Degree Tears Research Articles

Management After Obstetric Anal Sphincter Injury: Anorectal Manometry and Symptoms Predict Long-Term Fecal Incontinence.

Obstetric anal sphincter injury (OASI) is associated with serious morbidity and reduced quality of life. The role of anorectal manometry (ARM) to guide treatment is unclear. We aimed to define the role of ARM and symptom assessment after OASI in predicting anal incontinence at long-term follow-up. Prospective evaluation of 205 consecutive post-OASI women who underwent baseline ARM and symptom assessment in a tertiary setting was undertaken. Ninety-nine women were available for long-term follow-up (median 6.6 years). Associations between post-OASI ARM testing and short-term and long-term anal incontinence were examined in addition to clinical and obstetric factors. Fourth degree tears and lower anal resting and squeeze pressures were associated with short-term anal incontinence. Women with anal incontinence at baseline and women with lower anal resting pressure were more likely to suffer from long-term fecal incontinence (FI). A best-fit cutoff value of 59 mm Hg for baseline anal resting pressure predicted long-term FI, and none of the short-term asymptomatic women with an anal resting pressure of >59 mm Hg reported FI at long-term follow-up. Symptoms of anal incontinence and ARM in patients after OASI are both useful to predict subsequent long-term FI with a best-fit cutoff of 59 mm Hg for anal resting pressure. This provides rationale for routine ARM and accurate symptom assessment in all patients after OASI, to identify high-risk groups to follow and treat, and it may assist decision making regarding mode of subsequent obstetric deliveries.

Prevalence and associated factors of maternal birth trauma following vaginal delivery at University of Gondar Comprehensive Specialized Hospital, North-West Ethiopia, 2022

BackgroundMaternal injury with any form of perineal trauma following vaginal delivery is very common which ranges globally from 16.2 to 90.4%. The frequency of Obstetric anal sphincter Injuries and the incidence of cervical laceration increases rapidly. However, in Ethiopia, there is limited evidence on the prevalence of maternal birth trauma and its determinant factors after vaginal delivery.ObjectiveTo assess the magnitude and associated factors of Maternal Birth Trauma after vaginal delivery at University of Gondar Comprehensive Specialized Hospital, Gondar, North-West Ethiopia, 2022.MethodsAn Institution based cross-sectional study was conducted among mothers with singleton vaginal delivery at University of Gondar Comprehensive Specialized Hospital from 9th May to 9th August 2022 among 424 study participants. Pre-tested semi-structured questioner was utilized. Epi-Data version 4.6 was used for data entry and exported to SPSS version 25 for data management and analysis. To identify the determinant factors, binary logistic regression model was fitted and variables with p-value < 0.2 were considered for the multivariable binary logistic regression analysis. In the multivariable binary logistic regression analysis, Variables with P-value < 0.05 were considered to have statistical significant association with the outcome variable. The Adjusted Odds Ratio (AOR) with 95% CI was reported to declare the statistical significance and strength of association between Maternal Birth Trauma and independent variables.ResultsA total of 424 mothers who delivered vaginally were included. The mean age of participants was 26.83 years (± 5.220 years). The proportion of birth trauma among mothers after vaginal delivery was47.4% (95%CI: 43.1, 51.7). Of different forms of perineal trauma, First degree tear in 42.8%, OASIs in 1.5% and Cervical laceration in 2.5% study participants. In the multivariable binary logistic regression analysis being primiparous (AOR = 3.00; 95%CI: 1.68, 5.38), Gestational age ≥ 39 weeks at delivery (AOR = 2.96; 95%CI: 1.57, 5.57), heavier birth weight (AOR = 12.3; 95%CI: 7.21, 40.1), bigger head circumference (AOR = 5.45; 95%CI: 2.62, 11.31), operative vaginal delivery (AOR = 6.59; 95%CI: 1.44, 30.03) and delivery without perineum and/or fetal head support (AOR = 6.30; 95%CI: 2.21, 17.94) were significantly associated with the presence of maternal birth trauma.Conclusion and recommendationMaternal birth trauma following vaginal delivery was relatively high in this study. Prim parity, gestational age beyond 39 weeks at delivery, heavier birth weight, bigger head circumference, operative vaginal delivery and delivery without perineum and/or fetal head supported were factors affecting perineal outcome. The Ministry of Health of Ethiopia should provide regular interventional training as to reduce maternal birth trauma.

Minimizing tearing during vaginal delivery with a perineal protection device: a randomized controlled trial

There is a growing body of evidence indicating that second-degree tears cause both short- and long-term consequences. Very few preventative measures have been found to reduce the incidence of these tears. This study aimed to investigate whether the use of a perineal protection device during vaginal birth reduces severe perineal tearing (grade ≥2 tear) in primiparous women compared with routine manual perineal support. A single-center randomized controlled trial was conducted in Sweden from 2019 to 2021. Primiparous women at term were randomly allocated to the intervention group (n=43), where a perineal protection device was used, or to the routine care group (n=49). The primary outcome was grade of perineal tear. The secondary outcomes were vaginal and labial tearing. Continuous data were analyzed using the Student t test or Mann-Whitney U test. Dichotomous data were analyzed using the Pearson X2 test, Fisher exact test, and ordinal logistic regression. Women in the intervention group had a significantly lower risk of sustaining more extensive perineal tearing than those in the control group. The use of the perineal protection device decreased the risk of grade ≥2 tears in relation to grade 0 to 1 tears (odds ratio, 0.40; 95% confidence interval, 0.17-0.94). Ordinal logistic regression analyses revealed an odds ratio of 0.36 (95% confidence interval, 0.16-0.81) per incremetn of grade injury using the perineal protection device vs routine care (P=.013). The number needed to treat using the perineal protection device was 4.3 to avoid 1 grade ≥2 tear. Women in the treatment group showed less labial tearing (P=.016). No adverse effect was detected. The use of a perineal protection device reduced the risk of grade ≥2 perineal tearing by 60% and labial tearing. El resumen está disponible en Español al final del artículo.

Predicting perineal trauma during childbirth using data from a general obstetric population.

Perineal trauma is a common complication of childbirth and can have serious impacts on long-term health. Few studies have examined the combined effect of multiple risk factors. We developed and internally validated a risk prediction model to predict third and fourth degree perineal tears using data from a general obstetric population. Risk prediction model using data from all singleton vaginal deliveries at Cork University Maternity Hospital (CUMH), Ireland during 2019 and 2020. Third/fourth degree tears were diagnosed by an obstetrician or midwife at time of birth and defined as tears that extended into the anal sphincter complex or involved both the anal sphincter complex and anorectal mucosa. We used univariable and multivariable logistic regression with backward stepwise selection to develop the models. Candidate predictors included infant sex, maternal age, maternal body mass index, parity, mode of delivery, birthweight, post-term delivery, induction of labour and public/private antenatal care. We used the receiver operating characteristic (ROC) curve C-statistic to assess discrimination, and bootstrapping techniques were used to assess internal validation. Of 8,403 singleton vaginal deliveries, 8,367 (99.54%) had complete data on predictors for model development. A total of 128 women (1.53%) had a third/fourth degree tear. Three variables remained in the final model: nulliparity, mode of delivery (specifically forceps delivery or ventouse delivery) and increasing birthweight (per 100 gram increase) (C-statistic: 0.75, 95% CI: 0.71, 0.79). We developed a nomogram to calculate individualised risk of third/fourth degree tears using these predictors. Bootstrapping indicated good internal performance. Use of our nomogram can provide an individualised risk assessment of third/fourth degree tears and potentially aid counselling of women on their potential risk.

A pre-post implementation study of a care bundle to reduce perineal trauma in unassisted births conducted by midwives

ProblemThe perineal-bundle is a complex intervention widely implemented in Australian maternity care facilities. BackgroundMost bundle components have limited or conflicting evidence and the implementation required many midwives to change their usual practice for preventing perineal trauma. AimTo measure the effect of perineal bundle implementation on perineal injury for women having unassisted births with midwives. MethodsA retrospective pre-post implementation study design to determine rates of second degree, severe perineal trauma, and episiotomy. Women who had an unassisted, singleton, cephalic vaginal birth at term between two time periods: January 2011 – November 2017 and August 2018 – August 2020 with a midwife or midwifery student accoucheur. We conducted logistic regression on the primary outcomes to control for confounding variables. Findingsdata from 20,155 births (pre-implementation) and 6273 (post-implementation) were analysed. After implementation, no significant difference in likelihood of severe perineal trauma was demonstrated (aOR 0.86, 95% CI 0.71–1.04, p = 0.124). Nulliparous women were more likely to receive an episiotomy (aOR 1.49 95% CI 1.31–1.70 p < 0.001) and multiparous women to suffer a second degree tear (aOR 1.18 95% CI 1.09–1.27 p < 0.001). DiscussionThis study adds to the growing body of literature which suggests a number of bundle components are ineffective, and some potentially harmful. Why, and how, the bundle was introduced at scale without a research framework to test efficacy and safety is a key concern. ConclusionSuitably designed trials should be undertaken on all proposed individual or grouped perineal protection strategies prior to broad adoption.

The influence of the attending midwife on the occurrence of episiotomy: A retrospective cohort study

BackgroundEpisiotomy at the time of vaginal birth can result in short- and long-term complications for women. Therefore, it is important to study factors that influence the occurrence of episiotomy. AimTo examine to what extent the individual factors of clinical midwives in the same working conditions contribute to variations in episiotomy. MethodsA retrospective cohort study was performed at a secondary care hospital in Amsterdam, the Netherlands, using data from women who were assisted by a clinical midwife during birth in 2016. The clinical midwives filled out a questionnaire to determine individual factors. The predictive value of the individual factors of the clinical midwives was examined in a multiple logistic regression model on episiotomy. ResultsA total of 1302 births attended by 27 midwives were included. The mean episiotomy rate was 12.7%, with a range from 3.2% to 30.8% among midwives (p = 0.001). When stratified for parity, within the primipara group there was a significant variation in episiotomy among midwives with a range from 7.9% to 47.8% (p = 0.006). No significant variation was found in the occurrence of third/fourth degree tears or intact perineum. There was a significant difference in episiotomy for maternal indication among midwives (p = 0.041). Predictors for an episiotomy were number of years since graduation and place of bachelor education of the clinical midwife. ConclusionThis study shows that individual factors of clinical midwives influence the rate of episiotomy. Predictors for an episiotomy were the number of years since graduation and place of bachelor education. This shows that continuous training of clinical midwives could contribute to reducing the number of unnecessary episiotomies. Since suspected fetal distress is the only evidence based indication to perform an episiotomy, there is room for improvement given the variation in the number of episiotomies performed for maternal indication.

(214) Female bmg Urethroplasty and 2nd Degree Vaginal Tear Repair

Abstract Introduction Pregnancy and childbirth bring biological, psychological, and social changes which may influence women's health. Objective Second degree tears are the most common type of tear. A female urethral stricture is a less common condition. Buccal mucosa graft (BMG) is widely used tissue for urethral stricture repair. Methods We present a 38-year old female who suffered a 9-year long history of urethral stricture disease and dyspareunia after two vaginal child births. The patient (pt) had urethral injury and 2nd degree tear in vaginal wall and pelvic muscle. Despite repeated attempts of urethral dilations, the stricture and the obstructive complaints persisted. Additionally, lack of sexual arousal and painful intercourses, affected the patient’s quality of life. The pt was treated with a dorsal onlay urethroplasty using a buccal mucosa graft, excision of vaginal wall scar, pelvic floor muscle repair, and repair of vaginal opening The surgery was carried out with a suprameatal approach. A semicircular incision was performed and the urethra was dissected from the ventral aspect of the clitoris with a sharp and blunt dissection up to the proximal part of stricture. Then, a dorsal sagittal incision is performed over the stricture and the BMG is sutured dorsally for the edges and quilted with 4.0 polyglactin sutures. A 16Fr Foley catheter was left in place for two weeks. Then, we performed hydrodissection of posterior vaginal wall, scar excision from episiotomy and 2nd degree tear, approximation of levator ani muscle, vaginal wall and opening repair. Results Two weeks after surgery the patient urinates without strain and with no post voiding residual urine. Uroflow 6 weeks after surgery showed Qmax of 28ml/sec and urethra was easily passable for 20Fr Nelaton catheter. Eight weeks after surgery the patient reported having a normal sexual life without pain and lack of sexual satisfaction Conclusions Female dorsal onlay urethroplasty and vaginal wall tear repair are feasible and give great functional and aesthetical results Disclosure No

Warren flap repair for a chronic fourth degree tear

Warren flap repair for a chronic fourth degree tear

Predicting perineal trauma during childbirth using data from a general obstetric population

Background: Perineal trauma is a common complication of childbirth and can have serious impacts on long-term health. Few studies have examined the combined effect of multiple risk factors. We developed and internally validated a risk prediction model to predict third and fourth degree perineal tears using data from a general obstetric population. Methods: Risk prediction model using data from all singleton vaginal deliveries at Cork University Maternity Hospital (CUMH), Ireland during 2019 and 2020. Third/fourth degree tears were diagnosed by an obstetrician or midwife at time of birth and defined as tears that extended into the anal sphincter complex or involved both the anal sphincter complex and anorectal mucosa. We used univariable and multivariable logistic regression with backward stepwise selection to develop the models. Candidate predictors included infant sex, maternal age, maternal body mass index, parity, mode of delivery, birthweight, post-term delivery, induction of labour and public/private antenatal care. We used the receiver operating characteristic (ROC) curve C-statistic to assess discrimination, and bootstrapping techniques were used to assess internal validation. Results: Of 8,403 singleton vaginal deliveries, 8,367 (99.54%) had complete data on predictors for model development. A total of 128 women (1.53%) had a third/fourth degree tear. Three variables remained in the final model: nulliparity, mode of delivery (specifically forceps delivery or ventouse delivery) and increasing birthweight (per 100 gram increase) (C-statistic: 0.75, 95% CI: 0.71, 0.79). We developed a nomogram to calculate individualised risk of third/fourth degree tears using these predictors. Bootstrapping indicated good internal performance. Conclusions: Use of our nomogram can provide an individualised risk assessment of third/fourth degree tears and potentially aid counselling of women on their potential risk.

Frequency of Perineal Trauma in Women Undergoing Spontaneous vs Directed Valsalva Type Pushing in Labour

Objective: To compare the frequency of perineal trauma in women undergoing the spontaneous vs the Valsalva-type pushing in the second stage of labour. Study Design: Randomized controlled trial Duration of Study with Dates: The study was carried out from 15-12-2020 to 19-03-2021. Setting: Department of Obstetrics and Gynaecology, Combined Military Hospital, Lahore.National University of Medical Sciences NUMS. Material and Methods: A total of 154 labouring females were enrolled in the study. These females were randomly assigned to one of two groups, A (the Valsava-type pushing method group) and B (the spontaneous pushing group). After the delivery of the placenta, the patients were all examined for any perineal trauma as per the operational definition. Results: Patients ranged between 18-40 years of age with a mean age of 26.3±4.0 years in Group A and 27.0±3.3 years in Group B. All the patients were between 38-40 weeks of gestation at the time of enrollment with mean gestational age being 39±0.7 weeks for group A and 38.9±0.7 for group B. There were 61 primigravida (39.6%, 34 in Group A and 27 in Group B) and 93 multigravida (60.4%, 43 in Group A and 50 in Group B). All women delivered vaginally in the cephalic presentation. The mean length of the second stage of labor was 25.7±29.0 min for the Valsalva pushing group and 31.6±37.5 min for the spontaneous pushing group. The mean fetal weight was 3.1±0.3 kg for both groups. 43 (55.8%) patients in the Valsalva pushing group and 46 (59.7%) in the spontaneous pushing group underwent an episiotomy during delivery. 9 (11.7%) patients in each group sustained perineal trauma (x2 = 0.0, p = 1.0). No one in the sample suffered greater than a second degree laceration. Out of the nine patients that did incur perineal trauma in the Valsalva type pushing group, 4 (44.4%) were first degree perineal tears and 5 (55.6%) were second degree perineal tears while among those in the spontaneous pushing group, 2 (22.3%) fell in the first degree tear category and 7 (77.7%) in the second degree tear category (x2 = 1.0, p = 0.317). Conclusion: Our findings suggest that there is no association between the rate of perineal trauma among patients who underwent the directed Valsalva- type method of pushing and those that employed the spontaneous pushing method during the second stage of labour. Keywords: Perineal trauma, Perineal tears, Second stage of labour, Pushing methods in labour, Valsalva- type pushing, Directed pushing, Spontaneous pushing

The Maternal factors and short term outcomes associated with episiotomy during vaginal delivery at Women and Newborn Hospital , Lusaka, Zambia

Background: An episiotomy is a surgically planned incision on the posterior vaginal wall and perineum performed during the second stage of labour to facilitate the delivery of the neonate. The practice has been used for many decades in the belief that it offers benefit to the mother and the neonate. With the objective of protecting the pelvic floor and preventing fetal trauma, during the birth, its routine use was widely accepted in the past, principally in woman in her first delivery. However, it is not free from complications which include iatrogenic injury to the anal canal, perineal pain and excess bleeding. This study was therefore conducted to explore the short term maternal outcomes and factors associated with episiotomy.&#x0D; &#x0D; Methodology: An unmatched case control study was conducted in postnatal wards of Women and New-born hospital in Lusaka, Zambia between November 2019 and April 2020 with convenient sample for the cases and systematic sample for the controls. A semi-structured interviewer administered questionnaire was used and 102 participants (cases) who had episiotomy performed were recruited while 204(controls) were without episiotomies.&#x0D; &#x0D; Results: A total of 306 (102 are cases and 204 are control) were included. Age was found to be a good predictor of episiotomy in that those younger than 18 years were more than seven times likely to have an episiotomy (AOR=7.65; 95%CI 1.36-18.21; p=0.035). It was also found out that primi gravidas were five times likely to have an episiotomy performed compared to parous women (OR=4.96; 95%CI 2.58-9.52; p&lt;0.001). Out of those delivered by a midwife, 73(28.3%) participants had an episiotomy performed compared to 29(60.4%) delivered by a medical officer. Multivariate regression it was shown that being delivered by a midwife was protective against an episiotomy (OR=0.260; 95%CI 0.14-0.49; p=0.001). Out of the 102 participants who had an episiotomy, only two had third degree tear extension. It was also noted that 99 out of 102 (97%) participants who had an episiotomy experienced post-delivery perineal pain compared to 94 out of 204(46%) of those who had no episiotomies. In univariate analysis, it was found that post-delivery perineal pain was associated with episiotomy (p&lt;0.001). It was further found that those who had an episiotomy performed were about 4 times likely to experience perineal pain post- delivery (OR=3.8; 95%CI 1.2-12.3). The mean blood loss among those who has had no episiotomy was 230mls compared to 270mls among those who had an episiotomy. However, post-delivery blood loss was found to be a poor predictor of an episiotomy (OR=0.998; 95%CI 0.991-1.006; p=0.670).&#x0D; &#x0D; Conclusion: Maternal factors associated with episiotomy included age, parity, method of induction, and the personnel conducting the delivery Short term maternal outcomes of episiotomy were perineal tear extension, excess blood loss and post-delivery perineal pain. It was found that 8.5% of women had undergone an episiotomy done on them. Health professional conducting deliveries should be educated on indications of episiotomy, patient selection during episiotomy and trained on surgical skills to repair episiotomy to reduce morbidity associated the procedure.

The Maternal factors and short term outcomes associated with episiotomy during vaginal delivery at Women and Newborn Hospital , Lusaka, Zambia

Background: An episiotomy is a surgically planned incision on the posterior vaginal wall and perineum performed during the second stage of labour to facilitate the delivery of the neonate. The practice has been used for many decades in the belief that it offers benefit to the mother and the neonate. With the objective of protecting the pelvic floor and preventing fetal trauma, during the birth, its routine use was widely accepted in the past, principally in woman in her first delivery. However, it is not free from complications which include iatrogenic injury to the anal canal, perineal pain and excess bleeding. This study was therefore conducted to explore the short term maternal outcomes and factors associated with episiotomy.&#x0D; Methodology: An unmatched case control study was conducted in postnatal wards of Women and New-born hospital in Lusaka, Zambia between November 2019 and April 2020 with convenient sample for the cases and systematic sample for the controls. A semi-structured interviewer administered questionnaire was used and 102 participants (cases) who had episiotomy performed were recruited while 204(controls) were without episiotomies.&#x0D; Results: A total of 306 (102 are cases and 204 are control) were included. Age was found to be a good predictor of episiotomy in that those younger than 18 years were more than seven times likely to have an episiotomy (AOR=7.65; 95%CI 1.36-18.21; p=0.035). It was also found out that primi gravidas were five times likely to have an episiotomy performed compared to parous women (OR=4.96; 95%CI 2.58-9.52; p&lt;0.001). Out of those delivered by a midwife, 73(28.3%) participants had an episiotomy performed compared to 29(60.4%) delivered by a medical officer. Multivariate regression it was shown that being delivered by a midwife was protective against an episiotomy (OR=0.260; 95%CI 0.14-0.49; p=0.001). Out of the 102 participants who had an episiotomy, only two had third degree tear extension. It was also noted that 99 out of 102 (97%) participants who had an episiotomy experienced post-delivery perineal pain compared to 94 out of 204(46%) of those who had no episiotomies. In univariate analysis, it was found that post-delivery perineal pain was associated with episiotomy (p&lt;0.001). It was further found that those who had an episiotomy performed were about 4 times likely to experience perineal pain post- delivery (OR=3.8; 95%CI 1.2-12.3). The mean blood loss among those who has had no episiotomy was 230mls compared to 270mls among those who had an episiotomy. However, post-delivery blood loss was found to be a poor predictor of an episiotomy (OR=0.998; 95%CI 0.991-1.006; p=0.670).&#x0D; Conclusion: Maternal factors associated with episiotomy included age, parity, method of induction, and the personnel conducting the delivery Short term maternal outcomes of episiotomy were perineal tear extension, excess blood loss and post-delivery perineal pain. It was found that 8.5% of women had undergone an episiotomy done on them. Health professional conducting deliveries should be educated on indications of episiotomy, patient selection during episiotomy and trained on surgical skills to repair episiotomy to reduce morbidity associated the procedure.

O31 - Clinical outcomes for women participating in continuity of care experiences with pre-registration midwifery students

Midwifery students in Australia are required to care for a minimum of 10 women in a continuity of care experience (CoCE) as part of their pre-registration midwifery program. Clinical outcomes for women receiving care from midwifery students may be documented by students in portfolios or ePortfolios but are rarely reported. The extent to which students value add to women’s care is unknown. This novel study used a retrospective descriptive design to evaluate the routinely collected clinical outcomes of women who had participated in a CoCE with a midwifery student (n = 5972 during pregnancy and n = 3933 during labour and birth) in one Australian BMid program between 2015 and 2020. The clinical outcomes collected and reported by students were compared with the National Core Maternity Indicators. Clinical outcomes were analysed for (1) women in a CMC primary model and who had a CoCE; (2) women in fragmented primary model of care and who had a CoCE; and (3) a comparison of clinical outcomes for women according to their model of care. The analyses revealed that women who had a CoCE with a midwifery student experienced equal to, or better clinical outcomes than national outcomes. In particular, tobacco smoking after 20 weeks of pregnancy, fourth degree tears and episiotomy rates were reduced for women who had CoCE with a midwifery student. Greatest benefit of CoCE with midwifery students was achieved when care began earlier in pregnancy. It is recommended that midwifery students commence CoCE as early as possible in pregnancy and that pre-registration midwifery programs extend and develop CoCE to maximise benefits for students and women.

Berlin survey on obstetric anal sphincter injury (OASI)

Obstetric anal sphincter injuries (OASIs) complicate about 5% of vaginal births. The risk of anal incontinence is increased. OASI detection rates improve with knowledge and experience. This study describes Berlin's medical care 10years after starting training focusing on standards set at the German speaking country guideline on third degree tears. In 2018, women experiencing OASIs in Berlin's obstetric departments were informed about the study, including standardized after-care. Descriptive analysis in respect to anal sphincter function and risk factor analysis was performed. 207 OASIs occurred in Berlin. 189 women participated. In 148 cases guideline according terminology was applied (n = 57 IIIa, n = 58 IIIb, n = 23 IIIc, n = 10 IV). Minor tears predominated. Minor and major tears differed in respect to birthweight (p = 0.047). N = 75 reported no sphincter function affection. Macrosomia compromised sphincter function (p = 0.008). Univariate analysis showed age (p < 0.001), male infants (p = 0.017) and higher parity (p = 0.013) to be risk factors. Symptomatic women had weaker pelvic floor muscle (p = 0.009) and suffered from urinary incontinence (p < 0.001). Multiple regression analysis showed an association of St. Mark's Scores ≥ 5 with parity (CI 0.191-0.847, p = 0.016) and ≥ 10 with maternal age (CI 1.077-1.396, p = 0.002) and for urinary incontinence with birthweight (CI 1.000-1.002, p = 0.032 and St. Mark's categories ((0-4, 5-9, > 10) CI 2.657-10.904, p = 0.005)). Overall, Berlin's medical care of OASI is based on guideline standards. Anal and urinary incontinence correlate. Parity and higher age are risk factors in developing severe anal symptoms.

Is there a role for transperineal ultrasound imaging of the anal sphincter immediately after primary repair of third degree tears?

ObjectiveWhen obstetric anal sphincter injuries are identified, it is crucial that the defects are repaired appropriately to achieve a better outcome. Although the presence of an intact anal sphincter is not the sole mechanism for maintaining continence, and not all women with an anal sphincter defect are symptomatic, there is an association between sphincter defects and anal incontinence. Our aim was to evaluate whether transperineal ultrasound (TPUS) is useful in assessing anal sphincter integrity immediately following primary repair of obstetric anal sphincter injuries (OASIs). Study DesignThis is a prospective observational study of women who sustained OASIs during their first vaginal delivery. Three dimensional (3D) TPUS was performed immediately after repair of OASIs to identify anal sphincter defects. A repeat TPUS was performed 12 weeks following repair. Results21 women sustained OASIs of whom 20 (95%) attended follow up. Eight (40%) had a grade 3a tear and 12 (60%) a 3b tear.8/20 (40%) women had residual external anal sphincter (EAS) defects identified by TPUS immediately after repair. Of these eight defects, six (75%) persisted at 12 weeks postpartum. No new defects were seen at follow up among the twelve women in whom no defect was seen immediately following the repair.Six residual EAS defects were found at 12 weeks postpartum. An EAS defect at 12 weeks postpartum was associated with anal incontinence (p = 0.04). Women with 3b tears were more likely to have anal incontinence (AI) and residual sonographic EAS defects when compared with 3a tears but this was not statistically significant. ConclusionsWomen who had no TPUS defect detected immediately following primary repair of OASIs, remained as such at 12 weeks postpartum. Of those in whom a defect was seen immediately after repair, it persisted in 75% of cases at 12 weeks. We believe that the value of TPUS immediately after repair appears to be limited and would need to be defined if it were to be considered for routine practice. Further research on its role immediately after repair of major tears (Grade 3C/4) is needed. In addition, performing ultrasound would require widespread training of obstetricians to develop expertise. This highlights the importance of adequate training of obstetricians in OASI repair.

Incidence and Risk Factors for Perineal Trauma

Objective: To identify the Incidence of and risk factors for perineal trauma. Study Design: Prospective research Place and Duration of Study: Department of Obstetrics &amp; Gynaecology, Ayesha Hospital Nishat Colony Lahore from 01-07-2021 to 31-12-2021. Methodology: Four hundred and sixteen pregnant women with perineal trauma condition were enrolled who either delivered at homes or hospitals were detailed interviewed for their clinical history and characteristics regarding their condition. Results: The mean age of pregnant women was 24.2±3.3 years. Out of total births in singleton 264 were at hospital while 152 at home. The results showed that 2nd degree tear was significant higher (P&lt;0.05) in hospital delivery multiparous case. Conclusion: Women having multipara had a 3-fold higher incidence of intact perineum than nullipara. Keywords: Perineal trauma, Nulliparous, Multiparous

Prevalence, Associated Risk Factors and Maternal Outcomes of Lower Genital Tract Injuries in the Bamenda Regional Hospital

BACKGROUND: Tears of the genital tract are lesions resulting from the breakage of the continuity of the lower genital tract during childbirth. These injuries are associated with high maternal morbidity or mortality if severe, poorly managed or delayed in repair. It is a frequent complication of vaginal delivery. This study was aimed at determining the prevalence, demographic characteristics, risk factors, patterns and the t-term maternal outcomes of lower genital tract injuries in the labour room and the post-natal ward of the Bamenda Regional Hospital. METHODS: This was a hospital-based cross-sectional study of women managed for genital tract injuries following vaginal birth in the Bamenda Regional Hospital (BRH) from March 2019 to July 2019. A non-probabilistic, consecutive and exhaustive sampling technique was used to select participants (sample size estimated at 237). Among those selected were women who had a vaginal birth. However, the researchers’ interest was particularly centered on the women who had genital tract injuries. Data was collected using a pretested questionnaire and analyzed using the SPSS version 22 software. RESULTS: In total, 310 participants were included in this study. The mean age of the participants was 26.1 years (SD = 5.2), while the median age was 25 years (interquartile range = 22 - 29). Of the 310 participants included in the study, 128 developed a birth tract injury giving a prevalence of 41.3% (95% CI, 35.8 - 47.0). The most common type of injury was spontaneous tears (33.9%), the majority of which were perineal (30.6%) compared to episiotomies (7.4%). Most perineal tears were first degree tears (23.2%) followed by second-degree tears (6.8%). Third-degree perineal tears were rare (0.6%). We did not have any cases of fourth-degree perineal tears. We also encountered a few cases of cervical tears (0.6%). The factors associated with birth tract injury were assessed using bivariate and multiple logistic regression analysis. On bivariate analysis, being an adolescent parturient (OR = 2.8, 95% CI: 1.4 - 5.7, p = 0.005), single (OR = 1.78, 95% CI, 1.04 - 3.03, p = 0.034), having a history of birth tract injury (OR = 1.69, 95% CI, 1.01 - 2.95, p = 0.042), a duration of active phase of labour (OR = 2.1, 95% CI, 1.3 - 3.3, p = 0.002), being a primipara (OR = 2.8, 95% CI, 1.0 - 8.4, p = 0.045), inducing labour (OR = 2.4, 95% CI, 1.1 - 5.4, p = 0.033), augmenting labour (OR = 2.4, 95% CI, 1.1 - 5.4, p = 0.033), birthweight of 4000 g or more (OR = 3.0, 95% CI, 1.3 - 7.4, p cm (OR = 3.3, 95% CI, 1.5 - 7.9, p = 0.005) were statistically significantly associated with birth tract injuries. The majority of the blood loss post-partum was between 200 and 500 cc. Only one participant had a blood loss of 500 cc and above. Also, the severity of genital pain lasting beyond 24 hours postpartum was mostly less than 5/10 (50.6%) followed by genital pains > 7/10 (41.7%). The prevalence of infection of the injury was (1.6%) and no maternal death from injury was recorded. CONCLUSION: The prevalence of lower genital tract injuries in the Bamenda Regional hospital is high. First-degree tears were the most common followed by episiotomies. The perineal outcome in the BRH is poor and should be improved upon.

Incidence and risk factors of perineal tears of pregnant women delivering at a midwife obstetric unit South Africa

Aim: To estimate the incidence and risk factors for perineal tears of low-risk pregnant women delivering at a midwife obstetric unit.&#x0D; Methods: A retrospective study performed on perineal tear during childbirth from birth register at midwife run unit in Durban municipality, South Africa between January 2018 and October 2019. Risk factors were studied and bivariate and logistic regression done. Results are expressed with adjusted odds ratios (OR) and p-values &lt;0.05 are considered significant.&#x0D; Results: A total of 1578 women had singleton vaginal childbirths. Half (50.6%) of them have perineal tears. The incidences of episiotomy, combined first-and second, and third-and fourth- degree (OASI) tears are 24.3%, 25.1% and 1.1% respectively. Risk factors for any perineal tears are younger mothers (teenage OR=2.9, 20-24 years OR=2.2), primipara (OR= 15.8), received antenatal care (OR=.47) and gestational age (GA) (&lt;32 weeks OR=.05). The risk factors for episiotomy are; teenage (OR=5.4), ages 20-24 years (OR=4.2), ages 25-29 years (OR=3.0), primipara (OR=12.4), GA (£32 weeks OR=.16), GA 33-36 weeks (OR=.6) and having antenatal care (OR=.41). Birth weight &lt;2.5 kg and between 2.5-3.0 kgs (OR=.014) and (OR=.09) are protective for OASI.&#x0D; Conclusions: Risk factors for the perineal injuries are similar to those previously reported in other studies. Training of midwives on perineal care and selection for undertaking episiotomy is urgently needed to improve maternity services at the midwife obstetric unit. Identification of those at risk may reduce obstetric perineal injury.

Diabetes Mellitus in pregnancy-a risk factor for perineal injuries, independent of neonatal macrosomia

Perineal lacerations, mainly 3rd and 4th degree tears (also known as- OASIS), are obstetrical complications that may cause significant morbidity. DM can adversely affect the condition of body tissues and their blood supply, changes that may contribute to the risk of childbirth perineal trauma. Gestational diabetes can also affects other obstetrical characteristics such as macrosomia and induction of labor that are additional risk factors for perianal trauma. We investigated the association between DM in pregnancy (gestational and pre-gestational) and perineal tears during vaginal childbirth. A population-based cohort study was conducted and included all women who delivered vaginally beyond 24-week gestation. Deliveries occurred during the years 1988 and 2016 at a single large teaching medical center. Rates of perineal lacerations were compared between women with DM in pregnancy (GDMA1 and GDMA2) and pre-gestational DM to those without DM. In addition, obstetrical and neonatal characteristics were compared between women with different types of DM. Multiple gestations, women lacking prenatal care and complication of stillbirth were excluded. Multivariable models of negative binomial regression analysis were used to evaluate prediction of perineal lacerations and associated risk factors. The study population included 250,853 pregnant women who met the inclusion criteria. Of these, 239,535 were without DM, while 11,318 women were diagnosed with DM in pregnancy. Women with DM had a higher rate of lacerations (21.% vs. 18.8%) with higher rates of OASIS (table 1). In the multivariate analysis, DM was found to be a significant risk factor for perineal lacerations, after controlling for birth weight, maternal age and nulliparity. When comparing pre-gestational and gestational DM while no difference was found in overall rates of lacerations, more extensive tears (second degree and higher) were more common in the pre-gestational group, as were certain pregnancy complications (table 2). Women with DM in pregnancy have a higher risk for perineal lacerations during childbirth.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

A multidisciplinary approach is needed to improve mental health and social connectedness in women suffering with obstetric fistula, chronic 4th degree tear and severe pelvic organ prolapse in limited resource regions

The Australian and New Zealand Continence Journal (ANZCJ) is a quarterly scientific, peer reviewed journal, produced under the auspice of the Continence Foundation of Australia and the New Zealand Continence Association (NZCA).