Decreasing the incidence of anal sphincter tears during delivery.

OBJECTIVE: To estimate if an interventional program causes a decrease in the frequency of anal sphincter ruptures. METHODS: A total of 12,369 vaginal deliveries between 2002 and March 2007 were enrolled in the interventional cohort study. Slowing the delivery of the infant's head and instructing the mother not to push while the head is delivered was the intervention. Data were analyzed in relation to occurrence of anal sphincter tears. RESULTS: The proportion of parturients with anal sphincter tears decreased significantly during the study period from 4.03% (285 of 7,069) to 1.17% (42 of 3,577) (P<.001). A similar decrease was observed for instrumental deliveries (from 16.26% to 4.90%; P<.001) and noninstrumental deliveries (from 2.70% to 0.72%; P<.001). Although the number of patients with fourth-degree anal sphincter ruptures from 2002 through 2004 was 10, 13, and 11 per year, respectively, there was just one fourth-degree anal sphincter rupture during the whole study period of 18 months (P<.001). The number of episiotomies increased from 13.9% (980 of 7,069) in the years 2002-2004, to 23.1% during the first 9 months of the intervention (416 of 1,776; P<.001), but decreased to 21.1% (381 of 1,801) during the last 9 months of the intervention. CONCLUSION: As a result of this intervention the number of anal sphincter ruptures was reduced from 4.03% to 1.17%. LEVEL OF EVIDENCE: II.

[Low-risk pregnant women in an obstetric department--how do they give birth?]. / Lavrisikofødende ved en kvinneklinikk--hvordan føder de?

BACKGROUND: The aim of the study was to investigate the obstetric outcome for low-risk pregnant women delivering in a larger community hospital with 1800 deliveries annually. The investigation was carried out before the implementation of a differentiated plan for maternity care. MATERIAL AND METHODS: From January through June 2002, 920 women delivered. 520 were retrospectively considered low risk with spontaneous start of labour (56.5% of all labours). They were selected according to defined criteria. The results of this group with 197 nulliparous (37.7%) and 323 multiparous (62.1%) women are presented. RESULTS: There were 520 live newborns. 466 infants (89.6%) had an Apgar score > or = 8 after 1 minute; 509 a score > or = 8 after 5 minutes. In this low-risk group, 10.4% instrumental deliveries were performed, 2.7% caesareans and 7.7% vacuum extractions. In nulliparous women, the instrumental delivery rate was 19.7%, among the multiparous 4.6%. A surprisingly high number of low-risk women (38.7 %) were stimulated during labour with oxytocin, 62% of the primiparous and 24% of the multiparous. The indications for this were often obscure. Among oxytocin-stimulated primiparous women, 31.2% had an instrumental delivery, against 1.3% in non-stimulated women. Epidural analgesia was given to 22.3% of all low-risk women; of these, 91.4% received oxytocin. 3.1% had a perineal tear grade > or = 3. INTERPRETATION: The assistance given to women in a larger community hospital is more geared towards progress of labour than that given in smaller hospitals and midwife-controlled maternity homes. Frequent use of oxytocin to enhance contractions and epidural analgesia probably increases the rate of instrumental deliveries. This investigation points to the necessity of developing differentiated plans for maternity care given to low-risk women delivering in larger community hospitals, in line with a policy adopted by the Norwegian parliament.

Oxytocin and dystocia as risk factors for adverse birth outcomes: a cohort of low-risk nulliparous women.

OBJECTIVES: augmented and not augmented women without dystocia were compared to investigate associations between oxytocin and adverse birth outcomes. Augmented women with and without dystocia were compared, to investigate associations between dystocia and adverse birth outcomes. DESIGN: a cohort of low-risk nulliparous women originally included in a randomised controlled trial. SETTING: the Department of Obstetrics and Gynaecology, Østfold Hospital Trust, Norway. PARTICIPANTS: the study population consists of 747 well defined low-risk women. MEASUREMENTS: incidence of oxytocin augmentation, and associations between dystocia and augmentation, and mode of delivery, transfer of newborns to the intensive care unit, episiotomy and postpartum haemorrhage. FINDINGS: of all participants 327 (43.8%) were augmented with oxytocin of which 139 (42.5%) did not fulfil the criteria for dystocia. Analyses adjusted for possible confounders found that women without dystocia had an increased risk of instrumental vaginal birth (OR 3.73, CI 1.93-7.21) and episiotomy (OR 2.47, CI 1.38-4.39) if augmented with oxytocin. Augmented women had longer active phase if vaginally delivered and longer labours if delivered by caesarean section if having dystocia. Among women without dystocia, those augmented had higher body mass index, gave birth to heavier babies, had longer labours if vaginally delivered and had epidural analgesia more often compared to women not augmented. KEY CONCLUSION: in low-risk nulliparous without dystocia, we found an association between the use of oxytocin and an increased risk of instrumental vaginal birth and episiotomy. IMPLICATIONS FOR PRACTICE: careful attention should be paid to criteria for labour progression and guidelines for oxytocin augmentation to avoid unnecessary use.