BJOG Editor's Choice

Abstract

Women choose to have an elective caesarean section for the delivery of their second child for a variety of reasons. Most cases relate to previous caesarean section, some because of psychological reasons, such as unresolved delivery-related post-traumatic stress disorder, and others because of previous physical maternal birth trauma. The last includes previous serious perineal tears, the rate of which appears to be increasing across Europe. In the UK the rate of third- and fourth-degree perineal tears in primiparous women tripled from 1.8% to 5.9% during the period 2000–12 (Gurol-Urganci et al. BJOG 2013;120:1516–25) and in Finland it rose from 0.5% in 1997–99 to 1.8% in 2006/07 (Räisänen et al. Prev Med 2009;49:535–40). In Norway, in primiparous women, the rate rose from 0.6% in 1967 to 7% in 2004 and did so in parallel for both instrumental and noninstrumental deliveries. The rise persisted after adjusting for demographic and other risk factors and confounders (Baghestan et al. Obstet Gynecol 2010;116:25–34). Whether this rise is as a result of more accurate reporting or a change in practice is unclear. It has been suggested that the ‘hands off’ practice for normal delivery, promoted from the 1960s and 1970s (McCandlish, J Midwifery Womens Health 2001;46:396–401), may have contributed to the increased occurrence of obstetric anal sphincter injuries in noninstrumental deliveries. In the 1980s, when I was a very junior obstetrician and my wife was a very junior midwife, I am sure I was part of a culture where mild (e.g. 3a) tears as a result of an instrumental delivery were under-reported. At the same time my wife was part of a culture where midwives were expected to be very ‘hands on’ with their deliveries and even a second-degree tear was considered a heinous crime and would have the midwife brought before a formidable and unsympathetic midwifery sister. Regardless of the reasons for the increase in rate, a previous anal sphincter injury has important implications for a future delivery. On page 1695 Edozien et al. report findings from a UK-wide study of 639 402 primiparous women who had a singleton, vaginal, live birth between 2004 and 2011, and who also had a second birth by March 2012. They measured the mode of delivery and recurrence of tears at the second birth. For women who had a vaginal delivery at second birth, the rate of third/fourth-degree tear was 7.2% in women with a previous third/fourth-degree tear compared with 1.3% in women without. The latter finding is similar to most previous reports from smaller studies and will assist in counselling women who have had a previous anal sphincter injury. The rate of elective caesarean for the second birth in women who have had previous sphincter injury was 24%, a figure that is much higher than the range of 6–18% reported previously in other countries, but remarkably similar to the figure of 22% of UK obstetricians who, according to a recent survey, would recommend an elective caesarean section to prevent anal incontinence following previous anal sphincter injury (Fernando et al. BMC Health Serv Res 2002;2:9). Whether this advice is sound is unclear. The rate of faecal incontinence 12 years after delivery does not differ between women who have only elective caesarean sections and women who have only vaginal deliveries (MacArthur et al. BJOG 2011;118:1001–7). If we are to practice evidence-based obstetrics then a return to the ‘hands on’ approach to delivery may be a better solution, for which there is increasing evidence of benefit (Hals et al. Obstet Gynecol 2010;116:901–8; Stedenfeldt et al. BJOG 2014;121:83–91). Around 15% of cases of cerebral palsy are clearly attributable to adverse events during labour, of which nearly one-half are probably avoidable. On page 1720, using published data regarding the incidence and aetiology of cerebral palsy, Leigh et al. simulated the outcomes of a hypothetical cohort of UK live births using survival and quality-adjusted life-years analysis. They calculated that 207 (95% confidence interval 169–245) cases of asphyxia-related cerebral palsy were projected among UK children born during 2014, causing a loss valued by the NHS at £62.9 million. One proposed strategy to reduce error in the management of labouring women is the introduction of Practical Obstetric Multi-Professional Training (PROMPT), which involves hospital-based training comprising short lectures and scenario-based simulation training in obstetric emergencies delivered by trainers drawn from the hospital staff. On page 1710 we present a study from Australia on the effects of the introduction of PROMPT in eight maternity units, which includes an analysis of the effects on neonatal outcome in a total of 43 408 babies born before and after the time of its introduction. About 50% of all possible staff were trained in the first year of the programme. Statistically significant positive effects of training on neonatal outcomes are shown in Figures 1 and 2.