Fourth-degree Tears Research Articles

Can the incidence of obstetric anal sphincter injury be reduced? The STOMP experience

ObjectiveTo reduce the incidence of third and fourth degree perineal tears. Study designThis was a quality improvement project followed by an audit of outcomes. The population consisted of all women delivering vaginally over a 12 month period following implementation of the quality improvement measures. Following a review of clinical factors associated with all third and fourth degree tears over a 3 month period and a review of relevant evidence, a series of measures to try and reduce the incidence of such tears were introduced. These measures were collectively known as STOMP (Stop Traumatic OASIS Morbidity Project). These were adopted by all staff in our unit, with an accompanying programme of workshops and a publicity campaign to promote staff engagement. Data were collected on all third and fourth degree tears for a 12 month period following project launch. The primary outcome was the incidence of third and fourth degree perineal tears over a 12 month period. ResultsThere were a total of 3902 vaginal births during the 12 month period following project launch. Following full STOMP implementation, there was a significant decrease in the incidence of third/fourth degree tears (4.7% vs 2.2%, p<0.0001). The reduction was most pronounced in the first 5 months (4.7% vs 1.51%, p<0.0001). ConclusionsSTOMP is a simple and low cost series of measures that has lead to a significant decrease in the incidence of third and fourth degree tears in this cohort of women.

Variations in rates of severe perineal tears and episiotomies in 20 European countries: a study based on routine national data in Euro-Peristat Project.

Rates of severe perineal tears and episiotomies are indicators of obstetrical quality of care, but their use for international comparisons is complicated by difficulties with accurate ascertainment of tears and uncertainties regarding the optimal rate of episiotomies. We compared rates of severe perineal tears and episiotomies in European countries and analysed the association between these two indicators. We used aggregate data from national routine statistics available in the Euro-Peristat project. We compared rates of severe (third- and fourth-degree) tears and episiotomies in 2010 by mode of vaginal delivery (n = 20 countries), and investigated time trends between 2004 and 2010 (n = 9 countries). Statistical associations were assessed with Spearman's ranked correlations (rho). In 2010 in all vaginal deliveries, rates of severe tears ranged from 0.1% in Romania to 4.9% in Iceland, and rates of episiotomies from 3.7% in Denmark to 75.0% in Cyprus. A negative correlation between the rates of episiotomies and severe tears was observed in all deliveries (rho = -0.66; p = 0.001), instrumental deliveries (rho = -0.67; p = 0.002) and non-instrumental deliveries (rho = -0.72; p < 0.001). However there was no relation between time trends of these two indicators (rho = 0.43; p = 0.28). The large variations in severe tears and episiotomies and the negative association between these indicators in 2010 show the importance of improving the assessment and reporting of tears in each country, and evaluating the impact of low episiotomy rates on the perineum.

Non-surgical intrapartum practices for the prevention of severe perineal trauma: a systematic review protocol.

The objective of this review is to determine the effectiveness of non-surgical intrapartum practices in reducing the incidence of severe perineal trauma (third and fourth degree tears) during childbirth.

Risk factors for recurrent obstetric anal sphincter injury (rOASI): a systematic review and meta-analysis.

ObjectivesThe objective of this study was to estimate the risk of recurrent obstetric anal sphincter injury (rOASI) in women who have suffered anal sphincter injury in their previous pregnancy and analyse risk factors for recurrence through a systematic review and meta-analysis.Data sourcesA review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Searches were made in Ovid MEDLINE (1996 to May 2015), PubMed, EMBASE and Google Scholar, including bibliographies and conference proceedings.Methods of study selectionObservational studies (cohort/case–control) evaluating rOASI and risk factors were selected by two reviewers who also analysed methodological quality of those studies. Pooled odds ratios (OR) for rOASI and individual risk factors were calculated using RevMan 5.3.Tabulation, integration and resultsFrom the eight studies assessed, overall risk of rOASI was 6.3 % compared with a 5.7 % risk of OASI in the first pregnancy. The risk in parous women with no previous OASI was 1.5 %. Factors that increased the risk in a future pregnancy were instrumental delivery with forceps [OR 3.12, 95 % confidence interval (CI) 2.42–4.01) or ventouse (OR 2.44, 95 % CI 1.83–3.25), previous fourth-degree tear (OR 1.7, 95 % CI 1.24–2.36) and birth weight ≥4 kg (OR 2.29, 95 % CI 2.06–2.54). Maternal age ≥35 years marginally increased the risk (OR 1.16, 95 % CI 1–1.35).ConclusionThe overall rate of rOASI and associated risk factors for recurrence are similar to the rate and risk factors of primary OASI. Antenatal decisions could be based on assessment of foetal weight and intrapartum decisions based upon the requirement for an instrumental delivery.Electronic supplementary materialThe online version of this article (doi:10.1007/s00192-015-2893-4) contains supplementary material, which is available to authorized users.

Evaluation of delivery options for second-stage events

Cesarean delivery in the second stage of labor is common, whereas the frequency of operative vaginal delivery has been declining. However, data comparing outcomes for attempted operative vaginal delivery vs cesarean in the second stage are scant. Previous studies that examine operative vaginal delivery have compared it to a baseline risk of complications from a spontaneous vaginal delivery and cesarean delivery. However, when a woman has a need for intervention in the second stage, spontaneous vaginal delivery is not an option she or the provider can choose. Thus, the appropriate clinical comparison is cesarean vs operative vaginal delivery. Our objective was to compare outcomes by the first attempted operative delivery (vacuum, forceps vs cesarean delivery) in patients needing second-stage assistance at a fetal station of+2 or below. We conducted secondary analysis of an observational obstetric cohort in 25 academically affiliated US hospitals over a 3-year period. A subset of ≥37 weeks, nonanomalous, vertex, singletons, with no prior vaginal delivery who reached a station of+2 or below and underwent an attempt at an operative delivery were included. Indications included for operative delivery were: failure to descend, nonreassuring fetal status, labor dystocia, or maternal exhaustion. The primary outcomes included a composite neonatal outcome (death, fracture, length of stay ≥3 days beyond mother's, low Apgar, subgaleal hemorrhage, ventilator support, hypoxic encephalopathy, brachial plexus injury, facial nerve palsy) and individual maternal outcomes (postpartum hemorrhage, third- and fourth-degree tears [severe lacerations], and postpartum infection). Outcomes were examined by the 3 attempted modes of delivery. Odds ratios (OR) were calculated for primary outcomes adjusting for confounders. Final mode of delivery was quantified. In all, 2531 women met inclusion criteria. No difference in the neonatal composite outcome was observed between groups. Vacuum attempt was associated with the lowest frequency of maternal complications (postpartum infection 0.2% vs 0.9% forceps vs 5.3% cesarean, postpartum hemorrhage 1.4% vs 2.8% forceps vs 3.8% cesarean), except for severe lacerations (19.1% vs 33.8% forceps vs 0% cesarean). When confounders were taken into account, both forceps (OR, 0.16; 95% confidence interval, 0.05-0.49) and vacuum (OR, 0.04; 95% confidence interval, 0.01-0.17) were associated with a significantly lower odds of postpartum infection. The neonatal composite and postpartum hemorrhage were not significantly different between modes of attempted delivery. Cesarean occurred in 6.4% and 4.4% of attempted vacuum and forceps groups (P= .04). In patients needing second-stage delivery assistance with a station of+2 or below, attempted operative vaginal delivery was associated with a lower frequency of postpartum infection, but higher frequency of severe lacerations.

Autoethnography and severe perineal trauma--an unexpected journey from disembodiment to embodiment.

BackgroundThere is a lack of research reporting on the physical and emotional experiences of women who sustain severe perineal trauma (third and fourth degree tears). When the researcher identifies with the group being researched, autoethnography can allow an insight into the experiences of the marginalised group through the telling of a personal story. The aim of this paper is to share the journey travelled by an autoethnographer who on examining the issue of severe perineal trauma came to understand the challenges and rewards she experienced through this reflective and analytic process.MethodsA transformative emancipatory approach guided the design, data collection and analysis of findings from this study. For this paper, a multivocal narrative approach was taken in presenting the findings, which incorporated the words of both the autoethnographer and the twelve women who were interviewed as a component of the study, all of whom had sustained severe perineal trauma.ResultsAs an autoethnographer, being a member of the group being researched, can be confronting as the necessary reflection upon one’s personal journey may lead to feelings of vulnerability, sadness, and emotional pain. The transformation from disembodied to embodied self, resulted in a physical and emotional breakdown that occurred for this autoethnographer.ConclusionAutoethnographers may experience unexpected emotional and physical challenges as they reflect upon their experiences and research the experiences of others. When incorporating a transformative emancipatory framework, the hardships are somewhat balanced by the rewards of witnessing ‘self-transformation’ as a result of the research.

Prevalence of unrepaired third- and fourth-degree tears among women taken to the operating room for repair of presumed obstetric fistula during two fistula camps in Kenya.

More than 2 million women on earth today are said to be suffering from obstetric fistula (OF), a communication between the vagina and either the urinary tract or rectum. Since unrepaired third- and fourth-degree perineal tears often manifest with symptoms identical to OF, we hypothesized that the global burden of OF is in part due to these unrepaired deep obstetric tears. Four consultant gynecologists retrospectively reviewed the medical and operative records of all obstetric fistula cases that underwent surgical repair during the July and August, 2014, Kenyatta National Hospital and Embu Provincial Hospital Fistula Camps in Kenya. One hundred and eighty charts were reviewed. All 180 women had fecal incontinence (FI), urinary incontinence (UI), or both as their primary complaint. Sixty of the 180 (33%) women had isolated FI as their presenting symptom, and at operation, 57 of these 60 (95%) were found to have unrepaired third- and fourth-degree obstetric tears. Ninety-two of the 180 (51%) women with OF symptoms ultimately had true OF confirmed at operation. These findings suggest that many women with OF symptoms in Kenya may harbor unrepaired third- and fourth-degree tears. Additionally, women with isolated FI may be more likely to suffer from third- and fourth-degree tears than from true OF. Immediate postpartum diagnosis and repair of third- and fourth-degree perineal tears could significantly reduce the overall burden of women with symptoms of OF.

Clinical symptoms related to anal sphincter defects and atrophy on external phased-array MR imaging.

Introduction and hypothesisDefecatory complaints have a severe impact on quality of life. The additional value of pelvic floor MRI in patients with defecatory complaints is unclear. Our aim was to correlate the presence of defects and atrophy of the anal sphincter complex using pelvic floor MRI in women with mixed pelvic floor symptoms and to establish patient characteristics and self reported complaints predictive of pathology.MethodsThis is a retrospective study among women with mixed pelvic floor symptoms who underwent external phased-array MRI and completed a questionnaire on bothersome defecatory complaints. Data on patient characteristics, including obstetrical history and questionnaire scores were correlated with the assessment of anal sphincter defects and atrophy on pelvic floor MRI.ResultsOne hundred and fifty-eight women were included. A defect of the external anal sphincter (EAS) and internal anal sphincter (IAS) was found in 18 (11 %) and 5 (3 %) patients respectively. Atrophy of the EAS was present in 72 patients (46 %), with more cases of mild (n = 52, 33 %) than severe atrophy (n = 20, 13 %). The variable “previous third or fourth degree tear” had a significant positive association with an IAS defect on MRI, with an OR of 9.533 (1.425–63.776). Patients with EAS atrophy had higher scores for fecal incontinence (indicating more bother) than patients without EAS atrophy. Higher age and BMI were true predictors of the presence of more severe EAS atrophy.ConclusionAtrophy of the EAS was highly prevalent in this population and was associated with bothersome symptoms of fecal incontinence.

OC-085 Endoanal ultrasound findings and corresponding cleveland clinic faecal incontinence scores following a third or fourth degree perineal tear

Introduction Third and fourth degree perineal tears will occur in a small proportion of vaginal deliveries. When found at the time of delivery, they are typically repaired primarily. Patients may subsequently suffer from faecal incontinence. Method All patients with a third and fourth degree tear were referred for assessment. This included endoanal ultrasonography and estimation of incontinence with the Cleveland Clinic faecal incontinence score. Data from 2001 to 2013 were analysed. Results 888 patients were included. Of these, 551 (62%) were found to have a sphincter defect. 333 (38%) had intact sphincters. The majority of these had normal looking sphincters on ultrasonography. The mean (SD) incontinence score for those with a defect was 4.3 (5.5). The mean incontinence score for those with no defect was 4.2 (5.8). Conclusion The majority of patients had a sphincter defect. This suggests that there is a high failure rate from the primary repair. The high proportion of normal looking sphincters suggests that third and fourth degree tears may be over diagnosed. Despite the ultrasound findings, the incontinence scores for both groups were comparable. Disclosure of interest None Declared.

PWE-408 Should primigravida be made aware of the risk of sphincter injuries and their consequences during antenatal counselling?

<h3>Introduction</h3> The incidence of detected third and fourth degree tears is about 2–4%, the risk being higher in first vaginal delivery, assisted deliveries and where there is an abnormal presentation. Many become incontinent. <h3>Method</h3> 81 women with faecal incontinence after childhood trauma were interviewed. <h3>Results</h3> First vaginal delivery: 68 (84%). Assisted delivery: 57 (70%) (Ventouse alone 11, forceps alone 23, both 23). Third degree tear: 52 (64%) (repaired 27, missed 25). Fourth degree tear: 27 (33%) (repaired 13, missed 14). Neuropathy: 25 (31%). Recto-vaginal fistula: 14 (17%). Episiotomy fistula: 10 (12%). Stoma: 16 (20%) (7 still present). Urinary Incontinence: 42 (52%). All had severe bowel incontinence. Sexual dysfunction was present in 77 (95%). Emotional consequences included: anxiety: 80 (99%), embarrassment: 78 (96%), loss of dignity: 68 (84%), loss of confidence: 68 (84%), feeling isolated: 43 (53%), confined to the house: 24 (30%), antidepressant medication: 31 (38%), anger: 23 (28%). <h3>Conclusion</h3> More emphasis should be placed on antenatal counselling, particularly amongst mothers pregnant for the first time. <h3>Disclosure of interest</h3> None Declared.

Kielland's forceps: does it increase the risk of anal sphincter injuries? An observational study.

Rotational instrumental deliveries are thought to carry additional risks compared with non-rotational instrumental deliveries, including trauma to maternal tissues, and require specific expertise and training. We conducted a retrospective study to investigate the association between the type of forceps delivery and maternal perineal trauma, and in particular to investigate if Kielland's rotational forceps delivery increases obstetric anal sphincter injuries (OASIS). This is a retrospective observational study of 1,515 women who attended a tertiary maternity unit over a period of 5 years and had operative vaginal deliveries primarily or completed by forceps. Data were obtained through the hospital's maternity reporting system. The severity of maternal perineal trauma, particularly third and fourth-degree tears in relation to the type of forceps delivery was explored. Multinomial logistic regression models were used to estimate the crude and the adjusted relative risks (RR) of sustaining third-degree tears compared with other types of vaginal tears. Univariate analyses explored the crude associations between relative risks and age, ethnicity, birth weight, type of instrumental delivery and operator's experience. A multivariate multinomial logistic regression model estimated the adjusted relative risks and included all the previous variables as independent covariates. Of the 1,492 women included in the study, 150 women (77 %) had sustained category 1 tears, 63 women (4 %) had sustained category 2 tears and 279 women (19 %) had sustained third-degree tears. There was no statistically significant association between the severity of maternal perineal trauma and the type of forceps delivery (failed ventouse vs Kielland's forceps RR 1.52, p = 0.159 CI 0.84-2.72, Wrigleys vs Kielland's RR 0.59, p = 0.249, CI 0.24-1.43; Andersons vs Kielland's RR 1.16, p = 0.603, CI 0.65-2.05) after adjusting for age, birth weight, BMI, ethnicity and operator experience (full list of covariates not included). The incidence of third- and fourth-degree tears following rotational Kielland's forceps delivery and other non-rotational forceps deliveries is comparable.

The impact of first birth obstetric anal sphincter injury on the subsequent birth: a population-based linkage study.

BackgroundWith rising obstetric anal sphincter injury (OASI) rates, the number of women at risk of OASI recurrence is in turn increasing. Decisions regarding mode of subsequent birth following an OASI are complex, and depend on a variety of factors. We sought to identify the risk factors for OASI recurrence from first and subsequent births, and to investigate the effect of OASI birth factors on planned caesarean for the second birth.MethodsUsing two linked population datasets from New South Wales, Australia, we selected women giving birth between 2001 and 2011 with a first birth OASI and a subsequent birth. Multivariable logistic regression was used to identify the association of first and second birth factors with OASI recurrence, and to determine which factors were associated with a planned pre-labour caesarean at the second birth.ResultsOf 6,380 women with a first birth OASI who proceeded to a subsequent birth, 75.4% had a vaginal second birth, 19.4% a pre-labour caesarean, and 5.2% an intrapartum caesarean. Although the OASI recurrence rate of 5.7% was significantly higher than the first birth OASI rate of 4.5% (p < 0.01), this may not reflect a clinically significant increase. Following adjustment for first and second birth factors, first birth diabetes and second birthweight ≥3.5 kg were associated with increased likelihood of OASI recurrence, while first birthweight ≥4.0 kg and second gestation at 37–38 weeks were associated with decreased likelihood. A fourth degree tear at the first birth was the strongest factor associated with planned caesarean at the second birth, with other factors including epidural, spinal or general anaesthetic, birthweight, gestation, country of birth and maternal age.ConclusionsCompared with previous reports, the low OASI recurrence rate (approximately one in twenty) may reflect appropriate decision-making about subsequent mode of delivery following first birth OASI. This assertion is supported by evidence of different risk profiles for women who have planned caesareans compared with planned vaginal births.

Antibiotic prophylaxis for third- and fourth-degree perineal tear during vaginal birth.

One to eight per cent of women suffer third-degree perineal tear (anal sphincter injury) and fourth-degree perineal tear (rectal mucosa injury) during vaginal birth, and these tears are more common after forceps delivery (28%) and midline episiotomies. Third- and fourth-degree tears can become contaminated with bacteria from the rectum and this significantly increases in the chance of perineal wound infection. Prophylactic antibiotics might have a role in preventing this infection. To assess the effectiveness of antibiotic prophylaxis for reducing maternal morbidity and side effects in third- and fourth-degree perineal tear during vaginal birth. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (31 August 2014) and the reference lists of retrieved articles. Randomised controlled trials comparing outcomes of prophylactic antibiotics versus placebo or no antibiotics in third- and fourth-degree perineal tear during vaginal birth. Two review authors independently assessed the trial reports for inclusion and risk of bias, extracted data and checked them for accuracy. We identified and included one trial (147 women from a pre-planned sample size of 310 women) that compared the effect of prophylactic antibiotic (single-dose, second-generation cephalosporin - cefotetan or cefoxitin, 1 g intravenously) on postpartum perineal wound complications in third- or fourth-degree perineal tears compared with placebo. Perineal wound complications (wound disruption and purulent discharge) at the two-week postpartum check up were 8.20% and 24.10% in the treatment and the control groups respectively (risk ratio (RR) 0.34, 95% confidence interval (CI) 0.12 to 0.96). However, the high failed-appointment rate may limit the generalisability of the results. The overall risk of bias was low except for incomplete outcome data. The quality of the evidence using GRADE was moderate for infection rate at two weeks' postpartum, and low for infection rate at six weeks' postpartum. Although the data suggest that prophylactic antibiotics help to prevent perineal wound complications following third- or fourth-degree perineal tear, loss to follow-up was very high. The results should be interpreted with caution as they are based on one small trial.

Impact of third‐ and fourth‐degree perineal tears at first birth on subsequent pregnancy outcomes: a cohort study

To investigate, among women who have had a third- or fourth-degree perineal tear, the mode of delivery in subsequent pregnancies as well as the recurrence rate of third- or fourth-degree tears. A retrospective cohort study of deliveries using a national administrative database. The English National Health Service between 1 April 2004 and 31 March 2012. A total of 639,402 primiparous women who had a singleton, term, vaginal live birth between April 2004 and March 2011, and a second birth before April 2012. Multivariable logistic regression models were used to estimate odds ratios, adjusted for other risk factors. Mode of delivery and recurrence of tears at second birth. The rate of elective caesarean at second birth was 24.2% for women with a third- or fourth-degree tear at first birth, and 1.5% for women without (adjusted odds ratio, aOR 18.3, 95% confidence interval, 95% CI 16.4-20.4). Among women who had a vaginal delivery at second birth, the rate of third- or fourth-degree tears was 7.2% for women with a third- or fourth-degree tear at first birth, compared with 1.3% for women without (aOR 5.5, 95% CI 5.2-5.9). The risk of a severe perineal tear is increased five-fold in women who had a third- or fourth-degree tear in their first delivery. This increased risk should be taken into account when decisions about mode of delivery are made.

Variability in the rate of episiotomies and its relation to severe perineal tears and neonatal morbility

To determine the variability in the use of episiotomy among midwives and its relation to third and fourth-degree tears, and the impact on neonatal morbidity. A study was conducted on historical groups from a total of 2,366 eutocic births with a single live fetus greater than or equal to 37 weeks gestation and 18 midwives over a three year period (2009, 2010 and 2011) in "Mancha-Centro" Hospital (Alcázar de San Juan).The outcomes variables for this analysis were the incidence of episiotomy, perineal lacerations, and neonatal morbidity. The variability in the use of episiotomy ranged from 19.5% to 50.1% among the 18 midwives in the study, with an average rate of 34.9% (824). Grouped at intervals, 22.1% (524) had a rate of ≤25%, 26.1% (621) between 26-35%, 38% (898) between 36-44%, and 13.7% (323) a rate of ≥45%, with homogeneity between the groups for all the confounding factors. There was no statistical association between higher rates of episotomy and pH of umbilical artery<7.10, Apgar score after 5 min<7, and the level of neonatal resuscitation type iii and iv. There was also no relationship between the rate of episiotomy with perineal integrity and third and fourth-degree tears. The variability in the rate of episiotomy is high, and it is not related to the increased presence of third and fourth-degree tears or increased neonatal morbidity. Episiotomy rates should not be greater than 25%, in order to prevent perineal trauma or loss of fetal well-being.

Chronic non-healing sinus manifesting in episiotomy scar: hidden fistula-in-ano

A non-healing sinus manifesting in an episiotomy scar after it has healed is rare. We report one such woman. There were no underlying risk factors like third- or fourth-degree tear or inflammatory bowel disease. In spite of previous attempted exploration the problem had persisted. Examination of the case under anaesthesia revealed it to be a low fistula-in-ano. The methodical evaluation and management of the case is detailed. Fistulectomy completely cured the patient. Most of these patients present to obstetricians and gynaecologists. Awareness and a high index of suspicion of communication with the anorectal canal are important. A team approach with the colorectal surgeon would help in better preoperative counselling, planned evaluation and definitive procedure to completely cure the patient.

Postpartum anal incontinence in a resource-constrained setting: Prevalence and obstetric risk factors

Background . Postpartum anal incontinence (AI) is a common and debilitating condition, but data from resource-constrained settings are scarce. Objective . To show that AI is common in a resource-constrained setting and that obstetric factors contribute to its development. Methods . This prospective questionnaire-based study performed in the Durban metropolitan area of South Africa involved black Africans and Indians. Patients were recruited antenatally and followed up for 6 months after delivery. Data collected antenatally and 6 weeks and 6 months after delivery included demographics, obstetric factors and symptoms of AI. The association between these variables and AI were explored using bivariate and multivariate analysis. Results. The median age of the 1 248 participants was 24 years (range 13 - 45 years). The majority were black Africans (n=1 004, 80.4%), 86 (6.7%) underwent induction of labour, 95 (7.6%) required augmentation, 186 (14.9%) had epidural analgesia, 418 had mediolateral episiotomies (33.5%), and 51 (4.1%) had third- or fourth-degree tears. The antenatal prevalence of AI was 57.9% (n=722). Six weeks after delivery, 23.1% more women had symptoms of AI compared with the antenatal prevalence. At 6 months, only 0.7% of women reported symptoms. Being black African was significantly associated with AI (odds ratio (OR) 1.7, 95% confidence interval (CI) 1.2 - 2.7) and having had epidural analgesia was significantly associated with faecal incontinence (OR 1.7, 95% CI 1.1 - 2.9) at 6 weeks after delivery. At 6 months most women reported no symptoms of AI. Conclusion . Postpartum AI is common in our resource-constrained setting and appears to be transient, with most cases resolving by 6 months.

Instrumental vaginal deliveries; are midwives safer practitioners? A retrospective cohort study

To compare obstetric morbidity of midwife-performed instrumental vaginal deliveries with those performed by doctors. Retrospective cohort study. University Hospital, UK. Women undergoing an instrumental vaginal delivery of a singleton infant outside of the operating theater in Aberdeen Maternity Hospital, between June 2005 and June 2010. Prospectively entered data were obtained from the hospital data management system. Obstetric outcomes of deliveries by midwives were compared with those performed by any doctor and, in a secondary analysis, with those by junior doctors (fewer than two years at 'registrar' level). Sociodemographic characteristics and clinical outcomes were compared using the chi-squared test, Mann-Whitney U-test and independent sample t-test. Third- or fourth-degree tears. Among 2540 women identified, 330 (13%) were delivered by midwives. Maternal and clinical characteristics were comparable in each group. Midwives were more likely to use ventouse as their instrument of choice. Women delivered by midwives were less likely to suffer a third- or fourth-degree tears than those delivered by doctors and junior doctors. This difference did not reach statistical significance once adjusted for instrument used: odds ratio 0.6 (95% confidence interval: 0.3-1.2) and odds ratio 0.6 (95% confidence interval: 0.3-1.1), respectively. Instrumental vaginal deliveries performed by trained midwives are associated with equivalent maternal morbidity to those performed by doctors once adjusted for midwives' preference for the ventouse. This study highlights the potential contribution of an advanced role for midwives in the labor ward.

Functional and physiological outcomes following repair of obstetrics anal sphincter injury. A case

IntroductionObstetric anal sphincter injury has important psychosocial implications and impact on subsequent pregnancies. Sound operative repair is essential, yet between 14 and 61% patients with obstetric anal sphincter injuries report incontinence symptoms. Objective assessment of the outcome following repair can be performed using anorectal manometry and endoanal ultrasonography. The aim of this study was to assess functional and physiological outcome in patients undergoing operative repair of third or fourth degree tears. MethodsDemographic information and obstetric details were collected retrospectively for patients who sustained a third or fourth degree anal sphincter injury between the periods of 1st January 2008–31st December 2009. All patients were followed up by the Colorectal Nurse Specialist in a dedicated clinic. A detailed history, examination, anorectal manometry (AM) and endoanal ultrasound (EAU) were performed. ResultsOf 210 patients identified data was available for 190 (90%). Median age was 29 years and 74% of the patients were primagravida. Twenty one (11%) patients had grade 3 tear, 81 (43%) grade 3a, 63 (33%) grade 3b, 15 (8%) grade 3c and 10 (5%) patients had grade 4 tears. All patients underwent primary repair: where data was available for operative technique 68 (36%) patients underwent end-to-end and 96 (51%) had overlap repair. 177 (93%) of the repairs were performed by Registrars. Median follow up was 3 months and data was available for 142 (75%) patients. 29 (20%) patients exhibited symptoms of incontinence. Anal resting and squeeze pressure were reduced in patients experiencing incontinence symptoms (66 mHg vs 58 mmHg and 120 mmHg vs 98 mmHg respectively). EAU revealed one EAS (external anal sphincter)/IAS (internal AS) defect, seven IAS defects and 33 thinning of IAS. One quarter of patients with IAS thinning or defect exhibited incontinence symptoms. ConclusionOne fifth of patients experienced some incontinence following repair of obstetric anal sphincter injury, but only 2 patients were incontinent of faeces at 3 month follow up. This represents some improvement in outcome compared to results from the last two decades. Anal pressures in patients experiencing incontinence were reduced, and thinning of the IAS was more common in patients with incontinence symptoms. Efforts to identify occult IAS injury and repair this as well as the EAS may improve patient outcome.

Third‐ and fourth‐degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors

To describe the trends of severe perineal tears in England and to investigate to what extent the changes in related risk factors could explain the observed trends. A retrospective cohort study of singleton deliveries from a national administrative database. The English National Health Service between 1 April 2000 and 31 March 2012. A cohort of 1 035 253 primiparous women who had a singleton, term, cephalic, vaginal birth. Multivariable logistic regression was used to estimate the impact of financial year of birth (labelled by starting year), adjusting for major risk factors. The rate of third-degree (anal sphincter is torn) or fourth-degree (anal sphincter as well as rectal mucosa are torn) perineal tears. The rate of reported third- or fourth-degree perineal tears tripled from 1.8 to 5.9% during the study period. The rate of episiotomy varied between 30 and 36%. An increasing proportion of ventouse deliveries (from 67.8 to 78.6%) and non-instrumental deliveries (from 15.1 to 19.1%) were assisted by an episiotomy. A higher risk of third- or fourth-degree perineal tears was associated with a maternal age above 25 years, instrumental delivery (forceps and ventouse), especially without episiotomy, Asian ethnicity, a more affluent socio-economic status, higher birthweight, and shoulder dystocia. Changes in major risk factors are unlikely explanations for the observed increase in the rate of third- or fourth-degree tears. The improved recognition of tears following the implementation of a standardised classification of perineal tears is the most likely explanation.