4th Degree Perineal Lacerations Research Articles

Factors Affecting Clinical over and Underestimation of Fetal Weight-A Retrospective Cohort.

Clinical estimation of fetal weight is an integral component of obstetric care that might dictate the timing and mode of delivery. Inaccurate fetal weight estimation might result in unnecessary interventions or in underestimating potential risks, resulting in inappropriate intrapartum care. This retrospective study assessed factors associated with under- or overestimation of birthweight and evaluated the obstetric implications. It included singleton births ≥24 w with clinically estimated fetal weight (EFW) up to 1 week before delivery, during 2014-2020. Estimates >±10% of the actual birthweight were considered inaccurate and categorized as overestimation (>10% heavier than the actual birthweight) or underestimation (>10% smaller than the birthweight). Multivariable logistic regression was performed to reveal factors associated with inaccurate EFW. Maternal characteristics and obstetric outcomes were compared. The primary outcomes for the overestimation group were the neonatal composite adverse outcome, induction of labor and cesarean delivery rates. The primary outcomes for the underestimation group were rates of shoulder dystocia, 3rd- or 4th-degree perineal lacerations, and failed vacuum extraction. Among 38,615 EFW, 5172 (13.4%) were underestimated, 6695 (17.3%) were overestimated and 27,648 (69.3%) accurate. Multivariable logistic regression found increasing gestational age as an independent risk-factor for underestimation (odds ratio (OR) 1.15 for every additional week, 95% confidence interval (CI) 1.12-1.2). Major factors independently associated with overestimation were nulliparity (OR 1.95, CI 1.76-2.16), maternal obesity (OR 1.52, CI 1.33-1.74), smoking (OR 1.6, CI 1.33-1.93), and oligohydramnios (OR 1.92, CI 1.47-2.5). Underestimation was an independent risk-factor for shoulder dystocia (OR 1.61, CI 1.05-2.46) and 3rd- or 4th-degree perineal lacerations (OR 1.59, CI 1.05-2.43). Overestimation was an independent risk-factor for neonatal composite adverse outcome (OR 1.15, CI 1.02-1.3), induced labor (OR 1.30, CI 1.21-1.40) and cesarean delivery (OR 1.59, CI 1.41-1.79). Clinicians should be aware of factors and adverse obstetric implications associated with over- or underestimation of birthweight.

Can We Predict Feto-Maternal Adverse Outcomes of Vacuum Extraction?

Introduction Vacuum extraction (VE) is an important modality in modern obstetrics, yet sometimes results in maternal or neonatal adverse outcomes, which can cause a lifetime disability. We aimed to characterize potential risk factors for adverse outcomes that in retrospect would have led the physician to avoid the procedure. Materials and Methods Retrospective cohort of 3331 singleton pregnancies, ≥34w delivered by VE. 263 deliveries (7.9%) incurred a VE-related feto-maternal adverse outcome, defined as one or more of the following: 3-4th-degree perineal laceration, subgaleal hematoma, intracranial hemorrhage, shoulder dystocia, clavicular fracture, Erb's palsy or fracture of humerus. 3068 deliveries (92.1%) did not have VE-related adverse outcomes. Both groups were compared to determine potential risk factors for VE adverse outcomes. Results Multivariable regression found seven independent risk factors for VE-related feto-maternal adverse outcomes: Nulliparity - with an odds ratio (OR) of 1.82 (95% CI=1.11-2.98, p=0.018), epidural anesthesia (OR 1.99, CI=1.42-2.80, p<0.001), Ventouse-Mityvac (VM) cup (OR 1.86, CI=1.35-2.54, p<0.001), prolonged second stage as indication for VE (OR 1.54, CI=1.11-2.15, p=0.010), cup detachment (OR 1.66, CI=1.18-2.34, p=0.004), increasing procedure duration (OR 1.07 for every additional minute, CI=1.03-1.11, p<0.001) and increasing neonatal birthweight (OR 3.42 for every additional kg, CI=2.33-5.02, p<0.001). Occiput anterior (OA) position was a protective factor (OR 0.62, CI=0.43-0.89, p=0.010). Conclusions VE-related adverse outcomes can be correlated to clinical characteristics, such as nulliparity, epidural anesthesia, VM cup, prolonged second stage as indication for VE, cup detachment, prolonged procedure duration and increasing neonatal weight. OA position was a protective factor. This information may assist medical staff to make an informed decision whether to choose VE or cesarean delivery (CD).

Recovery from Obstetric Anal Sphincter Injury in a Prospective Cohort of First Births.

To identify risk factors for obstetric anal sphincter injuries (OASIS) for primiparous women who gave birth vaginally and to compare recovery by OASIS status in three domains as follows: (1) physical health and functioning, (2) mental health, and (3) healthcare utilization. This secondary analysis used data from 2,013 vaginal births in the First Baby Study, a prospective cohort study of women with first births between 2009 and 2011. Interview data at multiple time points were linked to birth certificate and hospital discharge data. The key exposure of interest was OASIS (3rd or 4th degree perineal laceration, identified in the hospital discharge data; n = 174) versus no OASIS (n = 1,839). We used multivariable logistic regression models to examine the association between OASIS and a range of outcomes including physical health and functioning, depression, and health care utilization, assessed at 1 month and 6 months postpartum. Eight percent of women had OASIS. In adjusted models, there were no differences in general physical health and functioning measures by OASIS (such as fatigue and overall self-rated health), but women with OASIS had higher rates of reporting perineal pain (p < 0.001), accidental stool loss (p = 0.001), and bowel problems (p < 0.001) at 1-month postpartum. By 6-month postpartum, there were no differences in reported physical health and functioning. There were no differences in probable depression at 1- or 6-month postpartum. Women with OASIS were more likely to attend a comprehensive postpartum visit, but there were no other differences in health care utilization by OASIS. Women with OASIS were at increased risk of accidental stool loss, bowel problems, and perineal pain in the immediate postpartum period. Women who had OASIS had similar physical functioning across a range of general health outcomes to women who gave birth vaginally without OASIS. · Higher risk of bowel problems and accidental stool loss 1-month postpartum with OASIS.. · Higher risk of perineal pain 1-month postpartum with OASIS.. · No differences in health outcomes at 6-months postpartum by OASIS..

Surgical technique - perineal leiomyoma after 4th degree laceration video

Leiomyomas are the most common pelvic tumors; however, they are rarely found at the perineum. Fewer than 10 cases of perineal leiomyomas have been reported to-date. While lipomas have been described in the literature after trauma, however this is only the second case that identifies a possible association between trauma and perineal myoma development. The etiology is speculative, given the paucity of cases, though some have hypothesized a relationship between myoma formation and post-traumatic fibroblast proliferation. This video showcases the surgical technique for perineal mass excision and repair of the resulting anatomy, essentially a 4th degree laceration. A 33-year-old female presented with a large approximately six centimeter midline perineal mass. Her history was significant only for a 4th degree perineal laceration sustained thirteen years previously. Imaging studies and lesion location suggested the mass was an angiomyxoma, and she underwent mass excision and repair. Pathologic review ultimately revealed that the tumor was most consistent with a leiomyoma. We aim to showcase our patient’s presentation, radiologic imaging, surgical care, pathologic investigation, and follow-up surveillance. Perineal leiomyomas are exceedingly uncommon and only one previously documented case after perineal trauma has been reported in the literature. We hereby offer an expansion of the differential when considering masses in the perineum as well as demonstrate the surgical excision and detailed repair of the equivalent 4th degree perineal laceration.

A nationwide cross-sectional survey of episiotomy practice in China

SummaryBackgroundA restrictive use of episiotomy was recommended by the obstetric society in China, but limited information on the epidemiology and the effects of restrictive use of episiotomy on maternal and fetal outcomes have been published.MethodsThe China Labor and Delivery Survey is a cross-sectional investigation with a cluster random sampling scheme in 2015-2016 with the aim to describe detailed epidemiology of labor and delivery in China. We calculated the episiotomy rate by parity using the survey data. Associated factors of episiotomy were selected using mixed models with a random effect for the hospital-level clustering. Logistic regression models were fitted to examine the effects of mediolateral episiotomy on maternal and neonatal outcomes among the propensity score-matched women.FindingsThe episiotomy rate among vaginal births was 41·7% [95% confidence interval (CI): 40·1% - 43·2%] in nulliparae and 21·5% (95% CI: 19·4% - 23·5%) in multiparae in China. Associated factors of episiotomy included prepregnancy BMI, maternal diseases, and obstetric factors. More than half of episiotomies in nulliparae and one-fourth in multiparae had no indications. Mediolateral episiotomy without indicators increased the risk of 3rd or 4th degree perineal laceration [odds ratio (OR) =2·64, 95% CI: 1·08-6·48)] in nulliparae without neonatal benefits.InterpretationEpisiotomy was performed more than medically necessary in China. Mediolateral episiotomy without indications more than doubled the risk of 3rd and 4th degree perineal laceration in nulliparae without neonatal benefits.FundingNational Natural Science Foundation of China and Shanghai Health Commission Programme.

Ultrasound vs routine care before instrumental vaginal delivery: A systematic review and meta-analysis.

The objective was to report the role of intrapartum ultrasound examination in affecting maternal and perinatal outcome in women undergoing instrumental vaginal delivery. MEDLINE, Embase, CINAHL, Google Scholar and ClinicalTrial.gov databases were searched. Inclusion criteria were randomized controlled trials comparing ultrasound assessment of fetal head position vs routine standard care (digital examination) before instrumental vaginal delivery (either vacuum or forceps). The primary outcome was failed instrumental delivery extraction followed by cesarean section. Secondary outcomes were postpartum hemorrhage, 3rd or 4th degree perineal lacerations, episiotomy, prolonged hospital stay, Apgar score<7 at 5min, umbilical artery pH<7.0 and base excess greater than -12mEq, admission to neonatal intensive care unit (NICU), shoulder dystocia, birth trauma, a composite score of adverse maternal and neonatal outcome and incorrect diagnosis of fetal head position. Risk of bias was assessed using the Revised Cochrane risk-of-bias tool for randomized trials (RoB-2). The quality of evidence and strength of recommendations were assessed using the Grading of Recommendations Assessment Development and Evaluation (GRADE) methodology. Head-to-head meta-analyses using a random-effect model were used to analyze the data and results are reported as relative risk with their 95% confidence intervals. Five studies were included (1463 women). There was no difference in the maternal, pregnancy or labor characteristics between the two groups. An ultrasound assessment prior to instrumental vaginal delivery did not affect the cesarean section rate compared with standard care (p=0.805). Likewise, the risk of composite adverse maternal outcome (p=0.428), perineal lacerations (p=0.800), postpartum hemorrhage (p=0.303), shoulder dystocia (p=0.862) and prolonged stay in hospital (p=0.059) were not different between the two groups. Composite adverse neonatal outcome was not different between the women undergoing and those not undergoing ultrasound assessment prior to instrumental delivery (p=0.400). Likewise, there was no increased risk with abnormal Apgar score (p=0.882), umbilical artery pH<7.2 (p=0.713), base excess greater than -12 (p=0.742), admission to NICU (p=0.879) or birth trauma (p=0.968). The risk of having an incorrect diagnosis of fetal head position was lower when ultrasound was performed before instrumental delivery, with a relative risk of 0.16 (95% confidence interval 0.1-0.3; I2 :77%, p<0.001). Although ultrasound examination was associated with a lower rate of incorrect diagnoses of fetal head position and station, this did not translate to any improvement of maternal or neonatal outcomes.

Duration of labor induction in nulliparous women with hypertensive disorders of pregnancy and maternal and neonatal outcomes

Objective The objective of this study was to quantify the association between duration of labor induction in nulliparous women with hypertensive disorders of pregnancy and maternal and neonatal morbidity. Methods This was a secondary analysis of a multicenter cohort study of 228,438 deliveries in 19 U.S. hospitals. The analysis included nulliparous women ≥18 years old with singleton gestation diagnosed with hypertensive disorders of pregnancy and undergoing induction of labor for that indication. Duration of labor induction, defined as time from admission to delivery, was examined by 4 h intervals from <12 h to ≥24 h in relation to maternal and neonatal composite outcomes. Maternal composite outcome included operative vaginal delivery, chorioamnionitis, blood transfusion, intensive care unit admission, placental abruption, 3rd or 4th degree perineal laceration, endometritis, postpartum hemorrhage, or venous thromboembolism. Neonatal composite outcome included neonatal intensive care unit (NICU) admission, respiratory distress syndrome, 5-minute Apgar score ≤7, seizure, infection, intrapartum meconium aspiration, intracranial hemorrhage, shoulder dystocia, and neonatal death. The trends in proportions of outcomes that occurred at different intervals were examined by Cochran-Armitage trend test. Relative risks were calculated with <12 h as the reference category and potential confounders adjusted by log-binomial or Poisson regression. Possible correlations within centers were taken into account using generalized estimating equations. Results A total of 3,990 women met inclusion criteria. The median labor duration was 19.8 h (interquartile range 12.9 h-27.9h), with 849 (21.3%) lasting <12 h and 1,426 (35.7%) >24 h. The frequency of composite maternal outcome was not associated with labor duration; however, the rates of chorioamnionitis (p < .001) and postpartum hemorrhage (p < .001) increased as labor duration increased. The frequency of composite neonatal outcome was greater with increasing labor duration (p < .001). After multivariable adjustment, duration of labor induction was associated with increased risks of maternal composite outcome after 24 h (aRR 1.39, 95% CI 1.20–1.62) and neonatal composite outcome after 24 h (aRR 1.32, 95% CI 1.11–1.56). Conclusions In nulliparous women with hypertensive disorders of pregnancy, duration of labor induction was associated with increased risks for maternal and neonatal morbidity after 24 h.

Is there an Association between Vaginal Birth after Cesarean Prediction and Obstetric Anal Sphincter Injury?

This study aimed to estimate whether there is an association between the predicted probability of vaginal birth after cesarean delivery (VBAC) and the occurrence of obstetric anal sphincter injuries (OASIS). This was a single-site retrospective cohort study of all women with a singleton vaginal birth after a previous cesarean section between January 2011 and December 2016. Women were divided into four ordinal groupings by the predicted probability of achieving vaginal birth after cesarean using the Maternal-Fetal Medicine Units Network VBAC calculator (less than 41%, 40.1-60%, 60.1-80%, and greater than 80%). The primary outcome was OASIS, defined as a 3rd or 4th degree perineal laceration. Bivariable and multivariable analyses were used to examine the association between predicted VBAC probability and OASIS. In total, 1,411 women met inclusion criteria and 73 (5.2%) sustained OASIS. The median predicted probability of VBAC was lower in women with OASIS compared with those without OASIS (60% [interquartile range {IQR}: 48-70%] vs. 66% (IQR: 52-80%), p = 0.02]. On bivariable and multivariable logistic regression, predicted probability of VBAC was associated with increased odds of OASIS (less than 41% probability: adjusted odds ratio [aOR]: 3.18, 95% confidence interval [CI]: 0.90-11.21; 41-60% probability: aOR: 3.76, 95% CI: 1.34-10.57; 61-80% probability aOR: 3.47, 95% CI: 1.25-9.69) relative to women with a predicted probability of VBAC of greater than 80%. Having a lower predicted probability of VBAC is associated with an increased risk of OASIS at the time of a VBAC relative to those with greater than 80% predicted probability. Incorporation of this aspect of maternal morbidity may inform risk-stratification at the time of trial of labor after cesarean, as well as the choice of performing an operative vaginal delivery. · Predicted probability of VBAC is associated with OASIS.. · Low predicted probability of VBAC is associated with increased odds of OASIS.. · Forceps delivery was associated with the highest odds of OASIS..

The Impact of Episiotomy on Adverse Perinatal Outcomes in Operative Vaginal Deliveries [40J

INTRODUCTION: There has been a large reduction in routine episiotomy, thus many provided today are likely clinically indicated. Thus, we sought to investigate the association between episiotomy and adverse perinatal outcomes in operative vaginal births. METHODS: This is a retrospective cohort study of singleton, non-anomalous, term spontaneous vaginal deliveries between 2007 and 2011 using linked vital statistics and ICD-9 data. The neonatal adverse outcomes examined included brachial plexus injury (BPI), clavicular fracture (CVFs), 5-min APGAR score &lt;7, neonatal intensive care unit (NICU) admission, and composite of severe neonatal outcomes (neonatal seizure, APGAR score ≤3, and neonatal death). The maternal adverse outcomes examined included postpartum hemorrhage (PPH), 3rd and 4th-degree perineal lacerations, and maternal blood transfusion (MBTs). Chi-square tests were used to compare rates of perinatal adverse outcomes for births with and without episiotomy. Multivariable logistic regression was used to control for maternal BMI, diabetes status, race/ethnicity, age, education, insurance status, parity, and prenatal care. RESULTS: In a cohort of 161,921 operative vaginal births, we found no statistically significant difference for adverse neonatal outcomes for births with and without episiotomy. Interestingly, women with episiotomy had decreased rates of postpartum hemorrhage, a relationship that remained after controlling for confounders of interest (aOR 0.55, 95% CI 0.35-0.84). CONCLUSION: Our study demonstrates that episiotomy does not improve neonatal outcomes in the setting of operative vaginal delivery and was not associated with severe perineal laceration, but that it may decrease the odds of maternal postpartum hemorrhage. Careful clinical consideration should be exercised when deciding to use an episiotomy.

Knowledge, attitude and experience of episiotomy practice among obstetricians and midwives in Jordan

IntroductionEpisiotomy is still performed routinely by clinicians in many countries. The aim of this study was to determine the knowledge of, attitudes towards and experience of episiotomy practice among clinicians working in public hospitals in Jordan. MethodsA cross-sectional study, using a self-administered survey questionnaire, was conducted among midwives and obstetricians in three public hospitals in Jordan. Results112 (87.5%) clinicians responded to the questionnaire. Low knowledge level of evidence about overuse and risk of episiotomy was identified among participants with a significant difference among obstetricians and midwives (P<0.05). Results revealed that both obstetricians and midwives have limited access to evidence which is not emphasised in their learning, practice, or hospital policy. The majority of obstetricians (80%) and midwives (79%) thought an episiotomy rate of 81% is about right. The most common reason for performing episiotomy identified by both obstetricians (83.1%) and midwives (75.5%) was to reduce the risk of 3rd and 4th degree perineal laceration. The most common obstacle to reducing episiotomy rate reported by obstetricians (78.0%) was lack of training on preventing perineal tears, while the most common obstacles reported by midwives were insufficient time to wait for the perineum to stretch (56.6%) and difficulty changing the conventional practices in the labour ward (52.8%). ConclusionThis study identifies that obstetricians and midwives in Jordan rely on non evidence-based beliefs to guide their practice on performing an episiotomy. Training, continuing education, and developing evidence based clinical policies and guidelines for surgical procedures, such as in an episiotomy, are needed.

59: Surgical management of acquired chronic rectovaginal cloacal defect

To review the key surgical steps of repair of a rectovaginal cloacal defect. In this video, a case is presented involving of the surgical management of an acquired chronic rectovaginal cloacal defect. A cloacal defect may occur secondary to breakdown of a 4th degree perineal laceration. Patients often present with fecal incontinence and dyspareunia. Examination will reveal complete absence of the perineal body and retraction of the external anal sphincters, resulting in the appearance of the classic “dovetail sign.” The posterior vaginal epithelium will abut the anterior anal mucosa above the level of the hymenal ring. The surgical steps in repair of a rectovaginal cloacal defect include the following: sharp dissection between the posterior vaginal subepithelial tissue and the anterior anal mucosal wall, closure of the anal mucosa, reapproximation of the internal anal sphincter, external anal sphincterplasty, and finally a distal rectocele repair with perineorrhaphy. This surgical technique demonstrates how a directed sequential reapproximation of the anatomic structures successfully reconstructs perineal anatomy in a patient with a longstanding cloacal defect.

Maternal and newborn outcomes with elective induction of labor at term

A growing body of evidence supports improved or not worsened birth outcomes with nonmedically indicated induction of labor at 39 weeks gestation compared with expectant management. This evidence includes 2 recent randomized control trials. However, concern has been raised as to whether these studies are applicable to a broader US pregnant population. Our goal was to compare outcomes for electively induced births at ≥39 weeks gestation with those that were not electively induced. We conducted a retrospective cohort study using chart-abstracted data on births from January 1, 2012, to December 31, 2017, at 21 hospitals in the Northwest United States. The study was restricted to singleton cephalic hospital births at 39+0-42+6 weeks gestation. Exclusions included previous cesarean birth, missing data for delivery type or gestational week at birth, antepartum stillbirth, cesarean birth without any attempt at vaginal birth, fetal anomaly, gestational diabetes mellitus, prepregnancy diabetes mellitus, and prepregnancy hypertension. The rate of cesarean birth for elective inductions at both 39 and 40 weeks gestation was compared with the rate in all other on-going pregnancies in the same gestational week. Maternal outcomes (operative vaginal birth, shoulder dystocia, 3rd- or 4th-degree perineal laceration, pregnancy-related hypertension, and postpartum hemorrhage) and newborn infant outcomes (macrosomia, 5-minute Apgar <7, resuscitation at delivery, intubation, respiratory complications, and neonatal intensive care unit admission) were also compared between elective inductions and on-going pregnancies at 39 and 40 weeks gestation. Logistic regression modeling was used to produce odds ratios for outcomes with adjustment for maternal age and body mass index. Results were stratified by parity and gestational week at birth. Duration of hospital stay (admission to delivery, delivery to discharge, and total stay) were compared between elective inductions and on-going pregnancies. A total of 55,694 births were included in the study cohort: 4002 elective inductions at ≥39+0 weeks gestation and 51,692 births at 39+0-42+6 weeks gestation that were not electively induced. In nulliparous women, elective induction at 39 weeks gestation was associated with a decreased likelihood of cesarean birth (14.7% vs 23.2%; adjusted odds ratio, 0.61; 95% confidence interval, 0.41-0.89) and an increased rate of operative vaginal birth (18.5% vs 10.8%; adjusted odds ratio, 1.8; 95% confidence interval, 1.28-2.54) compared with on-going pregnancies. In multiparous women, cesarean birth rates were similar in the elective inductions and on-going pregnancies. Elective induction at 39 weeks gestation was associated with a decreased likelihood of pregnancy-related hypertension in nulliparous (2.2% vs 7.3%; adjusted odds ratio, 0.28; 95% confidence interval, 0.11-0.68) and multiparous women (0.9% vs 3.5%; adjusted odds ratio, 0.24; 95% confidence interval, 0.15-0.38). Term elective induction was not associated with any statistically significant increase in adverse newborn infant outcomes. Elective induction of labor at 39 weeks gestation was associated with increased time from admission to delivery for both nulliparous (1.3 hours; 95% confidence interval, 0.2-2.3) and multiparous women (3.4 hours; 95% confidence interval, 3.2-3.6). Elective induction of labor at 39 weeks gestation is associated with a decrease in cesarean birth in nulliparous women, decreased pregnancy-related hypertension in multiparous and nulliparous women, and increased time in labor and delivery. How to use this information remains the challenge.

Can Fetal Head Circumference Assessment on Ultrasound Help Predict 3rd and 4th Degree Perineal lacerations? [40M

INTRODUCTION: Obstetric Anal Sphincter Injuries (OASIS) occur in 2 to 19% of vaginal deliveries in the United States. Neonatal measurements such as birthweight above 4000g or neonatal head circumference above 37cm are known risk factors for 3rd and 4th degree perineal laceration. Unfortunately, these predictors are identified after the delivery and therefore have very limited practical impact. We hypothesized that fetal Head Circumference (HC) size assessed by ultrasound in pregnancy can aid in predicting Obstetric Anal Sphincter Injuries (OASIS). METHODS: Secondary analysis of a retrospective cohort study assessing pregnancies with OASIS between 2005 and 2016. Inclusion criteria for this secondary analysis were third trimester ultrasound head circumference measurements. Antenatal ultrasound Head Circumference (HC) assessment, maternal demographics and labor and delivery data were documented and compared. P less than .05 was considered statistically significant. RESULTS: Of 2057 patients that had head circumference assessment, 121 (5.8%) had OASIS. In the unadjusted continuous analysis of the head circumference, an increase of 10% in the HC were associated with OASIS OR 1.12 (1.02-1.23) p=0.015. Although not statistically significant HC above the 90% appears to be associated with OASIS OR 3.37 (0.89-12.74) p=0.073. CONCLUSION: In our cohort, fetal head circumference percentile is associated with OASIS, specifically the larger the head circumference percentile, the greater the risk. Severe perineal lacerations significantly impact short and long term health outcomes such as perineal pain, dyspareunia, urinary and fecal incontinence. This piece of information might help clinicians antenatally during counseling of patients about the risk of OASIS and future implications of the injury.

The Extent of Incurred Pelvic Floor Damage during a Vaginal Birth and Pelvic Floor Complaints

Background: Pelvic floor damage through vaginal birth exists in approximately half the women postpartum. Through this damage, complaints like urinary incontinence, faecal incontinence, flatus, pelvic organ prolapse, dyspareunia and pain in the pelvic floor area whilst sitting may occur. However, these complaints are also seen in women who do not encounter pelvic floor damage after childbirth, and in women who never experienced childbirth. Aim: The purpose of this study was to examine how far the extent of pelvic floor damage during a vaginal birth is responsible for the development of pelvic floor complaints. Findings could help improve information for pregnant women, stimulate preventative measures before and at the time of birth and provide better-tailored care postpartum. Methods: This study was set up in a cross sectional design in The Netherlands. 379 women filled out an online questionnaire. 239 women between the ages of 18 and 45 met the inclusion criteria. 177 parous women who had a vaginal birth in the past two years and 62 nulliparous women were divided in five groups: no childbirth (control group), no reported damage, episiotomy, 1st and 2nd degree, and 3rd and 4th degree perineal laceration. Six pelvic floor complaints were investigated: urinary incontinence, faecal incontinence, flatus, pelvic organ prolapse, dyspareunia and pain in the pelvic floor area whilst sitting were subject of this study. It was expected that more severe pelvic floor damage would result in more or more severe pelvic floor complaints. Hypotheses were tested using multivariate analyses of variance, followed by contrast analysis. Results: Only dyspareunia occurs significantly more often after vaginal birth with 3rd and 4th degree perineal laceration in comparison with the control group. No significant differences between the five groups were found on urinary incontinence, faecal incontinence, pelvic organ prolapse and pain in the pelvic floor area whilst sitting. Conclusion: Dyspareunia is most likely to occur after vaginal birth with 3rd and 4th degree perineal lacerations

Labor stimulation with oxytocin: effects on obstetrical and neonatal outcomes.

Objective: to evaluate the effects of labor stimulation with oxytocin on maternal and neonatal outcomes. Method: descriptive and analytical study with 338 women who gave birth at a tertiary hospital. Obstetric and neonatal variables were measured and compared in women submitted and non-submitted to stimulation with oxytocin. Statistics were performed using Chi-square test, Fisher exact test, Student t-test; and crude Odds Ratio with 95% confidence interval were calculated. A p < 0.05 was considered statistically significant. Results: stimulation with oxytocin increases the rates of cesarean sections, epidural anesthesia and intrapartum maternal fever in primiparous and multiparous women. It has also been associated with low pH values of umbilical cord blood and with a shorter duration of the first stage of labor in primiparous women. However, it did not affect the rates of 3rd and 4th degree perineal lacerations, episiotomies, advanced neonatal resuscitation, 5-minute Apgar scores and meconium. Conclusion: stimulation with oxytocin should not be used systematically, but only in specific cases. These findings provide further evidence to health professionals and midwives on the use of oxytocin during labor. Under normal conditions, women should be informed of the possible effects of labor stimulation with oxytocin.

Obesity May Be Protective against Severe Perineal Lacerations.

Objective. To determine if there is an association between BMI and 3rd- or 4th-degree perineal lacerations in normal spontaneous and operative vaginal deliveries. Study Design. We performed a retrospective case control study using a large obstetric quality improvement database over a six-year period. Cases were identified as singleton gestations with third- and fourth-degree lacerations. Controls were obtained randomly from the database of patients without third- or fourth-degree lacerations in a 1 : 1 ratio. Univariate and multivariate logistic regression analyses were performed. Results. Of 32,607 deliveries, 22,011 (67.5%) charts with BMI documented were identified. Third- or fourth-degree lacerations occurred in 2.74% (n = 605) of patients. 37% (n = 223) were identified in operative vaginal deliveries. In the univariate analysis, obesity, older maternal age, non-Asian race, and birth weight <4000 g were all protective against 3rd- and 4th-degree lacerations. After controlling for age, race, mode of vaginal delivery, and birth weight, obesity remained significant. Conclusion. Being obese may protect against third- and fourth-degree lacerations independent of parity, race, birth weight, and mode of delivery.

Systemic and Individual Determinants of Maternal Morbidity in the United States

s / Annals of Epidemiology 25 (2015) 702e719 712 P40. Systemic and Individual Determinants of Maternal Morbidity in the United States Riddhi Doshi MBBS, MPH, Gregory Vaughan, Jun Yan PhD, Kiesha Benn MD, Robert H. Aseltine Jr. PhD. University of Connecticut Purpose: Obstetric trauma to the perineum and vulva was among the top five causes of hospitalization among young adults, resulting in almost 7.5 million hospital stays among Medicaid beneficiaries alone. Childbirth and related complications cost over 16 billion US dollars annually. The primary objective of this study is to determine the prevalence of perineal lacerations during childbirth, examine the associations with individual and systemic predictors and predict the risk of obstetric trauma. Methods: For this large retrospective cohort study, we utilized data regarding hospital deliveries from 30 hospitals integrated through the Connecticut Acute Care Hospital Inpatient Discharge Database (HIDD). Predictors can be broadly classified into individual (demographic, socioeconomic, clinical) and systemic (facility volume, payer/insurance type). Outcomes examined were 3rd and 4th degree perineal lacerations. R statistical package was utilized to perform generalized linear models. Logistic regressionmodeling was utilized to predict the risk of perineal injuries with significant systemic determinants. Results: Insurance type (p<0.001) and facility volume (p<0.001) of the delivering hospital were found to be significant systemic determinants of perineal injuries after childbirth. Income (p<0.025), maternal age (p<0.001) and instrument use (p<0.001) were significant predictors of trauma. Asian race doubled the odds of trauma (OR: 2.15; 95%CI 1.89-2.44) while instrument use increased it four times (OR: 3.98; 95%CI 3.56-4.44). Conclusions: The association between systemic factors like larger facility volume in terms of number of deliveries is a critical finding. This warrants further temporospatial investigation into facility-based systemic determinants of maternal health. P41. Systematic Determinants of Anemia Among Women in India: A Dis-integrated Analyses of Pregnant, Lactating and Non-Pregnant and Non-Lactating Women Riddhi Doshi MBBS, MPH, Srinivas Goli PhD. University of Connecticut Purpose: The prevalence of anemia among pregnant women in developing countries is almost five times that among developed countries [Prevalence: development (14%); developing (51%)]. India bears a high burden (upto 70%) of anemia prevalence. This study aims to determine the predictors of anemia among pregnant and lactatingwomen, thereby providing guidance for tailored health policy and programs. Methods: Analyses were performed on data from the National Family Health Survey (2005-06). Three binary logistic regression models determined the association of sociodemographic and economic predictors with the occurrence of anemia among pregnant, lactating, non-pregnant and non-lactating women. In addition, the regression models for pregnant and lactating women included predictors related to healthcare-seeking during pregnancy. Results: For pregnant women, duration of pregnancy, 2 children, work status, education of partners, wealth quintile, nutritional advice and supplementary nutritionwere found to be significant predictors. Among lactating women, the odds of anemia significantly increased during the third trimester. Young age (15-24 years), primary education among women and secondary education among partners significantly reduced the odds of developing anemia. For nonpregnant, non-lactating women, age 25 years, caste, secondary and higher education among women, primary education among partners, highest wealth quintile had a protective effect. Conclusions: Economic, cultural and individual factors need to be considered while assessing risk of anemia among pregnant and lactating women. India needs to strengthen Maternal and Child Health programs through a focus on nutritional care during pregnancy in order to improve the overall health outcomes among women.

Crohn’s Disease and Pregnancy

The optimal delivery method in patients with Crohn's disease is unknown, and there is no large-scale evidence on which to base decisions. The aim of this study was to compare delivery methods and outcomes in patients with and without Crohn's disease. The Nationwide Inpatient Sample and International Classification of Diseases, Ninth Revision codes were used to identify childbirth deliveries. Patients were stratified by the presence or absence of Crohn's disease and perianal disease (anorectal fistula or abscess, rectovaginal fistula, anal fissure, and anal stenosis). A large population-cohort database was used for the analysis. The primary outcomes measured were cesarean delivery and perineal lacerations. Of 6,794,787 pregnant women who delivered, 2882 had a diagnosis of Crohn's disease. Rates of cesarean delivery were higher in patients who had Crohn's disease with (83.1%) and without (42.8%) perianal disease in comparison with patients who did not have Crohn's disease with (38.9%) and without (25.6%) perianal disease (p < 0.001). Rates of 4th degree perineal lacerations were similar between patients who had or did not have Crohn's disease without perianal disease (1.4% vs 1.3%), but these rates increased significantly in patients with perianal disease (12.3%, p < 0.001). On multivariate analysis, perianal disease (OR, 10.9; 95% CI, 8.3-4.1; p < 0.001) and smoking (OR, 1.6; 95% CI, 1.5-1.7; p < 0.001) were independently associated with higher rates of 4th degree laceration. Crohn's disease was not independently associated with 4th degree laceration. This was a retrospective study with the inherent limitations of large databases. Patients with Crohn's disease have higher rates of cesarean delivery. Perianal disease predicts severe perineal laceration independent of the presence of Crohn's disease. In the absence of perianal disease, the method of delivery in women with Crohn's disease should be predicated on obstetric indication.

Regarding “A Positive or a Negative Confounding Variable? A Simple Teaching Aid for Clinicians and Students”

A restrictive use of episiotomy was recommended by the obstetric society in China, but limited information on the epidemiology and the effects of restrictive use of episiotomy on maternal and fetal outcomes have been published.The China Labor and Delivery Survey is a cross-sectional investigation with a cluster random sampling scheme in 2015-2016 with the aim to describe detailed epidemiology of labor and delivery in China. We calculated the episiotomy rate by parity using the survey data. Associated factors of episiotomy were selected using mixed models with a random effect for the hospital-level clustering. Logistic regression models were fitted to examine the effects of mediolateral episiotomy on maternal and neonatal outcomes among the propensity score-matched women.The episiotomy rate among vaginal births was 41·7% [95% confidence interval (CI): 40·1% - 43·2%] in nulliparae and 21·5% (95% CI: 19·4% - 23·5%) in multiparae in China. Associated factors of episiotomy included prepregnancy BMI, maternal diseases, and obstetric factors. More than half of episiotomies in nulliparae and one-fourth in multiparae had no indications. Mediolateral episiotomy without indicators increased the risk of 3rd or 4th degree perineal laceration [odds ratio (OR) =2·64, 95% CI: 1·08-6·48)] in nulliparae without neonatal benefits.Episiotomy was performed more than medically necessary in China. Mediolateral episiotomy without indications more than doubled the risk of 3rd and 4th degree perineal laceration in nulliparae without neonatal benefits.National Natural Science Foundation of China and Shanghai Health Commission Programme.

Decline of operative vaginal deliveries in the United States: Impact on severe perineal lacerations

ON SEVERE PERINEAL LACERATIONS HEATHER S. LIPKIND (F), RAY AARONS, LYNN L. SIMPSON, Columbia University, Maternal Fetal Medicine, New York, New York, Columbia University, Mailman School of Public Health, New York, New York OBJECTIVE: To determine trends of operative vaginal deliveries over the past decade and to examine the effect to which those trends have affected the associated odds of 3rd and 4th degree perineal lacerations. STUDY DESIGN: A large population-based retrospective cohort study using data from the National Hospital Discharge Summary Survey (19902001) that involved sampling from non-federal short stay hospitals in the United States (5,026,192 births) was performed. Temporal trends in forceps and vacuum deliveries were examined. The magnitude of the associated risk of 3rd and 4th degree perineal lacerations were quantified using the odds ratio (OR) with 95% confidence intervals (CI). RESULTS: During the 11 year study period, the rate of forceps procedures decreased by 65% from 6.4% to 2.4% of all deliveries. The total number of vacuum deliveries increased from 4.7% to 5.9% of all deliveries. With the decline in the total number of forceps deliveries, the odds of a severe perineal laceration associated with forceps increased from an OR of 6.9 (95% CI:6.17.9) to an OR of 9.8 (95% CI:8.4-11.6). The odds of a severe laceration associated with vacuum deliveries also increased from an OR of 4.1 (95% CI:3.5-4.7) to an OR of 5.2 (95% CI:4.5-5.9).