Individual-level Predictors of Birth Preparedness and Complication Readiness: Urban-Rural Comparison.

INTRODUCTION: Maternal mortality is a major public health problem. Birth preparedness and complication readiness (BP/CR) constitute a veritable strategy for reducing maternal mortality, yet adoption is low with wide urban-rural discrepancies. OBJECTIVES: The objectives of this study were to compare the practice of BP/CR amongst women in rural and urban areas of Rivers State, Nigeria, and determine the individual-level predictors. METHODS: A facility-based cross-sectional comparative study using a multistage sampling method was employed in the selection of 924 (462 urban and 462 rural) women who gave birth within the last 12 months in urban and rural local government areas. Outcome measures were birth preparedness (defined as undergoing antenatal care (ANC) with a skilled birth provider, voluntary counselling and testing for HIV and saving money for childbirth at an agreed place of delivery with a skilled birth attendant) and complication readiness (defined as being knowledgeable about danger signs, identifying decision-maker, a nearest functional institution in case of emergency, emergency means of transport and funds and a suitable blood donor). Bivariate and multivariate analyses were performed at P < 0.05. RESULTS: The proportion of women who were birth prepared was significantly higher amongst women in urban areas (85.9%; 95% confidence interval [CI]: 82.7%-89.1%) versus rural counterparts (56.7%; 95% CI: 52.2%-61.2%), whereas the proportion of complication readiness was significantly higher in rural (31.8%; 95% CI: 27.6%-36.1%) than urban (18.2%; 95% CI: 15.2%-47.8%) groups. Predictors were possession of secondary educational level or higher (adjusted odds ratio [AOR]: 4.9; 95% CI: 1.5-15.5), being employed (AOR: 2.7; 95% CI: 1.5-15.0) and ANC attendance (AOR: 29.2; 95% CI: 8.8-96.9) in urban, whereas amongst the rural, it was ANC attendance (AOR: 20.0; 95% CI: 9.1-43.7). CONCLUSION: In urban areas, more women were birth prepared while fewer women were complication ready compared to the women in rural areas, with predictors such as education, employment and ANC attendance in urban areas and only ANC attendance in rural areas. Measures to promote ANC uptake, maternal education and empowerment could promote BP/CR.

Effects of epidural analgesia on intrapartum maternal fever and maternal outcomes: an updated systematic review and meta-analysis.

OBJECTIVE: Epidural-related maternal fever in women is a common clinical phenomenon that leads to adverse consequences for mothers and neonates. The meta-analysis aimed to quantify the risk for intrapartum maternal fever after epidural analgesia (EA) stratified according to parity. The secondary objective was to investigate the association between EA and maternal outcomes. METHODS: An electronic literature search of the Medline/PubMed, Embase, Cochrane Library, Wanfang Data, and China National Knowledge Infrastructure databases was performed to identify studies reporting the occurrence of intrapartum fever in parturients. Studies were reviewed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and meta-analysis was performed using Review Manager version 5.3. RESULTS: Seventeen randomized controlled trials (RCTs) (5959 parturients) were included. Odds ratios for maternal fever in the analysis were 4.17 (95% confidence interval (CI) 2.93-5.94) and 5.83 (95% CI 4.96-6.87), respectively. Results of subgroup analysis according to parity were consistent. EA significantly prolonged the length of the first stage of labor (MD 34.52 [95% CI 12.13-56.91]) and the second stage of labor (MD 9.10 [95% CI 4.51-13.68]). Parturients who received EA were more likely to undergo instrumental delivery (OR 2.03 [95% CI 1.44-2.86]) and oxytocin augmentation (OR 1.45 [95% CI 1.12-1.88]). There were no differences in cesarean delivery rates between the EA and non-EA groups. CONCLUSIONS: Parturients who received EA exhibited a higher incidence of intrapartum fever. Credibility of the subgroup analyses was low because the mixed group did not effectively represent multiparas.

Risk factors analysis and multidisciplinary team first-aid simulation training for umbilical cord prolapse can improve neonatal outcomes.

OBJECTIVE: In the present study, we sought to identify risk factors for umbilical cord prolapse (UCP) and adapt the multidisciplinary team (MDT) first-aid simulation training for UCP patients. We evaluated the usefulness of the MDT first-aid simulation by comparing delivery outcomes for UCP patients before and after its implementation. MATERIAL AND METHODS: A retrospective review was conducted on 149 UCP cases (48 overt and 101 occult) and 298 control deliveries that occurred at the Third Affiliated Hospital of Sun Yat-sen University from January 1998 to December 2022. Patient data were compared between the groups. One-way analysis of variance (ANOVA) was used for means comparison, and the chi-square test was used for categorical data. Univariate and multivariate logistic regression analyses were performed to identify factors significantly associated with UCP. RESULTS: Overt UCP was strongly associated with all adverse delivery outcomes. Both univariate and multivariate analyses identified multiparity, breech presentation, polyhydramnios, and low birth weight as independent risk factors for overt UCP (all odds ratios [OR] > 1; all p < 0.05). Preterm labor and abnormal placental cord insertion were identified as independent risk factors for occult UCP (all OR > 1; all p < 0.05). After 2014, when obstetrical staff received MDT first-aid simulation training, patients with overt UCP experienced shorter decision-to-delivery intervals due to more timely cesarean sections. They also had higher Apgar scores at 1, 5, and 10 min, and lower admission rates to the neonatal intensive care unit compared to patients before 2014 (all p < 0.05). CONCLUSION: MDT first-aid simulation training for overt UCP can improve neonatal outcomes. However, medical simulation training efforts should initially focus on the early identification of risk factors for both overt and occult UCP.

Overt umbilical cord prolapse (UCP) is an obstetric emergency that can lead to adverse delivery outcomes. Early identification of risk factors for both overt and occult UCP is beneficial for facilitating early interventions. Multidisciplinary team first-aid simulation training specifically for overt UCP has been shown to effectively improve neonatal outcomes.

Obstetric vesico-uterine fistula in nine reference hospitals in the Democratic Republic of the Congo: epidemiological, clinical, and therapeutic aspects.

INTRODUCTION: With global cesarean section rates rising, there's concern about increase in obstetric vesico-uterine fistula (OVUF). Very little is known about this anatomoclinical entity of obstetric fistula in Africa in general and in DRC in particular. Our purpose was to describe the epidemiological, clinical, and therapeutic aspects of OVUF in the Democratic Republic of the Congo (DRC). METHODS: This was a descriptive cross-sectional study. Data were collected from patients who presented with OVUF across seven provinces of the DRC (North Kivu, Haut-Uélé, Kasai Central, Kwilu, Maniema, Nord-Ubangi and Sankuru) from January 2017 to December 2022. Study variables were epidemiological, clinical, and therapeutic features. RESULTS: Of 1,267 patients presenting with obstetric fistulas, 355 (28.0%) had OVUF. The mean age was 32.9 ± 11.6 years, 80.6% of patients (286/355) lived in rural areas, and the majority had a low level of education (40% no formal education, 30.1% primary school, 28.7% secondary school). In total, 64.8% of patients were primiparous (230/355) and in all (100%) cases, OVUF was caused iatrogenically during cesarean delivery. Majority (76.3%) of patients laboured for one day or less (mean duration 1.0 ± 0.5 days) before giving birth, and the fetus died in 58.3% of cases. In 35.8% of cases, the fistula had lasted more than 10 years (mean age 10.1 ± 10.0 years) before repair. A proportion of 88.2% (n = 313) of OVUF was isolated while 11.3% (n = 40) was associated with a uretero-vaginal fistula. In 82.8% (n = 294) of cases the OVUF was single. The average fistula size was 2.4 ± 1.0 cm (range: 0.5 and 5.5 cm) and 274 (77.2%) fistulas measured between 1.5 and 3 cm, with 14.9% (n = 53) of them larger than 3 cm. Fibrosis was present in 65.1% of cases, cervical involvement was absent in 97.7% and post-operative complications were absent in 94.4%. In all cases, the OVUF was surgically repaired abdominally with a success rate of 97.5% (346/355). CONCLUSION: The proportion of OVUF is relatively high in the DRC. Most affected patients were young, under-educated, primiparous women living in rural areas. Cesarean section was the sole identified cause of OVUF which was isolated, single, without fibrosis, in majority of cases. Abdominal repair of OVUF was very effective, with good results in almost all cases. Teaching young doctors working mainly in remote areas how to perform safe cesarean section is needed to reduce incidence of OVUF in DRC.

Impact of disrespectful maternity care on childbirth complications: a multicentre cross-sectional study in Ethiopia.

BACKGROUND: Globally, disrespectful, and abusive childbirth practices negatively impact women's health, create barriers to accessing health facilities, and contribute to poor birth experiences and adverse outcomes for both mothers and newborns. However, the degree to which disrespectful maternity care is associated with complications during childbirth is poorly understood, particularly in Ethiopia. AIM: To determine the extent to which disrespectful maternity care is associated with maternal and neonatal-related complications in central Ethiopia. METHODS: A multicentre cross-sectional study was conducted in the West Shewa Zone of Oromia, Ethiopia. The sample size was determined using the single population proportion formula. Participants (n = 440) were selected with a simple random sampling technique using computer-generated random numbers. Data were collected through face-to-face interviews with a pretested questionnaire and were entered into Epidata and subsequently exported to STATA version 17 for the final analysis. Analyses included descriptive statistics and binary logistic regression, with a 95% confidence interval (CI) and an odds ratio (OR) of 0.05. Co-founders were controlled by adjusting for maternal sociodemographic characteristics. The primary exposure was disrespectful maternity care; the main outcomes were maternal and neonatal-related complications. RESULTS: Disrespectful maternity care was reported by 344 women (78.2%) [95% CI: 74-82]. Complications were recorded in one-third of mothers (33.4%) and neonates (30%). Disrespectful maternity care was significantly associated with maternal (AOR = 2.22, 95% CI: 1.29, 3.8) and neonatal-related complications (AOR = 2.78, 95% CI: 1.54, 5.04). CONCLUSION: The World Health Organization advocates respectful maternal care during facility-based childbirth to improve the quality of care and outcomes. However, the findings of this study indicated high mistreatment and abuse during childbirth in central Ethiopia and a significant association between such mistreatment and the occurrence of both maternal and neonatal complications during childbirth. Therefore, healthcare professionals ought to prioritise respectful maternity care to achieve improved birth outcomes and alleviate mistreatment and abuse within the healthcare sector.

Intrapartum fever complicated with maternal bacteremia: prevalence, bacteriology, and risk factors.

PURPOSE: To assess the prevalence, microbial profile, and clinical risk factors of maternal bacteremia associated with intrapartum fever (IPF). METHODS: A retrospective cohort study, in a single tertiary university-affiliated medical center between 2012 and 2018. Demographic and labor characteristics of women, who delivered at term (37+0/7-41+6/7) and developed bacteremia following IPF were compared to a control group of women with IPF but without bacteremia. RESULTS: During the study period there were 86,590 deliveries in our center. Of them, 2074 women (2.4%) were diagnosed with IPF, of them, for 2052 women (98.93%) the blood maternal cultures were available. In 26 patients (1.25%) maternal bacteremia was diagnosed. A lower rate of epidural anesthesia (84.6% vs 95.9%, p = 0.02) and a higher rate of antibiotics prophylaxis treatment prior to the onset of fever (30.8%.vs 12.1%, p = 0.006) were observed in patients who developed maternal bacteremia in comparison to those who have not. Maternal hyperpyrexia developed after initiation of antibiotics or without epidural anesthesia remained significantly associated with maternal bacteremia after applying a multivariate analysis, (Odds Ratio 3.14 95% CI 1.27-7.14, p = 0.009; 4.76 95% CI 1.35-12.5, p = 0.006; respectively). CONCLUSION: Maternal fever developing after initiation of antibiotics or without epidural is associated with maternal bacteremia.

Pelvic floor symptoms according to the severity of second-degree perineal tears within 12 months post-partum: A longitudinal prospective cohort study.

INTRODUCTION: Second-degree perineal tears following vaginal birth are common and presumed to be of little clinical importance. However, the extent of damage to the perineal body varies widely, and there is reason to believe that larger second-degree tears may be associated with more pelvic floor symptoms, compared to lesser form. Therefore, the aim of this study was to assess differences in pelvic floor symptoms according to the severity of second-degree perineal tears up to 12 months post-partum, stratified by parity. MATERIAL AND METHODS: This was a prospective cohort study conducted at Akershus University Hospital, a tertiary referral hospital in Norway. The study sample consisted of 409 primiparas and 394 multiparas with vaginal births. Perineal tears were classified using the classification system recommended by the Royal College of Obstetricians and Gynecologists. Further, second-degree tears were subclassified as 2A, 2B, or 2C, depending on the percentage of damage to the perineal body. Episiotomies were analyzed as a separate group. Pelvic floor symptoms were assessed using the Karolinska Symptoms After Perineal Tear Inventory (KAPTAIN). A linear mixed model was estimated to assess the trend in pelvic floor symptom scores according to perineal tear category and stratified by parity. The primary and secondary outcome measures were the mean sum scores of the KAPTAIN-Inventory, measured in pregnancy (at 18 weeks of gestation), at 3- and 12 months post-partum, and the reported impact of genital discomfort on quality of life measured in pregnancy and at 12 months post-partum. RESULTS: There were no significant differences in pelvic floor symptom scores over time, or at any timepoint, between no tear, first-degree tear, or second-degree tear subcategories, for primi-, and multiparas. Pelvic floor symptoms increased from pregnancy to 3 months post-partum and remained higher at 12 months post-partum compared to pregnancy in all perineal tear categories. Compared to primiparas, multiparas reported a significantly higher impact of genital discomfort on quality of life in pregnancy and at 12 months post-partum. CONCLUSIONS: There were no statistically significant differences in pelvic floor symptoms according to the severity of second-degree perineal tears.

Childbirth Acquired Perineal Trauma study (CHAPTER): a UK prospective cohort study protocol.

INTRODUCTION: Childbirth-related perineal trauma (CRPT) is the most common complication of childbirth affecting 80% of women overall after vaginal birth. There remains a lack of comprehensive evidence relating to the prevalence of subsequent health problems. Current evidence is related to short-term outcomes, for example, pain, but there is less known about longer-term outcomes such as infection, wound dehiscence, pelvic floor function and psychological outcomes. This is a protocol for a cohort study assessing outcomes of women after CRPT. METHODS AND ANALYSIS: A multicentre, prospective UK cohort study aiming to include 1000 women. All women who have sustained CRPT will be eligible for inclusion and will be followed-up for 12 months after childbirth. The primary outcome will be perineal infection at 6 weeks post-birth. Secondary outcomes will include antibiotic use for perineal infection, wound breakdown, use of analgesia, the requirement for admission or surgical intervention, urinary and faecal incontinence, anxiety and depressive symptoms, sexual function and impact on daily activities. Outcomes will be measured at 6 weeks, 6 months and 12 months post partum, with some outcomes being measured at all time points and others at selected most appropriate time points only. Outcome data will be obtained from a review of clinical notes and from patient questionnaires. Simple descriptive statistics will be used to summarise characteristics and outcomes, with categorical variables expressed as percentages and continuous variables as mean averages, alongside the corresponding standard deviatons. ETHICS AND DISSEMINATION: Ethical approval has been granted by the Research Ethics Council with reference 23/WA/0169. Data collected from the Childbirth Acquired Perineal Trauma (CHAPTER) cohort study will highlight the prevalence and type of complications after CRPT and which women are more at risk. After the conclusion of this study, findings will be used to work with governmental organisations and Royal Colleges to target resources and ultimately improve care.

Factors influencing delivery-related complications and their consequences in hard-to-reach areas of Bangladesh.

BACKGROUND AND OBJECTIVES: Bangladesh's high maternal mortality ratio is exacerbated by delivery-related complications, particularly in hard-to-reach (HtR) areas with limited healthcare access. Despite this, few studies have explored delivery-related complications and factors contributing to these complications among the disadvantaged population. This study aimed to investigate the factors contributing to delivery-related complications and their consequences among the mothers residing in the HtR areas of Bangladesh. METHODS: Data were collected using a cross-sectional study design from 13 HtR sub-districts of Bangladesh between September 2019 and October 2019. Data from 1,290 recently delivered mothers were analysed. RESULTS: Around 32% (95% CI: 29.7-34.8) of the mothers reported at least one delivery-related complication. Prolonged labour pain (21%) was the highest reported complication during the delivery, followed by obstructive labour (20%), fever (14%), severe headache (14%). Mothers with higher education, a higher number of antenatal care (ANC) visits, complications during ANC, employed, and first-time mothers had higher odds of reporting delivery-related complications. More than one-half (51%) of these mothers had normal vaginal delivery. Nearly one-fifth (20%) of mothers who reported delivery-related complications were delivered by unskilled health workers at homes. On the other hand, about one-fifth (19%) of the mothers without any complications during delivery had a caesarean delivery. Nine out of ten of these caesarean deliveries were done at the private facilities. CONCLUSION: Delivery-related complications are significantly related to a woman's reproductive history and other background characteristics. Unnecessary caesarean delivery is prominent at private facilities.

Systematic Review and Meta-analysis of the Prevalence of Levator Ani Avulsion with Obstetric Anal Sphincter Injury and its Effects on Pelvic Floor Dysfunction.

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the prevalence of levator ani avulsion (LAA) among primiparous women with obstetric anal sphincter injury (OASI) and how this association could affect future pelvic floor dysfunction. METHODS: Three electronic databases (MEDLINE/PubMed/EMBASE) were searched in December 2018 and again in October 2022. Nine full-text articles were included in the analysis. The exclusion criteria were language other than English, studies not based on primiparous women only, conference abstracts, and evaluation without ultrasound or MRI. RESULTS: The overall prevalence of LAA was 24% (95% CI: 18-30%). Those with OASI, were at a higher risk of LAA, OR 3.49 (95% CI: 1.46 to 8.35). In women with LAA + OASI versus OASI alone, Three of Five studies showed worsened AI symptoms. Three of Five studies assessing urinary incontinence (UI) reported no significant difference in UI, whereas two reported increased UI. All studies that looked at pelvic organ prolapse reported a higher incidence of symptomatic prolapse and reduced pelvic floor muscle strength in women with LAA + OASI compared with those without LAA. CONCLUSION: Levator ani avulsion is prevalent following vaginal birth and is strongly associated with OASI. Incidence of AI does not increase in women with LAA and OASI, but they had greater symptom bother. OASI with LAA appears to increase the incidence of pelvic floor weakness and pelvic organ prolapse. There is no consensus agreement on the effect of LAA + OASI on UI.

Variation in Episiotomy Use Among Nulliparous Individuals by Maternity Care Provider and Associated Rates of Obstetric Anal Sphincter Injury.

OBJECTIVES: To quantify variation in the association between episiotomy and obstetric anal sphincter injury (OASI) by maternity care provider in spontaneous and operative vaginal deliveries (SVDs and OVDs). METHODS: Population-based retrospective cohort study of vaginal, term deliveries among nullipara in Canada (2004-2015). Adjusted rate ratios (ARRs) and 95% CIs were estimated using log-binomial regression to quantify the associations between episiotomy and OASI, stratified by care provider (obstetrician [OB], family physician [FP], or registered midwife [RM]) while adjusting for potential confounders. RESULTS: The study included 631 642 deliveries. Episiotomy use varied by provider: among SVDs, the episiotomy rate was 19.6%, 14.4%, and 8.4% in the OB, FP, and RM groups, respectively. The rate of OASI was higher among SVDs with versus without episiotomy (5.8% vs 4.6%). Conversely, OASI occurred less frequently in operative vaginal deliveries with episiotomy (15.3%) compared with those without (16.7%). In all provider groups, the ARR for OASI was increased with episiotomy in SVD and decreased with episiotomy with forceps delivery. No differences in these associations were observed by provider except among vacuum delivery (ARR with episiotomy vs. without, OB: 0.88, 95% CI 0.84-0.92; FP: 0.89, 95% CI 0.83-0.96, RM: 1.22, 95% CI 1.02-1.48). CONCLUSIONS: In nullipara, irrespective of maternity care provider, there is a positive association between episiotomy and OASI among SVDs and an inverse association between episiotomy and deliveries with forceps. The relationship between episiotomy and OASI is modified by maternity care providers among vacuum deliveries.

Perineal injuries during vaginal birth in low-resource countries.

Birth related perineal trauma (BRPT) and obstetric anal sphincter injuries (OASIS) are leading causes of anal incontinence in women, which negatively impacts on their quality of life, resulting in low self-esteem and abandonment. In low resource countries (LRC), the true incidence is not known and since most births are unattended or occur in community-based health care systems, one can anticipate that it is a significant problem. Dissemination of information to women, education of traditional birth attendants, improvement of resources and transport, and training of health professionals on the detection and appropriate surgical management of these injuries will reduce morbidity and improve outcome. Intrapartum measures such as controlled head descent and perineal support, correct episiotomy techniques and selective use of instruments to assist vaginal births is pivotal in avoiding these injuries. Policy makers should prioritize maternity care in LRC, and research is urgently needed to address all aspects of BRPT.

Is water delivery a good idea to prevent obstetric anal sphincter injuries in low risk primiparae? An exploratory study in a Swiss public teaching hospital.

OBJECTIVE: Obstetric anal sphincter injuries are feared perineal injuries that are associated with increased pelvic floor disorders. The knowledge of influencing factors as the mode of delivery is therefore important. The aim of this study is to compare the rate of obstetric anal sphincter injuries in primiparae after water and bed deliveries. STUDY DESIGN: In this retrospective cohort study 3907 primiparae gave birth in water or on a bed in a Swiss teaching hospital. The diagnosis of obstetric anal sphincter injuries was confirmed by a consultant of obstetrics and gynecology and treated by them. The rates of these injuries after water and bed births were compared. Subgroup analysis was performed to detect possible associative factors, such as birth weight, episiotomy, use of oxytocin in first and second stage of labor. RESULTS: 1844 (47.2 %) of the primiparae had a water delivery and 2063 (52.8 %) a bed delivery. 193 (4.94 %) were diagnosed with obstetric anal sphincter injuries, of which 68 (3.7 %) had a water delivery and 125 (6.1 %) a bed delivery, p < 0.001. Subgroup analysis revealed that, in the first and second stage of labor, the rate of obstetric anal sphincter injuries with oxytocin was significantly lower in water than in bed deliveries; p = 0.025, p < 0.017, respectively. The rate of obstetric anal sphincter injuries in the birth weight or episiotomy subgroups did not reach significance. CONCLUSIONS: In a teaching hospital setting with standardized labor management, primiparae with a water delivery have the lowest risk for obstetric anal sphincter injuries.

[Evolution of the rate of episiotomies and obstetric anal sphincter injuries since the last recommendations of 2018]. / Évolution du taux d'épisiotomies et des lésions obstétricales du sphincter de l'anus depuis les recommandations de 2018.

OBJECTIVES: There is a progressive reduction in the rate of episiotomies since the recommendations of the French college of gynaecologists. Our objective was to study the evolution of the rate of episiotomies and Obstetric Anus Sphincter Injury (OASI) since the restriction of episiotomies in our department. METHODS: Observational monocentric retrospective study performed at the Rouen University Hospital. The inclusion criteria were monofetal pregnancies, delivery at a term greater than or equal to 37 weeks of amenorrhea of a living, viable child and by cephalic presentation. We compared two periods corresponding to before and after the 2018 recommendations. We used logistic regression modelling to identify factors associated with the risk of episiotomies and of obstetrical anal injuries, overall and in case of instrumental delivery. RESULTS: We included 3329 patients for the 1st period and 3492 for the 2nd period, and the rate of instrumental deliveries were respectively of 16.4% (n=547) and 17.9% (n=626). Multivariate analysis showed a significant decrease in the rate of episiotomies in the 2nd period (OR 0.14, CI 95% [0.12; 0.16], P<0.0001). Main factors associated with the risk of OASI were primiparity (OR 6.21, CI 95% [3.19; 12.11]) and the use of forceps (OR 4.23, CI 95% [2.17; 8.27]) overall; and instrumental delivery using forceps (OR 3.25, CI 95% [1.69; 6.22]) and delivery during the 2nd period (OR 1.98, CI 95% [1.01; 3.88]) in case of instrumental delivery. CONCLUSIONS: Our study confirms that the voluntary reduction in the episiotomy rate does not seem to be associated with an increased risk of OASI, overall and in case of instrumental delivery. However, we show an increase in the rate of OASI in case of instrumental delivery since the latest recommendations.

The prevention of perineal trauma during vaginal birth.

Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%. The incidence of obstetrical anal sphincter injury is approximately 3%, with a significantly higher rate in primiparous than in multiparous women (6% vs 2%). Obstetrical anal sphincter injury is a significant risk factor for the development of anal incontinence, with approximately 10% of women developing symptoms within a year following vaginal birth. Obstetrical anal sphincter injuries have significant medicolegal implications and contribute greatly to healthcare costs. For example, in 2013 and 2014, the economic burden of obstetrical anal sphincter injuries in the United Kingdom ranged between £3.7 million (with assisted vaginal birth) and £9.8 million (with spontaneous vaginal birth). In the United States, complications associated with trauma to the perineum incurred costs of approximately $83 million between 2007 and 2011. It is therefore crucial to focus on improvements in clinical care to reduce this risk and minimize the development of perineal trauma, particularly obstetrical anal sphincter injuries. Identification of risk factors allows modification of obstetrical practice with the aim of reducing the rate of perineal trauma and its attendant associated morbidity. Risk factors associated with second-degree perineal trauma include increased fetal birthweight, operative vaginal birth, prolonged second stage of labor, maternal birth position, and advanced maternal age. With obstetrical anal sphincter injury, risk factors include induction of labor, augmentation of labor, epidural, increased fetal birthweight, fetal malposition (occiput posterior), midline episiotomy, operative vaginal birth, Asian ethnicity, and primiparity. Obstetrical practice can be modified both antenatally and intrapartum. The evidence suggests that in the antenatal period, perineal massage can be commenced in the third trimester of pregnancy to increase muscle elasticity and allow stretching of the perineum during birth, thereby reducing the risk of tearing or need for episiotomy. With regard to the intrapartum period, there is a growing body of evidence from the United Kingdom, Norway, and Denmark suggesting that the implementation of quality improvement initiatives including the training of clinicians in manual perineal protection and mediolateral episiotomy can reduce the incidence of obstetrical anal sphincter injury. With episiotomy, the International Federation of Gynecology and Obstetrics recommends restrictive rather than routine use of episiotomy. This is particularly the case with unassisted vaginal births. However, there is a role for episiotomy, specifically mediolateral or lateral, with assisted vaginal births. This is specifically the case with nulliparous vacuum and forceps births, given that the use of mediolateral or lateral episiotomy has been shown to significantly reduce the incidence of obstetrical anal sphincter injury in these groups by 43% and 68%, respectively. However, the complications associated with episiotomy including perineal pain, dyspareunia, and sexual dysfunction should be acknowledged. Despite considerable research, interventions for reducing the risk of perineal trauma remain a subject of controversy. In this review article, we present the available data on the prevention of perineal trauma by describing the risk factors associated with perineal trauma and interventions that can be implemented to prevent perineal trauma, in particular obstetrical anal sphincter injury.

Cervical Lacerations: A Review of Risks.

Cervical laceration (CL), although infrequent, is an often-unrecognized complication of vaginal birth and can cause significant blood loss in the immediate postpartum period. The rate of clinically significant CL ranges from 0.14% to 0.2% of births. Nulliparity, operative vaginal birth, occiput posterior position of the fetus, induction of labor, and episiotomy have been cited as possible risk factors. Much of the available literature regarding CL, however, is dated or anecdotal, and there are varying and inconsistent risk associations with its occurrence. Given this unpredictability, CL should be considered in all women with immediate postpartum hemorrhage when there is difficulty obtaining hemostasis. Although midwives receive training about CLs, the low incidence may lead to delay in diagnosis and management. This Clinical Rounds case presents a composite case of postpartum hemorrhage caused by a CL. Risk factors, diagnosis and midwifery management are discussed.

Predelivery sonographic predictors of obstetric anal sphincter injury among nulliparous women.

OBJECTIVE: Data available at admission to delivery of nulliparous has rarely been investigated for prediction of obstetric anal sphincter injury (OASI). The aim of the present study was to study risk factors for OASI in nulliparous based on information available at admission. METHODS: A retrospective study of all nulliparous women undergoing labor, during March 2011 to January 2021 was performed. We compared women with OASI following delivery to those without by univariate and multivariable regression. RESULTS: A total of 30 262 deliveries were included and 4181 (13.4%) of those were delivered by an emergent cesarean delivery. OASI followed 453 (1.5%) deliveries. Women in the OASI group were younger 29 ± 4.4 versus 30 ± 4.8, P = 0.001. In a multivariable regression analysis, higher sonographic estimated fetal weight was positively associated with OASI occurrence (aOR, 95% CI: 1.13 [1.00-1.29]). Maternal age was inversely associated with OASI occurrence (adjusted odds ratio [aOR], 95% confidence interval [CI] 0.95 [0.92-0.97]). CONCLUSION: Sonographic fetal weight estimation is an independent risk factor for OASI occurrence that may be available at admission for delivery among nulliparous women.