The association of obstetric anal sphincter injury and mediolateral episiotomy with increasing birth weight and duration of second stage of labour in spontaneous vaginal delivery.

OBJECTIVES: Analysis of the association of mediolateral episiotomy (MLE) with obstetric anal sphincter injury (OASI) in women with spontaneous vaginal delivery. DESIGN: Population-based cohort study with data from the Netherlands Perinatal Registry, describing 541 055 women who delivered a singleton live born infant in cephalic presentation spontaneously at term. Risk indicators for OASI were tested using univariate and multivariate analysis. Additional analysis for the interaction of MLE with other risk indicators was performed. RESULTS: The rate of OASI was 4.2 % in 215 241 nulliparous and 1.4 % in 325 814 multiparous women. In nulliparous and multiparous women MLE was associated with a reduction of OASI (adjusted OR (aOR) 0.3, 95 % CI 0.30-0.34 and aOR 0.32, 95 % CI 0.30-0.34). The association of MLE with a reduced rate of OASI was stronger in high birthweight and in prolonged 2nd stage groups. In nulliparous women, the number needed to treat (NNT) for the use of MLE to prevent one OASI is 31 in general. With MLE, the OASI rate reduced from 11.5 % to 2.9 with a NNT of 12 in the group with a birth weight ≥ 4000 g and a duration of the second stage of labour of 60-120 min. The NNT is 9 In the group with a birth weight ≥ 4000 g and a duration of the second stage of labour ≥ 120 min (reduction rate of OASI from 14.2 % to 3.5 %). CONCLUSIONS: Use of MLE is associated with a reduction of OASI in spontaneous vaginal delivery. In nulliparous women, an episiotomy with an anticipated birth weight > 4000 g and a duration of the 2nd stage of more than 60 min should be considered.

Obstetric Anal Sphincter Injury Care Bundle: A Quality Improvement Initiative.

INTRODUCTION AND HYPOTHESIS: The objective was to implement an evidence-based peri-partum care bundle for women sustaining obstetric anal sphincter injuries and to evaluate compliance with recommendations for antibiotics use, repair in the operating room, and follow-up before and after implementation. METHODS: This project was reviewed by the Institutional Review Board and determined to be exempt. A clinical care bundle containing education and standardized orders in the electronic medical record was implemented. Characteristics of pre- (October 2017 to September 2019) and post-intervention (October 2019 to August 2021) cohorts were compared and compliance with recommendations for antibiotics use, surgical repair location, and follow-up were evaluated. Chi-squared, Fisher's exact, ANOVA F, and Kruskal-Wallis tests were performed, as indicated. Significance level was p < 0.05. RESULTS: A total of 185 cases were identified. Seventy-five percent of women were nulliparous. Mean gestational age was 39 weeks. Pre- and post-intervention groups did not differ in age, BMI, race, parity, gestational age, comorbidities, birthweight, or delivery type. Ninety-eight cases were identified pre-implementation. Eighty-six (88%) had third-degree lacerations. Post-implementation, 87 cases were identified. Seventy (80%) had third-degree lacerations (p = 0.17). Recommended antibiotic-type use improved from 35% pre-implementation to 93% post-implementation (p < 0.001). Repair in the operating room was similar pre-implementation and post-implementation (16.0% vs 12.6%, p = 0.48). Post-partum follow-up within 2 weeks improved from 16.3% pre-implementation to 52.8% post-implementation and mean time to follow-up was shorter post-implementation than pre-implementation (18 vs 33 days; both p < 0.001). CONCLUSIONS: Implementation of an evidence-based peri-partum care bundle resulted in standardization of care in accordance with established recommendations. Compliance with recommendations for surgical repair in the operating room remained unchanged.

Bladder Responses to Thoracolumbar Epidural Stimulation in Female Urethane-Anesthetized Rats with Graded Contusion Spinal Cord Injuries.

Spinal cord epidural stimulation (scES) is a therapeutic option that promotes functional improvements in sensory, motor, and autonomic functions following spinal cord injury (SCI). Previous scES mapping studies targeting the lower urinary tract (LUT) in rats demonstrated functional response variability based upon lumbosacral level, parameters used, extent of injury (spinally intact vs. chronic anatomically complete spinal transections), and sex. In the current study, female rats with clinically relevant graded incomplete T9 contusion injuries were mapped with scES at 60 days post-injury at three spinal levels (T13, L3, L6) with a novel miniature 15-electrode array designed to deliver optimal specificity. The results obtained during bladder fill and void cycles conducted under urethane anesthesia indicate frequency dependent sub-motor threshold effects on LUT function with a single row of electrodes positioned across the full medio-lateral extent of the dorsal cord. The findings of improved storage and emptying, represented by significantly longer inter-contractile intervals with T13 scES and L3 scES and by a significantly increased estimated void efficiency with L6 scES, respectively, are consistent with previous studies using intact and chronic complete transected male and female rats. The data support the efficacy of selective spinal network stimulation to drive functionally relevant networks for storage versus emptying phases of the urinary cycle. The current findings further demonstrate the translational promise of scES for SCI individuals with LUT dysfunctions, regardless of injury severity.

Platelet-Rich Plasma in Urogynecology: A Case Series.

Platelet-rich plasma (PRP) use in urogynecology is expanding as it shows good results with minimal side effects. We present three new indications of PRP use in urogynecology that have not been previously reported. Our case series demonstrated that PRP improved wound healing and recovery in a woman with chronic obstetric anal sphincter injuries (OASIS) after home delivery, decreased pain in a patient suffering from vulvodynia, and enhanced epithelization in recurrent vaginal stenosis after Fournier gangrene. We have also reviewed patient selection criteria, PRP preparation prerequisites, and techniques. A safe, simple protocol with an optimal platelet yield without using commercial PRP kits is described.

Problems with repairing gut sphincters malfunctions.

Correcting a gut sphincter malfunction is a difficult problem. Because each sphincter has two opposite functions, that of closure and opening, repairing one there is a risk of damaging the other. Indeed, widening a narrow sphincter, such as lower esophageal sphincter (LES) and anal sphincter, may cause gastroesophageal reflux and fecal incontinence, respectively, whereas narrowing a wide sphincter, may cause a difficult transit. All the corrective treatments for difficult or retrograde transit concerning LES and anal sphincter with their unwanted consequences have been analyzed and discussed. To overcome the drawbacks of sphincter surgical repairs, researchers have devised devices capable of closing and opening the gut lumen, named artificial sphincters (ASs). Their function is based on various mechanisms, e.g., hydraulic, magnetic, mechanical etc, operating through many complicated components, such as plastic cuffs, balloons, micropumps, micromotors, connecting tubes and wires, electromechanical clamps, rechargeable batteries, magnetic devices, elastic bands, etc. Unfortunately, these structures may facilitate the onset of infections and induce a local fibrotic reaction, which may cause device malfunctioning, whereas the compression of the gut wall to occlude the lumen may give rise to ischemia with erosions and other lesions. Some ASs are already being used in clinical practice, despite their considerable limits, while others are still at the research stage. In view of the adverse events of the ASs mentioned above, we considered applying bioengineering methods to analyze and resolve biomechanical and biological interaction problems with the aim to conceive and build efficient and safe biomimetic ASs.

Obstetric Anal Sphincter Injury After Episiometer-Guided Versus Conventional Episiotomy in Instrumental Deliveries: A Randomized Controlled Trial.

INTRODUCTION AND HYPOTHESIS: Guidelines recommend episiotomy for instrumental vaginal delivery with an optimal incision angle of 60° to protect the anal sphincter. The "Episiometer" is a new device promising a 60° incision angle. We compared the incidence of obstetric anal sphincter injury (OASI) and post-repair suture angle of episiotomies made with conventional "eyeballing" versus Episiometer guided during instrumental delivery. METHODS: We conducted this randomized controlled trial in a tertiary care teaching institute in southern India after ethical committee approval, trial registration, and informed consent. We randomized (block) 328 pregnant women aged 18 years and above with term, singleton fetuses delivered by instruments into Episiometer-guided (164) or conventional episiotomy (164) groups (allocation concealed). We compared the OASI (identified clinically) and the suture angle measured from the midline (assessor blinded) in the two groups. We followed up on the subjects at 6 and 12 weeks to assess perineal pain and fecal/flatus incontinence. RESULTS: The incidence of OASI of 0.61% in the Episiometer group was significantly lower compared with 4.88% in the eyeballing group (Chi-squared = 5.6; p = 0.02; adjusted risk ratio = 5.9; CI 0.7-46.1; p = 0.09). A significantly higher proportion of subjects (59.1%) in the Episometer group had a post-suture angle between 36 and 40° compared with 36.6% in the eyeballing group (Chi-squared = 21.8, p < 0.001). We found no significant difference in the perineal pain or Wexner score during follow-up. CONCLUSION: The Episiometer-guided episiotomy during instrumental delivery resulted in a significantly higher suture angle and lower obstetric anal sphincter injuries than with conventional eyeballing.

Experimental evaluation of an artificial anal sphincter based on biomechanical compatibility.

BACKGROUND: The artificial anal sphincter is a device used to treat patients with fecal incontinence who are unable to control their bowel movements on their own. Long-term morphological changes in the tissue surrounding the artificial anal sphincter can cause biomechanical compatibility problems, which seriously affect the clinical application of the artificial anal sphincter. METHODS: In this paper, the superelasticity of shape memory alloys was utilized to design and fabricate a biomechanically compatible constant force clamping artificial anal sphincter. An in vitro simulation system was constructed to verify the effectiveness, safety, and constant force characteristics of the artificial anal sphincter. RESULTS: The experimental results demonstrated that the artificial anal sphincter could be effectively closed with no leakage of the liquid-like intestinal contents, which are most likely to leak. The pressure of the artificial anal sphincter on the intestinal tube gradually increased and eventually became constant during closure, and the pressure value was always less than the intestinal blood supply pressure threshold. CONCLUSIONS: In this paper, we designed an artificial anal sphincter based on biomechanical compatibility and the corresponding in vitro simulation experimental program and preliminarily verified the effectiveness, safety, and constant force characteristics of the artificial anal sphincter.

Midterm complications after primary obstetrical anal sphincter injury repair in France.

BACKGROUND: Incidence of complications following obstetrical anal sphincter injury (OASI) during vaginal delivery are poorly defined. They are only studied in high level maternities, small cohorts, all stages of perineal tear or in low-income countries. The aim of our study was to describe complications after primary OASI repair following a vaginal delivery in all French maternity wards at short and midterm and to assess factors associated with complication occurrence. METHODS: We conducted a historical cohort study using the French nationwide claim database (PMSI) from January 2013 to December 2021. All women who sustained an OASI repair following a vaginal delivery were included and virtually followed-up for 2 years. Then, we searched for OASIS complications. Finally, we evaluated factors associated with OASIS complication repaired or not and OASIS complication repairs. RESULTS: Among the 61,833 included women, 2015 (2.8%) had an OASI complication and 842 (1.16%) underwent an OASI complication repair. Women were mainly primiparous (71.6%) and 44.3% underwent an instrumental delivery. During a follow-up of 2 years, 0.6% (n = 463), 0.3% (n = 240), 0.2% (n = 176), 0.1% (n = 84), 0.06% (n = 43) and 0.01% (n = 5) of patients underwent second surgery for a perineal repair, a fistula repair, a sphincteroplasty, a perineal infection, a colostomy and a sacral nervous anal stimulation, respectively. Only one case of artificial anal sphincter was noticed. Instrumental deliveries (OR = 1.56 CI95%[1.29;1.9]), private for-profit hospitals (OR = 1.42 [1.11;1.82], reference group "public hospital"), obesity (OR = 1.36 [1;1.84]), stage IV OASIS (OR = 2.98 [2.4;3.72]), perineal wound breakdown (OR = 2.8 [1.4;5.48]), ages between 25 and 29 years old (OR = 1.59 [1.17;2.18], refence group "age between 13 and 24 years old") and 30 and 34 years old (OR = 1.57 [1.14; 2.16], refence group "age between 13 and 24 years old") were factors associated with OASIS complication repairs. CONCLUSIONS: Maternal age, stage IV OASIS, obesity, instrumental deliveries and private for-profit hospitals seemed to predict OASIS complications. Understanding factors associated with OASIS complications could be beneficial for the patient to inform them and to influence the patient's follow-up in order to prevent complications, repairs and maternal distress.

Muscle regeneration therapy using dedifferentiated fat cell (DFAT) for anal sphincter dysfunction.

PURPOSE: We investigated the effects of mouse-derived DFAT on the myogenic differentiation of a mouse-derived myoblast cell line (C2C12) and examined the therapeutic effects of rat-derived DFAT on anal sphincter injury using a rat model. METHODS: C2C12 cells were cultured using DMEM and DFAT-conditioned medium (DFAT-CM), evaluating MyoD and Myogenin gene expression via RT-PCR. DFAT was locally administered to model rats with anorectal sphincter dysfunction 3 days post-CTX injection. Therapeutic effects were assessed through functional assessment, including anal pressure measurement using solid-state manometry pre/post-CTX, and on days 1, 3, 7, 10, 14, 17, and 21 post-DFAT administration. Histological evaluation involved anal canal excision on days 1, 3, 7, 14, and 21 after CTX administration, followed by hematoxylin-eosin staining. RESULTS: C2C12 cells cultured with DFAT-CM exhibited increased MyoD and Myogenin gene expression compared to control. Anal pressure measurements revealed early recovery of resting pressure in the DFAT-treated group. Histologically, DFAT-treated rats demonstrated an increase in mature muscle cells within newly formed muscle fibers on days 14 and 21 after CTX administration, indicating enhanced muscle tissue repair. CONCLUSION: DFAT demonstrated the potential to enhance histological and functional muscle tissue repair. These findings propose DFAT as a novel therapeutic approach for anorectal sphincter dysfunction treatment.

Automatic anal sphincter integrity detection from ultrasound images via convolutional neural networks.

BACKGROUND: The anal sphincter complex comprises the anal sphincter and the U-shaped deep and superficial puborectalis muscle. As an important supporting structure of the posterior pelvic floor, together with its surrounding tissues and muscles, the anal sphincter complex maintains the normal physiological functions of defecation and continence. OBJECTIVE: The plane required for diagnosing anal sphincter injury and the diagnosis of anal sphincter integrity through pelvic floor ultrasound are highly dependent on sonographers' experience. We developed a deep learning (DL) tool for the automatic diagnosis of anal sphincter integrity via pelvic floor ultrasound. METHODS: A 2D detection network was trained to detect the bounding box of the anal sphincter. The pelvic floor ultrasound image and its corresponding oval mask were input into a 2D classification network to determine the integrity of the anal sphincter. The average precision (AP) and intersection over union (IoU) were used to evaluate the performance of anal sphincter detection. Receiver operating characteristic (ROC) analysis was used to evaluate the performance of the classification model. RESULTS: The Pearson correlation coefficients (r values) of the topmost and bottommost layers detected by the CNN and sonographers were 0.932 and 0.978, respectively. The best DL model yielded the highest area under the curve (AUC) of 0.808 (95% CI: 0.698-0.921) in the test cohort. The results from the CNN agreed well with the diagnostic results of experienced sonographers. CONCLUSIONS: We proposed, for the first time, a CNN to obtain the plane required for diagnosing anal sphincter injury on the basis of pelvic floor ultrasound and for preliminarily diagnosing anal sphincter injury.

Study on Intestinal Pressure after Implantation of Biaxial Actuated Artificial Anal Sphincter in Animal.

Fecal incontinence (FI) referred to the inability to control the leakage of solid, liquid, or gaseous feces, the artificial anal sphincter (AAS) was the last resort for patients with FI except enterostomy. In order to the clinical application value of AAS was improved, the detection and analysis of intestinal pressure information was very necessary. Biaxial actuated artificial anal sphincter (BAAS) was a new type of AAS, which not only had a stable, long-term and safe energy supply, but also could provide real-time feedback of intestinal pressure information. In this paper, the BAAS was implanted into piglets for a long-term animal experiment. Piglets' life habits, defecation habits and intestinal pressure were analyzed. The analysis results showed that the BAAS system had good feces control effect, when the actuator of the BAAS system was closed, there was basically no fecal leakage of piglets, and when the actuator of the BAAS system was opened, the piglets could defecate normally. Under the normal condition of the piglets' health state and the BAAS's operating state, the accuracy of the defecation perception reached to 65.79%. This study realized the in-depth study of the mechanism of piglets' defecation, and provided guidance for the development of a new generation of AAS.

Episiotomy: Are Indian Obstetricians Getting the Angle Right?

Background: A mediolateral episiotomy is recommended when indicated at a 60° angle at crowning, to avoid obstetric anal sphincter injuries (OASIs) by episiotomies angled too close or distant to the anus. This study surveyed obstetricians in India regarding the recommended episiotomy angle and their ability to correctly draw the angle. Methods: Workshops were conducted in India to share knowledge in the prevention and repair of OASIs. A questionnaire was distributed prior to the workshop. Participants were asked to describe the recommended episiotomy angle and to draw this on a paper replica of the perineum. The intra-class correlation coefficient (ICC) was calculated to assess the inter-rater reliability between the angle stated and drawn. A 2° difference was deemed acceptable. Standard errors of measurement (SEM) were calculated to measure the range of error of each measurement. Results: One hundred and forty doctors participated. 47.9% described the angle of an episiotomy to be 60°. Only 2.2% drew an angle of 60°, but 8.7% (n = 12) drew between 58 and 62°. Only 5.8% (n = 6) of doctors correctly drew the episiotomy angle they described. There was poor agreement ICC = 0.18 (- 0.01 to 0.36) with a SEM of ± 12.2°. Conclusions: Knowledge surrounding the recommended episiotomy angle is lacking. Doctors are failing to estimate their desired episiotomy angle. This highlights the need for national guidelines, the creation and validation of structured training programmes to improve accuracy, or using fixed-angle devices such as the EPISCISSORS-60 or other proven measurement aids to minimise preventable harm due to human error.

Skeletal Muscle Complex Between the Vagina and Anal Canal: Implications for Perineal Laceration.

INTRODUCTION AND HYPOTHESIS: The anatomy of the skeletal muscles located between the vagina and anus is important during complex obstetric laceration reconstructions. We aimed to clarify the composition of skeletal muscles located between the vagina and anal canal and their three-dimensional configuration relevant to perineum repair. METHODS: This observational study involved ten female cadavers. An anatomical dissection was performed to observe the muscles around the vagina and anal canal. Immunohistological analysis of the midsagittal section was performed to clarify the composition of the muscles, and dissection was performed to correspond to the cross-section. Wide-range serial sectioning and three-dimensional reconstruction were used to support these findings histologically and visualize the three-dimensional arrangement. RESULTS: The region between the vagina and anal canal included the anterior part of the external anal sphincter, superficial transverse perineal muscle approaching from the lateral side, and levator ani, located cranially. They converge three-dimensionally in the median from each direction, forming a muscle complex between the vagina and anal canal. CONCLUSIONS: The medial region between the vagina and anal canal in those giving birth includes a skeletal muscle complex formed by the confluence of the external anal sphincter, anterior bundle of the levator ani, and superficial transverse perineal muscle. In cases of severe perineal lacerations, these muscles could be injured. The anatomical knowledge that a part of the levator ani forms a muscle sling anterior to the anal canal is particularly important for obstetricians and gynecologists repairing obstetric lacerations and treating pelvic floor disorders.

Caesarean section and anal incontinence in women after obstetric anal sphincter injury: A systematic review and meta-analysis.

BACKGROUND: Approximately 50% women who give birth after obstetric anal sphincter injury (OASI) develop anal incontinence (AI) over their lifetime. OBJECTIVE: To evaluate current evidence for a protective benefit of planned caesarean section (CS) to prevent AI after OASI. SEARCH STRATEGY: MEDLINE/PubMed, Embase 1974-2024, CINAHL and Cochrane to 7 February 2024 (PROSPERO CRD42022372442). SELECTION CRITERIA: All studies reporting outcomes after OASI and a subsequent birth, by any mode. DATA COLLECTION AND ANALYSIS: Eighty-six of 2646 screened studies met inclusion criteria, with nine studies suitable to meta-analyse the primary outcome of 'adjusted AI' after OASI and subsequent birth. Subgroups: short-term AI, long-term AI, AI in asymptomatic women. SECONDARY OUTCOMES: total AI, quality of life, satisfaction/regret, solid/liquid/flatal incontinence, faecal urgency, AI in women with and without subsequent birth, change in AI pre- to post- subsequent birth. MAIN RESULTS: There was no evidence of a difference in adjusted AI after subsequent vaginal birth compared with CS after OASI across all time periods (OR = 0.92, 95% CI 0.72-1.20; 9 studies, 2104 participants, I2 = 0% p = 0.58), for subgroup analyses or secondary outcomes. There was no evidence of a difference in AI in women with or without subsequent birth (OR = 1.00 95% CI 0.65-1.54; 10 studies, 970 participants, I2 = 35% p = 0.99), or pre- to post- subsequent birth (OR = 0.79 95% CI 0.51-1.25; 13 studies, 5496 participants, I2 = 73% p = 0.31). CONCLUSIONS: Due to low evidence quality, we are unable to determine whether planned caesarean is protective against AI after OASI. Higher quality evidence is required to guide personalised decision-making for asymptomatic women and to determine the effect of subsequent birth mode on long-term AI outcomes.

Obstetric anal sphincter injuries during instrumental vaginal delivery: An observational study based on 18-years of real-world data.

OBJECTIVE: To determine the prevalence and secular trends of obstetric anal sphincter injuries (OASIS) in vacuum and forceps deliveries in Norway, both with and without episiotomy. DESIGN: Population-based real-world data collected during 2001-2018. SETTING: Medical Birth Registry Norway. POPULATION OR SAMPLE: Nulliparous women with singleton foetuses in a cephalic presentation delivered by either vacuum or forceps (n = 70 783). METHODS: Logistic regression analyses were applied to the OASIS prevalence in six 3-year time periods. Both crude odds ratios and adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were determined. MAIN OUTCOME MEASURES: OASIS prevalence. RESULTS: The OASIS prevalence in vacuum and forceps deliveries decreased from 14.8% during 2001-2003 to 5.2% during 2016-2018. The overall reduction between the first and last 3-year time period was 61% (aOR = 0.39, 95% CIs = 0.35-0.43). The only exception to this decreasing trend in OASIS was found in forceps deliveries performed without an episiotomy. The OASIS prevalence was approximately twofold higher in forceps compared to vacuum deliveries (aOR = 1.92, 95% CIs = 1.79-2.05). Performing either a mediolateral or lateral episiotomy was associated with a 45% decrease in the prevalence of OASIS relative to no episiotomy (aOR = 0.55, 95% CIs = 0.52-0.58). CONCLUSIONS: Opting for vacuum rather than forceps delivery in conjunction with a mediolateral or lateral episiotomy could significantly lower the OASIS prevalence in nulliparous women.

Patterns of connexin36 and eGFP reporter expression among motoneurons in spinal sexually dimorphic motor nuclei in mouse.

BACKGROUND: Sexually dimorphic spinal motoneurons (MNs) in the dorsomedial nucleus (DMN) and dorsolateral nucleus (DLN) as well as those in the cremaster nucleus are involved in reproductive behaviours, and the cremaster nucleus additionally contributes to testicular thermoregulation. It has been reported that MNs in DMN and DLN are extensively linked by gap junctions forming electrical synapses composed of connexin36 (Cx36) and there is evidence that subpopulation of MNs in the cremaster nucleus are also electrically coupled by these synapses. METHODOLOGY: We used immunofluorescence methods to detect enhanced green fluorescent protein (eGFP) reporter for Cx36 expression in these motor nuclei. RESULTS: We document in male mice that about half the MNs in each of DMN and DLN express eGFP, while the remaining half do not. Further, we found that the eGFP+ vs. eGFP- subsets of MNs in each of these motor nuclei innervate different target muscles; eGFP+ MNs in DMN and DLN project to sexually dimorphic bulbocavernosus and ischiocavernosus muscles, while the eGFP- subsets project to sexually non-dimorphic anal and external urethral sphincter muscles. Similarly, eGFP+ vs. eGFP- cremaster MNs were found to project to anatomically distinct portions of the cremaster muscle. By immunofluorescence, nearly all motoneurons in both DMN and DLN displayed punctate labelling for Cx36, including at eGFP+/eGFP+, eGFP+/eGFP- and eGFP-/eGFP- cell appositions. CONCLUSIONS: Most if not all motoneurons in DMN and DLN are electrically coupled, including sexually dimorphic and non-dimorphic motoneurons with each other, despite absence of eGFP reporter in the non-dimorphic populations in these nuclei that have selective projections to sexually non-dimorphic target muscles.

Incidence of obstetric anal sphincter injuries according to the type of forceps used in the Mexican population.

OBJECTIVE: This study describes the frequency of obstetric anal sphincter injuries (OASIS) in patients after instrumental delivery according to the type of forceps used. METHODS: A retrospective comparative cohort study was conducted on patients who underwent instrumental delivery from January 2017 to April 2022. The primary outcome was the presence of OASIS following delivery. Patients were categorized into Cohort A if only rotation forceps were used, Cohort B for only traction forceps, and Cohort C if both types were used sequentially. Statistical analysis was performed with SPSS (IBM, New York, NY) with χ2, Fisher's exact, and analysis of variance testing. A P-value <0.05 was considered significant. RESULTS: OASIS occurred in 45 of 328 instrumental deliveries. OASIS after rotation forceps occurred in 12.9% (n = 8) of cases, after traction forceps in 13.2% (n = 34), and after sequential use of rotation and traction forceps in 37.5% (n = 3) of cases (p = 0.141). An odds ratio (OR) of 0.91 (95% confidence interval [CI] 0.40-2.08) for OASIS was obtained with the use of rotation forceps, 0.81 (95% CI 0.38-1.70) for traction forceps, and 3.97 (95% CI 0.91-17.2) for the sequential use of rotation and traction forceps. CONCLUSION: There were no significant differences in the presence of OASIS comparing traction and rotation forceps. A non-significant trend of higher OASIS following the sequential use of traction and rotation forceps was observed.

Obstetric Characteristics and Functional Outcomes in Women with Obstetric Anal Sphincter Injury.

BACKGROUND: Obstetric anal sphincter injury is a complication of vaginal delivery, if left untreated, causes significant maternal morbidities; urinary problems and fecal/ flatus incontinence. The aim of this study was to determine the incidence and describe the obstetric characteristics and functional outcomes of women who had vaginal delivery at Paropakar Maternity and Women's Hospital Nepal and sustained Obstetric anal sphincter injury. METHODS: This retrospective descriptive study included women who had vaginal delivery, irrespective of parity, in the labor room or birthing unit of Paropakar Maternity and Women's Hospital from April 2018 to September 2020, and sustained Grade III or IV Obstetric anal sphincter injury after 28 weeks period of gestation. Maternal characteristics, obstetric details and perineal status after vaginal delivery were noted after review of hospital records. The patients were further inquired via telephone for their current status of fecal and/or urinary incontinence. RESULTS: The incidence of OASI was 106 (0.33%) among 31, 786 Nepalese women with vaginal birth over a 2-year period. The mean age women with Obstetric anal sphincter injury was 24.6 ± 4.3 years and 45(52.9%) cases belonged to Janajati ethnicity. Fifty two (61.2 %) were primipara and 77 (90.6%) had spontaneous vaginal deliveries. Episiotomy was not performed on most of the patients (63, 74.1%). Problems with flatus holding, stool holding and urine holding was reported by 28.3%, 13.2% and 22.6% women respectively. CONCLUSIONS: The incidence of Obstetric anal sphincter injury among Nepalese women with vaginal birth over a 2-year period was 0.33%, which was lower than other South Asian studies. Grade III Obstetric anal sphincter injury was the frequent most type. The injuries were more common in women with Janajati ethnicity, primipara and women who did not have episiotomy. Problems with flatus holding and urine holding were present in almost one-fourth of the women with Obstetric anal sphincter injury at follow up.

Histiocitosis de células de Langerhans en un paciente con lesión perianal. Caso clínico / Langerhans cell histiocytosis in a patient with perianal lesion. A case report

La histiocitosis de células de Langerhans es una expresión de células dendríticas mieloides, asociada a un componente inflamatorio significativo y compromiso sistémico variado. La edad más frecuente de presentación es entre 1 y 4 años, y predomina en el sexo masculino. Se comunica el caso de un niño de 5 años de edad cuya forma de presentación fue una lesión granulomatosa con fístula perianal, afectación pulmonar y de oído externo. El abordaje interdisciplinario permitió llegar al diagnóstico, realizar las intervenciones necesarias e iniciar el tratamiento adecuado.

Langerhans cell histiocytosis is an expression of myeloid dendritic cells, associated with a significant inflammatory component and varied systemic involvement. The most common age at presentation is between 1 and 4 years, and it prevails among male subjects. Here we describe the case of a 5-year-old boy who presented with a granulomatous lesion with perianal fistula and lung and external ear involvement. An interdisciplinary approach helped to make a diagnosis, provide the necessary interventions, and start an adequate treatment.