Risk indicators for obstetrical anal sphincter injury in vaginal birth after caesarean section compared to first vaginal delivery.

OBJECTIVES: Comparison of the rate of obstetric anal sphincter injury (OASI) between women having their first vaginal birth after caesarean section (CS) and true nulliparous women with a vaginal delivery. Assessment of risk indicators for OASI in women with vaginal birth after one CS (VBAC). STUDY DESIGN: 28 535 women with their first VBAC and a cohort of 275 439 nulliparous women with a vaginal delivery of a liveborn infant in a cephalic position from the Dutch perinatal registry were analyzed. We compared the OASI rate with univariate and multivariate analysis. In women with VBAC possible risk indicators for OASI were assessed using univariate and multivariate logistic regression analysis. RESULTS: The rate of OASI was 5.2% in women with vaginal birth after CS and 4.0% in women with a first vaginal delivery. The adjusted OR (aOR) for vaginal birth after an elective CS was higher (aOR 1.34, 95% CI 1.23-1.47) compared to vaginal birth after an emergency CS (aOR 1.16, 95% CI 1.08-1.25). In women with vaginal birth after emergency CS, the aOR for the indication non-progressive labor was 1.18 (95% CI 1.08-1.29), whereas CS for suspected fetal distress was not significantly associated with obstetric anal sphincter injury in VBAC. In the 28 535 women with a VBAC, mediolateral episiotomy (MLE), birth weight < 3000 g and maternal age < 25 years were associated with a significantly lower rate of OASI. A gestational age of 42 weeks, birth weight ≥ 3500 g, operative vaginal delivery and duration of the 2nd stage of labour of ≥ 60 min were associated with a significantly higher rate of OASI. CONCLUSIONS: Women with a VBAC have a higher rate of OASI in comparison with women with a first vaginal delivery, with the exception of women with a vaginal birth after an emergency CS for suspected fetal distress. Factors associated with a significantly lower rate for OASI were MLE, maternal age < 25 and birth weight < 3000 g. A gestational age of 42 weeks, birth weight between 3500 and 4000 g and ≥ 4000 g, operative vaginal delivery and duration of the 2nd stage of delivery longer dan 60 min were associated with a significantly higher rate of OASI.

Induction of labor with Foley catheter and risk of subsequent preterm birth: follow-up study of two randomized controlled trials (PROBAAT-1 and -2).

OBJECTIVE: To evaluate the rate of preterm birth (PTB) in a subsequent pregnancy in women who had undergone term induction using a Foley catheter compared with prostaglandins. METHODS: This was a follow-up study of two large randomized controlled trials (PROBAAT-1 and PROBAAT-2). In the original trials, women with a term singleton pregnancy with the fetus in cephalic presentation and with an indication for labor induction were randomized to receive either a 30-mL Foley catheter or prostaglandins (vaginal prostaglandin E2 in PROBAAT-1 and oral misoprostol in PROBAAT-2). Data on subsequent ongoing pregnancies > 16 weeks' gestation were collected from hospital charts from clinics participating in this follow-up study. The main outcome measure was preterm birth < 37 weeks' gestation in a subsequent pregnancy. RESULTS: Fourteen hospitals agreed to participate in this follow-up study. Of the 1142 eligible women, 572 had been allocated to induction of labor using a Foley catheter and 570 to induction of labor using prostaglandins. Of these, 162 (14%) were lost to follow-up. In total, 251 and 258 women had a known subsequent pregnancy > 16 weeks' gestation in the Foley catheter and prostaglandin groups, respectively. There were no differences in baseline characteristics between the groups. The overall rate of PTB in a subsequent pregnancy was 9/251 (3.6%) in the Foley catheter group vs 10/258 (3.9%) in the prostaglandin group (relative risk (RR), 0.93; 95% CI, 0.38-2.24), and the rate of spontaneous PTB was 5/251 (2.0%) vs 5/258 (1.9%) (RR, 1.03; 95% CI, 0.30-3.51). CONCLUSION: In women with term singleton pregnancy, induction of labor using a 30-mL Foley catheter is not associated with an increased risk of PTB in a subsequent pregnancy, as compared to induction of labor using prostaglandins. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.

Which factors are associated with anal incontinence after obstetric anal sphincter injury?

OBJECTIVES: Obstetric anal sphincter injury (OASI) is an important factor in the etiology of anal incontinence. This study aimed to evaluate whether anal sphincter defects, levator avulsion or levator ballooning after OASI are associated with severity of anal incontinence. Furthermore, we evaluated whether factors such as constipation and altered stool consistency are associated with symptoms of incontinence after OASI. METHODS: In this multicenter prospective observational cohort study, women with OASI were invited to participate at least 3 months after primary repair. All women completed validated questionnaires, including St Mark's incontinence score, Bristol stool scale (BSS) and Cleveland clinic constipation score (CCCS), and underwent four-dimensional (4D) transperineal ultrasound for assessment of the levator ani muscle and anal sphincter. RESULTS: In total, 220 women were included. Median follow-up was 4 months (range, 3-98 months). Univariate linear regression analysis showed an association of St Mark's incontinence score with a residual defect of the external anal sphincter (EAS) (ß, 1.55 (95% CI, 0.04-3.07); P = 0.045), higher parity (ß, 0.85 (95% CI, 0.02-1.67); P = 0.046), BSS (ß, 1.28 (95% CI, 0.67-1.89); P < 0.001) and CCCS (ß, 0.36 (95% CI, 0.18-0.54); P < 0.001). However, multivariate linear regression found an association of St Mark's incontinence score only with BSS (ß, 1.50 (95% CI, 0.90-2.11); P < 0.001) and CCCS (ß, 0.46 (95% CI, 0.29-0.63); P < 0.001). CONCLUSIONS: Residual defects of the EAS, detected on 4D transperineal ultrasound, are associated with severity of anal incontinence symptoms measured using St Mark's incontinence score 4 months after OASI repair. Furthermore, clinical factors such as constipation and altered stool consistency appear to influence this association and may therefore play a more important role in clinical management. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Risk factors for the recurrence of obstetrical anal sphincter injury and the role of a mediolateral episiotomy: an analysis of a national registry.

OBJECTIVE: The assessment of risk factors, including mediolateral episiotomy (MLE), for the recurrence of obstetric anal sphincter injury (rOASI). DESIGN: Population-based cohort study. SETTING: Data from the nationwide database of the Dutch Perinatal Registry (Perined). POPULATION: A cohort of 391 026 women at term, of whom 9943 had an OASI in their first delivery and had a second vaginal delivery of a liveborn infant in cephalic position. METHODS: Possible risk factors were tested for statistical significance using univariate and multivariate logistic regression analysis. MAIN OUTCOME MEASURES: Rate of rOASI. RESULTS: The rate of rOASI was 5.8%. Multivariate analysis identified a birthweight of ≥4000 g (adjusted OR, aOR, 2.1, 95% CI 1.6-2.6) and a duration of second stage of ≥30 minutes (aOR 1.8, 95% CI 1.4-2.3) as statistically significant risk factors for rOASI. Mediolateral episiotomy was associated with a statistically significant lower rate of rOASI in spontaneous vaginal delivery (SVD) (aOR 0.4, 95% CI 0.3-0.5) and in operative vaginal delivery (OVD) (aOR 0.2, 95% CI 0.1-0.5). CONCLUSIONS: Women with a history of OASI have a higher rate of OASI in their next delivery. Duration of the second stage of ≥30 minutes and a birthweight of ≥4000 g are significantly associated with an increased rate of rOASI. Mediolateral episiotomy is associated with a significantly lower rate of rOASI in both SVD and OVD. TWEETABLE ABSTRACT: Mediolateral episiotomy is associated with a significant lower recurrence rate of OASI in women with an OASI in their first delivery.

The role of mediolateral episiotomy during operative vaginal delivery.

The role of episiotomy with regard to prevention of anal sphincter injuries (OASIS) is under discussion. The recently published guideline of the WHO "Intrapartum care for a positive childbirth experience" states that the role of episiotomy during operative vaginal deliveries remains to be established. This guideline is based on the evidence coming from randomised clinical trials. However, since the turn of the century large observational studies have pointed out that adequately performed mediolateral episiotomies may play an important role in the prevention of OASIS during operative vaginal deliveries. In this paper we present this evidence and plead for a broader vision on, and use of other evidence than randomised clinical trials solely, the preventive role of mediolateral episiotomy with regard to the occurrence of OASIS.

Comparing induction of labour with oral misoprostol or Foley catheter at term: cost-effectiveness analysis of a randomised controlled multi-centre non-inferiority trial.

OBJECTIVE: To assess the costs of labour induction with oral misoprostol versus Foley catheter. DESIGN: Economic evaluation alongside a randomised controlled trial. SETTING: Obstetric departments of six tertiary and 23 secondary care hospitals in the Netherlands. POPULATION: Women with a viable term singleton pregnancy in cephalic presentation, intact membranes, an unfavourable cervix (Bishop score <6) without a previous caesarean section, were randomised for labour induction with oral misoprostol (n = 924) or Foley catheter (n = 921). METHODS: We performed economic analysis from a hospital perspective. We estimated direct medical costs associated with healthcare utilisation from randomisation until discharge. The robustness of our findings was evaluated in sensitivity analyses. MAIN OUTCOME MEASURES: Mean costs and differences were calculated per women induced with oral misoprostol or Foley catheter. RESULTS: Mean costs per woman in the oral misoprostol group and Foley catheter group were €4470 versus €4158, respectively [mean difference €312, 95% confidence interval (CI) -€508 to €1063]. Multiple sensitivity analyses did not change these conclusions. However, if cervical ripening for low-risk pregnancies in the Foley catheter group was carried out in an outpatient setting, with admittance to labour ward only at start of active labour, the difference would be €4470 versus €3489, respectively (mean difference €981, 95% CI €225-1817). CONCLUSIONS: Oral misoprostol and Foley catheter generate comparable costs. Cervical ripening outside labour ward with a Foley catheter could potentially save almost €1000 per woman. TWEETABLE ABSTRACT: Oral misoprostol or Foley catheter for induction of labour generates comparable costs.

The impact of pelvic floor surgery on female sexual function: a mixed quantitative and qualitative study.

OBJECTIVE: To assess whether the current condition-specific sexual function questionnaire provides full insight into sexual function following pelvic floor surgery. DESIGN: Prospective, mixed quantitative and qualitative study. SETTING: Urogynaecology clinic in a large university hospital. POPULATION: Thirty-seven women undergoing surgery for pelvic organ prolapse (POP) and/or stress urinary incontinence (SUI). METHODS: Women were seen before surgery and 3 months postoperatively. At both visits the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ) was completed and a qualitative face-to-face semi-structured interview was conducted. PISQ total and domain scores, as well as the change in the preoperative and postoperative score, were calculated and analysed using Wilcoxon signed rank test and one-sample t-test. The qualitative data were systematically analysed using data-matrices. MAIN OUTCOME MEASURES: The impact of pelvic floor surgery on female sexual function. RESULTS: Significant improvement was seen for PISQ total score (P = 0.003) as well as Physical (P < 0.001) and Partner-related (P = 0.002) domains, but not for the Behavioural/Emotive domain (P = 0.220). Analysis of qualitative data showed that improvement in sexual function was a result of cure of POP and SUI symptoms. Deterioration of sexual function was due to dyspareunia, fear of causing damage to the surgical result, new symptoms and a disappointing result of surgery. CONCLUSIONS: Our qualitative data show that PISQ is limited in the assessment of sexual function after pelvic floor surgery as it does not assess most surgery-specific negative effects on sexual function.

Cost-effectiveness of induction of labour at term with a Foley catheter compared to vaginal prostaglandin E2 gel (PROBAAT trial).

OBJECTIVE: To assess the economic consequences of labour induction with Foley catheter compared to prostaglandin E2 gel. DESIGN: Economic evaluation alongside a randomised controlled trial. SETTING: Obstetric departments of one university and 11 teaching hospitals in the Netherlands. POPULATION: Women scheduled for labour induction with a singleton pregnancy in cephalic presentation at term, intact membranes and an unfavourable cervix; and without previous caesarean section. METHODS: Cost-effectiveness analysis from a hospital perspective. MAIN OUTCOME MEASURES: We estimated direct medical costs associated with healthcare utilisation from randomisation to 6 weeks postpartum. For caesarean section rate, and maternal and neonatal morbidity we calculated the incremental cost-effectiveness ratios, which represent the costs to prevent one of these adverse outcomes. RESULTS: Mean costs per woman in the Foley catheter group (n = 411) and in the prostaglandin E2 gel group (n = 408), were €3297 versus €3075, respectively, with an average difference of €222 (95% confidence interval -€157 to €633). In the Foley catheter group we observed higher costs due to longer labour ward occupation and less cost related to induction material and neonatal admissions. Foley catheter induction showed a comparable caesarean section rate compared with prostaglandin induction, therefore the incremental cost-effectiveness ratio was not informative. Foley induction resulted in fewer neonatal admissions (incremental cost-effectiveness ratio €2708) and asphyxia/postpartum haemorrhage (incremental cost-effectiveness ratios €5257) compared with prostaglandin induction. CONCLUSIONS: Foley catheter and prostaglandin E2 labour induction generate comparable costs.

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.

Development of de novo prolapse in untreated vaginal compartments after prolapse repair with and without mesh: a secondary analysis of a randomised controlled trial.

OBJECTIVE: To compare the de novo prolapse rate in the untreated vaginal compartments following conventional vaginal prolapse repair and tension-free vaginal mesh repair. DESIGN: Secondary analysis of a randomised controlled trial. SETTING: Thirteen centres in the Netherlands. POPULATION: Women with recurrent pelvic organ prolapse stage II or higher. METHODS: Random assignment to either conventional vaginal native tissue repair or vaginal mesh insertion. PRIMARY OUTCOME: de novo pelvic organ prolapse stage II or higher in the untreated vaginal compartments at 12 months after surgery. SECONDARY OUTCOMES: de novo pelvic organ prolapse at and beyond the hymen, de novo prolapse beyond the hymen and prolapse domain scores of the Urogenital Distress Inventory. RESULTS: At 12 months ten of 59 women (17%) in the conventional group versus 29 of 62 women (47%) in the mesh group were diagnosed with a de novo pelvic organ prolapse stage II or higher in the untreated compartment (P < 0.001, odds ratio 4.3, 95% confidence interval 1.9-10.0). Additional apical support to a mesh-augmented anterior repair significantly reduced the de novo prolapse rate. Women with a de novo prolapse in the mesh-treated group demonstrated significantly higher mean bother scores on the domain genital prolapse of the Urogenital Distress Inventory score (13.1 ± 24.2) compared with those without de novo prolapse (2.9 ± 13.9) (P = 0.03). CONCLUSION: Mesh-augmented prolapse repair in only one vaginal compartment is associated with a higher de novo prolapse rate in the untreated compartments compared with conventional vaginal native tissue repair in women with recurrent pelvic organ prolapse.

A rare complication of a vaginal breech delivery.

Rectal lesions without anal sphincter trauma in childbirth are only sporadically described in literature. We describe the case of a 29-year-old primigravida who delivered a child in frank breech presentation. During the second stage of labour a foot presented transanally through a rectal laceration with intact anal sphincters. The laceration was repaired immediately after delivery in theatre. Follow-up visits showed a properly cured laceration and no complaints of incontinence or foul discharge.

The Eocene Arctic Azolla bloom: environmental conditions, productivity and carbon drawdown.

Enormous quantities of the free-floating freshwater fern Azolla grew and reproduced in situ in the Arctic Ocean during the middle Eocene, as was demonstrated by microscopic analysis of microlaminated sediments recovered from the Lomonosov Ridge during Integrated Ocean Drilling Program (IODP) Expedition 302. The timing of the Azolla phase (approximately 48.5 Ma) coincides with the earliest signs of onset of the transition from a greenhouse towards the modern icehouse Earth. The sustained growth of Azolla, currently ranking among the fastest growing plants on Earth, in a major anoxic oceanic basin may have contributed to decreasing atmospheric pCO2 levels via burial of Azolla-derived organic matter. The consequences of these enormous Azolla blooms for regional and global nutrient and carbon cycles are still largely unknown. Cultivation experiments have been set up to investigate the influence of elevated pCO2 on Azolla growth, showing a marked increase in Azolla productivity under elevated (760 and 1910 ppm) pCO2 conditions. The combined results of organic carbon, sulphur, nitrogen content and 15N and 13C measurements of sediments from the Azolla interval illustrate the potential contribution of nitrogen fixation in a euxinic stratified Eocene Arctic. Flux calculations were used to quantitatively reconstruct the potential storage of carbon (0.9-3.5 10(18) gC) in the Arctic during the Azolla interval. It is estimated that storing 0.9 10(18) to 3.5 10(18) g carbon would result in a 55 to 470 ppm drawdown of pCO2 under Eocene conditions, indicating that the Arctic Azolla blooms may have had a significant effect on global atmospheric pCO2 levels through enhanced burial of organic matter.

Mediolateral episiotomy reduces the risk for anal sphincter injury during operative vaginal delivery.

OBJECTIVE: To determine the risk factors for anal sphincter injuries during operative vaginal delivery. SETTING AND DESIGN: A population-based observational study. POPULATION: All 21 254 women delivered with vacuum extraction and 7478 women delivered with forceps, derived from the previously validated Dutch National Obstetric Database from the years 1994 to 1995. METHODS: Anal sphincter injury was defined as any injury, partial or complete, of the anal sphincters. Risk factors were determined with multivariate logistic regression analysis. MAIN OUTCOME MEASURES: Individual obstetric factors, e.g. fetal birthweights, duration of second stage, etc. RESULTS: Anal sphincter injury occurred in 3.0% of vacuum extractions and in 4.7% of forceps deliveries. Primiparity, occipitoposterior position and fetal birthweight were associated with an increased risk for anal sphincter injury in both types of operative vaginal delivery, whereas duration of second stage was associated with an increased risk only in vacuum extractions. Mediolateral episiotomy protected significantly for anal sphincter damage in both vacuum extraction (OR 0.11, 95% CI 0.09-0.13) and forceps delivery (OR 0.08, 95% CI 0.07-0.11). The number of mediolateral episiotomies needed to prevent one sphincter injury in vacuum extractions was 12, whereas 5 mediolateral episiotomies could prevent one sphincter injury in forceps deliveries. CONCLUSIONS: Primiparity and occipitoposterior presentation are strong risk factors for the occurrence of anal sphincter injury during operative vaginal delivery. The highly significant protective effect of mediolateral episiotomies in both types of operative vaginal delivery warrants the conclusions that this type of episiotomy should be used routinely during these interventions to protect the anal sphincters.

Long-term effects of anal sphincter rupture during vaginal delivery: faecal incontinence and sexual complaints.

OBJECTIVE: To determine the long-term effects of obstetric anal sphincter rupture on the frequency of faecal incontinence and sexual complaints. DESIGN: Retrospective case-control study. SETTING: Department of Gynaecology and Obstetrics, Ikazia Hospital, The Netherlands. POPULATION: All 171 women operated for anal sphincter rupture between 1971 and 1990 and 171 controls matched for parity and date of delivery. METHODS: Postal questionnaires regarding faecal incontinence were sent in 1996 and 2005 to all cases and controls with questions regarding sexual complaints added to the questionnaire in 2005. MAIN OUTCOME MEASURES: Anorectal complaints defined as any form of faecal incontinence including faecal urgency and faecal soiling. Sexual complaints defined as dyspareunia or faecal incontinence during intercourse. RESULTS: Sixty-one percent of the women responded to both questionnaires. Anorectal complaints were reported by 38% of case versus 16% of controls in 1996 (risk difference: 0.22, 95% CI 0.10-0.34) and by 61% of cases versus 22% of controls in 2005 (risk difference: 0.41, 95% CI 0.29-0.53). In contrast to the control group, the increase of anorectal complaints in the case group between 1996 and 2005 was highly significant (P < 0.0001). Postmenopausal state was not associated with an increased risk for faecal incontinence. Dyspareunia was reported by 29% of cases versus 13% of controls (P = 0.01). Faecal incontinence during intercourse was reported by 13% of cases versus 1% of controls (P = 0.005). CONCLUSIONS: Obstetric anal sphincter rupture is an important risk factor for sexual complaints and for faecal incontinence increasing with age irrespective of menopausal state.

Anal sphincter damage after vaginal delivery: functional outcome and risk factors for fecal incontinence.

OBJECTIVE: To assess the role of anal sphincter damage following delivery in the development of anorectal complaints and urinary incontinence, and to identify obstetric factors associated with subsequent fecal incontinence. METHODS: The retrospective cohort study with matched controls used a postal questionnaire and analysis of delivery and operation records from all women who underwent primary repair of a third or fourth degree perineal rupture in our hospital between 1971 and 1991, and their controls, matched for date and parity. Frequencies of complaints were compared using the Mantel-Haenszel common odds ratio [OR] for matched-control studies. Obstetric risk factors for fecal incontinence were assessed with multivariate logistic regression analysis. RESULTS: In the period studied, 171 women underwent a primary repair. One hundred and forty-seven of which returned the questionnaire (86%), compared with 131 of the controls (73%). Analysis was performed on 125 matched pairs with a median follow-up of 14 years. Fecal incontinence was reported by 39 patients and 16 controls (OR: 3.09; 95% confidence interval: 1.57-6.10). Urinary incontinence was reported by 65 cases and 52 controls (OR:1.46; 95% CI: 0.91-2.37). Among women with anal sphincter damage, the extent of anal sphincter damage was an independent risk factor for fecal incontinence. (OR: 2.54; 95% CI: 1.45-4.45). Subsequent vaginal delivery was not associated with the development of fecal incontinence (OR: 2.32; 95% CI: 0.85-6.33). In primiparous women mediolateral episiotomy protected for fecal incontinence after anal sphincter damage (OR: 0.17; 95% CI: 0.05-0.60). CONCLUSIONS: Anal sphincter damage following delivery is significantly associated with subsequent anorectal complaints, but not with urinary incontinence. The extent of sphincter damage is an independent risk factor for the development of fecal incontinence. Mediolateral episiotomy protects for fecal incontinence in primiparous women.

Biosynthetic controls on the 13C contents of organic components in the photoautotrophic bacterium Chloroflexus aurantiacus.

To assess the effects related to known and proposed biosynthetic pathways on the (13)C content of lipids and storage products of the photoautotrophic bacterium Chloroflexus aurantiacus, the isotopic compositions of bulk cell material, alkyl and isoprenoid lipids, and storage products such as glycogen and polyhydroxyalkanoic acids have been investigated. The bulk cell material was 13 per thousand depleted in (13)C relative to the dissolved inorganic carbon. Evidently, inorganic carbon fixation by the main carboxylating enzymes used by C. aurantiacus, which are assumed to use bicarbonate rather than CO(2), results in a relatively small carbon isotopic fractionation compared with CO(2) fixation by the Calvin cycle. Even carbon numbered fatty acids, odd carbon numbered fatty acids, and isoprenoid lipids were 14, 15, and 17-18 per thousand depleted in (13)C relative to the carbon source, respectively. Based on the (13)C contents of alkyl and isoprenoid lipids, a 40 per thousand difference in (13)C content between the carboxyl and methyl carbon from acetyl-coenzyme A has been calculated. Both sugars and polyhydroxyalkanoic acid were enriched in (13)C relative to the alkyl and isoprenoid lipids. To the best of our knowledge this is the first report in which the stable carbon isotopic composition of a large range of biosynthetic products in a photoautotrophic organism has been investigated and interpreted based on previously proposed inorganic carbon fixation and biosynthetic pathways. Our results indicate that compound-specific stable carbon isotope analysis may provide a rapid screening tool for carbon fixation pathways.