIS) and the control group (women who did not experience perineal tears but had similar obstetric-related data to the case). Women were invited for a gynecological exam, PFM assessment, and consultation on PFM training. Women in the case group had three consultations, and women in the control group had two. Women were presented with four sets of questions about pre-pregnancy condition and questions related to UI and FI after delivery. Results were considered significant when p < 0.05. Results: OASIS were detected in 13 (0.4%) women in 2021. Risk factors for OASIS were found to be fetal macrosomia (p = 0.012), fetal occiput posterior position (p = 0.001), and epidural analgesia (p = 0.003). After one year of performing PFM strengthening exercises, some women in the study group exhibited stronger PFM contractions (p = 0.076), while others held the contracted PFM for a longer time (p = 0.133). UI affected women in the control group more often (p = 0.019). Two years after delivery, gas incontinence was mentioned significantly more frequently in the case group (p = 0.019). One year after initial consultation, gas incontinence was also more significantly common in the case group (p = 0.037). Conclusions: This study found that PFM strengthening exercises significantly improved pelvic floor function in women who experienced OASIS two years after delivery. Participants exhibited stronger PFM contractions and an increased ability to maintain these contractions. Women reported a better understanding of PFM exercises and proper techniques.

Severe Perineal Lacerations in First Delivery: Association with Subsequent Reproductive Outcomes

Background: Severe perineal lacerations (SPLs), common worldwide, are associated with short- and long-term complications: pelvic floor disorders, fecal incontinence, fistula, and profound psychological impacts. Limited research suggests that experiencing SPL may influence future reproductive intentions, but research on outcomes is lacking. Methods: We analyzed the effect of experiencing SPL during a first delivery among a large cohort of Swedish births between 1992 and 2013. We used linear and multinomial logistic regression to estimate the associations between SPL and four reproductive outcomes: subsequent total birth number, probability of a second birth, interpregnancy interval (IPI), and subsequent scheduled cesarean birth. Results: Among 947,035 singleton live-born first-births, we found that experiencing SPL was associated with slightly fewer overall births in fully adjusted models (a decrease of -0.020 births; 95% confidence interval [CI]: -0.028 to -0.012), but no difference in the probability of a second birth (risk ratio [RR]: 1.00; 95% CI: 0.99 to 1.00) or IPI. Scheduled cesarean was increased in births after SPL (adjusted RR: 4.57; 95% CI: 4.42 to 4.73). A secondary comparison of SPL to severe postpartum hemorrhage suggests that some of these observed differences may be related to experiencing any severe outcome, and some specifically to perineum disruption. Conclusion: This study provides a deeper understanding of the long-term impacts of SPL, which may be useful in informing best clinical practices for supporting women who have experienced SPL.

A core outcome set for clinical trials of first- and second-degree perineal tears prevention and treatment: a study protocol for a systematic review and a Delphi survey

BACKGROUND

Perineal tear is a common consequence of vaginal births affecting females globally. Even mild perineal tears could cause short- and long-term complications for females. Though many studies of interventions to prevent or treat perineal tears to minimize the consequences have been conducted, there is a significant heterogeneity in the outcomes measured and reported in existing studies, which makes meaningful comparison difficult and makes the generalizability to clinical practice challenging. Developing a core outcome set (COS) could solve these methodological concerns. In this paper, we report a protocol to develop a COS for clinical trials of mild perineal tears, which shall assist in establishing the evidence base and implementation of effective measures to reduce the incidence and minimize the consequences of mild perineal tears.

METHODS/DESIGN

The development of this COS will be guided by a study advisory group composed of obstetricians, midwives, nursing managers, service users, and methodologists. This study will include four stages: (1) a systematic research of the literature to identify outcomes reported in prior studies, (2) a semi-structured interview with key stakeholders to collect their opinions on important outcomes, (3) a panel of experts will be invited to conduct a three-round Delphi survey to prioritize these outcomes, and (4) a consensus meeting with key stakeholders to determine the list of outcomes included in the final COS.

DISCUSSION

The development of this COS will provide international standards for the outcomes to be collected and reported in all clinical trials and audits of practice, which involve prevention and treatment of first- and second-degree perineal tears for women with vaginal delivery. This will facilitate comparing and contrasting of studies and allow for combining of appropriate studies with the ultimate goal of improved perineal care for women choosing vaginal delivery.

TRIAL REGISTRATION

This study was registered in the database of Core Outcome Measures in Effectiveness Trials (COMET) on June11th, 2021 ( https://comet-initiative.org/Studies/Details/1884 ).

Fishing for (in)continence: long-term follow-up of women with OASIS-still a taboo

PURPOSE

Obstetric anal sphincter injuries (OASIS) increase the risk for pelvic floor dysfunctions. The goal of this study was to examine the long-term outcomes after OASIS on pelvic floor functions and quality of life.

MATERIAL AND METHODS

Between 2005 and 2013, 424 women had an OASIS at the Women University Hospital Ulm. Out of these 71 women completed the German pelvic floor questionnaire, which includes questions regarding prolapse symptoms as well as bladder, bowel and sexual function. In addition, 64 women were physically examined, including a speculum examination to evaluate the degree of prolapse, a cough test to evaluate urinary stress incontinence (SI) and an evaluation of both pelvic floor sphincter (modified Oxford score) and anal sphincter contraction.

RESULTS

A high rate of pelvic floor disorders after OASIS was found, as 74.6% of women reported SI, 64.8% flatus incontinence and 18.3% stool incontinence, respectively. However, only few women stated a substantial negative impact on quality of life. The clinical examination showed that a positive cough test, a weak anal sphincter tone and a diagnosed prolapse correlated with the results of the self-reported questionnaire.

CONCLUSION

On one hand, OASIS has an influence on pelvic floor function going along with lots of complaints, while on the other hand, it still seems to be a taboo topic, as none of the participants spoke about the complaints after OASIS with a doctor. Therefore, the gynecologist should actively address these issues and offer therapy options for the women with persisting problems.

Temporal decline in the improved detection rates following OASIS workshops

INTRODUCTION AND HYPOTHESIS

To evaluate the long-term sustainability of the effect of a hands-on workshop on the diagnosis of deliveries complicated by obstetrical anal sphincter injuries (OASIS).

METHODS

A population-based retrospective cohort study looking over a 4-year period, 1 year before and 3 years after an OASIS workshop. All deliveries that took place at the Soroka University Medical Center during the study period were included. Data were collected from the obstetrical electronic database. Interrupted time series analysis assessing the change in the OASIS detection rate over time from the workshop was conducted, assuming that the OASIS rate remained constant during the study period.

RESULTS

During the study period, 147 parturients suffered from OASIS. The baseline characteristics of the patients before and after the workshop did not differ. In the year following the workshop a significant increase in the detection rate was noted compared with the year prior to the workshop. In an interrupted time series analysis, the improved detection rate declined with time. In the last year following the workshop the detection rate declined, almost reaching the pre-workshop rate.

CONCLUSIONS

Attending an OASIS workshop increases the detection rate in the year following the workshop but declines gradually. To maximize its benefits, the workshop must be repeated periodically.

Comparison of 3D endoanal ultrasound and external phased array magnetic resonance imaging in the diagnosis of obstetric anal sphincter injuries

Objectives

The gold standard of postpartum anal sphincter imaging has been the 3D endoanal ultrasound (EAUS). Development of magnetic resonance imaging (MRI) has allowed anal sphincter evaluation without the use of endoanal coils. The aim of this study is to compare these two modalities in diagnosing residual sphincter lesions post obstetric anal sphincter injury (OASI).

Methods

Forty women were followed up after primary repair of OASI with both 3D EAUS and external phased array MRI. Details of the anal sphincter injury and sphincter musculature were gathered and analysed.

Results

There was a moderate interrater reliability (κ = 0.510) between the two imaging modalities in detecting sphincter lesions, with more lesions detected by MRI. There was a moderate intraclass correlation (ICC) between the circumference of the tear (κ = 0.506) and a fair ICC between the external anal sphincter thickness measurements at locations 3 and 9 on the proctologic clock face (κ = 0.320) and (κ = 0.336).

Conclusions

The results of our study indicate that the use of external phased array MRI is feasible for detecting obstetric anal sphincter lesions postpartum. This allows for imaging of the sphincter defects in centres where EAUS imaging is not available.

Key Points

• A two centre prospective study that showed external phased array MRI to be a valid imaging modality for diagnosing obstetric anal sphincter injuries.

Electronic supplementary material

The online version of this article (10.1007/s00330-019-06125-8) contains supplementary material, which is available to authorized users.

"Struggling to settle with a damaged body" - A Swedish qualitative study of women's experiences one year after obstetric anal sphincter muscle injury (OASIS) at childbirth

OBJECTIVE

This study aimed to explore women's experiences related to recovery from obstetric anal sphincter muscle injuries (OASIS) one year after childbirth.

METHOD

This is a qualitative study based on written responses from 625 women approximately one year after childbirth in which OASIS occurred. Data was obtained from a questionnaire distributed by the national Perineal Laceration Register (PLR) in Sweden. Inductive qualitative content analysis was applied for analysis.

RESULTS

The theme "Struggling to settle with a damaged body" indicated that the first year after OASIS involved a struggle to settle to and accept living with a changed and sometimes still-wounded body. Many participants described problems related to a non-functional sexual life, physical and psychological problems that left them feeling used and broken, and increased worries for their future health and pregnancies. However, some women had adjusted to their situation, had moved on with their lives, and felt recovered and strong. Encountering a supportive and helpful health care professional was emphasized as vital for recovery after OASIS.

CONCLUSION

This study provides important insights on how women experience their recovery approximately one year after having had OASIS at childbirth, wherein many women still struggled to settle into their damaged bodies. Clear pathways are needed within health care organizations to appropriate health care services that address both physical and psychological health problems of women with prolonged recovery after OASIS.

Impact of electronic and blended learning programs for manual perineal support on incidence of obstetric anal sphincter injuries: a prospective interventional study

BACKGROUND

Obstetric anal sphincter injuries (OASIS) are associated with anal incontinence, dyspareunia and perineal pain. Bimanual perineal support technique (bPST) prevents OASIS. The aim of this study was to assess the effect of two different bPST training-methods on OASIS incidence.

METHODS

This is a prospective-interventional quality improvement study conducted in two Palestinian maternity units between June 1 2015 and December 31 2016. Women having spontaneous or operative vaginal-delivery at ≥24 gestational-weeks or a birthweight of ≥1000 g (n = 1694) were recruited and examined vaginally and rectally immediately after vaginal birth by a trained assessor. Data on baseline OASIS incidence were collected during Phase-1 of the study. Subsequently, birth attendants in both maternity units were trained in bPST using two training modalities. A self-directed electronic-learning (e-learning) using an animated video was launched in phase-2 followed by a blended learning method (the animated e-learning video+ structured face-to-face training) in phase-3. OASIS incidence was monitored during phases-2 and 3. Variations in OASIS incidence between the three phases were assessed using Pearson-χ²-test (or Fisher's-Exact-test). The impact of each training-method on OASIS incidence was assessed using logistic-regression analysis.

RESULTS

A total of 1694 women were included; 376 in phase-1, 626 in phase-2 and 692 in phase-3. Compared to Phase-1, OASIS incidence was reduced by 45% (12.2 to 6.7%, aOR: 0.56, CI; 0.35-0.91, p = 0.018) and 74% (12.2 to 3.2%, aOR, 0.29, CI; 0.17-0.50, p < 0.001) in phases-2 and 3, respectively. There was also a significant reduction in OASIS incidence by 52% from phase-2 to phase-3 (6.7% (42/626) to 3.2% (22/692), p = 0.003). These reductions reached statistical significance among parous-women only (aOR: 0.18, CI; 0.07-0.49, p = 0.001) after the first training method tested in phase-2. However, the reduction was significant among both primiparous (aOR: 0.39, CI; 0.21-0.74, p = 0.004) and parous-women (aOR: 0.11, CI; 0.04-0.32, p < 0.001) after implementing the blended learning method in phase-3.

CONCLUSION

The animated e-learning video had a positive impact on reducing OASIS incidence. However, this reduction was enhanced by the use of a blended learning program combining both e- learning and face-to-face training modalities.

STUDY REGISTRATION NUMBER

ClinicalTrialo.gov identifier: NCT02427854 , date: 28 April 2015.

Enhancing recognition of obstetric anal sphincter injuries in six maternity units in Palestine: an interventional quality improvement study

OBJECTIVE

To explore the impact of a training intervention on obstetric anal sphincter injuries' (OASIS) detection rate.

DESIGN

Prospective quality improvement interventional study.

SETTING

Six secondary and tertiary maternity units in Palestine.

POPULATION

Women having singleton vaginal births ≥23 weeks' gestation or babies weighing ≥500 g (n=22 922). Caesarean births (n=5431), multiple gestations (n=443) and vaginal births of unregistered perineum status (n=800) were excluded.

INTERVENTIONS

Training programme for enhancing OASIS detection was conducted between 31 January and 31 December 2015. International experts delivered 2-day standardisation workshop teaching OASIS diagnosis and repair to each maternity unit. They also provided additional training to three research fellows employed in three of the maternity units. This was followed by 13-week period of data collection (phase 1). Research fellows then delivered training intervention over 15-week interval (phase 2), including theoretical teaching and 'onsite' training in perineal trauma assessment within the six maternity units. Finally, 13-week postintervention observation (phase 3) followed.

PRIMARY OUTCOME MEASURE

OASIS rates were used as surrogate for OASIS recognition. OASIS rates were compared between different phases and between the two maternity unit groups (research fellow and non-research fellow based) using Pearson's χ² test.

RESULTS

A total 22 922 women were included. Among primiparous women, OASIS rate was higher in phase 2 (2.8%, p<0.001) and phase 3 (3.1%, p<0.001) than phase 1 (0.5%). However, no significant differences were detected in the rates of severe OASIS (third-degree 3c and fourth-degree tears) between phase 1 and 2 (0.5% vs 0.3%), because this would have required at least 103 women with severe OASIS to be included in each phase. Among parous women, OASIS rate was significantly higher in phase 2 (0.6%, p=0.002) but not in phase 3 (0.4%, p=0.071) compared with phase 1 (0.2%). Research fellows' maternity units showed higher OASIS rates among primiparous women in phase 2 (3.6% vs 1.4%, p=0.001) and phase 3 (4.3% vs 0.8%, p<0.001) than non-research fellows' maternity units.

CONCLUSIONS

This work is basically an epidemiological study which has identified the prevalence of perineal lacerations and their severity on a large sample of women representative of an entire geographical ethnic region. The quality improvement intervention improved OASIS detection mainly in the research fellows' maternity units. Regular mandatory national programmes in obstetric perineal trauma assessment and management by local champions are essential to mitigate the risk of missing significant degrees of trauma.

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.

Fetal head size and effect of manual perineal protection

OBJECTIVE

The aim of this study was to evaluate whether a previously identified modification of Viennese method of perineal protection remains most effective for reduction of perineal tension in cases with substantially smaller or larger fetal heads.

METHODS

A previously designed finite element model was used to compare perineal tension of different modifications of the Viennese method of perineal protection to "hands-off" technique for three different sizes of the fetal head. Quantity and extent of tension throughout the perineal body during vaginal delivery at the time when the suboccipito-bregmatic circumference passes between the fourchette and the lower margin of the pubis was determined.

RESULTS

The order of effectiveness of different modifications of manual perineal protection was similar for all three sizes of fetal head. The reduction of perineal tension was most significant in delivery simulations with larger heads. The final position of fingers 2cm anteriorly from the fourchette (y = +2) consistently remains most effective in reducing the tension. The extent of finger movement along the anterior-posterior (y-axis) contributes to the effectiveness of manual perineal protection.

CONCLUSION

Appropriately performed Viennese manual perineal protection seems to reduce the perineal tension regardless of the fetal head size, and thus the method seems to be applicable to reduce risk of perineal trauma for all parturients.

Estimating the incidence and the economic burden of third and fourth-degree obstetric tears in the English NHS: an observational study using propensity score matching

OBJECTIVE

Obstetric care is a high-risk area in healthcare delivery, so it is essential to have up-to-date quantitative evidence in this area to inform policy decisions regarding these services. In light of this, the objective of this study is to investigate the incidence and economic burden of third and fourth-degree lacerations in the English National Health Service (NHS) using recent national data.

METHODS

We used coded inpatient data from Hospital Episode Statistics (HES) for the financial years from 2010/2011 to 2013/2014 for all females that gave birth during that period in the English NHS. Using HES, we used pre-existing safety indicator algorithms to calculate the incidence of third and fourth-degree obstetric tears and employed a propensity score matching method to estimate the excess length of stay and economic burden associated with these events.

RESULTS

Observed rates per 1000 inpatient episodes in 2010/2011 and 2013/2014, respectively: Patient Safety Indicator-trauma during vaginal delivery with instrument (PSI 18)=84.16 and 91.24; trauma during vaginal delivery without instrument (PSI 19)=29.78 and 33.43; trauma during caesarean delivery (PSI 20)=3.61 and 4.56. Estimated overall (all PSIs) economic burden for 2010/2011=£10.7 million and for 2013/2014=£14.5 million, expressed in 2013/2014 prices.

CONCLUSIONS

Despite many initiatives targeting the quality of maternity care in the NHS, the incidence of third and fourth-degree lacerations has increased during the observed period which signals that quality improvement efforts in obstetric care may not be reducing incidence rates. Our conservative estimates of the financial burden of these events appear low relative to total NHS expenditure for these years.

The impact of anal sphincter injury on perceived body image

OBJECTIVE

Obstetric anal sphincter injury is common but the effect on body image is unreported. The aim of this study was to explore patient perceived changes in body image and other psychological aspects in women attending a perineal follow-up clinic.

STUDY DESIGN

This retrospective study analysed women's responses to a self-reported questionnaire. Consecutive women with anal sphincter injury who attended a United Kingdom Maternity Hospital perineal follow-up clinic between January 1999 and January 2012 were identified and the records obtained and reviewed. Multivariate regression analyses were performed to examine variables influencing self-reported change in body image.

RESULTS

Questionnaires and operation notes were analysed from 422 women who attended at a median of four months after delivery. 222 (53%) reported a change in body image with 80 (19%) reporting lower self-esteem and 75 (18%) a change in their personality due to the change in body image. 248 (59%) perceived an anatomical change due to the delivery. Factors associated with increased likelihood of reporting a change in body image were reporting a perceived change in anatomy due to the delivery, adjusted OR 6.11 (3.56-10.49), anal incontinence, OR 1.97 (1.16-3.36), and delivery by forceps, OR 2.59 (1.23-5.43).

CONCLUSIONS

This is the first study to quantify body image changes in women after anal sphincter injury sustained in childbirth. These were found to be very common, affecting up to 50% of women. The study has several limitations but it does highlight the significant psychosocial problems of negative self-esteem and personality changes associated with a perceived change in body image that has not previously been reported. It also outlines the further research questions that need to be addressed.

Do women of reproductive age presenting with pelvic floor dysfunction have undisclosed anal incontinence: A retrospective cohort study

BACKGROUND

Indirect and direct trauma following vaginal birth can negatively impact on the pelvic floor function increasing the risk of anal incontinence. It is often difficult for women to openly disclose that they have anal incontinence and there are limited data collection tools available for the identification of these women in a clinical setting.

AIM

This study aims to describe the prevalence of undisclosed anal incontinence in antenatal and postnatal women with pelvic floor dysfunction.

METHODS

Retrospective cohort study of 230 antenatal and postnatal women referred to a Continence Nursing Service in a large tertiary hospital in South Australia, Australia, with pelvic floor dysfunction. A criteria list was utilised to access the primary reason for referral, anal incontinence assessments and attendance to an appointment.

RESULTS

Anal incontinence was identified in 26% of women (n=59). Anal incontinence was the primary reason for referral amongst 8 women, with the remaining 51 women identified as having anal incontinence following clinical screening via phone consultation. Eighty six percent of women stated they had not previously disclosed anal incontinence to health professionals. Overall, 71% of symptomatic women (n=28 antenatal and n=14 postnatal women) attended appointments to a service specialising in pelvic floor dysfunction.

CONCLUSION

Women presenting with urinary incontinence or other markers of pelvic floor dysfunction should be actively screened for anal incontinence as the prevalence of this condition is high amongst childbearing women.

Perineal Injury During Childbirth Increases Risk of Postpartum Depressive Symptoms and Inflammatory Markers

INTRODUCTION

Perineal lacerations during childbirth affect more than 65% of women in the United States. Little attention has been given to the long-term biologic consequences associated with perineal lacerations or possible associations with postpartum mental health. In this article, we describe the results of a study that explored inflammatory cytokines in women who reported perineal lacerations during childbirth and the relationship with stress and depressive symptoms during the first 6 months postpartum.

METHODS

A repeated measures design was used to explore the relationship between varying degrees of perineal lacerations, inflammatory cytokines, postpartum stress, and depressive symptoms in 153 women over 6 months. Depressive symptoms were measured using the Edinburgh Postnatal Depression Scale (EPDS), and maternal stress was measured using the Perceived Stress Scale. Plasma was analyzed for proinflammatory (tumor necrosis factor alpha, interleukin 6 (IL-6), interleukin-1 beta, interferon gamma) and anti-inflammatory (interleukin 10) cytokines. Levels of cytokines were compared between women with or without varying degrees of injury.

RESULTS

A relationship was identified between symptoms of depression and a second-degree or more severe perineal laceration starting at one month postpartum (P = .04) and continuing through 3 months postpartum (P = .03). Similarly, stress symptoms were higher at 3 months postpartum (P = .02). Markers of inflammation were significantly higher among this group, with IL-6 increased at 2 weeks postpartum (P = .02) and remaining elevated through 2 months postpartum (P = .003); there were also significant differences in pro- to anti-inflammatory cytokine ratios out to 6 months postpartum. Regression analysis indicated that second-degree or more severe lacerations accounted for 5.9% of the variance in EPDS score at one month postpartum (P = .024, F = 2.865, t = 2.127), increasing substantially when the one month stress score was included as well.

DISCUSSION

This study suggests that perineal lacerations, inflammation, stress, and depressed mood are associated; however, more research is needed to elucidate the actual relationship between inflammation and mental health in women who experience such injuries.