Degree Perineal Lacerations Research Articles

Lotus petal flap for unusual indication: A recto-vaginal fistula with perineal defect after vaginal delivery.

Introduction and importanceThree to five percent of vaginal deliveries are complicated by third or fourth degree perineal laceration. Misdiagnosed perineal injuries may be associated with a poor sexual and psychological prognosis. Management of old perineal tears and laceration is challenging with a high failure rate. In such condition, interposition tissue technic or local flap can be a good surgical alternative. Lotus petal Flap, usually indicated in management of large perineal defect in gynecological oncology can be used.Case presentationWe report a case of 32-year-old women presenting complex and relapsed perineal fistula after vaginal delivery associated with perineal defect treated by lotus petal flap with a good outcome.DiscussionPerineal defects are commonly encountered after oncologic, traumatic or infectious perineal excisions and described as a challenging situation. In case of perineal defects after obstetrical tears, no validated surgical filler technics are recommended. Inspired from oncologic surgical technics to fill perineal defects, Lotus Flap can be used. Its advantages are to mobilize a satisfactory tissue volume to fill important perineal defect compared to the small bulbocavernous flap with a hidden scar comparing to gracilis muscle flap. This technic is associated with a good sexual and self-imaging outcome.ConclusionLotus petal flap may be required as a solution to manage perineal defect in case of perineal fistula. This technique provides aesthetic and good results for perineal reconstruction.

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.

Clinical Effects of Form-Based Management of Forceps Delivery under Intelligent Medical Model.

Background Forceps delivery is one of the most important measures to facilitate vaginal delivery. It can reduce the rate of first cesarean delivery. Frustratingly, adverse maternal and neonatal outcomes associated with forceps delivery have been frequently reported in recent years. There are two major reasons: one is that the abilities of doctors and midwives in forceps delivery vary from hospital to hospital and the other one is lack of regulations in the management of forceps delivery. In order to improve the success rate of forceps delivery and reduce the incidence of maternal and neonatal complications, we applied form-based management to forceps delivery under an intelligent medical model. The aim of this work is to explore the clinical effects of form-based management of forceps delivery. Methods Patients with forceps delivery in Maternal and Child Health Hospital Affiliated to Nanchang University were divided into two groups: form-based patients from January 1, 2019, to December 31, 2020, were selected as the study group, while traditional protocol patients from January 1, 2017, to December 31, 2018, were chosen as the control group. Then, we compared the maternal and neonatal outcomes of these two groups. Results There were significant differences in the maternal and neonatal adverse outcomes such as rate of postpartum hemorrhage, degree of perineal laceration, and incidence of neonatal facial skin abrasions between the two groups, whereas differences in the incidence of asphyxia and intracranial hemorrhage were not significant. Conclusions Form-based management could help us assess the security of forceps delivery comprehensively, as it could not only improve the success rate of the one-time forceps traction scheme but also reduce the incidence of maternal and neonatal adverse outcomes effectively.

Episiotomy Practice in China

Background: A restrictive use of episiotomy was recommended by the obstetric society in China, but limited information has been published on the episiotomy practice at a country level. While midline episiotomy has been demonstrated as a risk factor for 3 rd or 4 th degree lacerations, the effects of mediolateral episiotomy (the more common type) in China, remain unclear. Methods: The China Labor and Delivery Survey is a cross-sectional investigation with a cluster random sampling scheme in 2015-2016. We calculated the episiotomy rate by parity at national and regional levels. 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 “normal” women. Findings: The episiotomy rate 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 3 rd or 4 th degree perineal laceration [odds ratio (OR) =2·64, 95% CI: 1·08-6·48)] in nulliparae without neonatal benefits. Interpretation: Episiotomy was performed more than medical necessary in China. Mediolateral episiotomy without indications more than doubled the risk of 3 rd and 4 th degree perineal laceration in nulliparae without neonatal benefits. Funding: The project was supported by National Natural Science Foundation of China (81273091) and Shanghai Health Commission Programme (GWIV-26.2). Declaration of Interest: The authors declare that they have no competing interests. Ethical Approval: The study protocol was approved by the Research Project Review Panel of the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction at the Department of Reproductive Health and Research of WHO, and the WHO Research Ethics Review Committee, Geneva, Switzerland, and the ethics committees at the Xinhua Hospital and all participating centers.

Early postpartum biofeedback assisted pelvic floor muscle training in primiparous women with second degree perineal laceration: Effect on sexual function and lower urinary tract symptoms

ObjectiveTo evaluate the short-term effect of routine early postpartum electromyographic biofeedback assisted pelvic floor muscle training on sexual function and lower urinary tract symptoms. Materials and methodsFrom December 2016 to November 2017, primiparous women with vaginal delivery, who experienced non-extended second-degree perineal laceration were invited to participate. Seventy-five participants were assigned into a pelvic floor muscle training (PFMT) group or control group. Women in the PFMT group received supervised biofeedback-assisted pelvic floor muscle training at the 1st week and 4th week postpartum. Exercises were performed at home with the same protocol until 6 weeks postpartum. The Pelvic Organ Prolapse Urinary Incontinence Sexual Questionnaire (PISQ-12) and the Urinary Distress Inventory short form questionnaire (UDI-6) were used to evaluate sexual function and lower urinary tract symptoms respectively at immediate postpartum, 6 weeks, 3 months, and 6 months postpartum. ResultsForty-five women (23 in PFMT group,22 in control group) completed all questionnaires at 6 months postpartum. For overall sexual function and the three sexual functional domains, no statistically significant difference was found in PISQ scores from baseline to 6 weeks, 3 months, and 6 months postpartum between the PFMT and control groups. For postpartum lower urinary tract symptoms, all symptoms gradually improved over time for both groups without a statistically significant difference between groups. ConclusionOur study showed that supervised biofeedback-assisted pelvic floor muscle training started routinely at one week postpartum did not provide additional improvement in postpartum sexual function and lower urinary tract symptoms.

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 Vaginal Breech Delivery Still a Safe Option?

To determine whether there was any difference in neonatal and maternal outcomes between breech vaginal delivery and cephalic vaginal delivery. A retrospective, case-control study was conducted between January 2015 and December 2017 in a Portuguese hospital. A total of 26 cases of breech vaginal delivery were considered eligible and 52 pregnant women formed the control group. Induced labor was more frequent in the breech vaginal delivery group (46% versus 21%, p = 0.022). Episiotomy was more common in the breech vaginal delivery group (80% versus 52%, p = 0.014), and one woman had a 3rd degree perineal laceration. Newborns in the study group had a lower birthweight (2,805 g versus 3,177 g, p < 0.001). There was no significant difference in the neonatal outcomes. The present study showed that breech vaginal delivery at term compared with cephalic presentation was not associated with significant differences in neonatal and maternal morbidity. It also suggests that breech vaginal delivery remains a safe option under strict selection criteria and in the presence of an experienced obstetrician.

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..

Anal incontinence and unrecognized anal sphincter injuries after vaginal delivery\u2013 a cross-sectional study in Norway

BackgroundAim of the study was to estimate the prevalence of postpartum anal incontinence among women who delivered vaginally, and to assess the extent to which obstetric injuries to the anal sphincters are missed.MethodsAll women (both primiparous and multiparous) who delivered vaginally and received any kind of sutures in the perineal area at Innlandet Hospital Trust Elverum in Norway between January 1, 2015 and June 30, 2016 were invited to answer a questionnaire on St. Mark’s incontinence score and to participate in a clinical examination of the pelvic floor including endoanal sonography.ResultsIn total 52,3% (n = 207) of the 396 invited women participated in the study. Mean St. Mark’s score was 1.8 points (95% CI 1.4 to 2.1) at examination 14 months (mean) postpartum, and none of the participants suffered from weekly fecal leakage. Fecal urgency affected 11.7% (95% CI 7.1 to 16.3) of the participants, and 8.7% (95%CI 5.1 to 12.8) had weekly involuntary leakage of flatus. Nine women (9.3%, 95% CI 4.1 to 15.5) had a previously undetected third degree obstetric anal sphincter injury.ConclusionThe prevalence of anal incontinence among women who have delivered vaginally and received sutures due to 1st and 2nd degree perineal lacerations is low. Some obstetric anal sphincter injuries remain unrecognized at the time of delivery, but the symptoms of anal incontinence due to these injuries are in the lower half of the St. Mark’s incontinence score. Women with persistent symptoms like fecal urgency or leakage of gas and/or feces should be referred to evaluation by a colorectal surgeon in order to achieve optimal treatment.

914: Second stage of labor: Maternal and perinatal outcomes of cesarean versus attempted operative vaginal delivery

Among women who reach the second stage of labor and require operative delivery, little data exists on the maternal and perinatal outcomes based on attempted operative vaginal delivery (OVD) vs cesarean delivery (CD) without attempted OVD. The objective of this study was to compare the maternal and perinatal outcomes among these two groups. This is a secondary analysis of data from a multicenter prospective study for women enrolled in the Cesarean Registry. We compared the maternal and perinatal outcomes based on whether OVD was attempted or CD was performed without attempt. This study includes singleton, at > 37 weeks, pregnancies that were eligible for OVD (10cm dilated and +2 station). Exclusion criteria included those who underwent CD in second stage with primary indication of non-reassuring fetal heart rate tracing and those with anomalous fetuses. Primary outcome was composite maternal morbidity and secondary outcome was composite neonatal morbidity. A multivariable Poisson regression analysis was used to examine the association between attempt of OVD and outcomes, while adjusting for potential confounding factors that were different between groups at a p value of < 0.1 in univariate analysis. A total of 1,432 women met the inclusion criteria: 1,025 (71%) had an attempted OVD and 407 underwent CD without attempt (39%). Women who attempted OVD were more likely to have composite maternal morbidity (aRR 2.93, 95% CI 1.92-4.49), mostly from third and fourth degree perineal lacerations (Table 1). There was no significant difference in rates of composite neonatal morbidity between groups; however, neonatal birth injury was significantly more frequent in the group who had an attempted OVD (aRR 4.79, 95% CI 1.85-12.42)(Table 2). In women reaching the second stage, CD without attempt was associated with lower maternal morbidity and less neonatal birth injury. Given that OVD training is declining in residency programs, these data may have clinical implications regarding counseling of patients eligible for OVD.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

515: Racial disparities in postpartum opioid prescribing for women undergoing cesarean section

To determine the association between inpatient postpartum opioid use, amount of opioids prescribed at discharge, and racial demographics. This retrospective cohort study identified women undergoing cesarean delivery at a single tertiary academic institution between July 2018 and October 2018 with any inpatient opioid order within the electronic medical record. Women with postoperative wound complications, third and fourth degree perineal lacerations, cesarean hysterectomy, or a known history of opioid abuse were excluded. The primary outcome was the number of oxycodone 5 mg tablets prescribed at discharge, stratified by race. Race was categorized as “Black” and “White,” with other identities excluded due to low absolute numbers of each. Women in the highest and lowest quartiles of inpatient opioid tablet use were compared using multivariable logistic regression. A sensitivity analysis was performed for women who received zero postoperative oxycodone tablets. A total of 268 women were included. The median number of oxycodone tablets consumed following delivery was seven (IQR: 2.5–12 tablets). White women were more likely to deliver at higher maternal age (median 32 vs. 30; p< 0.01) and lower maternal BMI (31.6 vs. 34.5; p=0.02). White women were also significantly more likely to have private insurance (p < 0.01). No significant difference between black and white women was noted in the total number of inpatient opioid tablets consumed (0, 1-6, 7-12, or >13) nor in number of opioid tablets prescribed at discharge. Women who consumed zero tablets inpatient (n=38) received a range of 0-30 tablets at discharge, with no difference between the two groups. At our large, academic hospital, patient race does not impact inpatient opioid use or opioid prescribing practices.

1173: Inpatient opioid use and prescribing practices after cesarean delivery

To quantify the association between inpatient use of opioids and amount prescribed at discharge following cesarean delivery. This retrospective cohort study identified women undergoing cesarean delivery at a single tertiary academic institution between July 2018 and October 2018 with any inpatient opioid order in the electronic medical record. Women with postoperative wound complications, third and fourth degree perineal lacerations, cesarean hysterectomy, or a known history of opioid abuse were excluded. The electronic medical record was reviewed to determine the number of postoperative oxycodone 5 mg tablets taken as an inpatient and dispensed at hospital discharge. The primary outcome was the number of oxycodone 5 mg tablets prescribed at discharge. Women in the highest and lowest quartiles of inpatient opioid tablet use were compared using multivariable logistic regression. A sensitivity analysis was performed for length of stay. A total of 268 women were included; the median number of oxycodone tablets consumed following delivery was seven (IQR: 2.5–12 tablets). No difference was found in inpatient opioid usage between race, maternal age, payor type, maternal BMI, or discharge provider type (intern, resident, or attending). All patients in the highest quartile of use (>12 tablets consumed; n=74) and 85% of those in the lowest quartile of use (< 2.5 tablets consumed; n=67) received at least 10 tablets on discharge. This difference was not statistically significant. The difference remained non-significant when a cutoff of 20 tablets was used. Excluding women discharged after post-operative day five did not change our findings. At our large, academic hospital, providers prescribe a consistent number of oxycodone tablets at discharge, regardless of inpatient usage. We suggest that providers more closely review inpatient usage and prescribe a scalar quantity at discharge.

787: The effect of neuraxial morphine (Duramorph) on postpartum pain after a severe perineal laceration

Postpartum pain has negative consequences on maternal-infant bonding, future narcotic abuse, and development of chronic pain. With the rise of the opioid epidemic, it is important to find novel approaches in managing this pain. This pilot study investigates the use of neuraxial morphine (Duramorph) in postpartum pain control after a severe perineal laceration. A single-blind randomized controlled trial (NCT03926559) was conducted on parturients admitted to the obstetric service at Augusta University Medical Center. Patients were enrolled if they had an epidural and if they had a second, third, or fourth degree perineal laceration that was identified immediately postpartum. Participants were randomized to receive either 2mg of Duramorph or sham injection of no drug within 30 minutes after their perineal laceration repair, prior to the removal of their epidural. Primary outcomes were perineal pain at 24 and 48 hours postpartum as measured on a 11-point Numerical Rating Scale (NRS-11). Secondary outcomes were amount of additional oral narcotics used in morphine milliequivalents (MME) over 24 and 48 hours postpartum, and maternal satisfaction as measured on a Likert (1-10) scale. Between 04/2019 to 08/2019, 154 patients were consented, of which 78 patients had a severe perineal tear and were eligible for the study. 58, 13, and 7 patients had second, third, and fourth degree perineal tears respectively. Baseline demographic characteristics between the groups were comparable. As seen in Table 1, there was a statistically significant reduction in pain scores at 24 hours in women who received Duramorph compared to sham for all perineal tears. There was also a statistically significant decrease in narcotic use at 24 hours, as well as an increase in maternal satisfaction for all perineal tear groups in the Duramorph group compared to sham (Table 2). The use of Duramorph in the immediate postpartum setting may alleviate pain in the first 24 hours and may also decrease the number of oral narcotics consumed during the early postpartum period.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Randomized, Double-Blind, Placebo-Controlled Trial on the Efficacy of Hyaluronidase in Preventing Perineal Trauma in Nulliparous Women.

PurposeHyaluronidase (HAase) has many uses in medicine, and reports suggest that it affects perineal tissue during fetal passage through the vaginal canal. However, its potential use for preventing perineal trauma has yet to be determined. This study sought to evaluate the efficacy and safety of perineal HAase injections in reducing perineal trauma during vaginal delivery.Materials and MethodsA multi-center, double-blind, placebo-controlled, randomized study was conducted from January 2016 to March 2017. Nulliparous women who planned to undergo vaginal delivery were recruited, and the enrolled women were randomly assigned to the HAase injection group (HAase injection, 5000 IU, n=75) or the control group (normal saline injection, n=73). The degree of perineal laceration, rate of episiotomy, and grade of perineal edema at 1 hour and 24 hours after spontaneous vaginal delivery were compared between the two groups.ResultsA total of 148 women who underwent vaginal delivery were recruited. No significant differences were observed between the HAase injection and control groups in the rates of perineal laceration (p=0.422). Perineal edema significantly decreased 24 hours after delivery in the women treated with perineal HAase injections, compared to women in the control group (p=0.008). The overall incidences of adverse events, such as redness of the injection site, infection, and wound dehiscence, were similar between the two groups.ConclusionHAase injections in nulliparous women afforded no reductions in the rates of perineal lacerations and episiotomy. However, the use of perineal HAase injections did reduce perineal edema without severe adverse events.

Water Birth and Perinatal Outcomes in British Columbia: A Retrospective Cohort Study.

This study aimed to quantify adverse neonatal outcomes in a cohort of registered midwife (RM)-attended conventional and water births in British Columbia. The study included all term singleton births in British Columbia between January 1, 2005 and March 31, 2016 attended by RMs. Births were allocated to a conventional birth cohort or a water birth cohort according to where the actual birth of the neonate took place. The primary outcome was a composite adverse neonatal outcome (Apgar <7 at 5 minutes, resuscitation need, neonatal intensive care unit admission). Secondary outcomes included individual components of the primary outcome, maternal length of labour, and degree of perineal laceration (Canadian Task Force Classification Level II-2). The population included 25798 births. Of these, 23201 were conventional, and 2567 were water births. The rate of the composite adverse neonatal outcome was not higher in water births compared with conventional births (hospital conventional, 5.0%; hospital water, 4.2%; home conventional, 3.4%; and home water, 2.9%). Rates of individual components of the composite adverse neonatal score were not greater in the water birth cohort. Maternal outcomes included statistically shorter labours in the water birth cohort and no difference between the cohorts in incidence of third- and fourth-degree lacerations. Water births attended by RMs in British Columbia are not associated with higher rates of adverse neonatal outcomes than conventional births attended by midwives.

Risk factors for severe postpartum haemorrhage: A population-based retrospective cohort study.

Severe postpartum haemorrhage (PPH) is a serious clinical problem that is increasing in incidence. To identify risk factors for severe PPH. Population-based retrospective cohort study of all women who gave birth in Victoria in 2009-2013 using the validated Victorian Perinatal Data Collection. Three multivariable logistic regression models estimated the adjusted risk of severe PPH. Adjusted odds ratios (aOR) and their 95% confidence intervals are reported. The primary outcome was severe PPH (estimated blood loss of ≥1500mL). Severe PPH occurred in 1.4% of all births (n=5122). Maternal characteristics significantly associated with severe PPH included: multiple pregnancy; older maternal age; overweight/obesity; first births. Other risk factors included placental complications, macrosomia, instrumental vaginal birth, third and fourth degree perineal lacerations, in-labour caesarean section, birth at a gestation other than 37-41weeks, duration of labour 12 to <24h, and use of oxytocin infusions in labour. Planned pre-labour caesarean section was associated with reduced odds of severe PPH. Severe PPH also occurred in 0.7% (n=104) of women with none of the identified risk factors. Numerous risk factors for severe PPH are identified but some cases are not modifiable or predictable. Limiting use of oxytocin infusions in labour to cases with clear indications, and strategies to prevent severe perineal lacerations would prevent some severe PPHs. Close surveillance of all women in the hours immediately following birth is crucial to detect and manage excessive blood loss and reduce severe PPH and associated morbidity.

Obstetric Perineal Lacerations in Women With Female Genital Mutilation (FGM) [11G

INTRODUCTION: To evaluate whether or not women, who have undergone FGM III, have an increased rate of second degree and higher obstetric perineal lacerations than a control group of similar patients. METHODS: For this retrospective chart review, we searched the electronic medical record (EMR) for patients speaking Somali, Arabic, Kurdish, Swahili, and French, who delivered at the University of Louisville Hospital from April 10, 2016 through August 10, 2017. We then entered baseline characteristics and delivery details into a secure database. A total of 110 patients were included. We looked at type of FGM, mode of delivery, rates of assisted delivery and primary cesarean section, types of perineal lacerations, and whether or not defibulation was performed. RESULTS: The baseline characteristics had several significant differences between the controls (n=84), FGM II (n=11), and FMG III (n=15) patients. Most strikingly, the FGM III population was 93% nulliparous. We controlled for this in our analysis with logistic regression models. The odds ratios (OR) of a second degree or higher perineal laceration comparing FGM III to controls (OR 5.06, 0.87-53.84) was not significant (p=0.0687). After logistic regression was applied controlling for body mass index, nulliparity, and assisted delivery, there was no increased risk of laceration in women with FGM III (AOR 1.06, CI 0.11-10.35, p=0.9571). We found that we correctly followed the standard of care and defibulated 89% (8/9) of women with FGM III that underwent vaginal delivery. CONCLUSION: Women with FGM III did not appear to have an increased risk of second degree and higher perineal lacerations.

Perineal Warm Compresses During the Second Stage of Labour Decrease Incidence and Degree of Perineal Laceration in Primiparous

Perineal Warm Compresses During the Second Stage of Labour Decrease Incidence and Degree of Perineal Laceration in Primiparous

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.