Prevention of obstetric anal sphincter injuries with perineal support and lateral episiotomy: A historical cohort study.

INTRODUCTION: There are many risk factors for obstetric anal sphincter injury (OASIS) and the interaction between these risk factors is complex and understudied. The many observational studies that have shown a reduction of OASIS rates after implementation of perineal support have short follow-up time. We aimed to study the effect of integration of active perineal support and lateral episiotomy on OASIS rates over a 15-year period and to study interactions between risk factors known before delivery. MATERIAL AND METHODS: We performed a historical cohort study over the periods 1999-2006 and 2007-2021 at Stavanger University Hospital, Norway. The main outcome was OASIS rates. Women without a previous cesarean section and a live singleton fetus in cephalic presentation at term were eligible. The department implemented in 2007 the Finnish concept of active perineal protection, which includes support of perineum, control of fetal expulsion, good communication with the mother and observation of perineal stretching. The practice of mediolateral episiotomy was replaced with lateral episiotomy when indicated. We analyzed the OASIS rates in groups with and without episiotomy stratified for delivery mode, fetal position at delivery and for parity, and adjusted for possible confounders (maternal age, gestational age, oxytocin augmentation and epidural analgesia). RESULTS: We observed a long-lasting reduction in OASIS rates from 4.9% to 1.9% and an increase in episiotomy rates from 14.4% to 21.8%. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with instrumental vaginal deliveries and occiput anterior (OA) position; 3.4% vs 10.1% (OR 0.31; 95% CI: 0.24-0.40) and 6.1 vs 13.9% (OR 0.40; 95% CI: 0.19-0.82) in women with occiput posterior (OP) position. Lateral episiotomy was also associated with lower OASIS rates in nulliparous women with spontaneous deliveries and OA position; 2.1% vs 3.2% (OR 0.62; 95% CI: 0.49-0.80). The possible confounders had little confounding effects on the risk of OASIS in groups with and without episiotomy. CONCLUSIONS: We observed a long-lasting reduction in OASIS rates after implementation of preventive procedures. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with an instrumental delivery. Special attention should be paid to deliveries with persistent OP position.

Maternal deaths in Norway 2005-2009.

BACKGROUND: Norway has low maternal mortality, but such deaths are underreported even in high-income countries. Our goal was to identify the exact number of maternal deaths, the causes of death and the potential for improvement through medical care in Norway. MATERIAL AND METHOD: We traced maternal deaths in the period from 1 January 2005 to 31 December 2009 by linking the Medical Birth Registry and the Cause of Death Registry, supplemented with data from maternity clinics. We identified the cause of death and the lessons that could be learned by a meticulous review of each case. RESULTS: We found 26 maternal deaths during the period, 14 of which were due to direct causes and 12 to indirect causes. The maternal mortality ratio was 8.7/100,000 live births. Fourteen of the deaths were registered in official statistics. Of the 12 deaths that were not included in the statistics, 11 were found through matching the registers and one had been reported directly by the hospital. The most common causes of death were hypertensive disorders during pregnancy (n = 6), thromboembolism (n = 4) and mental illness (n = 4). None of the deaths due to thromboembolism appeared in official statistics. The same applied to nine of the 12 indirect maternal deaths. We found a potential for improved medical care in 14 of 26 cases. Half of these were deaths due to hypertensive disorders during pregnancy or thromboembolism. INTERPRETATION: Maternal death was considerably underreported in Norwegian official statistics during the period studied. Greater attention should be given to better blood-pressure treatment, stabilisation and timely delivery in the case of hypertension during pregnancy, and to screening for possible pulmonary embolism. The same applies to mental illness and internal medical disorders in pregnant women.

The overlap technique versus end-to-end approximation technique for primary repair of obstetric anal sphincter rupture: a randomized controlled study.

OBJECTIVE: To compare the outcome of end-to-end approximation versus the overlap technique for primary repair of obstetric anal sphincter rupture (OASR) at 12 month follow-up. DESIGN: Prospective, randomized controlled study. SETTING: University hospital. Sample. One hundred and twenty-eight patients with grade 3b, 3c or 4 OASR were randomized; 119 (end-to-end 60, overlap 59) received the allocated treatment. We obtained information concerning fecal incontinence from 101 (85%) patients. METHODS: The obstetric team on call performed the repairs. Wexner score, endoanal ultrasound (EAUS), and manometry were used to evaluate anal sphincter function at 12 months post-surgery. MAIN OUTCOME MEASURES: Primary outcome was incidence of solid stool leakage at least once a week. Secondary outcomes were flatus incontinence, Wexner score, external anal muscle defect examined by EAUS, and anal manometry results. RESULTS: One patient in the end-to-end group and none in the overlap group reported leakage of solid stool once a week or more. Fourteen patients in the end-to-end group and 10 in the overlap group reported flatus incontinence (p = 0.48). Mean Wexner score was similar in both groups, 2.4 versus 2.2. One patient in the end-to-end group and none in the overlap group had a Wexner score >10 (severe anal incontinence) (NS). External sphincter defect was found in 2/46 in the end-to-end group compared to 0/41 in the overlap group (NS). Anal manometry findings were similar in both groups. CONCLUSION: The overlap repair was not superior to the approximation technique with regard to fecal incontinence at 12 months.