Abstract
Introduction and hypothesisThe aim of this study was to develop a new protocol for documentation of perineal lacerations and to validate the latter against the most common obstetric record system in Sweden. The hypothesis was that the new protocol would render more complete data on perineal lacerations than the current documentation method.MethodsA protocol for documentation of perineal lacerations was developed to be sufficiently comprehensive to serve research purposes. All women delivering their first child vaginally from 13 October 2015 to 1 February 2016 at Örebro University Hospital were eligible for the validation study. Perineal lacerations were documented using the protocol in parallel with the regular obstetric record system (ObstetriX). Cross tabulations were used to compare the coverage regarding perineal lacerations between the two documentation methods. McNemar’s test was used to evaluate systematic differences between the methods.ResultsA total of 187 women were included. The coverage of documentation regarding perineal laceration was significantly higher (p < 0.001) in the new protocol (89%) compared with ObstetriX (18%). Incidence of second-degree perineal tears was 26% according to the new protocol and 11% according to ObstetriX. The incidence of third-degree perineal tears A, B, and C was 2.7%, 2.1%, and 2.1%, respectively, according to the new protocol, and 3.2%, 2.7%, and 1.1% according to ObstetriX.ConclusionsThis validation study of a new documentation protocol showed that it delivered significantly more comprehensive information regarding perineal lacerations than the most common obstetric record system in Sweden.
Highlights
Introduction and hypothesisThe aim of this study was to develop a new protocol for documentation of perineal lacerations and to validate the latter against the most common obstetric record system in Sweden
The present study shows that the new documentation protocol delivers more comprehensive information regarding perineal lacerations compared with the current obstetric record system, ObstetriX, when used in primiparous women
We could not see any difference in the ability to diagnose third-degree perineal tears, but the new protocol gave more comprehensive information regarding suturing
Summary
The aim of this study was to develop a new protocol for documentation of perineal lacerations and to validate the latter against the most common obstetric record system in Sweden. Methods A protocol for documentation of perineal lacerations was developed to be sufficiently comprehensive to serve research purposes. All women delivering their first child vaginally from 13 October 2015 to 1 February 2016 at Örebro University Hospital were eligible for the validation study. Incidence of second-degree perineal tears was 26% according to the new protocol and 11% according to ObstetriX. The incidence of third-degree perineal tears A, B, and C was 2.7%, 2.1%, and 2.1%, respectively, according to the new protocol, and 3.2%, 2.7%, and 1.1% according to ObstetriX. Data are automatically extracted from the medical record system in most Swedish
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