Does the implementation of a restrictive episiotomy policy for operative deliveries increase the risk of obstetric anal sphincter injury?

PURPOSE: Our main objective was to investigate whether the implementation of a restrictive episiotomy policy in operative deliveries changes the incidence of obstetric anal sphincter injury (OASI). METHODS: This is an observational study over an 11-year period in Poitiers University Maternity, France. We included women with vaginal operative deliveries after 34 gestational weeks for singleton births in cephalic presentation. We collected data on the mother and operative delivery characteristics: indication, instrument, epidural analgesia, labor length, episiotomy, OASI, and birthweight. We investigated the changes in the mediolateral episiotomy (MLE) and OASI rates and the association between MLE and OASI. The primary outcome was the evolution of the OASI and MLE rates. The secondary outcome was the occurrence of OASI during operative delivery with or without MLE. RESULTS: In total, 2357 operative deliveries were assessed, including 847 vacuum-, 1350 forceps- and 160 spatula-assisted deliveries. Of these, 950 were performed with MLE and 1407 without; 37 OASIs (3.9%) occurred in the MLE group, and 137 (9.7%) in the no-MLE group. Between 2005 and 2015, MLE use decreased from 78.5 to 16.2% and OASI occurrence increased from 3.1 to 12.7%. The increase in OASI occurrence was significant for forceps deliveries, but not for vacuum or spatula deliveries. Operative delivery with MLE was associated with a three times lower OASI occurrence than that without MLE (adjusted OR = 0.29, 95% CI [0.20-0.43]). CONCLUSIONS: Implementation of a restrictive MLE policy for operative delivery seems to be associated with an increase in OASI incidence with forceps, but not with vacuum.

Obstetrical anal sphincter injuries and symptoms after subsequent deliveries: A 60 patient study.

INTRODUCTION: More than half of women with a history of prior obstetric anal sphincter injuries (OASIS) will have another pregnancy. Currently, little is known concerning post-partum perineal symptoms in cases of a subsequent vaginal delivery. The aim of this study was to assess the frequency of perineal functional symptoms following a vaginal delivery after OASIS while comparing them to patients who did not have a subsequent delivery. MATERIAL AND METHOD: Retrospective cohort study between January 2000 and December 2011. A questionnaire was sent by post to all women who sustained an OASIS at the Poitiers University Hospital, France. Perineal functional symptoms and quality of life were assessed using validated self-administered questionnaires: Female Pelvic Floor Questionnaire, Pescatori anal incontinence score, EuroQoL five-dimension score, and pain visual analogue scale. RESULTS: 159 women of 237 contacted (67%) responded to the questionnaire, on average 46 months after the delivery complicated with OASIS. 135 (85%) of women had a 3rd degree laceration and 24% a 4th degree laceration. 99 women (63%) did not have an ensuing delivery since the event (OASIS - No Subsequent Delivery: SD-). 60 women (37%) had a subsequent delivery (OASIS -Subsequent Delivery: SD + ), with 53 (88%) having a vaginal birth. Among these women, 3 (6%) experienced a recurrent OASIS. The mean score for perineal symptoms (FPFQ) was 6.95 in the OASIS-SD (-) group and 7.40 in the OASIS-SD (+) group (p = 0.64). No significant difference in quality of life (EuroQol 5D) was found between the two groups (p = 0.91). CONCLUSION: We did not observe a deterioration of perineal functional symptomatology after vaginal delivery in women with known prior OASIS, compared to women who did not have a subsequent delivery. Even if the risk of occurrence of these lesions is higher in women with history of previous OASIS compared to those without perineal injury, it is still comparable to incidence among primiparous women.