Overlapping compared with end-to-end repair of complete third-degree or fourth-degree obstetric tears: three-year follow-up of a randomized controlled trial.

OBJECTIVE: To report on a 3-year follow-up of women who underwent overlapping repair of a complete third-degree or fourth-degree obstetric tear. METHODS: Primiparous women sustaining a complete third-degree or a fourth-degree tear of the perineum were randomized to a primary sphincter repair using either an end-to-end or an overlapping surgical technique. At 1, 2, and 3 years, questionnaires on rates of flatal and fecal incontinence were mailed to participants. RESULTS: At 1 year, women who underwent an end-to-end repair reported lower rates of flatal and fecal incontinence than women who had an overlapping repair. For flatal incontinence the rates were 31% compared with 56% (95% confidence interval for the rate difference 6-43%, P=.012). For fecal incontinence, the rates were 7% compared with 16% (95% confidence interval for the rate difference -4% to 21%, P=.17). The difference between the two methods of surgical repair had largely disappeared by the end of year 2. CONCLUSION: At 1-year follow-up, end-to-end repair of complete third-degree or fourth-degree obstetric anal sphincter tears is associated with significantly lower rates of anal incontinence when compared with overlapping repair. There is no long-term benefit associated with either technique over the other. CLINICAL TRIAL REGISTRATION: ISRCTN Register, http://isrctn.org, ISRCTNO 4149919. LEVEL OF EVIDENCE: I.

Neonatal outcome following failed Kiwi OmniCup vacuum extraction.

OBJECTIVE: To evaluate neonatal outcomes following failed vacuum extraction using the Kiwi OmniCup vacuum device. METHODS: We conducted a retrospective study of 288 failed vacuum deliveries using the OmniCup device. The neonatal morbidity was recorded for each delivery. RESULTS: Of the 288 women involved, 82.3% were nulliparous. In 245 cases (85.1%), failed vacuum was followed by successful forceps delivery; failed vacuum and failed forceps was followed by Caesarean section in 5.9%; failed vacuum was followed by spontaneous vaginal delivery in 3.8%; and failed vacuum was followed by Caesarean section in 5.2%. Cephalhematoma was diagnosed in 19.8% of the 288 infants delivered. There were no cases of neonatal intracranial or subgaleal hemorrhage. CONCLUSION: Although the method of delivery following failed vacuum extraction is controversial, and most national guidelines warn of increased neonatal morbidity with subsequent use of forceps, the low morbidity in this study is reassuring. In our cohort, low forceps delivery (station > 2 cm) following failed vacuum extraction was not associated with serious neonatal morbidity.

Overlapping compared with end-to-end repair of third- and fourth-degree obstetric anal sphincter tears: a randomized controlled trial.

OBJECTIVE: To compare overlapping repair with end-to-end repair of obstetric tears and to investigate which procedure results in a higher rate of flatal incontinence. METHODS: One-hundred forty-nine primiparous women sustaining a complete third- or a fourth-degree tear of the perineum were assigned randomly to a primary sphincter repair using either an end-to-end (n=75) or an overlapping surgical technique (n=74) using 3-0 polyglyconate. Outcome measures at 6 months included rates of flatal and fecal incontinence, quality-of-life scores, integrity of the internal and external anal sphincters by anal ultrasonography, and anal sphincter function as reflected by anal manometry. RESULTS: Women who underwent overlapping repair compared with end-to-end repair had higher rates of flatal incontinence, 61% compared with 39% (odds ratio [OR] 2.44, confidence interval [CI] 1.2-5.0). The rate of fecal incontinence was also higher, 15% compared with 8% (OR 1.97, CI 0.62-6.3) but did not attain statistical significance. Rates of internal and external anal sphincter defects did not differ significantly between groups and did not correlate with anal incontinence symptoms. Fecal incontinence was higher when there was a defect in both sphincter muscles. Anal sphincter function as assessed by manometry did not differ significantly between groups. CONCLUSION: End-to-end repair of third- or fourth-degree obstetric anal sphincter tears is associated with lower rates of anal incontinence when compared with overlapping repair. CLINICAL TRIAL REGISTRATION: ISRCTN Register, isrctn.org, ISRCTN04149919. LEVEL OF EVIDENCE: I.

A prospective observational study of 1000 vacuum assisted deliveries with the OmniCup device.

OBJECTIVE: To determine the maternal and perinatal outcomes associated with delivery by the rigid plastic OmniCup vacuum delivery device. METHODS: We conducted a prospective observational study of 1000 consecutive vacuum-assisted deliveries using the OmniCup vacuum device in singleton pregnancies. The relationship of the cup application to the flexion point was independently observed after delivery and related to the neonatal outcome, including scalp trauma. RESULTS: Of the 1000 women, 70% were nulliparous and 30% parous (> or = para 1). In 87.1% of the women, vacuum-assisted delivery was completed; spontaneous or forceps delivery occurred in 10.9%, and Caesarean section was performed in 2%. The vacuum was applied for < or = 10 minutes in 97.4% of deliveries, < or = 3 pulls were required in 95.6%, and < or = 25 lb traction force was required in 85.7% of cases. There was a statistically significant relationship between unfavourable cup applications (deflexing and paramedian) and scalp trauma in infants born to nulliparous women (P < 0.01). Four cases of neonatal intracranial hemorrhage (0.4%) were identified, and three of these infants were subsequently neurodevelopmentally normal. There was one subgaleal hemorrhage. CONCLUSIONS: There is a relationship between unfavourable cup application during vacuum assisted delivery and neonatal scalp trauma in infants born to nulliparous women.