A Multicenter Interventional Program to Reduce the Incidence of Anal Sphincter Tears

Hals, Elisabeth; Øian, Pål; Pirhonen, Tiina; Gissler, Mika; Hjelle, Sissel; Nilsen, Elisabeth Berge; Severinsen, Anne Mette; Solsletten, Cathrine; Hartgill, Tom; Pirhonen, Jouko

doi:10.1097/aog.0b013e3181eda77a

Cited by 193 publications

(184 citation statements)

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“…More free text comments were made about ‘chinning’ than any other technique; mostly around unfamiliarity with this method. The introduction of a combination of strategies, including ‘chinning’ to routine care at birth was associated with a significant drop in the OASI rate in Norway 16, 17, 18, 19. It is unclear whether ‘chinning’ by itself had any effect, or whether the decrease was driven by the other ‘hands on’ techniques, and/or by other strategies individually or in combination with each other.…”

Section: Discussionmentioning

confidence: 99%

“…Other strategies, including emphasis on selective mediolateral (as opposed to midline) episiotomy, good visualisation of the perineum at birth and communication with the mother regarding slow pushing, were also implemented. With OASI rates decreasing from 4–5 to 1–2%,16, 17, 18, 19 questions about the appropriateness of abandoning traditional perineal support practices have been raised.…”

Section: Introductionmentioning

confidence: 99%

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Perineal management techniques among midwives at five hospitals in New South Wales – A cross‐sectional survey

Ampt

Vroome

Ford

2015

Aust NZ J Obst Gynaeco

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BackgroundMidwives are reported to have changed from ‘hands on’ to ‘hands poised or off’ approaches to birth at the same time as obstetric anal sphincter injuries (OASIs) are increasing. As perineal management details are not routinely collected, it is difficult to quantify practice.AimsTo determine which perineal protections techniques midwives prefer for low‐risk non‐water births; whether preference is associated with technique taught or with other characteristics; and whether midwives change preference according to clinical scenario.Materials and MethodsMidwives in Northern Sydney Local Health District (NSLHD) were surveyed during a 2‐week period in 2014. Multiple‐choice questions were used, with free text option. Descriptive analyses, chi‐square and McNemar tests were undertaken.ResultsOne hundred and eight midwives participated (response rate 76.7%). ‘Hands poised or off’ was preferred by 63.0% for a low‐risk birth. Current practice was associated with technique taught (P < 0.01). For scenarios with increased OASI risk midwives reported switching to ‘hands on’, with 83.4% employing ‘hands on’ whether there was concern about an impending OASI. There has been a shift over time from teaching ‘hands on’ to ‘hands poised or off’.ConclusionThe preferred technique for a low‐risk birth appears to have changed from ‘hands on’ to ‘hands poised or off’, but most midwives adopt ‘hands on’ in situations of high risk for OASI. Further research is needed to establish whether there is an association with the rising OASI rate and the change in preferred perineal management technique for a low‐risk birth.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Perineal management techniques among midwives at five hospitals in New South Wales – A cross‐sectional survey

Ampt

Vroome

Ford

2015

Aust NZ J Obst Gynaeco

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“…[68][69][70][71] The implementation of manual assistance and perineal protection techniques during the second stage of labour have significantly reduced the incidence of perineal tears in Norway. 72,73 Antenatal perineal massage reduces the likelihood of perineal trauma (mainly episiotomies), but is not routinely practiced in the UK. 74 Wider application of the 'hands-poised' approach, combined with the reluctance to use episiotomies, could have resulted in a higher risk of a third-or fourth-degree tears.…”

Section: Comparison With Previous Literaturementioning

confidence: 99%

Third‐ and fourth‐degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors

Gurol‐Urganci

Cromwell

Edozien

et al. 2013

BJOG

346

270

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Objective To describe the trends of severe perineal tears in England and to investigate to what extent the changes in related risk factors could explain the observed trends.Design A retrospective cohort study of singleton deliveries from a national administrative database.Setting The English National Health Service between 1 April 2000 and 31 March 2012.Population A cohort of 1 035 253 primiparous women who had a singleton, term, cephalic, vaginal birth.Methods Multivariable logistic regression was used to estimate the impact of financial year of birth (labelled by starting year), adjusting for major risk factors.Main outcome measure The rate of third-degree (anal sphincter is torn) or fourth-degree (anal sphincter as well as rectal mucosa are torn) perineal tears.Results The rate of reported third-or fourth-degree perineal tears tripled from 1.8 to 5.9% during the study period. The rate of episiotomy varied between 30 and 36%. An increasing proportion of ventouse deliveries (from 67.8 to 78.6%) and non-instrumental deliveries (from 15.1 to 19.1%) were assisted by an episiotomy. A higher risk of third-or fourth-degree perineal tears was associated with a maternal age above 25 years, instrumental delivery (forceps and ventouse), especially without episiotomy, Asian ethnicity, a more affluent socio-economic status, higher birthweight, and shoulder dystocia.Conclusions Changes in major risk factors are unlikely explanations for the observed increase in the rate of third-or fourth-degree tears. The improved recognition of tears following the implementation of a standardised classification of perineal tears is the most likely explanation.Keywords Episiotomy, instrumental delivery, severe perineal trauma, trends, vaginal delivery.

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“…This hypothesis was tested in Norway in two hospital-based studies (2010 and 2012) that showed a significant decrease of OASIS by 50-70% 1,16 . It is interesting that these two studies were commissioned by the Norwegian Board of Health in 2004 as part of the national strategy to reduce OASIS, since hospitals were heavily criticised for having a high OASIS rate of 4.5% in 2004, and were therefore required to implement programs to reduce this.Following these two studies 1,16 , there was a UK population-based study in 2016 that replicated the study design of the Norwegian studies 21 . This UK study showed that 'hands-on' the perineum during the crowning at second stage reduced the OASIS overall rates by 23% and the 3c third degree and 4th degree tears by 71%.…”

mentioning

confidence: 84%

“…There are reports that OASIS is a risk factor for the development of anal incontinence [1][2][3][4] , with significantly worse bowel symptoms and anorectal function with the higher degree of OASIS 5,6 . In addition, the economic cost of anal incontinence management following OASIS has been estimated to be approximately £1625 per patient 7 or £78 million per annum in the United Kingdom alone 8 .…”

mentioning

confidence: 99%

Hands-on or hands-off the perineum at childbirth: A re-appraisal of the available evidence

Antonakou¹

2017

Eur J Midwifery

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Obstetric anal sphincter injuries (OASIS), or third-degree and fourth-degree perineal tears, represent a serious complication of vaginal birth. There are reports that OASIS is a risk factor for the development of anal incontinence [1][2][3][4] , with significantly worse bowel symptoms and anorectal function with the higher degree of OASIS 5,6 . In addition, the economic cost of anal incontinence management following OASIS has been estimated to be approximately £1625 per patient 7 or £78 million per annum in the United Kingdom alone 8 . The current UK based maternity practice at second stage of labour involves two techniques 9,10 : 1) 'hands-on', where one hand of the practitioner applies pressure on the fetal head while the other hand supports the perineum, 2) 'hands-poised', where the hands of the practitioner are poised, ready to apply light pressure on the fetal head to avoid rapid expulsion. Most often, however, this latter technique has been misinterpreted as a 'hands-off technique'.The Royal College of Midwives (RCM) in 2012, and in line with the NICE 2007 guidance on intrapartum care, has suggested that the available evidence is inconclusive as to whether the 'hands-on' technique reduces the incidence of severe perineal trauma , which have however received heavy criticism from later studies as to the validity of their results and the robustness of their study design and methodology 14,15 . In the United Kingdom the incidence of OASIS for primiparous women has been reported to have tripled from 1.8% to 5.9%, over a 12-year period 8 . In Norway, the OASIS rate has increased from <1% in the 1960s to 4.3% at the beginning of the past decade 16,17 . A similar increase has been noted in other European countries, with the exception of Finland where the OASIS rate has remained stable at less than 1% over the past 25 years 18,19 . It is considered that this increase is secondary to the increased incidence of instrumental deliveries, improved training for health professionals and changing maternal-fetal risk factors. Nevertheless, regardless of the above-mentioned factors, the low risk of OASIS in Finland is suggested to be due to the classic 'hands-on' technique of perineal support at birth 19,20 . This hypothesis was tested in Norway in two hospital-based studies (2010 and 2012) that showed a significant decrease of OASIS by 50-70% 1,16 . It is interesting that these two studies were commissioned by the Norwegian Board of Health in 2004 as part of the national strategy to reduce OASIS, since hospitals were heavily criticised for having a high OASIS rate of 4.5% in 2004, and were therefore required to implement programs to reduce this.Following these two studies 1,16 , there was a UK population-based study in 2016 that replicated the study design of the Norwegian studies 21 . This UK study showed that 'hands-on' the perineum during the crowning at second stage reduced the OASIS overall rates by 23% and the 3c third degree and 4th degree tears by 71%. In a recent metanalysis in 2015 of observational studies, ...

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A Multicenter Interventional Program to Reduce the Incidence of Anal Sphincter Tears

Abstract: II.

Cited by 193 publications

References 20 publications

Perineal management techniques among midwives at five hospitals in New South Wales – A cross‐sectional survey

Perineal management techniques among midwives at five hospitals in New South Wales – A cross‐sectional survey

Third‐ and fourth‐degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors

Hands-on or hands-off the perineum at childbirth: A re-appraisal of the available evidence

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