Maternal outcomes in subsequent delivery after previous obstetric anal sphincter injury (OASI): a multi-centre retrospective cohort study.

INTRODUCTION AND HYPOTHESIS: Women with a history of obstetric anal sphincter injury (OASI) are at increased risk of recurrence (rOASI) at subsequent delivery; however, evidence regarding the factors influencing this risk is limited. Furthermore, little is known about what factors influence the decision to alternatively deliver by elective caesarean section (ELLSCS). METHODS: Retrospective univariate and multivariate logistic regression analysis of prospectively collected data from four NHS electronic maternity databases including primiparous women sustaining OASIS during a singleton, term, cephalic, vaginal delivery between 2004 and 2015, who had a subsequent delivery. RESULTS: Two thousand two hundred seventy-two women met the criteria; 10.2% delivering vaginally had a repeat OASI and 59.4% had a second-degree tear. Women having an ELLSCS were more likely to be Caucasian, older, have previously had an operative vaginal delivery (OVD) and have a more severe degree of OASI. Positive predictors for rOASI were increased birth weight and maternal age at both index and subsequent deliveries, a more severe degree of initial OASI and Asian ethnicity. The overall mediolateral episiotomy (MLE) rate was 15.6%; 77.2% of those who had an episiotomy sustained no spontaneous perineal trauma. Only 4.4% of women with a rOASI had an MLE, whilst the MLE rate was 16.9% in those without a recurrence (p < 0.001). MLE decreased the risk of rOASI by 80%. Birth weight > 4 kg increased the risk 2.5 fold. CONCLUSIONS: Women with previous OASIS are at an increased risk of recurrence. A more liberal use of MLE during subsequent vaginal delivery could significantly reduce the risk of recurrence.

A biography of William Tuke (1732-1822): Founder of the modern mental asylum.

William Tuke was a 19th-century reformist and philanthropist notable for his work in mental health. He was known for his strict self-discipline and judicious manner. He was also a firm believer in the Quaker faith and actively supported the group and employed many of their principles in his work, especially in his chef d'oeuvre, The Retreat, established in 1792, a mental asylum in York. Possibly catalysed by the very public mismanagement of King George III's 'madness', he pioneered the use of moral treatment, a new humane method of treating mental illness. This focussed on allowing patients to live in a community, partake in daily activities and not be subjected to the brutality of the commonplace asylum, all of which were very rare in the treatment of lunatics at that time. Described as 'The Period of Humane Reform', his work coincided with the emergence of similar approaches in France, most famously by Philippe Pinel (1745-1826) and his pupil Jean Esquirol (1772-1840) in Paris. Tuke eventually went on to aid in the reform of the law with regards to asylums.