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.

Pelvic Floor Health Index: Initial validation of a practical postpartum tool for busy clinicians.

OBJECTIVE: To design a primary care clinical tool (Pelvic Floor Health Index [PFHI]) to screen for postpartum pelvic floor disorders, as well as complete its psychometric validation. DESIGN: Prospective cohort study. SETTING: Two tertiary care obstetric centres in Vancouver, BC. PARTICIPANTS: Primiparous women older than 19 years of age who were in the immediate postpartum period. MAIN OUTCOME MEASURES: The PFHI was administered to 74 primiparous women immediately postpartum and at 2, 4, and 6 months postpartum. For evaluation of convergent and divergent construct validity, participants also completed several validated questionnaires, including the Female Sexual Functioning Index, the Pelvic Floor Distress Inventory, the 36-Item Short Form Health Survey, and the Edinburgh Postnatal Depression Scale. Fifteen women repeated their 6-month questionnaires 2 weeks later in order to determine test-retest reliability. Responsiveness was assessed by measuring the PFHI score change from baseline to 6 months postpartum. RESULTS: Pelvic Floor Health Index score was inversely correlated with subscale scores on the Pelvic Floor Distress Inventory at all time points. There were moderate correlations between PFHI score and the Female Sexual Functioning Index and 36-Item Short Form Health Survey scores at several time points. There were weak correlations with postpartum depression scores. The intraclass correlation coefficient for test-retest reliability was 0.78 (95% CI 0.47 to 0.92). The PFHI mean total score significantly improved by 1.8 (95% CI 1.0 to 2.6) at 6 months postpartum. CONCLUSION: The PFHI is a 10-item, newly validated, and psychometrically robust questionnaire that can be administered to patients in the postpartum period to screen for pelvic floor dysfunction.

Reducing urinary tract infection in female pelvic surgery: A retrospective cohort study.

OBJECTIVE: To compare prebundle versus postbundle implementation urinary tract infection (UTI) rates among inpatients within 6 weeks of clean-contaminated pelvic reconstructive surgery. METHODS: The authors conducted a retrospective cohort study from September 2019 to December 2021 at a tertiary hospital. The bundle strategy included the following: universal preoperative UTI check with treatment if positive, replacing prolonged postoperative voiding trials on the ward with earlier discharge and indwelling catheter removal by a nurse continence advisor the next day, and daily cranberry extract for 6 weeks postoperatively. UTI was defined as positive urine culture (≥100 000 colony-forming unit per mL) in a symptomatic patient. Data analysis involved hypothesis testing and logistic regression. RESULTS: The authors reviewed 132 postbundle inpatient charts and retained 93 for analyses. The results were compared with 204 prebundle inpatient charts. The rate of postoperative UTI decreased from 17.6% in the prebundle group to 6.5% after bundle implementation (P = 0.01). The adjusted odds ratio for postbundle versus prebundle likelihood of UTI was 0.35 (95% confidence interval, 0.13-0.98; P = 0.045). Significantly more postbundle patients compared with prebundle patients were discharged home on the first day postoperatively (76.3% vs. 37.7%, P < 0.001). CONCLUSIONS: A clinical bundle can significantly decrease both UTI rates and hospital stay after pelvic reconstructive surgery.

Pelvic floor healing milestones after obstetric anal sphincter injury: a prospective case control feasibility study.

INTRODUCTION AND HYPOTHESIS: Severe perineal tears can predict bothersome pelvic floor disorders later in life. We have a poor understanding of pelvic floor changes during the third trimester and the first few postpartum months. We aimed to compare women with severe perineal trauma during childbirth with women who experienced minimal trauma, for condition-specific quality of life, sexual function, mental health and overall quality of life in the first 6 months postpartum. METHODS: We recruited primiparous women with third- or fourth-degree tears (obstetric anal sphincter injuries, OASIS) and age-matched controls with no tears or first-degree tears in the immediate postpartum period. Participants completed validated questionnaires at baseline, 2, 4 and 6 months postpartum. Mixed effects linear regression or quantile regression adjusted for baseline score were used to compare the groups as appropriate. RESULTS: A total of 74 women completed at least one questionnaire (35 OASIS, 39 controls). Both groups had similar demographics. Women with OASIS tended to have worse Pelvic Floor Distress Index-40 scores at month 2; median scores were similar in the two groups by month 6. They also had significantly lower Female Sexual Function Index scores (mean difference: -6.1; 95% CI: -11.9, -0.2, p=0.043) at month 2. There were no mental health group differences and quality of life improved over time, mainly in the OASIS group. Six-month participant attrition rate was 52%. CONCLUSIONS: Women with OASIS encounter specific pelvic floor challenges during the first 6 months postpartum. Although our recruitment rate was high, the attrition rate was also high, demonstrating challenges with retention of postpartum women into longitudinal research.

Documenting Perineal and Obstetrical Anal Sphincter Injury Care at Childbirth: A Cross-Sectional Study.

OBJECTIVE: This study evaluates whether maternity care providers document guideline-based recommendations for the prevention and care of obstetrical anal sphincter injuries (OASIS) for their labour and delivery patients. METHODS: We performed a cross-sectional study, aiming for a convenience sample of 60 primiparous women, over 19 years of age, equally representative of patients who experienced severe (third- and fourth-degree) and minimal (intact or first-degree) tears during vaginal birth. Information on patient demographics, delivery details, and guideline-endorsed preventative and management measures were collected. Descriptive statistics were used when appropriate. RESULTS: We enrolled a total of 73 women, 34 of whom had severe tears and 39 of whom had minimal tears. Preventative measures, including fetal head control and perineal support during delivery, were documented for 1 out of 73 patients. The use of perineal massage and warm compress to the perineum was not documented. A rectal exam after delivery was documented for 30% (22/73) of all patients and 62% (21/34) of patients with OASIS. Sixty-five percent (22/34) of patients with OASIS received intravenous antibiotics, 88% (30/34) received laxatives, and 100% received nonsteroidal anti-inflammatory drugs. Post-void residual was not documented for any patients. Patients recalled being informed about their OASIS in 68% (23/34) of cases and being referred to pelvic physiotherapy in 47% (16/34) of cases. CONCLUSION: In our study, perineal care practices during and after childbirth, as detailed in the national OASIS guideline, were incompletely documented. This may indicate partial guideline adherence or suboptimal medical record-keeping.

Trends in Female Authorship: A Bibliometric Analysis of The Annals of Thoracic Surgery.

BACKGROUND: Women continue to comprise a small minority of cardiothoracic surgeons. Representation of women in areas of academic achievement has not been well characterized. This study aims to evaluate female representation among authorship positions in high-impact articles published in The Annals of Thoracic Surgery. METHODS: Altmetric scores were used to identify the top 50 articles published in 2013, 2015, and 2017 in The Annals of Thoracic Surgery. Article characteristics as well as author demographics were collected. Bibliometric analysis was performed to identify longitudinal changes with regard to female representation as first and last authors. RESULTS: Female authors remain underrepresented in authorship, despite a temporal trend toward improvement in female representation over the years for first author position (16% in 2013, 22% in 2015, 20% in 2017) and last author position (8% in 2013, 16% in 2015, 20% in 2017). Articles authored by women were equally likely to achieve high impact as compared with men, as evaluated by Altmetric score (women 30.1 ± 38.6 vs men 39.1 ± 73.5, P = .53), citations (women 14.3 ± 19.1 vs men 17.6 ± 20.8, P = .45), and to be mentioned by news outlets, blogs, patents, Facebook, Wikipedia, Mendeley, Google, LinkedIn, and Reddit. Female first and last authors achieved comparable numbers of publications and H-index scores compared with male authors. CONCLUSIONS: Significant sex-based differences in authorship representation persist, but with favorable improvement in female representation over time. Importantly, citations and high-impact status were independent of author sex. Characterization of the representation of women in academic achievement helps us strive for gender equity in our specialty.

Predictors of High-Impact Articles in The Annals of Thoracic Surgery.

BACKGROUND: Altmetric scores are increasingly used as nontraditional metrics of scholarly impact that capture article social media attention. This study aims to characterize articles from The Annals of Thoracic Surgery that achieved the greatest online reach over a longitudinal period. METHODS: The 50 articles with the highest Altmetric scores published in The Annals of Thoracic Surgery for 2013, 2015, and 2017 were identified. Spearman rank correlation coefficient was used to assess the correlation of Altmetric scores with citations. Independent predictors of Altmetric scores (25 or greater) were identified through univariable and multivariable logistic regression analysis. RESULTS: Over time, article Altmetric scores increased significantly (2013, 11.9; 2015, 24.8; and 2017, 75.3; P < .001); with more authors on Twitter in recent years to disseminate scholarly work (2013, 10%; 2015, 20%; and 2017, 42%; P < .001). Recent articles attracted greater attention from news outlets (2013, 1.02; 2015, 2.36; and 2017, 7.48; P < .001) and tweets (2013, 1.84; 2015, 6.68; and 2017, 27.8; P < .001), reaching a larger readership through Twitter (2013, 4210; 2015, 19,300; and 2017, 66,800; P < .001). Log-transformed Altmetric scores were correlated with log-transformed citations for articles published in 2017 (rs = 0.40; P = .02). On multivariable analysis, tweets (odds ratio = 1.27; 95% confidence interval, 1.01-1.61; P = .044) and mentions by news outlets (odds ratio = 30.49; 95% confidence interval, 4.03-230.16; P = .001) were predictive of high Altmetric scores. CONCLUSIONS: This longitudinal analysis demonstrates that social media attention related to top performing articles has increased in recent years. Social media is an effective tool to increase article reach and knowledge translation, with Altmetric scores that correlated with citations.

Eye movement training is most effective when it involves a task-relevant sensorimotor decision.

Eye and hand movements are closely linked when performing everyday actions. We conducted a perceptual-motor training study to investigate mutually beneficial effects of eye and hand movements, asking whether training in one modality benefits performance in the other. Observers had to predict the future trajectory of a briefly presented moving object, and intercept it at its assumed location as accurately as possible with their finger. Eye and hand movements were recorded simultaneously. Different training protocols either included eye movements or a combination of eye and hand movements with or without external performance feedback. Eye movement training did not transfer across modalities: Irrespective of feedback, finger interception accuracy and precision improved after training that involved the hand, but not after isolated eye movement training. Conversely, eye movements benefited from hand movement training or when external performance feedback was given, thus improving only when an active interceptive task component was involved. These findings indicate only limited transfer across modalities. However, they reveal the importance of creating a training task with an active sensorimotor decision to improve the accuracy and precision of eye and hand movements.