Impact of a quality improvement project to reduce the rate of obstetric anal sphincter injury: a multicentre study with a stepped-wedge design.

OBJECTIVE: To evaluate the impact of a care bundle (antenatal information to women, manual perineal protection and mediolateral episiotomy when indicated) on obstetric anal sphincter injury (OASI) rates. DESIGN: Multicentre stepped-wedge cluster design. SETTING: Sixteen maternity units located in four regions across England, Scotland and Wales. POPULATION: Women with singleton live births between October 2016 and March 2018. METHODS: Stepwise region by region roll-out every 3 months starting January 2017. The four maternity units in a region started at the same time. Multi-level logistic regression was used to estimate the impact of the care bundle, adjusting for time trend and case-mix factors (age, ethnicity, body mass index, parity, birthweight and mode of birth). MAIN OUTCOME MEASURES: Obstetric anal sphincter injury in singleton live vaginal births. RESULTS: A total of 55 060 singleton live vaginal births were included (79% spontaneous and 21% operative). Median maternal age was 30 years (interquartile range 26-34 years) and 46% of women were primiparous. The OASI rate decreased from 3.3% before to 3.0% after care bundle implementation (adjusted odds ratio 0.80, 95% CI 0.65-0.98, P = 0.03). There was no evidence that the effect of the care bundle differed according to parity (P = 0.77) or mode of birth (P = 0.31). There were no significant changes in caesarean section (P = 0.19) or episiotomy rates (P = 0.16) during the study period. CONCLUSIONS: The implementation of this care bundle reduced OASI rates without affecting caesarean section rates or episiotomy use. These findings demonstrate its potential for reducing perineal trauma during childbirth. TWEETABLE ABSTRACT: OASI Care Bundle reduced severe perineal tear rates without affecting caesarean section rates or episiotomy use.

Perineal management: Midwives' confidence and educational needs.

OBJECTIVE: The overall aim of this study was to collate information to inform the updating of a perineal management educational programme for midwives. This paper explores midwives' confidence and educational needs in managing the woman's perineum during the second stage of labour, focusing on future quality initiatives to improve midwives' experiences and expertise in the prevention of perineal trauma during birth. DESIGN: A mixed-methods sequential exploratory design was used. PARTICIPANTS AND SETTING: Midwives and clinical midwife managers assisting with births in the labour ward of a large urban university stand-alone maternity hospital in the Republic of Ireland with approximately 9,000 births per year participated in the study. MEASUREMENTS: A questionnaire and two focus groups were used to collect the data. FINDINGS: Fifty-two midwives from a total of 64 eligible labour ward midwives completed the questionnaire, a response rate of 81.2%. Midwives indicated that perineal management workshops did not cover prevention of perineal trauma, and mainly focused on suturing and repair of the perineum. The majority of midwives (85%) indicated that they would like further education on the prevention of perineal trauma. Higher levels of confidence in making a decision to perform an episiotomy, infiltrating the perineum and at performing an episiotomy were reported in experienced midwives. Midwives want improved and additional education in the management of women's perinea during the second stage of labour and made various recommendations regarding the content, format, timing and frequency of the workshop. Suggestions for further education included techniques for preventing perineal trauma during labour and birth and how to perform an episiotomy. KEY CONCLUSIONS: This study provides key insights into midwives' confidence and educational needs in relation to managing the woman's perineum during the second stage of labour. The findings from this study demonstrates the appetite of midwives for additional education in the area of perineal management, particularly prevention strategies. IMPLICATIONS FOR PRACTICE: Midwives play an essential role in reducing the rates of perineal trauma through regular education. It is therefore important that midwives keep up to date with the best available evidence. Updating existing perineal management educational programmes that are tailor made to midwives' needs could not only improve clinical skills and perineal protection techniques but also midwives' confidence in decision making. The overall aim is to reduce perineal trauma in women having a spontaneous vaginal birth.

FIGO Statement: Restrictive use rather than routine use of episiotomy.

International standards for clinical staffing of delivery care in maternity units are currently lacking, with resulting gaps in provision leading to adverse outcomes and very poor experiences of care for women and families. While evidence­informed modelling approaches have been proposed based on population characteristics and estimated rates of complications, their application and outcomes in low­resource settings have not been reported. Here, FIGO's Safe Motherhood and Newborn Health Committee proposes indicative standards for labor wards as a starting point for policy and program development. These standards consider the volume of deliveries, the case mix, and the need to match clinical care requirements with an appropriate mix of professional skills among midwifery and obstetric staff. The role of Shift Leader in busy labor wards is emphasized. Application of the standards can help to assure women and their families of a safe but also positive birthing experience. FIGO calls for investment by partners to test these clinically­informed recommendations for delivery unit staffing at hospital and district level in low­ and middle­income country settings.

[Better training in perineal injury is desirable]. / Betere training over perineumletsel gewenst.

Better training in perineal injury is desirable One of the most common complaints from women following childbirth is perineal pain, caused by perineal trauma. The episiotomy technique, the suture material chosen, the suture technique, and the knowledge and skills of the care-provider all influence healing and subsequent symptoms. Evidence-based techniques are associated with fewer symptoms and complications; however, the literature reveals that care-providers are often inexperienced, not well trained or not conscientious enough in: performing an accurate episiotomy; assessing perineal trauma; diagnosing anal-sphincter injuries; and evidence-based repair techniques. The angle at which an episiotomy is performed and the suture techniques used vary considerably, while the evidence shows emphatically which techniques are optimal. We believe that the responsibility for the improvement of knowledge and skills lies with the care-providers. Despite the absence of obligation, they should attend repeated training sessions, to guarantee the optimal quality of perineal care following childbirth.

Birth-Related Perineal Trauma in Low- and Middle-Income Countries: A Systematic Review and Meta-analysis.

Introduction Birth-related perineal trauma (BPT) is a common consequence of vaginal births. When poorly managed, BPT can result in increased morbidity and mortality due to infections, haemorrhage, and incontinence. This review aims to collect data on rates of BPT in low- and middle-income countries (LMICs), through a systematic review and meta-analysis. Methods The following databases were searched: Medline, Embase, Latin American and Caribbean Health Sciences Literature (LILACs), and the World Health Organization (WHO) regional databases, from 2004 to 2016. Cross-sectional data on the proportion of vaginal births that resulted in episiotomy, second degree tears or obstetric anal sphincter injuries (OASI) were extracted from studies carried out in LMICs by two independent reviewers. Estimates were meta-analysed using a random effects model; results were presented by type of BPT, parity, and mode of birth. Results Of the 1182 citations reviewed, 74 studies providing data on 334,054 births in 41 countries were included. Five studies reported outcomes of births in the community. In LMICs, the overall rates of BPT were 46% (95% CI 36-55%), 24% (95% CI 17-32%), and 1.4% (95% CI 1.2-1.7%) for episiotomies, second degree tears, and OASI, respectively. Studies were highly heterogeneous with respect to study design and population. The overall reporting quality was inadequate. Discussion Compared to high-income settings, episiotomy rates are high in LMIC medical facilities. There is an urgent need to improve reporting of BPT in LMICs particularly with regards to births taking in community settings.

Are we performing episiotomies correctly? A study to evaluate French technique in a high-risk maternity unit.

INTRODUCTION: The aim of this study was to evaluate episiotomy technique, in particular suture angles, and any correlation between suture angle and severe perineal tears. MATERIAL AND METHODS: An observational questionnaire-based study was conducted between 01 August 2015 and 30 April 2016 among accoucheurs performing episiotomies in a French maternity unit with facilities for high-risk pregnancies. For each patient included, accoucheurs were asked to measure the episiotomy suture angle, and to record the angle at which they thought they had cut, the length of the episiotomy, its distance from the anus, and whether the woman sustained a sphincter injury. RESULTS: The centre's episiotomy rate during the study period was 15%. We analyzed the characteristics of episiotomies performed on 89 women (68 by doctors and 21 by midwives). Only 43% of suture angles were between 45° and 60° (45.6% of those performed by doctors vs 38.1% by midwives, p=0.8623), whereas 91% of accoucheurs thought they had cut within the correct range. Doctors made longer incisions than midwives (4 [4.2-5.0] vs 3 [2.5-3.5] cm, p=0.0006). Only 40.5% of accoucheurs correctly estimated the incision angle. Twelve (13.64%) of the 88 women sustained a third-degree perineal tear. The risk of sphincter injury was higher with suture angles <45° (odds ratio 5.46 [1.11-26.75], p=0.037). After multivariate analysis, this result was no longer significant (p=0.079). CONCLUSION: It appears that many accoucheurs have difficulty estimating episiotomy incision angles correctly and that education and training in this domain requires improvement.

De-medicalization of birth by reducing the use of oxytocin for augmentation among first-time mothers - a prospective intervention study.

BACKGROUND: The use of synthetic oxytocin for augmentation of labor is rapidly increasing worldwide. Hyper-stimulation is the most significant side effect, which may cause fetal distress and operative delivery. We performed an intervention consisting of an educational program and modified guidelines to achieve a more appropriate use of oxytocin. METHODS: This prospective intervention study included 431 first-time mothers at term with spontaneous onset of labor before (October 2012 to May 2013), and 664 after the intervention (April 2014 to April 2015). Our outcomes were prevalence and duration of oxytocin treatment, mode of delivery, indication for operative delivery, episiotomy, anal sphincter tears, bleeding, labor duration, pain relief and the effect of oxytocin on mode of delivery. RESULTS: After the intervention, 52.9% were diagnosed with dystocia, compared with 68.9% before (p < 0.001). Oxytocin was not always used in accordance with the guidelines, but a significant reduction in oxytocin rates from 63.3% to 54.1% (p < 0.001) was obtained. More women without dystocia according to the existing guidelines were augmented after the intervention (18.9% vs 8.4%, p < 0.001). Assessing all labors, the median duration of oxytocin treatment was reduced by 72% (from 90 to 25 min) without increasing the median duration of labor (385 min in both groups). There was a moderate reduction in operative vaginal deliveries from 26.9 to 21.5% (p = 0.04), and dystocia as an indication for these deliveries increased (p = 0.01). There was a moderate increase in caesarean sections from 6.7 to 10.2% (p = 0.05), but no increase in dystocia as an indication for these deliveries. Women receiving oxytocin were more likely to have an operative vaginal birth, even after adjusting for birth weight, epidural analgesia and labor duration, OR: 2.1 (CI 1.1-4.0) before and OR 2.7 (CI 1.6-4.5) after the intervention. CONCLUSIONS: Our intervention led to a significant reduction in the use of oxytocin. However, more than half of the women remained diagnosed with dystocia. Operative vaginal births seem to be associated with oxytocin treatment. Therefore, augmentation with oxytocin should be used with caution and only when medically indicated. Even more modified guidelines for augmentation than the ones applied in this study might be appropriate.

Perineal tears - A review

BACKGROUND: The female perineum is the diamond-shaped inferior outlet of the pelvis. This structure is at risk of trauma during labour because of spontaneous perineal tears of varying degrees or iatrogenic episiotomies. These injuries can result in disabling immediate and long-term complications in the woman. OBJECTIVE: The aim of this article is to provide general practitioners (GPs) with a good understanding of perineal tears by discussing the different classifications, immediate and long-term management, and recommendations for future deliveries. DISCUSSION: Although the majority of perineal tears are managed by obstetricians and gynaecologists, it is important for GPs to understand their management in the event that a patient presents to general practice with concerns during the antenatal or postpartum period.

Selective versus routine use of episiotomy for vaginal birth.

BACKGROUND: Some clinicians believe that routine episiotomy, a surgical cut of the vagina and perineum, will prevent serious tears during childbirth. On the other hand, an episiotomy guarantees perineal trauma and sutures. OBJECTIVES: To assess the effects on mother and baby of a policy of selective episiotomy ('only if needed') compared with a policy of routine episiotomy ('part of routine management') for vaginal births. SEARCH METHODS: We searched Cochrane Pregnancy and Childbirth's Trials Register (14 September 2016) and reference lists of retrieved studies. SELECTION CRITERIA: Randomised controlled trials (RCTs) comparing selective versus routine use of episiotomy, irrespective of parity, setting or surgical type of episiotomy. We included trials where either unassisted or assisted vaginal births were intended. Quasi-RCTs, trials using a cross-over design or those published in abstract form only were not eligible for inclusion in this review. DATA COLLECTION AND ANALYSIS: Two authors independently screened studies, extracted data, and assessed risk of bias. A third author mediated where there was no clear consensus. We observed good practice for data analysis and interpretation where trialists were review authors. We used fixed-effect models unless heterogeneity precluded this, expressed results as risk ratios (RR) and 95% confidence intervals (CI), and assessed the certainty of the evidence using GRADE. MAIN RESULTS: This updated review includes 12 studies (6177 women), 11 in women in labour for whom a vaginal birth was intended, and one in women where an assisted birth was anticipated. Two were trials each with more than 1000 women (Argentina and the UK), and the rest were smaller (from Canada, Germany, Spain, Ireland, Malaysia, Pakistan, Columbia and Saudi Arabia). Eight trials included primiparous women only, and four trials were in both primiparous and multiparous women. For risk of bias, allocation was adequately concealed and reported in nine trials; sequence generation random and adequately reported in three trials; blinding of outcomes adequate and reported in one trial, blinding of participants and personnel reported in one trial.For women where an unassisted vaginal birth was anticipated, a policy of selective episiotomy may result in 30% fewer women experiencing severe perineal/vaginal trauma (RR 0.70, 95% CI 0.52 to 0.94; 5375 women; eight RCTs; low-certainty evidence). We do not know if there is a difference for blood loss at delivery (an average of 27 mL less with selective episiotomy, 95% CI from 75 mL less to 20 mL more; two trials, 336 women, very low-certainty evidence). Both selective and routine episiotomy have little or no effect on infants with Apgar score less than seven at five minutes (four trials, no events; 3908 women, moderate-certainty evidence); and there may be little or no difference in perineal infection (RR 0.90, 95% CI 0.45 to 1.82, three trials, 1467 participants, low-certainty evidence).For pain, we do not know if selective episiotomy compared with routine results in fewer women with moderate or severe perineal pain (measured on a visual analogue scale) at three days postpartum (RR 0.71, 95% CI 0.48 to 1.05, one trial, 165 participants, very low-certainty evidence). There is probably little or no difference for long-term (six months or more) dyspareunia (RR1.14, 95% CI 0.84 to 1.53, three trials, 1107 participants, moderate-certainty evidence); and there may be little or no difference for long-term (six months or more) urinary incontinence (average RR 0.98, 95% CI 0.67 to 1.44, three trials, 1107 participants, low-certainty evidence). One trial reported genital prolapse at three years postpartum. There was no clear difference between the two groups (RR 0.30, 95% CI 0.06 to 1.41; 365 women; one trial, low certainty evidence). Other outcomes relating to long-term effects were not reported (urinary fistula, rectal fistula, and faecal incontinence). Subgroup analyses by parity (primiparae versus multiparae) and by surgical method (midline versus mediolateral episiotomy) did not identify any modifying effects. Pain was not well assessed, and women's preferences were not reported.One trial examined selective episiotomy compared with routine episiotomy in women where an operative vaginal delivery was intended in 175 women, and did not show clear difference on severe perineal trauma between the restrictive and routine use of episiotomy, but the analysis was underpowered. AUTHORS' CONCLUSIONS: In women where no instrumental delivery is intended, selective episiotomy policies result in fewer women with severe perineal/vaginal trauma. Other findings, both in the short or long term, provide no clear evidence that selective episiotomy policies results in harm to mother or baby.The review thus demonstrates that believing that routine episiotomy reduces perineal/vaginal trauma is not justified by current evidence. Further research in women where instrumental delivery is intended may help clarify if routine episiotomy is useful in this particular group. These trials should use better, standardised outcome assessment methods.

Indications for episiotomy performance - a cross-sectional survey and review of the literature.

Our objective was to assess the reported reasons for episiotomy performance in Israel and to review the relevant professional literature. Using anonymous questionnaires, a survey was conducted among obstetricians and midwives in four northern Israel hospitals, and the accoucheurs were asked to score their agreement with 13 proposed indications for episiotomy. Overall, 84 doctors and 32 midwives completed the questionnaires. 86.1% of the responders reported performing episiotomy in all or most cases of shoulder dystocia, and more than half reported performing it in most cases of vacuum deliveries, fetal macrosomia and advanced perineal tear in previous delivery. Subjective assessment of perineal characteristics constituted a justified reason for episiotomy for 15.8-43.9% of the accoucheurs. In conclusion, there is a wide variation in reported reasons for episiotomy between the obstetricians, and many of these indications are not congruent with international practice guidelines. Uniform protocols and educational programmes are needed to guide episiotomy practice.

Midwives' and doctors' perceptions of their preparation for and practice in managing the perineum in the second stage of labour: a cross-sectional survey.

OBJECTIVE: to identify the perceptions of midwives and doctors at Monash Women's regarding their educational preparation and practices used for perineal management during the second stage of labour. DESIGN: anonymous cross-sectional semi-structured questionnaire ('The survey'). SETTING: the three maternity hospitals that form Monash Women's Maternity Services, Monash Health, Victoria, Australia. PARTICIPANTS: midwives and doctors attending births at one or more of the three Monash Women's maternity hospitals. METHODS: a semi-structured questionnaire was developed, drawing on key concepts from experts and peer-reviewed literature. FINDINGS: surveys were returned by 17 doctors and 69 midwives (37% response rate, from the 230 surveys sent). Midwives and doctors described a number of techniques they would use to reduce the risk of perineal trauma, for example, hands on the fetal head/perineum (11.8% of doctors, 61% of midwives), the use of warm compresses (45% of midwives) and maternal education and guidance with pushing (49.3% of midwives). When presented with a series of specific obstetric situations, respondents indicated that they would variably practice hands on the perineum during second stage labour, hands off and episiotomy. The majority of respondents indicated that they agreed or strongly agreed that an episiotomy should sometimes be performed (midwives 97%, doctors 100%). All the doctors had training in diagnosing severe perineal trauma involving anal sphincter injury (ASI), with 77% noting that they felt very confident with this. By contrast, 71% of the midwives reported that they had received training in diagnosing ASI and only 16% of these reported that they were very confident in this diagnosis. All doctors were trained in perineal repair, compared with 65% of midwives. Doctors were more likely to indicate that they were very confident in perineal repair (88%) than the midwives (44%). Most respondents were not familiar with the rates of perineal trauma either within their workplace or across Australia. KEY CONCLUSIONS: Midwives and doctors indicated that they would use the hands on or hands off approach or episiotomy depending on the specific clinical scenario and described a range of techniques that they would use in their overall approach to minimising perineal trauma during birth. Midwives were more likely than doctors to indicate their lack of training and/or confidence in conducting perineal repair and diagnosing ASI. IMPLICATIONS FOR PRACTICE: many midwives indicated that they had not received training in diagnosing ASI, perineal repair and midwives' and doctors' knowledge of the prevalence of perineal outcomes was poor. Given the importance of these skills to women cared for by midwives and doctors, the findings may be used to inform the development of quality improvement activities, including training programs and opportunities for gaining experience and expertise with perineal management. The use of episiotomy and hands on/hands off the perineum in the survey scenarios provides reassurance that doctors and midwives take a number of factors into account in their clinical practice, rather than a preference for one or more interventions over others.

Evaluation of accuracy of mediolateral episiotomy incisions using a training model.

BACKGROUND: Episiotomy is one of the most commonly performed surgical procedures worldwide. In the UK the use of episiotomy is selective, rather than routine, and a right mediolateral episiotomy (RMLE) is considered standard practice. According to The National Institute of Health and Care Excellence (NICE, 2007) guideline for intrapartum care such an episiotomy should be cut at an angle between 45° and 60° to the vertical axis. Recent evidence suggests that the angle of incision of mediolateral episiotomy (MLE) is associated with risk of obstetric anal sphincter injury (OASIS). OBJECTIVE: to assess the accuracy of individual practitioner's techniques when performing a RMLE. DESIGN: an audit of practice against nationally set standards. SETTING: at a national midwifery conference and prior to three multiprofessional perineal repair training workshops in the West Midlands region of the UK. PARTICIPANTS: 144 midwives and 53 obstetric trainees. MEASUREMENTS: practitioners were asked to perform a RMLE incision on a bespoke training model, which is designed to give a realistic representation of a stretched perineum at crowning of the baby's head. Four parameters were measured: (1) distance of the starting point from the midline; (2) angle subtended to the perpendicular; (3) length and (4) shape of the incision (curved, straight or J-shaped). FINDINGS: of the 197 incisions performed only 12.7% (14.6%, n=21/144 of midwives and 7.5%, n=4/53 of obstetricians) complied with the defined technique of a RMLE for correctness of angle and placement. A 2-sided Fisher's exact test showed no significant difference between previous attendance at perineal management training and incision accuracy.

Embolización de las arterias uterinas en hematoma disecante de la episiotomía / Uterine artery embolization in dissecting hematoma after episiotomy

Antecedentes. La hemorrragia posparto es una complicación potencialmente grave, siendo de vital importancia que el diagnóstico y el tratamiento tengan lugar de forma precoz. Dentro de los sangrados posparto cabe mencionar los hematomas del canal del parto. Caso. Presentamos un caso grave de hematoma del canal del parto que requirió técnica de embolización selectiva tras el fracaso del tratamiento quirúrgico local, con shock hipovolémico y coagulación intravascular diseminada. Conclusión. Hay que tener en cuenta que la embolización precisa de una infraestuctura y tecnología que se encuentran en hospitales de tercer nivel; la premura en el diagnóstico y una paciente estable hemodinámicamente permitirán el abordaje mediante técnicas de embolización. La embolización de las arterias uterinas en manos expertas permitirá preservar la fertilidad futura de la paciente con escasas complicaciones (AU)

Background. Postpartum hemorrhage is a potentially serious complication and includes bruising of the birth canal. It is vitally important that the diagnosis and treatment take place at an early stage. Case. We report a serious case of bruising of the birth canal that required selective embolization after unsuccessful local surgical treatment, with hypovolemic shock and disseminated intravascular coagulation. Conclusion. Embolization requires an infrastructure and technology that are available in tertiary care hospitals. Early diagnosis allows embolization to be performed in hemodynamically stable patients. Uterine artery embolization in expert hands enables future fertility to be preserved with few complications (AU)

Classification of episiotomy: towards a standardisation of terminology.

Seven episiotomy incisions are described in the literature, although only midline, mediolateral or lateral episiotomies are commonly used. Recent research has demonstrated variations in both site and direction of the incision, and differences between the angle of incision at the time of crowning of the fetal head and the angle of the scar once the wound has been repaired. We review this evidence and suggest that this variation may undermine the reliability of much published work. We suggest a standardised definition of each type of episiotomy to establish uniformity going forward, so that future studies are amenable to comparison and meta-analysis.

Intern's experiences with episiotomy and its repair

Background: Episiotomy ­an incision of the perineum at the time of vaginal delivery is a common obstetric procedure. If the repair is inadequately done, it may leave the woman suffering from perineal pain and other long term conditions with serious impact on the woman's health and social wellbeing. The importance of skill in the obstetric procedure of episiotomy and its repair cannot be over emphasized. Objectives: The study aims to determine the interns' training and experience with episiotomy and its repair. Materials and Methods: A questionnaire study of medical interns' who had their houseman ship at the Federal Medical Centre Owerri, over a period of two years between 2003 and 2005. Results were analyzed with the SPSS version 10. Results: 70 (77.7%) of the 90 interns to whom the questionnaire was administered responded correctly. They had an average age of 28.81 ±3.36 years. 44 (62.9%) had a formal demonstration on episiotomy repair done at their medical training institution. 56 (80%) of the interns were comfortable with episiotomy repair while 14 (20%) were not. 10 (45.45%) of the females and 4 (8.33%) of the males were not comfortable with episiotomy repair. 30% of those who got their skill on episiotomy repair at the period of houseman ship were not comfortable with the procedure as opposed to 4.3% of those who had a formal training at their medical training institution. Discussion: A formal demonstration at the medical school of training does not appear to be a constant event in the medical schools as only 62.9% of the interns in this study accepted receiving such. However, despite the above, 80% of these interns' were comfortable with the repairs of episiotomy. Conclusions: It would be preferred if a formal demonstration is given on this procedure while a student is still in training

[Evaluation and efficacy of preventive measures in intrapartum bleeding]. / Evaluación y eficacia de las medidas preventivas en la anemia intraparto.

OBJECTIVES: To evaluate the efficacy, applicability and safety of two recently introduced preventive-restrictive measures on the use of episiotomy and active management of the third stage of labour, in order to reduce puerperal bleeding results. MATERIAL AND METHOD: Cohort study of a prospective series of 1098 women who gave birth in the Obstetrics and Gynaecology Department of the La Mancha General Hospital. Data were collected in two phases (1st phase, before applying the measures: 591; 2nd phase, after: 507). The main objective was to assess intrapartum blood loss. The independent variables analysed were active management of the third stage of labour and episiotomy rate. Age, parity, prematurity, weight of the newborn child, analgesia, duration and type of childbirth (spontaneous or induced), tears, retained placenta and neonatal results were included as control variables. Caesarean deliveries and those cases with increased bleeding risk factors were excluded. RESULTS: Both postpartum anaemia and excessive hemorrhagic loss were significantly lowered (8.7% and 50% respectively). Likewise, episiotomy rate was also significantly reduced (8.6%) and active management of the third stage of labour increased to 86.6%. Neonatal outcome results did not change throughout the study. CONCLUSIONS: The restrictive use of episiotomy and active management during the third stage of labour were effective, and with no side effects, in reducing intrapartum blood loss and improving puerperal quality of life.

A prospective multicenter audit of labor-room episiotomy and anal sphincter injury assessment in the Netherlands.

OBJECTIVE: To assess the length and angle of mediolateral episiotomies performed by midwives and resident gynecologists at 3 teaching hospitals in the Netherlands, and determine the incidence of obstetric anal sphincter injury. METHODS: In this prospective audit conducted between February and September 2008, all women delivered at the 3 hospitals were examined in the labor room for perineal injury. When an injury was assessed as being grade 2 or higher, it was re-evaluated. The incidence of anal sphincter injury was then compared with that reported in the preceding year. RESULTS: Of 1979 women delivered, 420 (21.2%) were given an episiotomy and 58 (2.9%) sustained anal sphincter injury. The episiotomies formed a mean angle of 40 degrees with the perineal midline. There was no difference in length or angle between the episiotomies performed by resident gynecologists and those performed by midwives, and the angle of most episiotomies was sufficiently wide. Compared with the preceding year, the rate of anal sphincter injury was significantly higher. CONCLUSION: The quality of episiotomies did not differ when performed by midwives or resident gynecologists. To improve the recognition and classification of obstetric anal sphincter injuries, audits based on an internationally accredited classification could easily become a part of routine hospital practice.

[Evaluating a policy of restrictive episiotomy before and after practice guidelines by the French College of Obstetricians and Gynecologists]. / Evaluation d'une politique restrictive d'épisiotomie avant et après les recommandations du Collège national des gynécologues obstétriciens français.

AIM: To evaluate our practice following Clinical Practice Guidelines (CPG) of the French College of Obstetricians and Gynecologists (CNGOF) in 2005 advocating a policy of restrictive episiotomy and to show that a significative decrease in the rate of episiotomy does not increase the number of third and fourth degree perineal tears. MATERIAL AND METHODS: A retrospective study of episiotomies and third/fourth degree perineal tears of the year 2003 (before the CPG) was compared with the year 2007 (after the CPG). We analyzed the indications of episiotomies and compared the rate of episiotomies and severe perineal tears between the two periods. RESULTS: In 2003, the rate of episiotomies was 18.8% (upon 1755 vaginal deliveries). We observed 16 (9 per thousand) third-degree perineal tears, five of which was associated with episiotomies; and two (1 per thousand) fourth-degree perineal tears. In 2007, the rate of episiotomies was 3.4% (upon 1940 vaginal deliveries). There were eight (4 per thousand) third-degree and four (2 per thousand) fourth-degree perineal tears. The two periods of study were similar in terms of age, parity, gestational age, birthweight, rate of spontaneous deliveries, breech and instrumental deliveries. There were a difference regarding deliveries in the occipitoposterior position (5.8% vs 13.8% ; p=0.02). No significant difference was found between the rates of third degree (9 per thousand vs 4 per thousand ; p=0.059) and fourth degree perineal tears (1 per thousand vs 2 per thousand ; p=0.487). However, there was a significant decrease in the rate of episiotomies between the two periods (18.8% vs 3.4% ; p<0.001). CONCLUSION: An episiotomy rate of 3.4% is much lower than the threshold rate of 30% recommanded. A policy of restrictive episiotomy is possible without increasing the rate of severe perineal tears. Aknowledging the risks and benefits of each obstetrical procedure might decrease the number of episiotomies, whose practice should be evaluated in every labour ward.

Episiotomy for vaginal birth.

BACKGROUND: Episiotomy is done to prevent severe perineal tears, but its routine use has been questioned. The relative effects of midline compared with midlateral episiotomy are unclear. OBJECTIVES: The objective of this review was to assess the effects of restrictive use of episiotomy compared with routine episiotomy during vaginal birth. SEARCH STRATEGY: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (March 2008). SELECTION CRITERIA: Randomized trials comparing restrictive use of episiotomy with routine use of episiotomy; restrictive use of mediolateral episiotomy versus routine mediolateral episiotomy; restrictive use of midline episiotomy versus routine midline episiotomy; and use of midline episiotomy versus mediolateral episiotomy. DATA COLLECTION AND ANALYSIS: The two review authors independently assessed trial quality and extracted the data. MAIN RESULTS: We included eight studies (5541 women). In the routine episiotomy group, 75.15% (2035/2708) of women had episiotomies, while the rate in the restrictive episiotomy group was 28.40% (776/2733). Compared with routine use, restrictive episiotomy resulted in less severe perineal trauma (relative risk (RR) 0.67, 95% confidence interval (CI) 0.49 to 0.91), less suturing (RR 0.71, 95% CI 0.61 to 0.81) and fewer healing complications (RR 0.69, 95% CI 0.56 to 0.85). Restrictive episiotomy was associated with more anterior perineal trauma (RR 1.84, 95% CI 1.61 to 2.10). There was no difference in severe vaginal/perineal trauma (RR 0.92, 95% CI 0.72 to 1.18); dyspareunia (RR 1.02, 95% CI 0.90 to 1.16); urinary incontinence (RR 0.98, 95% CI 0.79 to 1.20) or several pain measures. Results for restrictive versus routine mediolateral versus midline episiotomy were similar to the overall comparison. AUTHORS' CONCLUSIONS: Restrictive episiotomy policies appear to have a number of benefits compared to policies based on routine episiotomy. There is less posterior perineal trauma, less suturing and fewer complications, no difference for most pain measures and severe vaginal or perineal trauma, but there was an increased risk of anterior perineal trauma with restrictive episiotomy.

A behavioral intervention to improve obstetrical care.

BACKGROUND: Implementation of evidence-based obstetrical practices remains a significant challenge. Effective strategies to disseminate and implement such practices are needed. METHODS: We randomly assigned 19 hospitals in Argentina and Uruguay to receive a multifaceted behavioral intervention (including selection of opinion leaders, interactive workshops, training of manual skills, one-on-one academic detailing visits with hospital birth attendants, reminders, and feedback) to develop and implement guidelines for the use of episiotomy and management of the third stage of labor or to receive no intervention. The primary outcomes were the rates of prophylactic use of oxytocin during the third stage of labor and of episiotomy. The main secondary outcomes were postpartum hemorrhage and birth attendants' readiness to change their behavior with regard to episiotomies and management of the third stage of labor. The outcomes were measured at baseline, at the end of the 18-month intervention, and 12 months after the end of the intervention. RESULTS: The rate of use of prophylactic oxytocin increased from 2.1% at baseline to 83.6% after the end of the intervention at hospitals that received the intervention and from 2.6% to 12.3% at control hospitals (P=0.01 for the difference in changes). The rate of use of episiotomy decreased from 41.1% to 29.9% at hospitals receiving the intervention but remained stable at control hospitals, with preintervention and postintervention values of 43.5% and 44.5%, respectively (P<0.001 for the difference in changes). The intervention was also associated with reductions in the rate of postpartum hemorrhage of 500 ml or more (relative rate reduction, 45%; 95% confidence interval [CI], 9 to 71) and of 1000 ml or more (relative rate reduction, 70%; 95% CI, 16 to 78). Birth attendants' readiness to change also increased in the hospitals receiving the intervention. The effects on the use of episiotomy and prophylactic oxytocin were sustained 12 months after the end of the intervention. CONCLUSIONS: A multifaceted behavioral intervention increased the prophylactic use of oxytocin during the third stage of labor and reduced the use of episiotomy. (ClinicalTrials.gov number, NCT00070720 [ClinicalTrials.gov]; Current Controlled Trials number, ISRCTN82417627 [controlled-trials.com].).