Duration of the active first stage of labour and severe perineal lacerations and maternal postpartum complications: a population-based cohort study.

OBJECTIVE: The impact of first stage labour duration on maternal outcomes is sparsely investigated. We aimed to study the association between a longer active first stage and maternal complications in the early postpartum period. DESIGN: A population-based cohort study. SETTING: Regions of Stockholm and Gotland, Sweden, 2008-2020. POPULATION: A cohort of 159 459 term, singleton, vertex pregnancies, stratified by parity groups. METHODS: The exposure was active first stage duration, categorised in percentiles. Poisson regression analysis was performed to estimate the adjusted relative risk (aRR) and the 95% confidence interval (95% CI). To investigate the effect of second stage duration on the outcome, mediation analysis was performed. MAIN OUTCOME MEASURES: Severe perineal lacerations (third or fourth degree), postpartum infection, urinary retention and haematoma in the birth canal or ruptured sutures. RESULTS: The risks of severe perineal laceration, postpartum infection and urinary retention increased with a longer active first stage, both overall and stratified by parity group. The aRR increased with a longer active first stage, using duration of <50th percentile as the reference. In the ≥90th percentile category, the aRR for postpartum infection was 1.64 (95% CI 1.46-1.84) in primiparous women, 2.43 (95% CI 1.98-2.98) in parous women with no previous caesarean delivery (CD) and 2.33 (95% CI 1.65-3.28) in parous women with a previous CD. The proportion mediated by second stage duration was 33.4% to 36.9% for the different outcomes in primiparous women. The risk of haematoma or ruptured sutures did not increased with a longer active first stage. CONCLUSIONS: Increasing active first stage duration is associated with maternal complications in the early postpartum period.

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.

Factors Associated with Obstetric Anal Sphincter Injury During Vacuum-Assisted Vaginal Delivery.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injury (OASI) is a major complication associated with vacuum-assisted vaginal delivery (VAVD). The aim of this study was to evaluate risk factors related to vacuum extraction that are associated with OASI. METHODS: This was a case-control study performed at a tertiary university teaching hospital. Included were patients aged 18-45 years who had a singleton pregnancy resulting in a live, term, VAVD. The study group consisted of women diagnosed with OASI following vacuum extraction. The control group included women following VAVD without OASI. Matching at a ratio of 1:2 was performed. Groups were compared regarding demographic, obstetric. and labor-related parameters, specifically focusing on variables related to the vacuum procedure itself. RESULTS: One hundred and ten patients within the study group and 212 within the control group were included in the final analysis. Patients in the OASI group were more likely to undergo induction of labor, use of oxytocin during labor, increased second stage of labor, higher likelihood of the operator being a resident, increased number of pulls, procedure lasting under 10 min, occipito-posterior head position at vacuum initiation, episiotomy, increased neonatal head circumference, and birthweight. Multivariate logistic regression analysis revealed that increased week of gestation (OR 1.67, 95% CI 1.25-2.22, p < 0.001), unsupervised resident performing the procedure (OR 4.63, 95% CI 2.17-9.90), p < 0.001), indication of VAVD being fetal distress (OR 2.72, 95% CI 1.04-7.10, p = 0.041), and length of procedure under 10 min (OR 4.75, 95% CI 1.53-14.68, p = 0.007) were associated with OASI. Increased maternal age was associated with lower risk of OASI (OR 0.9, 95% CI 0.84-0.98, p = 0.012). CONCLUSIONS: When performing VAVD, increased week of gestation, unsupervised resident performing the procedure, fetal distress as vacuum indication, and vacuum procedure under 10 min were associated with OASI. In contrast, increased maternal age was shown to be a protective factor.

Lidocaine spray vs mepivacaine local infiltration for suturing 1st/2nd grade perineal lacerations: a randomised controlled non-inferiority trial.

BACKGROUND: Perineal lacerations are a very common complication of post-partum. Usually, the repair of 1st and 2nd-grade lacerations is performed after the administration of local anesthesia. Despite the great relevance of the problem, there are only a few studies about the best choice of local anesthetic to use during suturing. We performed a randomised controlled trial to evaluate the efficacy and safety of the use of a local anesthetic spray during the suturing of perineal lacerations in the post-partum. METHODS: We compared the spray with the standard technique, which involves the infiltration of lacerated tissues, using the NRS scale. 136 eligible women who had given birth at University Hospital of Udine were enrolled and randomly assigned to receive nebulization of Lidocaine hydrochloride 10% spray (experimental group) or subcutaneous/submucosal infiltration of mepivacaine hydrochloride (control group) during suturing of perineal laceration. RESULTS: The lacerations included 84 1st-grade perineal traumas (61.7%) and 52 2nd-grade perineal traumas (38.2%). All the procedures were successfully completed without severe complications or serious adverse reactions. There were no statistically significant differences between the two groups in terms of blood losses or total procedure time. Moreover, there were no statistically significant differences in terms of NRS to none of the intervals considered. Regarding the application of the spray in the B group, in 36 cases (52.9%) it was necessary to improve the number of puffs previously supposed to be sufficient (5 puffs). Just in 3 cases, an additional injection was necessary (4.4%). CONCLUSIONS: Our study demonstrates that lidocaine spray alone can be used as a first line of local anesthetic during the closure of I-II-grade perineal lacerations, as it has comparable efficacy to mepivacaine infiltration. TRIAL REGISTRATION: The trial was recorded on https://clinicaltrials.gov . Identification number: NCT05201313. First registration date: 21/01/2022. Unique Protocol ID: 0042698/P/GEN/ARCS.

Occurrence and risk factors for second-degree perineal tears: A prospective cohort study using a detailed classification system.

BACKGROUND: The amount of tissue trauma within second-degree perineal tears varies widely. Therefore, subcategorization of second-degree tears and a better understanding of their occurrence and risk factors are needed. The aim of this study was to assess the occurrence of perineal tears when second-degree tears were subcategorized. Furthermore, we aimed to assess the association between variables related to perineal anatomy and other potential risk factors, with second-degree tear subcategories. METHODS: This prospective cohort study included 880 primiparous and multiparous women giving birth to one child vaginally. Perineal tears were categorized using the classification system recommended by the Royal College of Obstetricians and Gynaecologists. In addition, second-degree tears were subcategorized as 2A, 2B, or 2C according to the percentage of damage to the perineal body. Selected variables related to perineal anatomy were as follows: length of genital hiatus; perineal body length; and previous perineal trauma. Risk factors for second-degree tear subcategories were analyzed using a multinominal regression model. RESULTS: Perineal tears occurred as follows: first-degree: 35.6% (n = 313), 2A: 16.3% (n = 143), 2B: 9.1% (n = 80), 2C: 6.6% (n = 58), and third- or fourth-degree: 1.6% (n = 14). In total, 169/880 participants underwent an episiotomy. When episiotomies were excluded, the risk for 2B, or 2C tears increased with smaller genital hiatus, larger perineal body, previous perineal trauma, primiparity, higher gestational age, instrumental vaginal delivery and fetal presentation other than occiput anterior. CONCLUSION: The occurrence of second-degree tear subcategories was 16.3% for 2A tears, 9.1% for 2B tears, and 6.6% for 2C tears. Factors related to perineal anatomy increased the odds for experiencing a second-degree tear in a more severe subcategory.

First and Second Stage Risk Factors Associated with Perineal Lacerations.

OBJECTIVE: To determine intrapartum factors associated with perineal laceration at delivery. METHODS: This was a planned secondary analysis of a multicenter randomized clinical trial of delayed versus immediate pushing among term nulliparous women in labor with neuraxial analgesia conducted in the United States. Intrapartum characteristics were extracted from the medical charts. The primary outcome was perineal laceration, defined as second degree or above, characterized at delivery in women participating in longer term pelvic floor assessments post-delivery. Multivariable logistic regression was used to refine risk estimates while adjusting for randomization group, birth weight, and maternal age. RESULTS: Among the 941 women participating in the pelvic floor follow-up, 40.6% experienced a perineal laceration. No first stage labor characteristics were associated with perineal laceration, including type of labor or length of first stage. Receiving an amnioinfusion appeared protective of perineal laceration (adjusted odds ratio, 0.48; 95% confidence interval 0.26-0.91; P = 0.01). Second stage labor characteristics associated with injury were length of stage (2.01 h vs. 1.50 h; adjusted odds ratio, 1.36; 95% confidence interval 1.18-1.57; P < 0.01) and a prolonged second stage (adjusted odds ratio, 1.64; 95% confidence interval 1.06-2.56; P < 0.01). Operative vaginal delivery was strongly associated with perineal laceration (adjusted odds ratio, 3.57; 95% confidence interval 1.85-6.90; P < 0.01). CONCLUSION: Operative vaginal delivery is a modifiable risk factor associated with an increased risk of perineal laceration. Amnioinfusion appeared protective against injury, which could reflect a spurious finding, but may also represent true risk reduction similar to the mechanism of warm perineal compress.

Conservative management versus systematic suture of isolated vaginal or first-degree perineal tears after delivery: A preliminary randomized efficacy trial.

BACKGROUND: The objective of this study was to assess the preliminary efficacy and safety of conservative management compared with systematic suture in isolated vaginal or first-degree perineal tears after birth. METHODS: We conducted a preliminary efficacy, open-label, randomized, controlled, and prospective trial. This study implemented Simon's 2-step plan (interim analysis and final analysis) to test the success rate of the digital compression strategy group. Primiparous women aged ≥18 years with isolated vaginal or first-degree perineal tears after spontaneous vaginal birth of a cephalic presenting term (≥37 weeks) neonate were randomly allocated to the conservative management (CM) group (digital compression if bleeding followed by suture if persistent bleeding) or a systematic suture (SS) group. The primary outcome was the success of the intervention 10 days after delivery, defined by pain as evaluated using a visual analog scale < 3, satisfactory healing defined by a REEDA score ≤ 2, and no bleeding or infection. Sexual well-being was assessed at 2 and 6 months postpartum. RESULTS: Among 861/2209 eligible women, 143 consenting women with a superficial perineal tear were randomized: 72 in the systematic suture group and 71 in the conservative management group. Success rate was 87.8% (90% CI [70.5-93.54]) (42/55) in the systematic suture group vs 90% (90% CI [78.3-93.8]) (53/61) in the conservative management group. The REEDA score was significantly higher in the systematic suture group (1.4 vs 0.9; P = 0.036). Perineal pain was significantly higher at day 1 in the systematic suture group (2.38 vs 1.69; P = 0.034). For the Female Sexual Functional Index score, no significant difference was found between the two groups at inclusion or at 2 and 6 months postpartum. CONCLUSIONS: Conservative management of superficial perineal tears shows an efficacy rate ≥90%. Women in the conservative management group had less pain at the 1st day follow-up and lower REEDA scores at the 10th day follow-up.

Risk factors for severe perineal lacerations during childbirth: A systematic review and meta-analysis of cohort studies.

AIMS AND OBJECTIVES: To evaluate and quantify the best available evidence regarding risk factors for severe perineal lacerations. BACKGROUND: Many studies have evaluated the risk factors for severe perineal lacerations. However, the results of those studies are inconsistent, and meta-analysis which thoroughly evaluates the risk factors for severe perineal lacerations is still lacking. DESIGN: Systematic review and meta-analysis of cohort studies based on the PRISMA guideline. METHODS: PubMed, Embase, the Cochrane Library, CINAHL, ClinicalTrials.gov, CNKI, Wanfang Data, VIP and SinoMed were systematically searched for cohort studies reporting at least one risk factor for severe perineal lacerations from 1 January 2000 to 2 June 2021. Two reviewers independently conducted quality appraisal by NOS scale and extracted data. Data synthesis was conducted via RevMan 5.3 using a random-effects or fixed-effects model. RESULTS: A total of 47 studies with 7,043,218 women were included. The results showed that prior caesarean delivery (OR: 1.46, 95% CI 1.12-1.92) and pre-pregnant underweight (OR: 1.31, 95% CI 1.22-1.41) significantly increased the risk of severe perineal lacerations. The results also demonstrated that episiotomy was protective against severe perineal lacerations in forceps delivery (OR: 0.56, 95% CI 0.42-0.74), but not spontaneous vaginal delivery (OR: 1.30, 95% CI 0.81-2.07) or vacuum delivery (OR: 0.76, 95% CI 0.45-1.28). Nulliparity, foetus in occipitoposterior or occipitotransverse position, and midline episiotomy were also independent risk factors for severe perineal lacerations. CONCLUSIONS: Severe perineal lacerations are associated with many factors, and evidence-based risk assessment tools are needed to guide the midwives and obstetricians to estimate women's risk of severe perineal lacerations. RELEVANCE TO CLINICAL PRACTICE: This systematic review and meta-analysis identified some important risk factors for severe perineal lacerations, which provides comprehensive insights to guide the midwives to assess women's risk for severe perineal lacerations and take appropriate preventive measures to decrease the risk.

Postpartum urinary incontinence and birth outcomes as a result of the pushing technique: a systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: Directed pushing while using the Valsalva maneuver is shown to lead to bladder neck descent, especially in women with urinary incontinence (UI). There is insufficient evidence about the benefits or adverse effects between the pushing technique during the second stage of labor and urinary incontinence postpartum. The objective of this study was to evaluate the effects of the pushing technique for women during labor on postpartum UI and birth outcomes. METHODS: Scientific databases were searched for studies relating to postpartum urinary incontinence and birth outcomes when the pushing technique was used from 1986 until 2020. RCTs that assessed healthy primiparas who used the pushing technique in the second stage of labor were included. In accordance with Cochrane Handbook guidelines, risk of bias was assessed and meta-analyzed. Certainty of evidence was assessed using the GRADE approach. RESULTS: Seventeen RCTs (4606 primiparas) were included. The change in UI scores from baseline to postpartum was significantly lower as a result of spontaneous pushing (two studies; 867 primiparas; standardized mean difference: SMD -0.18, 95% CI -0.31 to -0.04). Although women were in the recumbent position during the second stage, directed pushing group showed a significantly shorter labor by 21.39 min compared with the spontaneous pushing group: there was no significant difference in the duration of the second stage of labor between groups. CONCLUSIONS: Primiparas who were in the upright position and who experienced spontaneous pushing during the second stage of labor could reduce their UI score from baseline to postpartum.

Selective versus routine use of episiotomy for vaginal births in Shanghai hospitals, China: a comparison of policies.

BACKGROUND: To assess the effects of policy of selective versus routine episiotomy on mother and baby for women delivering vaginally in Shanghai and whether the hospital type has any effect on the outcomes. METHOD: This was a multi-center retrospective cohort study in Shanghai between March 2015 and May 2017. The study population were vaginal births with selective or routine episiotomy (n = 5478) in 20 secondary or tertiary hospitals. Main Outcome Measure was the incidence of severe perineal lacerations. The adjusted odds ratios (aOR) and 95% confidence intervals (CI) were estimated by logistic regression and presented as the effect sizes. All models were stratified by the utilization of level (secondary and tertiary) and type (general and Obstetric) of hospital. RESULTS: The primary outcome was not significantly different between vaginal births with routine and selective episiotomy. Patients with selective episiotomy had a lower risk of postpartum hemorrhage, and newborns in the selective episiotomy group had a lower risk of shoulder dystocia and Neonatal Ward compared to those with routine episiotomy. Newborns in selective episiotomy group had a lower risk of birth injury in tertiary hospital. However, newborns in selective episiotomy group had a higher risk of birth injury in general hospitals. CONCLUSION: Selective episiotomy is safe and can be recommended over routine episiotomy in obstetric and tertiary hospital settings in China.

An extremely prolonged second stage of labor increases maternal complications but has no adverse effect on neonatal outcomes.

AIM: To investigate how an extremely prolonged second stage of labor of 12 h or more affects maternal and neonatal outcomes. MATERIAL AND METHODS: This retrospective cohort study included nulliparous, pregnant women with 37 + 0 to 41 + 6 weeks of gestation whom vaginal delivery was attempted at the Yokohama City University Medical Center between 2014 and 2018. RESULTS: In 446 cases of the prolonged second stage of labor, there were 296 women (66%) in the 2- to 6-h second stage of labor group, 112 women (25%) in the 6- to 12-h group, and 38 women (8.5%) in the 12-h or longer group. The longer the second stage of labor, the more significant was the increase in the rates of augmentation of the delivery, emergency cesarean delivery, and operative vaginal delivery. Even in the 12 h or longer group, 82% were able to have vaginal delivery. The 6- to 12-h group had a significant increase in third- or fourth-degree perineal lacerations compared to the 2- to 6-h group (aOR 8.12 [95% CI 1.55-42.6]). Clinical chorioamnionitis was significantly increased in the 12 h or longer group (aOR 4.88 [95% CI 1.62-14.8]). In terms of neonatal outcomes, comparison between the three groups showed no significant difference. CONCLUSION: With an extremely prolonged second stage of labor, maternal complications involved a significant increase in severe perineal lacerations and chorioamnionitis; however, there was no increase in adverse outcomes for neonates. It was not possible to conclusively determine if the duration of the second stage is acceptable.

[Third- and fourth-degree post-delivery perineal tears : retrospective analysis and management adaptation]. / Les déchirures périnéales des 3ème et 4ème degrés post-accouchement : analyse rétrospective et adaptation de la prise en charge.

Third- and fourth-degree perineal tears are injuries involving the anal sphincter that occur during vaginal delivery. Their prevalence is between 0.25 and 6 %, which highlights the variability of obstetrical practice among different countries. This type of tear can lead to short- and long-term complications for the mothers, affecting their quality of life. Therefore, it seems essential that their management should be optimal. In this study, we analyzed the records of all women who suffered from an obstetric anal sphincter injury between January 2015 and January 2021. During this period, out of 11222 vaginal deliveries, 61 records (0.54%) were retained. Maternal, fetal, and delivery-related risk factors were studied and were mostly similar to those found in the literature. However, the treatment of these lesions was very heterogeneous among patients and lacked standardization. A better management of these tears through the establishment of a decision algorithm would potentially reduce the long-term morbidity.

Les déchirures périnéales des troisième et quatrième degrés sont des lésions entreprenant le sphincter anal et survenant lors de l'accouchement par voie vaginale. Leur prévalence est comprise entre 0,25 et 6 %, ce qui souligne la variabilité de la pratique obstétricale selon les pays. Ce type de lésion peut entraîner des complications à court et long termes pour les patientes, affectant leur qualité de vie. Dès lors, il semble essentiel que leur prise en charge soit optimale. Dans cette étude rétrospective monocentrique, les dossiers des femmes ayant présenté une lésion obstétricale du sphincter anal entre janvier 2015 et janvier 2021 ont été analysés. Durant cette période, sur 11.222 accouchements par voie basse, 61 dossiers (0,54 %) ont été retenus. Les facteurs de risque maternels, fœtaux et liés à l'accouchement ont été étudiés et sont majoritairement similaires à ceux retrouvés dans la littérature. En revanche, la prise en charge de ces lésions était très hétérogène parmi les patientes, avec un manque de standardisation. Une meilleure gestion de ces déchirures via l'instauration d'un algorithme décisionnel permettrait potentiellement d'en diminuer la morbidité à long terme.

Obstetric anal sphincter injury in adolescent mothers.

BACKGROUND: Obstetric anal sphincter injury (OASI) is a debilitating complication of vaginal delivery which has yet to receive ample attention in adolescents. The aim of this study was to describe risk for OASI in adolescent mothers compared to adults. We further attempted to compare risk factors for OASI between these two age groups. METHODS: We performed a retrospective cohort study between 2003 and 2019. Primiparous women who delivered vaginally, 21 years and younger were compared to women ages 26-35. Excluded were preterm, multifetal, non-vertex, cesarean deliveries as well as intrauterine fetal death. Rate of OASI as well as obstetric and labor characteristics of women with OASI, were compared between groups. Finally, risk factors were assessed for each group separately. Univariate and multivariate logistic regression model were performed. RESULTS: Final analysis was performed on 5113 nulliparous adolescents and 13,845 nulliparous in the 26-35 age group. Allocation to study groups was according to OASI - Sixty-seven adolescents (1.3%) had a 3rd or 4th degree perineal tear and were defined as the OASI group, while 5046 patients (98.7%) did not have such a tear. In the adult group, 199 out of 13,845 patients (1.4%) were diagnosed with OASI. Occurrence of OASI did not differ between groups (p = 0.510). Comparison of women with OASI in the adolescent group vs. adult group found differences with regard to operative vaginal delivery, (20.9% vs. 36.2%, respectively; p = 0.023) and meconium stained amniotic fluid (9.1% vs. 21.3%, respectively; p = 0.027). Following multivariate analysis the only parameter independently associated with OASI in the adolescent age group was head circumference ≥ 90th percentile with an adjusted odds ratio of 3.08 (CI 1.48-6.38, p = 0.003). In the adult group the similar analysis revealed operative vaginal delivery (OR = 2.44, CI 1.72-3.47, p < 0.001) and a birthweight≥90th percentile (OR = 2.23, CI 1.19-4.18, p = 0.012) to be independent risk factors for OASI. CONCLUSION: Adolescents have similar risk for OASI compared to adults but differ in risk factors leading to OASI. Head circumference ≥ 90th percentile was found to be associated with OASI in this age group.

Severe obstetric lacerations associated with postpartum depression among women with low resilience - a Swedish birth cohort study.

OBJECTIVE: Women's levels of resilience and attitudes towards perineal lacerations vary greatly. Some women see them as part of the birthing process, while others react with anger, depressed mood or even thoughts of self-harm. A previous study has reported increased risk of postpartum depressive (PPD) symptoms in women with severe perineal lacerations. The aim of this study was to assess the association between severe obstetric perineal lacerations and PPD. A secondary objective was to assess this association among women with low resilience. DESIGN: Nested cohort study. SETTING: Uppsala, Sweden. SAMPLE: Vaginally delivered women with singleton pregnancies (n = 2990). METHODS: The main exposure was obstetric perineal lacerations. Resilience was assessed in gestational week 32 using the Swedish version of the Sense of Coherence Scale. A digital acyclic graph was used to identify possible confounders and mediators. Logistic regression was used to estimate odds ratios (OR) and 95% confidence intervals (CI). A sub-analysis was run after excluding women with normal or high resilience. MAIN OUTCOME MEASURES: Postpartum depression, assessed with the Depression Self-Reporting Scale, completed at 6 weeks postpartum. RESULTS: There was no significant association between severe obstetric perineal lacerations and PPD at 6 weeks postpartum. However, a significant association was found between severe lacerations and PPD in women with low resilience (OR = 4.8, 95% CI 1.2-20), persisting even after adjusting for confounding factors. CONCLUSION: Healthcare professionals might need to identify women with low resilience, as they are at increased risk for PPD after a severe perineal laceration. TWEETABLE ABSTRACT: Severe perineal lacerations associated with postpartum depression in women with low resilience in a Swedish cohort.

Duration of second stage of labor and instrumental delivery as risk factors for severe perineal lacerations: population-based study.

BACKGROUND: We sought to investigate the impact of the duration of second stage of labor on risk of severe perineal lacerations (third and fourth degree). METHODS: This population based cohort study was conducted in the Stockholm/Gotland region, Sweden, 2008-2014. Study population included 52 211 primiparous women undergoing vaginal delivery with cephalic presentation at term. Unconditional logistic regression analysis was used to calculate crude and adjusted odds ratios (OR), using 95% confidence intervals (CI). Main exposure was duration of second stage of labor, and main outcome was risks of severe perineal lacerations (third and fourth degree). RESULTS: Risk of severe perineal lacerations increased with duration of second stage of labor. Compared with a second stage of labor of 1 h or less, women with a second stage of more than 2 h had an increased risk (aOR 1.42; 95% CI 1.28-1.58). Compared with non-instrumental vaginal deliveries, the risk was elevated among instrumental vaginal deliveries (aOR 2.24; 95% CI 2.07-2.42). The risk of perineal laceration increased with duration of second stage of labor until less than 3 h in both instrumental and non-instrumental vaginal deliveries, but after 3 h, the ORs did not further increase. After adjustments for potential confounders, macrosomia (birth weight > 4 500 g) and occiput posterior fetal position were risk factors of severe perineal lacerations. CONCLUSIONS: The risk of severe perineal laceration increases with duration until the third hour of second stage of labor. Instrumental delivery is the most significant risk factor for severe lacerations, followed by duration of second stage of labor, fetal size and occiput posterior fetal position.

Perineal laceration treated with negative pressure wound therapy following colostomy.

A male in his early 30s was transported to the emergency room after being hit by a vehicle while inebriated and lying in the street. His general condition was stable; however, he had a perineal laceration that extended to the coccyx. Due to the proximity of the wound margin to the anus, we were concerned regarding the potential contamination and opted not to suture it. Therefore, we refrained from suturing the wound and kept the wound open after irrigation and debridement. Additionally, we performed a transverse colostomy. On day 4, we initiated negative pressure wound therapy for 40 days, during which sufficient wound granulation occurred. The patient was discharged, and the colostomy was closed approximately 4 months after the injury. Our case illustrates the effectiveness of negative pressure wound therapy in managing perineal lacerations.

Asian-White disparities in obstetric anal sphincter injury: a systematic review and meta-analysis.

OBJECTIVE: Obstetrical anal sphincter injury describes a severe injury to the perineum and perianal muscles after birth. Obstetrical anal sphincter injury occurs in approximately 4.4% of vaginal births in the United States; however, racial and ethnic inequities in the incidence of obstetrical anal sphincter injury have been shown in several high-income countries. Specifically, an increased risk of obstetrical anal sphincter injury in individuals who identify as Asian vs those who identify as White has been documented among residents of the United States, Australia, Canada, Western Europe, and the Scandinavian countries. The high rates of obstetrical anal sphincter injury among the Asian diaspora in these countries are higher than obstetrical anal sphincter injury rates reported among Asian populations residing in Asia. A systematic review and meta-analysis of studies in high-income, non-Asian countries was conducted to further evaluate this relationship. DATA SOURCES: MEDLINE, Ovid, Embase, EmCare, and the Cochrane databases were searched from inception to March 2023 for original research studies. STUDY ELIGIBILITY CRITERIA: Observational studies using keywords and controlled vocabulary terms related to race, ethnicity and obstetrical anal sphincter injury. All observational studies, including cross-sectional, case-control, and cohort were included. 2 reviewers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Meta-analysis of Observational Studies in Epidemiology recommendations. METHODS: Meta-analysis was performed using RevMan (version 5.4; Cochrane Collaboration, London, United Kingdom) for dichotomous data using the random effects model and the odds ratios as effect measures with 95% confidence intervals. Subgroup analysis was performed among Asian subgroups. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal tools. Meta-regression was used to determine sources of between-study heterogeneity. Results: A total of 27 studies conducted in 7 countries met the inclusion criteria encompassing 2,337,803 individuals. The pooled incidence of obstetrical anal sphincter injury was higher among Asian individuals than White individuals (pooled odds ratio, 1.64; 95% confidence interval, 1.48-1.80). Subgroup analyses showed that obstetrical anal sphincter injury rates were highest among South Asians and among population-based vs hospital-based studies. Meta-regression showed that moderate heterogeneity remained even after accounting for differences in studies by types of Asian subgroups included, study year, mode of delivery included, and study setting. Conclusion: Obstetrical anal sphincter injury is more frequent among Asian versus white birthing individuals in multiple high-income, non-Asian countries. Qualitative and quantitative research to elucidate underlying causal mechanisms responsible for this relationship are warranted.

Risk Factors for Intrapartum Anorectal Mucosal Lacerations and Rectovaginal Fistula: A Retrospective Comparative Study.

Introduction: We examined the risk factors for fourth-degree perineal lacerations (intrapartum anorectal mucosal lacerations) and rectovaginal fistulas as one of the later complications. Methods: We reviewed the obstetric records of all singleton vaginal deliveries after 22 weeks of gestation at our institute between January 2006 and December 2018 (n = 19,370). Results: Of the 19,370 deliveries, 61 had fourth-degree perineal lacerations (0.31%). Of the 61 women, 5 (8.2%) developed rectovaginal fistulas 2-3 weeks after their deliveries. Upon multivariate analysis, nulliparity (Adjusted odds ratios (OR) 3.58, 95% confidence interval (CI) 1.6-8.1, p < 0.01), midline episiotomy (Adjusted OR 2.10, 95% CI 1.0-4.2, p = 0.03), vacuum extraction (Adjusted OR 7.01, 95% CI 3.5-14, p < 0.01), and forceps delivery (Adjusted OR 22.0, 95% CI 7.8-61, p < 0.01) were independently associated with fourth-degree perineal lacerations, while mediolateral episiotomy (Adjusted OR infinity, 95% CI 2.1-infinity, p = 0.03) and forceps delivery (Adjusted OR infinity, 95% CI 14.5-infinity, p = 0.01) were independently associated with rectovaginal fistulas. In addition, in the women with fourth-degree perineal lacerations, mediolateral episiotomy was associated with rectovaginal fistulas (OR infinity, 95% CI 1.8-infinity, p = 0.04). Conclusions: Midline episiotomy and instrument-assisted delivery are independent risk factors for fourth-degree perineal lacerations after vaginal delivery. Mediolateral episiotomy and forceps delivery were independently associated with rectovaginal fistulas. Once fourth-degree perineal lacerations occurred, women with mediolateral episiotomies were more likely to develop rectovaginal fistulas.

Prediction models for perineal lacerations during childbirth: A systematic review and critical appraisal.

BACKGROUND: Perineal lacerations could lead to substantial morbidities for women. A reliable prediction model for perineal lacerations has the potential to guide the prevention. Although several prediction models have been developed to estimate the risk of perineal lacerations, especially third- and fourth-degree perineal lacerations, the evidence about the model quality and clinical applicability is scarce. OBJECTIVES: To systematically review and critically appraise the existing prediction models for perineal lacerations. METHODS: Seven databases (PubMed, Embase, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, SinoMed, China National Knowledge Infrastructure, and Wanfang Data) were systematically searched from inception to July 2022. Studies that developed prediction models for perineal lacerations or performed external validation of existing models were considered eligible to include in the systematic review. Two reviewers independently conducted data extraction according to the Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies. The risk of bias and the applicability of the included models were assessed with the Prediction Model Risk of Bias Assessment Tool. A narrative synthesis was performed to summarize the characteristics, risk of bias, and performance of existing models. RESULTS: Of 4345 retrieved studies, 14 studies with 22 prediction models for perineal lacerations were included. The included models mainly aimed to estimate the risk of third- and fourth-degree perineal lacerations. The top five predictors used were operative vaginal birth (72.7 %), parity/previous vaginal birth (63.6 %), race/ethnicity (59.1 %), maternal age (50.0 %), and episiotomy (40.1 %). Internal and external validation was performed in 12 (54.5 %) and seven (31.8 %) models, respectively. 13 studies (92.9 %) assessed model discrimination, with the c-index ranging from 0.636 to 0.830. Seven studies (50.0 %) evaluated the model calibration using the Hosmer-Lemeshow test, Brier score, or calibration curve. The results indicated that most of the models had fairly good calibration. All the included models were at higher risk of bias mainly due to unclear or inappropriate methods for handling missing data and continuous predictors, external validation, and model performance evaluation. Six models (27.3 %) showed low concerns about applicability. CONCLUSIONS: The existing models for perineal lacerations were poorly validated and evaluated, among which only two have the potential for clinical use: one for women undergoing vaginal birth after cesarean delivery, and the other one for all women undergoing vaginal birth. Future studies should focus on robust external validation of existing models and the development of novel models for second-degree perineal laceration. PROSPERO REGISTRATION NUMBER: CRD42022349786. TWEETABLE ABSTRACT: The existing models for perineal lacerations during childbirth need external validation and updating. Tools are needed for second-degree perineal laceration.

Severe Perineal Lacerations in First Delivery: Association with Subsequent Reproductive Outcomes.

Background: Severe perineal lacerations (SPLs), common worldwide, are associated with short- and long-term complications: pelvic floor disorders, fecal incontinence, fistula, and profound psychological impacts. Limited research suggests that experiencing SPL may influence future reproductive intentions, but research on outcomes is lacking. Methods: We analyzed the effect of experiencing SPL during a first delivery among a large cohort of Swedish births between 1992 and 2013. We used linear and multinomial logistic regression to estimate the associations between SPL and four reproductive outcomes: subsequent total birth number, probability of a second birth, interpregnancy interval (IPI), and subsequent scheduled cesarean birth. Results: Among 947,035 singleton live-born first-births, we found that experiencing SPL was associated with slightly fewer overall births in fully adjusted models (a decrease of -0.020 births; 95% confidence interval [CI]: -0.028 to -0.012), but no difference in the probability of a second birth (risk ratio [RR]: 1.00; 95% CI: 0.99 to 1.00) or IPI. Scheduled cesarean was increased in births after SPL (adjusted RR: 4.57; 95% CI: 4.42 to 4.73). A secondary comparison of SPL to severe postpartum hemorrhage suggests that some of these observed differences may be related to experiencing any severe outcome, and some specifically to perineum disruption. Conclusion: This study provides a deeper understanding of the long-term impacts of SPL, which may be useful in informing best clinical practices for supporting women who have experienced SPL.