The impact of national guidelines on EBM implementation in clinical practice: a comparison between the practices in two countries

Background: Obstetric anal sphincter injuries (OASIs) are a major cause of maternal morbidity. This audit evaluated risk factors, intrapartum management, postoperative care, and follow-up of OASI cases at a UK district general hospital, benchmarking practices against national guidance.Methodology: Retrospective audit of women who sustained OASI between January 1 and December 31, 2023. Data were extracted from electronic and paper records. Outcomes were assessed against Royal College of Obstetricians and Gynecologists (RCOG) Green-top Guideline No. 29 standards. The prevalence of OASI among total and vaginal deliveries in 2023 was reported.Results: Twenty-eight women sustained OASI; 23 (82%) were primiparous, and 10 (36%) had an instrumental delivery. Episiotomy was performed in 14 (50%). Perineal support was recorded in 19 (68%). Postoperative care aligned well with standards: antibiotics in 26 cases (93%), physiotherapy referral in 27 (96%), and laxatives in 22 (79%). Gynecology follow-up referral was documented in 21 (75%) cases. OASI prevalence in 2023 was 13.3% of all births and 22.8% of vaginal births at our unit.Conclusions: Primiparity and instrumental delivery were common risk factors. Immediate postoperative care met most standards, but documentation and follow-up referrals were inconsistent. A structured OASI proforma and standardized referral pathway are recommended to improve continuity of care. Recognition of high-risk women and consistent use of preventive strategies, together with structured counselling for future deliveries, may further improve outcomes.

Classification and management of extensive obstetric perineal injuries in the Czech and Slovak Republics

Perineal trauma affects approximately 350,000 women per annum in the United Kingdom (UK) and is associated with considerable morbidity. Symptoms are most severe following obstetric anal sphincter injuries (OASIS) compared with other grades of perineal trauma. The Royal College of Obstetricians and Gynaecologists (RCOG) guidelines indicate that the rate of OASIS is 1 % of vaginal deliveries. In 2011, the RCOG implemented the "Maternity Dashboard" so that units could benchmark their performance against national standards of which OASIS is a component. Our primary objective was to establish the national rate of OASIS and audit variations in incidence and management of obstetric perineal trauma. We carried out a questionnaire-based survey auditing national practice. Every UK maternity unit was contacted regarding perineal outcomes after all deliveries between January 2009 and January 2010. 215 of the 265 units in the UK responded (81 %). 692,259 of the 790,197 deliveries in the UK for the same period were sampled (88 %). 75 % delivered vaginally. The median national OASIS rate was 2.85 % (0-8 %). 20.2 % of women delivering vaginally had episiotomies; none were midline. 12.4 % of second-degree tears were not repaired in low-risk units compared with 5.9 % in high-risk units. 57.1 % of units used the perineal trauma classification of the RCOG. This study provides comprehensive data regarding the incidence and management of perineal trauma across the UK. Clinicians and policy-makers, both local and at the RCOG, can devise up-to-date realistic guidelines on the anticipated rate of OASIS and help to assess the compliancy of units with guidelines on the appropriate management of perineal trauma.

Information about the long-term severity and subjective impact of anal incontinence in women after 1 or 2 consecutive obstetrical anal sphincter injuries is still scarce and contradictory. This study aimed to describe the severity and impact of anal incontinence among women with 2 previous deliveries 2 decades after birth and to analyze the relative effect of 1 vs 2 obstetrical anal sphincter injuries in comparison with no obstetrical anal sphincter injuries and the possible influence of obstetrical anal sphincter injury on other pelvic floor disorders. We linked prospectively registered data in the Swedish Medical Birth Register with information from a postal and web-based questionnaire in 2015. Statistics Sweden identified women with 2 vaginal births from 1992 to 1998, and a simple random sample of 11,000 women was drawn from a source cohort of 64,687 women. To achieve equal-sized groups of women with 1 or 2 obstetrical anal sphincter injuries, the latter group was oversampled from 1987 to 2000. The final study cohorts consisted of 6760 women with no obstetrical anal sphincter injury, 357 women with 1 injury, and 324 women with 2 obstetrical anal sphincter injuries. Third- and fourth-degree perineal tears were grouped together for analysis. Anal incontinence was defined as either fecal or isolated gas incontinence, and fecal incontinence was defined as involuntary leakage of solid or liquid stool with or without concomitant gas. Frequencies of leakage of stool and gas were dichotomized into low frequency (less than once a month) and high frequency (several times a month or more often). Pairwise comparisons were analyzed using Fisher exact tests, Mantel-Haenszel statistics, and the Mann-Whitney U test. Trends were analyzed using Mantel-Haenszel statistics and the Spearman rank correlation test. Logistic regression models were used to obtain the age- and body-mass-index -adjusted odds ratios for outcomes. Statistical significance was set at P<.05. The response rate was 65.5% in the randomly selected cohort and 70.1% among women with 2 obstetrical anal sphincter injuries. Bothersome fecal incontinence occurred in 3.3% (212/6458) of women without obstetrical anal sphincter injury, in 10.4% (36/345) (adjusted odds ratio, 3.25; 95% confidence interval, 2.23-4.73) of those with 1 injury, and in 16.5% (52/315) (adjusted odds ratio, 5.16; 95% confidence interval, 3.69-7.22) of those with 2 obstetrical anal sphincter injuries (trend P<.0001). Fecal incontinence was perceived as bothersome in 28.2% (212/753) of women without an obstetrical anal sphincter injury compared with in 43.9% (36/82) and 46.0% (52/113) of those with 1 or 2 obstetrical anal sphincter injuries (trend P<.0001). Leakage of liquid stool occurred in 10.8% (724/6717) of those without injury, in 21.7% (77/355) of women with 1 injury, and 34.9% (113/324) of women with 2 obstetrical anal sphincter injuries (trend P<.0001). Incontinence affecting daily life was reported by 8.6% (577/6672) of women without injury and by 19.7% (69/351) and 29.6% (96/324) of women with 1 and 2 sphincter injuries, respectively (trend P<.0001). The mean Jorge-Wexner score was 2.44, 3.26, and 3.88 for women with no, 1, or 2 sphincter injuries (trend P<.0001). Among women with a Jorge-Wexner score of 6, >50% had bothersome anal incontinence. The adjusted odds ratio for the overall effect of 1 vs 2 obstetrical anal sphincter injuries on measures of anal incontinence was 2.19 (95% confidence interval, 1.68-2.85) and 3.91 (95% confidence interval, 3.06-5.00), respectively, when compared with no obstetrical anal sphincter injury (both P<.0001). Having 1 or 2 obstetrical anal sphincter injuries had no significant effect on other pelvic floor disorders or on lower urinary tract symptoms (P=.73 and P=.69). A consistent additive effect of 1 or 2 sphincter injuries on the severity and impact of anal incontinence was observed in women 2 decades after 2 vaginal births. This information is important for healthcare economics, clinical practice, and policy.

Editor's highlights

Obstetric anal sphincter injuries (OASIS) represent a serious morbidity that can cause short- and long-term consequences. It has attracted attention leading to the development of a national guideline by the Royal College of Obstetricians and Gynaecologists (RCOG). The aim of this study was to establish the current management of these injuries in hospitals across the UK. An anonymous self-construct questionnaire was posted to clinical directors/lead obstetricians in all hospitals in the UK and a total of 104 out of 233 (44.6%) questionnaires were returned. Over 90% of respondents’ hospitals had protocols that required repair in theatre, as well as the prescription of laxatives and antibiotics and included these injuries in the risk management list. More than half of the respondents’ hospitals did not have a dedicated perineal trauma clinic or used symptoms and quality of life questionnaires, endoanal scans or anal manometry routinely at follow-up. Over a third of respondents indicated that their units did not provide any training on repair of OASIS and did not have a multidisciplinary meeting involving colorectal surgeons. More effort is needed to improve all these aspects of care.

There are no data on midwives' knowledge and management of obstetric anal sphincter injuries (OASIs) in the USA. We performed a cross-sectional national survey characterizing OASI practice by certified nurse midwives (CNMs), hypothesizing that few midwives personally repair OASIs and that there are gaps in CNM OASI training/education. We emailed a REDCap internet-based survey to 6909 American College of Nurse Midwives members (ACNM). We analyzed responses from active clinicians performing at least one delivery per month, asking about OASI risks, prevention, repair, and management. We summarized descriptive data then evaluated OASI knowledge by patient and provider characteristics. We received 1070 (15.5%) completed surveys, and 832 (77.8%) met the inclusion/exclusion criteria. Participants were similar to ACNM membership. Respondents most frequently identified prior OASI (87%) and nutrition (71%) as antepartum OASI risk factors and, less frequently, nulliparity (36%) and race (22%). Identified intrapartum risks included forceps delivery (94%) and midline episiotomy (88%). When obstetric laceration is suspected, 13.6% of respondents perform a rectal examination routinely. Only 15% of participants personally perform OASI repair. Overall, participants matched 64% of evidence-based answers. OASI education/training courses were attended by 30% of respondents, and 44% knew of OASI protocols within their group/institution. Of all factors evaluated, the percent of evidence-based responses was only different for respondent education/CME and protocols. Quality initiatives regarding OASI prevention and management may improve care. Our data suggest OASI training for midwives may improve delivery care in the US. Further studies of other obstetric providers are needed.

This paper deals with the influence of air accidents on legislation in civil aviation in the Slovak Republic and Czech Republic. Firstly, it focuses on defining essential terms, organizations, laws, and regulations which are affecting air accidents investigation. All these elements are based on the aviation regulation L13 (ANNEX 13). Then it deals with detailed analysis of chosen air accidents that happened in Czech or Slovak Republic. As a result of previous research have been defined categories of the most common causes of air accidents between the year 2016 and 2020 which occurred in Czech and Slovak Republic and created their classification. The main goal of the paper was to identify new legislation measures and changes, which have been propounded or adopted to prevent another air accidents with the same or similar causes in the future. Among those regulations belongs for example area 100 KSA, AUPRT or background checks. Lastly it deals with the upcoming legislation changes affecting civil aviation in Slovak Republic.

This study aims to identify the differences in the use of HPV vaccination between female medical students in the Czech and Slovak Republics and their possible causes. We performed a cross-sectional survey among female students of general medicine in all faculties of medicine in the Czech and Slovak Republics. We obtained 630 questionnaires from the Czech Republic and 776 questionnaires from the Slovak Republic. In the Czech Republic, 65.4% of female medical students underwent HPV vaccination, while in the Slovak Republic, the figure was 21.1%. In the Czech Republic, residency and religion of students did not influence their rate of vaccination. However, in the Slovak Republic, village residency with less than 5,000 inhabitants lowered the probability of vaccination with OR = 0.56 (95% CI: 0.38-0.84), and the Catholic religion lowered the probability of vaccination with OR = 0.40 (95% CI: 0.28-0.57). Czech students were informed about the possibility of vaccination by a paediatrician in 55.7% of cases, while the figure for Slovak students was 26.8%. In the Czech Republic, 75.7% of students participated in regular cervical oncologic screening, while in the Slovak Republic, the figure was 57.7%. Vaccination of relatives would be recommended by 86.5% and 80.5% of Czech and Slovak students, respectively. The adoption of an oncologic prevention programme and the more extensive propagation by paediatricians are probably the medical reasons for the higher HPV vaccination among Czech students. Demographic factors - village residency and religion - are also important.

At the beginning of 1999, the new Framework 5 research program of the European Union was launched. Ten formerly socialist European countries have been admitted as associated participants. On this occasion, Robert Koenig published an article (News Focus, 1 Jan. p. [22][1]) discussing the level and current problems of science in those countries. We would like to point out some problems with the treatment of the data on citation statistics and offer a few additional comments on the subject. Having analyzed in detail the data provided by the Institute for Scientific Information (ISI), we conclude that the table on citation impacts in Koenig's article is based on an option that allows the user to extract the citation impact for a 5-year period, 1993 to 1997. This particular choice seems unfair, specifically for the Czech and Slovak republics. Czechoslovakia split into two states, the Czech Republic and the Slovak Republic, at the beginning of 1993. ISI provides independent statistics for the Czech and Slovak republics only from 1994 on. The split of the former Soviet Union and Yugoslavia occurred earlier. Therefore, the new states formed on these territories have had separate representations in the ISI database since 1993. Consequently, only the 4-year citation impact for the Czech and Slovak Republic was compared with the 5-year impact for the other countries in the table. We recalculated the citation impacts for all the countries listed in the table for the 4-year period 1994 to 1997 to make them directly comparable with the data available for the Czech and Slovak republics. After this recalculation, the Czech Republic becomes 22nd and the Slovak Republic 27th out of 33 European countries, instead of 29th and 33rd, as stated in Koenig's article. It may be useful to recall that the typical citation half-time of the journals followed by ISI is 4 to 10 years or even more. Therefore, the citation impact from a recent period may not be the most suitable measure of scientific output. Perhaps more interesting is the secular evolution of the citation impact for Czechoslovakia and the Czech Republic. The acceleration, starting around 1991, that is, after the fall of the communist system, is notable. This acceleration started at the same time that the political barriers preventing free contacts of Czechoslovak scientists and their Western colleagues were removed, a promising indication for the future. No doubt the community of Czech scientists cannot be satisfied with their current citation impact. Even among ex-socialist countries, the Czech Republic falls behind Hungary, Estonia, and Poland. A more detailed study will be needed to find out how much this can directly be ascribed to a lower quality of Czech publications in comparison with those from other countries. Many of us still remember too well that especially in the period after the Soviet invasion in 1968, Czechoslovakia became one of the most isolated socialist countries. Many Czech and Slovak scientists who had been working abroad, often with remarkable success, were forced to sever contacts with science in their home country. The situation was better in Poland and Hungary. Polish and Hungarian scientists who decided to live abroad, even without the permission of their Soviet-controlled governments, did not lose the links to their home institutions. There were also other barriers that should be considered in a comprehensive study of the subject. Yet, we prefer to see positive signs of future development. For example, in 1991, Czechoslovak astronomers decided to be the first community from all the ex-socialist countries to join their national journal, Bulletin of the Astronomical Institutes of Czechoslovakia, with the largest European astronomical journal, Astronomy and Astrophysics. This change was followed by an increase in the number of their accepted and published papers. [1]: /lookup/doi/10.1126/science.283.5398.22

Internal anal sphincter injury in the immediate postpartum period; Prevalence, risk factors and diagnostic methods in the Swedish perineal laceration registry

Please cite this paper as: Baghestan E, Irgens L, Bordahl P, Rasmussen S. Risk of recurrence and subsequent delivery after obstetric anal sphincter injuries. BJOG 2012;119:62–69. Objective To investigate the recurrence risk, the likelihood of having further deliveries and mode of delivery after third to fourth degree obstetric anal sphincter injuries (OASIS). Design Population-based cohort study. Setting The Medical Birth Registry of Norway. Population A cohort of 828 864 mothers with singleton, vertex-presenting infants, weighing 500 g or more, during the period 1967–2004. Methods Comparison of women with and without a history of OASIS with respect to the occurrence of OASIS, subsequent delivery rate and planned caesarean rate. Main outcome measures OASIS in second and third deliveries, subsequent delivery rate and mode of delivery. Results Adjusted odds ratios of the recurrence of OASIS in women with a history of OASIS in the first, and in both the first and second deliveries, were 4.2 (95% CI 3.9–4.5; 5.6%) and 10.6 (95% CI 6.2–18.1; 9.5%), respectively, relative to women without a history of OASIS. Instrumental deliveries, in particular forceps deliveries, birthweights of 3500 g or more and large maternity units were associated with a recurrence of OASIS. Instrumental delivery did not further increase the excess recurrence risk associated with high birthweight. A man who fathered a child whose delivery was complicated by OASIS was more likely to father another child whose delivery was complicated by OASIS in another woman who gave birth in the same maternity unit (adjusted OR 2.1; 95% CI 1.2–3.7; 5.6%). However, if the deliveries took place in different maternity units, the recurrence risk was not significantly increased (OR 1.3; 95% CI 0.8–2.1; 4.4%). The subsequent delivery rate was not different in women with and without previous OASIS, whereas women with a previous OASIS were more often scheduled to caesarean delivery. Conclusion Recurrence risks in second and third deliveries were high. A history of OASIS had little or no impact on the rates of subsequent deliveries. Women with previous OASIS were delivered more frequently by planned caesarean delivery.

Rising rates of obstetric anal sphincter injury (OASI) led to a collaborative effort by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) to develop and evaluate the OASI Care Bundle (OASI-CB). The OASI-CB comprises four practices (antenatal discussion about OASI, manual perineal protection, mediolateral episiotomy at 60° from the midline, and systematic examination of the perineum, vagina and ano-rectum after vaginal birth) and was initially implemented as part of a quality improvement (QI) project—“OASI1”—in 16 maternity units across Great Britain. Evaluation of the OASI1 project found that the care bundle reduced OASI rates and identified several barriers and enablers to implementation. This paper summarises the key findings, including strengths, limitations and lessons learned from the OASI1 QI project, and provides rationale for further evaluation of the OASI-CB.

Retrospective analysis of 3a obstetric anal sphincter injury repairs in a teaching hospital: Subjective and objective outcomes

Antibiotic treatment during surgical repair of obstetric anal sphincter injuries (OASIS) had been a matter of debate. We aimed to review the available literature regarding the efficacy of metronidazole administration in women undergoing perineal repair following obstetric OASIS. To identify potentially eligible studies, we searched PubMed, Scopus, Embase and the Cochrane Library from inception to January 13th, 2019.Reference lists of identified studies were searched. No language restrictions were applied. We used a combination of keywords and text words represented by "Metronidazole", "obstetrics", "obstetric anal sphincter injury", "OASIS", "third degree tear", "fourth degree tear", "third degree laceration", "fourth degree laceration", "antibiotic therapy", "perineal damage" and "perineal trauma". Two reviewers independently screened the titles and abstracts of records retrieved from the database searches. Both reviewers recommended studies for the full-text review. Thescreen of full-text articles recommended by at least one reviewer was done independently by the same two reviewers and assessedfor inclusion in the systematic review. Disagreements between reviewers were resolved by consensus. The electronic database search yielded a total of 54,356 results (Fig.1). After duplicate exclusion 28,154 references remained. Of them, 26 were relevant to the review based on title and abstract screening. None of these articles dealt with the use of metronidazole for the prevention of infections complicating anal sphincter repair in women with OASIS. A Cochrane review addressing antibiotic prophylaxis for patients following OASIS, compared prophylactic antibiotics against placebo or no antibiotics, included only one randomized controlled trial of 147 participants. This study showed that prophylactic antibiotics (not metronidazole) may be helpful to prevent perineal wound complications following OASIS. Fig. 1 Study seection process CONCLUSION: Anaerobic infections potentially complicate wound repair after OASIS. Although scientific societies recommend the use of antibiotics for the prevention of infectious morbidity after OASIS, no study has specifically assessed the role of metronidazole.