Degree Tears Research Articles

Obstetric profiles and pregnancy outcomes of immigrant women in New South Wales, 1990-1992.

This study examined the obstetric profiles and pregnancy outcomes of immigrant women in New South Wales (NSW). The source of data was the NSW Midwives Data Collection. The characteristics of 64,922 immigrant women were compared with 189,357 Australian-born non-Aboriginal women who delivered babies between 1990-1992 in NSW. The study demonstrated that immigrant women were older, generally had less private health insurance coverage and fewer teenage pregnancies. Immigrant women showed lower rates of essential hypertension, but higher rates of hepatitis B and gestational diabetes. While induced labour was conducted less frequently among immigrant women, episiotomy, instrumental delivery and Caesarean section were performed more frequently among this group. The incidence of postpartum complications was higher among immigrant women. Differences were assessed among women from European, Asian, Middle Eastern, American, New Zealand/Oceania and African backgrounds. For example, the higher rates of hepatitis B, gestational diabetes, episiotomy, instrumental delivery, Caesarean section, postpartum haemorrhage, third degree tear and puerperal infection among Asian-born women were of concern. By contrast, pregnancies among Middle Eastern-born women were associated with fewer complications in spite of their high parity and high percentage of teenage pregnancies. Infants of immigrant mothers were more likely to be resuscitated and/or admitted to special care nursery/neonatal intensive care unit. These findings in immigrant women in NSW suggested the need for culturally appropriate obstetric services, clinical practice reviews, and the greater involvement of general practitioners in obstetric care.

Episiotomy at the Royal Women's Hospital, Brisbane: a comparison of practices in 1986 and 1992

Objective: to determine whether the incidence of perineal outcomes, including episiotomy, at the Royal Women's Hospital (RWH) Brisbane reflected trends reported in the literature. Design: retrospective record review. Setting: RWH Brisbane. Participants: 953 women who delivered vaginally at the RWH in 1986 and 1992. Measurements and findings: there was a decline in the episiotomy rate from 65% in 1986 to 36% in 1992. This was accompanied by an increase in the incidence of intact perinea and spontaneous perineal tears. There was no difference in the incidence of spontaneous third degree tears. The decline in the incidence of episiotomy was found when other factors, such as parity, were considered, with the exception of operative vaginal delivery, where no difference in the use of episiotomy was found. There was no significant increase in the number of babies with an Apgar score of <7 at one minute of age, despite a significant reduction in the use of episiotomy when delivering these babies (55% in 1986 and 19% in 1992; P<0.001). The second stage was significantly longer in 1992 ( P<0.01). Key conclusions: the findings reflect the decline in the incidence of episiotomy reported in the literature. This decline in rate was accompanied by an increase in the length of second stage and in the incidence of both intact perinea and perineal tears. Lowering the incidence of episiotomy did not result in a rise in the rate of babies with an Apgar score of <7 at one minute.

Birth in standing position: A high frequency of third degree tears

During the past years a major change in the use of delivery position has occurred in Sweden. Recumbent delivery positions have been replaced by a variety of positions: squatting, standing, lateral, kneeling and quadruped. The consequences of this shift in obstetrical practice for development of perineal lacerations are largely unknown. Retrospective comparison of uncomplicated deliveries in standing (n = 650) and sitting (n = 264) position with respect to third degree lacerations. The standing and sitting delivery group were similar with respect to maternal, infant and delivery characteristics. The frequency of third degree tears was 2.50% in standing and 0.38% in sitting birth position (p < 0.05). In nulliparous women, third degree tears occurred in 4.2% in standing and 1.0% in sitting position. The present data implies that the risk of third degree lacerations is considerably higher (7 x) in standing than in sitting birth positions.

Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair.

To determine (i) risk factors in the development of third degree obstetric tears and (ii) the success of primary sphincter repair. (i) Retrospective analysis of obstetric variables in 50 women who had sustained a third degree tear, compared with the remaining 8553 vaginal deliveries during the same period. (ii) Women who had sustained a third degree tear and had primary sphincter repair and control subjects were interviewed and investigated with anal endosonography, anal manometry, and pudendal nerve terminal motor latency measurements. Antenatal clinic in teaching hospital in inner London. (i) All women (n = 8603) who delivered vaginally over a 31 month period. (ii) 34 women who sustained a third degree tear and 88 matched controls. Obstetric risk factors, defecatory symptoms, sonographic sphincter defects, and pudendal nerve damage. (i) Factors significantly associated with development of a third degree tear were: forceps delivery (50% v 7% in controls; P = 0.00001), primiparous delivery (85% v 43%; P = 0.00001), birth weight > 4 kg (P = 0.00002), and occipito-posterior position at delivery (P = 0.003). No third degree tear occurred during 351 vacuum extractions. Eleven of 25 (44%) women who were delivered without instruments and had a third degree tear did so despite a posterolateral episiotomy. (ii) Anal incontinence or faecal urgency was present in 16 women with tears and 11 controls (47% v 13%; P = 0.00001). Sonographic sphincter defects were identified in 29 with tears and 29 controls (85% v 33%; P = 0.00001). Every symptomatic patient had persistent combined internal and external sphincter defects, and these were associated with significantly lower anal pressures. Pudendal nerve terminal motor latency measurements were not significantly different. Vacuum extraction is associated with fewer third degree tears than forceps delivery. An episiotomy does not always prevent a third degree tear. Primary repair is inadequate in most women who sustain third degree tears, most having residual sphincter defects and about half experiencing anal incontinence, which is caused by persistent mechanical sphincter disruption rather than pudendal nerve damage. Attention should be directed towards preventive obstetric practice and surgical techniques of repair.

Management of the third stage of labour in women at low risk of postpartum haemorrhage

Objective: To compare active management with physiological management of the third stage of labour in women at low risk of postpartum haemorrhage. Design: Randomised allocation of women in labour at low risk of postpartum haemorrhage to either physiological or active management of the third stage. Setting: Labour ward in a district general hospital. Patients: 193 Women with spontaneous vaginal delivery at term completed the study. Exclusion criteria were induction or augmentation of labour, antepartum or previous postpartum haemorrhage, premature rupture of membranes, previous caesarean section, raised blood pressure, cervical lacerations and third degree tears. Interventions: Active management with syntometrine and controlled cord traction; or physiological management, where the cord was not clamped and the placenta was delivered by maternal effort. Measurements: Blood loss was measured subjectively at delivery and estimated objectively by comparing the haemoglobin in labour with that on the third postpartum day. The duration of the third stage was also measured as was the incidence of retained placenta and blood transfusion. Results: There was no significant difference in the estimated blood loss or haemoglobin drop between the two groups ( P > 0.5). In addition the duration of the third stage was significantly longer in the physiological group ( P < 0.001). Out of 90 women having physiological management, 7 received oxytocics for presumed postpartum haemorrhage. Only one case in the active group required further oxytocics and one other case in this group required a manual removal of placenta. Conclusions: This preliminary study confirms that active management results in a reduction in the length of the third stage of labour. However, it suggests that active management does not reduce blood loss when compared to physiological management in the woman at low risk of postpartum haemorrhage.

Anal manometric studies following 3d degree perineal tear

This study shows clinical and manometric data of fecal continence following third degree tears in correlation to anamnestic findings. The results are discussed with reference to the literature.

Episiotomy and perineal trauma during childbirth.

A study was conducted to assess the frequency of episiotomy and spontaneous tears in 807 primiparas during singleton births. The incidence of episiotomy was 50%, spontaneous tears 22% and intact perineum 28%. A significantly lower frequency of episiotomy (P less than 0.001) as well as epidural anaesthesia (P less than 0.001) was found among immigrant women. There were no indications registered for 58% of the episiotomies. The non-episiotomy group experienced more clitoris/labia tears (P less than 0.01). On the other hand there was a tendency towards an increased risk for second and third degree tears, 4.2% in the episiotomy group compared to 1.7% in the non-episiotomy group (P = 0.06). Haemorrhage (greater than 600 ml) was more frequent in the episiotomy group than in the non-episiotomy group (P less than 0.001). We conclude that there is little support for the claim that episiotomy prevents tears in normal deliveries, and that the rationale for the practice of episiotomy is in need of reappraisal.

Episiotomy and the perineum: a random controlled trial

SummaryA random controlled trial comparing restricted and liberal use of episiotomy was conducted. In the patients in whom the use of episiotomy was restricted (episioto-mies 32 per cent in primigravidae, 2 per cent in multi-gravidae), 32 per cent of primigravidae and 54 per cent of multigravidae had an intact perineum or a first degree tear. With liberal use of episiotomy (primigravidae 79 per cent, multigravidae 48 per cent), only 4 per cent of primigravidae and 26 per cent of multigravidae had an intact perineum or a first degree tear. Symptoms on the 3rd day postpartum were, on average, reduced in the patients in whom the use of episiotomy was restricted.

Five year prospective survey of risk of booking for a home birth in Essex.

A prospective survey was undertaken in 26 practices in Essex to assess the risks associated with a home birth. The 202 women who were booked for a home confinement were compared with a similar group of 185 women who were booked for hospital delivery under consultant care. The principal difference in outcome was the induction rate of 19% in the hospital group compared with 8% in the group booked for delivery at home. A higher rate of episiotomy and second degree tears and more Apgar scores of 7 or below were found in those who were booked for hospital. There were no perinatal deaths in either group. The results of this study showed no evidence of an increased risk associated with home confinements but indicated that there were fewer problems than were encountered in the deliveries in mothers confined in hospital.

An operation for rectovaginal fistula complicated by a third degree tear: Darner, H. Lauran: Surgery, Gynecology and Obstetrics, 1927, xliv, 105

An operation for rectovaginal fistula complicated by a third degree tear: Darner, H. Lauran: Surgery, Gynecology and Obstetrics, 1927, xliv, 105