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The association of episiotomy with obstetric anal sphincter injury--a population based matched cohort study.

ABSTRACT: To estimate the independent association of episiotomy with obstetric anal sphincter injuries (OASIS) using first a cross-sectional and then a matched pair analysis.A matched cohort.Data was gathered from the Finnish Medical Birth Register from 2004-2011.All singleton vaginal births (n = 303,758).Women resulting matched pairs (n = 63,925) were matched based on baseline risk of OASIS defined based on parity (first or second/subsequent vaginal births), age, birth weight, mode of delivery, prior caesarean section, and length of active second stage of birth.In cross-sectional analysis episiotomy was associated with a 12% lower incidence of OASIS (adjusted odds ratio (aOR) 0.88, 95% confidence interval (CI) 0.80 to 0.98) in first vaginal births and with a 132% increased incidence of OASIS in second or subsequent vaginal births (aOR 2.32, 95% CI 1.77 to 3.03). In matched pair analysis episiotomy was associated with a 23% (aOR 0.77, 95% CI 0.69 to 0.86) lower incidence of OASIS in first vaginal births and a 61% (aOR 1.61, 95% CI 1.14 to 2.29) increased incidence of OASIS in second or subsequent vaginal births compared to women who gave birth without an episiotomy. The matched pair analysis showed a 12.5% and a 31.6% reduction in aORs of OASIS associated with episiotomy, respectively.A matched pair analysis showed a substantial reduction in the aORs of OASIS with episiotomy, due to confounding by indication. This indicates that results of observational studies evaluating an association between episiotomy and OASIS should be interpreted with caution.

SUBMITTER: Raisanen S

PROVIDER: S-EPMC4159295 | biostudies-other | 2014

REPOSITORIES: biostudies-other

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Assessing the association of oxytocin augmentation with obstetric anal sphincter injury in nulliparous women: a population-based, case-control study.

Project description:ObjectiveTo assess the association of oxytocin augmentation with obstetric anal sphincter injury among nulliparous women.DesignPopulation-based, case-control study.SettingPrimary and secondary teaching hospital serving a Norwegian region.Population15?476 nulliparous women with spontaneous start of labour, single cephalic presentation and gestation ?37?weeks delivering vaginally between 1999 and 2012.MethodsBased on the presence or absence of oxytocin augmentation, episiotomy, operative vaginal delivery and birth weight (<4000 vs ?4000?g), we modelled in logistic regression the best fit for prediction of anal sphincter injury. Within the modified model of main exposures, we tested for possible confounding, and interactions between maternal age, ethnicity, occiput posterior position and epidural analgaesia.Main outcome measureObstetric anal sphincter injury.ResultsOxytocin augmentation was associated with a higher OR of obstetric anal sphincter injuries in women giving spontaneous birth to infants weighing <4000?g (OR 1.8; 95% CI 1.5 to 2.2). Episiotomy was not associated with sphincter injuries in spontaneous births, but with a lower OR in operative vaginal deliveries. Spontaneous delivery of infants weighing ?4000?g was associated with a threefold higher OR, and epidural analgaesia was associated with a 30% lower OR in comparison to no epidural analgaesia.ConclusionsOxytocin augmentation was associated with a higher OR of obstetric anal sphincter injuries during spontaneous deliveries of normal-size infants. We observed a considerable effect modification between the most important factors predicting anal sphincter injuries in the active second stage of labour.

| S-EPMC4120359 | biostudies-literature

Anovaginal distance and obstetric anal sphincter injury: a prospective observational study.

Project description:Introduction and hypothesisNo measurements are available for diagnosing the extent of obstetric lacerations. The primary aim of this study was to evaluate the relation between the anovaginal distance (AVD) measured with transperineal ultrasound immediately after delivery and external anal sphincter injury. A secondary aim was to assess whether the palpated perineal thickness was associated with the AVD.MethodsA prospective observational study of 150 primiparous women at the University Hospital, Linköping, Sweden. After vaginal delivery, initial inspection and palpation of the perineal thickness were performed by the midwife. The women were then divided into subgroups depending on the degree of the suspected perineal laceration. Transperineal ultrasound of the AVD was performed by a physician. Diagnostics of the perineal laceration were done according to standard care.ResultsWomen with an external sphincter injury had a shorter AVD and shorter palpatory perineal thickness compared with women without anal sphincter injury. No external sphincter injuries were diagnosed when the AVD and/or palpation height was > 20 mm. The mean AVD in the group with probable second-degree laceration (n = 85) was 18.8 mm (95% CI 17.8-19.8), in suspected third-degree laceration (n = 33) 15.7 mm (95% CI 13.7-17.7) and in probable third-degree laceration (n = 32) 11.8 mm (95% CI 9.7-13.9) (p < 0.001).ConclusionsA short AVD could be a warning sign postpartum and should increase the awareness of possible external sphincter injury before suturing. An AVD of 20 mm seems to indicate a cutoff level of the occurrence of external sphincter injury, but this needs further evaluation.

| S-EPMC6511353 | biostudies-literature

A modified surgical approach to women with obstetric anal sphincter tears by separate suturing of external and internal anal sphincter. A modified approach to obstetric anal sphincter injury.

Project description:BackgroundLong-term results after obstetric anal sphincter injury (OASI) are poor. We aimed to improve the long-term outcome after OASI by lessening symptoms of anal incontinence.MethodsIn a prospective study at Malmö University Hospital, twenty-six women with at least grade 3B OASI were classified and sutured in a systematic way, including separate suturing of the internal and external sphincter muscles with monofilament absorbable sutures. The principal outcome assessed by answers given to six questions, was a difference in anal incontinence score, between the study group and two control groups (women with prior OASI [n = 180] and primiparous women delivered vaginally without a diagnose of OASI [n = 100]).ResultsAn anal incontinence score of zero (i.e., no symptoms) was found in 74% of the study group, 47% of the OASI control group, and 66% of the vaginal control group (p = 0.02 and 0.5, as compared to the study group).ConclusionsA modified suturing technique was followed by significant improved one-year symptoms of anal incontinence as compared to historical cases.

| S-EPMC2949785 | biostudies-literature

Incidence and Predictors of Anal Incontinence After Obstetric Anal Sphincter Injury in Primiparous Women.

Project description:This study aimed to describe the incidence of fecal incontinence (FI) at 6, 12, and 24 weeks postpartum; anal incontinence (AI) and fecal urgency at 24 weeks; and identify predictors of AI in women with obstetric anal sphincter injury (OASI).Primiparous women sustaining OASIs were identified at 8 clinical sites. Third-degree OASIs were characterized using World Health Organization criteria, 3a (<50%) or 3b (>50%) tear through the sphincter. Fecal incontinence was defined as leakage of liquid/solid stool and/or mucus in the past month; AI was defined as leakage of liquid/solid stool and/or mucus and/or gas in the past month and was assessed at 6, 12, and 24 weeks postpartum using the Fecal Incontinence Severity Index. Logistic regression identified variables associated with AI.Three hundred forty-three women participated: 297 subjects sustained a third-degree OASI, 168 type 3a, 98 type 3b and 31 indeterminant; 45 had a fourth-degree OASI. Overall FI incidence at 6, 12, and 24 weeks was 7% [23/326; 95% confidence interval (CI), 4%-10%], 4% (6/145; 95% CI, 2%-9%), and 9% (13/138; 95% CI, 5%-16%), respectively. At 24 weeks, AI incidence was 24% (95% CI, 17%-32%) and fecal urgency 21% (95% CI, 15%-29%). No significant differences in FI and AI rates were noted by third-degree type or between groups with third and fourth OASI. Flatal incontinence was greater in women sustaining a fourth-degree tear (35% vs 16%, P = 0.04). White race (adjusted odds ratio, 4.64; 95% CI, 1.35-16.02) and shorter duration of second stage (adjusted odds ratio, 1.47 per 30 minute decrease; 95% CI, 1.12-1.92) were associated with AI at 24 weeks.Overall 24-week incidence of FI is 9% (95% CI, 5%-16%) and AI is 24% (95% CI, 17%-32%). In women with OASI, white race and shorter second-stage labor were associated with postpartum AI.NCT01166399 (http://clinicaltrials.gov).

| S-EPMC4481184 | biostudies-literature

Incidence of obstetric anal sphincter injuries after training to protect the perineum: cohort study.

Project description:ObjectiveTo compare the incidence of obstetric anal sphincter injuries (OASIS) in two time periods, before and after implementing a training programme for improved perineal support aimed at reducing the incidence of obstetric anal sphincter injuries. The secondary aim was to study incidence of obstetric anal sphincter injuries in subgroups defined by risk factors for OASIS.DesignPopulation-based cohort study.SettingUniversity hospital setting in Oslo, Norway.ParticipantsTwo cohorts of all delivering women in the largest hospital in Norway during two time periods (2003-2005 and 2008-2010) were studied. After excluding caesarean sections and preterm deliveries (< week 32), the study population consisted of 31 709 deliveries, among which 907 women were identified with obstetric anal sphincter injury.Primary and secondary outcome measuresIncidence of OASIS in two time periods. Maternal, obstetrical and foetal risk factors for OASIS were collected from the hospital obstetric database. Univariate analyses and multivariate logistic regression analyses, presenting adjusted ODs for OASIS, were performed.ResultsThe OASIS incidence was significantly reduced by 50%, from 4% (591/14787) in the first time period to 1.9% (316/16 922) in the second. This reduction could not be explained by changes in population characteristics or OASIS risk factors during the study years. The reduction of incidence of OASIS between the two study periods was consistent across subgroups of women; regardless of parity, delivery method and infant birth weight.ConclusionsA marked reduction in the incidence of OASIS was observed in all studied subgroups of women after implementing the training programme for perineal protection. Further, this reduction could not be explained by the differences in patient characteristics across the study period. These findings indicate that the training programme with improved perineal protection markedly reduced the risk of OASIS.

| S-EPMC3488722 | biostudies-literature

Management of obstetric anal sphincter injury: a systematic review & national practice survey.

Project description:BackgroundWe aim to establish the evidence base for the recognition and management of obstetric anal sphincter injury (OASI) and to compare this with current practice amongst UK obstetricians and coloproctologists.MethodsA systematic review of the literature and a postal questionnaire survey of consultant obstetricians, trainee obstetricians and consultant coloproctologists was carried out.ResultsWe found a wide variation in experience of repairing acute anal sphincter injury. The group with largest experience were consultant obstetricians (46.5% undertaking > or = 5 repairs/year), whilst only 10% of responding colorectal surgeons had similar levels of experience (p < 0.001). There was extensive misunderstanding in terms of the definition of obstetric anal sphincter injuries. Overall, trainees had a greater knowledge of the correct classification (p < 0.01). Observational studies suggest that a new 'overlap' repair using PDS sutures with antibiotic cover gives better functional results. However, our literature search found only one randomised controlled trial (RCT) on the technique of repair of OASI, which showed no difference in incidence of anal incontinence at three months. Despite this, there was a wide variation in practice, with 337(50%) consultants, 82 (55%) trainees and 80 (89%) coloproctologists already using the 'overlap' method for repair of a torn EAS (p < 0.001). Although over 50% of colorectal surgeons would undertake long-term follow-up of their patients, this was the practice of less than 10% of obstetricians (p < 0.001). Whilst over 70% of coloproctologists would recommend an elective caesarean section in a subsequent pregnancy, only 22% of obstetric consultants and 14% of trainees (p < 0.001).ConclusionAn agreed classification of OASI, development of national guidelines, formalised training, multidisciplinary management and further definitive research is strongly recommended.

| S-EPMC116576 | biostudies-literature

What is the total impact of an obstetric anal sphincter injury? An Australian retrospective study.

Project description:IntroductionMost data on obstetric anal sphincter injury (OASI) reflect short-term (< 12 months) or much longer term (> 10 years) impact. This study aimed to collate the extent of medium-term symptomology (1-6 years) and observe the effect on future birth choices to evaluate the cumulative impact of OASI in affected women.MethodsA retrospective cohort of women affected by OASI completed a questionnaire covering bowel symptomology, sexual function, life impact and future birth choices. A custom-created adverse composite outcome for OASI incorporating effects on daily life, flatal/fecal incontinence and sexual function (OASIACO) was used as a threshold score to identify women with high levels of symptoms.ResultsOf 265 eligible and contactable women, 210 questionnaires were received (response rate 79%) at a mean of 4 years post-OASI. More than half (54%) experienced an OASIACO. A forceps birth (p = 0.03) or more severe grade of tear (p = 0.03) was predictive of OASIACO. One hundred one women had further children, with 48% reporting their delivery choices were impacted, 32% electing a cesarean delivery and 26% shifting to private care. Eighty women (40%) had not given birth again, and 29 (36%) of these indicated their OASI influenced this decision.ConclusionsThe total impact of an OASI on women affected is substantial. More than half experience ongoing symptoms and close to half report an impact on their future birth choices. It follows there would be a consequential load on the healthcare sector, and improved management and prevention programs should be implemented.

| S-EPMC7093361 | biostudies-literature

Body mass index and complications after obstetric anal sphincter injury, 8 weeks postpartum.

Project description:Introduction and hypothesisThe impact of body mass index (BMI) on pelvic floor recovery after an obstetric anal sphincter injury (OASI) is unclear. The aim of this study was to evaluate the hypothesis that urinary incontinence (UI) and anal incontinence (AI) are more common in overweight and obese women than in normal-weight women 8 weeks postpartum in women with OASI.MethodsA population-based cohort study including 6,595 primiparous women, with an OASI, delivered between 2014 and 2019. Exposure and questionnaire data were retrieved from the Swedish Perineal Laceration Registry. Uni- and multivariate analyses were used to compare normal-weight (BMI ≤24.9, reference), overweight (25.0-29.9), and obese (≥ 30) women with regard to UI and AI at 8 weeks post-partum.ResultsMultivariate analyses showed an increased risk for urinary incontinence (OR 1.54, 95% CI 1.27-1.87) among overweight women as well as among obese women (OR 1.72, 95% CI 1.32-2.24). In contrast to our hypothesis, both overweight women (OR 0.68, 95% CI 0.56-0.83) and obese women (OR 0.65, 95% CI 0.49-0.87) were at a decreased risk for any gas and/or faecal incontinence after adjustment to possible confounding factors. The absolute rate of AI was 40.1% among normal-weight women, 34.2% among overweight women, and 29.1% in the obese group.ConclusionsUrinary incontinence is more common, whereas AI is less common among overweight and obese women than in primiparous women with a BMI <24.9, 8 weeks after an OASI. The new finding, that overweight women report less AI than normal-weight women, merits further study.

| S-EPMC9666295 | biostudies-literature

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

Project description:BackgroundWomen 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.ObjectiveWe sought to conduct a systematic review and meta-analysis to investigate potential risk factors for recurrent OASIs.Search strategyStudies up to May 2019 were identified from PubMed, Scopus, Cochrane Library, and ISI Web of Science.Selection criteriaStudies 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 analysisData 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 resultsThe 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.ConclusionPrenatal and intrapartum risk factors are associated with recurrence of OASI. PROSPERO registration no. CRD42020178125.

| S-EPMC9298380 | biostudies-literature

The impact of mode of subsequent birth after obstetric anal sphincter injury on bowel function and related quality of life: a cohort study.

Project description:Introduction and hypothesisThe objective was to assess the impact of mode of subsequent birth on bowel function and related quality of life (QoL) in pregnant women with previous obstetric anal sphincter injury (OASI).MethodsA prospective cohort study, designed, undertaken and reported using the Strengthening the Reporting of Observational Studies in Epidemiology statement and checklist. All pregnant women with previous OASI recruited at a specialist antenatal OASI clinic in a tertiary hospital to discuss mode of subsequent birth, between 1 January 2014 and 31 October 2015. Women are counselled in line with local guidelines based on Royal College of Obstetricians and Gynaecologists Green-top recommendations. In addition to routine endoanal ultrasound scan (EAUS), women recruited to the study were asked to complete the validated Manchester Health Questionnaire (MHQ) at both 34 weeks' gestation and 6 months postnatally.ResultsOf the 175 study participants, 125 (71.4%) completed follow-up at 6 months. There was no significant change in frequency of bowel symptoms or QoL domain scores in women who had a subsequent vaginal birth compared with caesarean section. Multivariate analysis showed the odds of having poor "incontinence impact" (OR 2.91, 95% CI 1.03-8.21) and "physical limitations" (OR 4.56, 95% CI 1.02-20.45) were significantly higher for women who had a subsequent caesarean section.ConclusionsFor women with previous OASI, a subsequent vaginal birth is suitable for those with no bowel symptoms and normal EAUS and caesarean section is reasonable for women who do not have normal bowel function and/or normal EAUS findings; however, for some of these women bowel symptoms and QoL may be worsened.

| S-EPMC7561530 | biostudies-literature

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