Modifiable risk factors of obstetric anal sphincter injury in primiparous women: a population–based cohort study

Jangö, Hanna; Langhoff‐Roos, Jens; Rosthøj, Susanne; Sakse, A.

doi:10.1016/j.ajog.2013.08.043

Cited by 131 publications

(129 citation statements)

References 32 publications

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“…The number needed to treat to prevent one obstetric anal sphincter injury during vacuum‐assisted delivery was found to be 50. This finding is supported by previous studies, which reported a decrease in obstetric anal sphincter injuries when episiotomy was used in operative vaginal deliveries 8, 25, 28, 29. Jangö et al report a number needed to treat of 23 mediolateral episiotomies and Raisänen et al report a number needed to treat of 66 lateral episiotomies to prevent one case of obstetric anal sphincter injury in vacuum‐assisted deliveries, thus favoring more frequent use of episiotomy in such cases 28, 30.…”

Section: Discussionsupporting

confidence: 89%

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Risk and protective factors for obstetric anal sphincter injuries: A retrospective nationwide study

Marschalek

Worda

Kuessel

et al. 2018

Birth

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BackgroundIn view of the reported increase in obstetric anal sphincter injuries, the objective of this study was to evaluate the incidence of such injuries over time and the associated risk and protective factors.MethodsThis was a retrospective cohort study from a national database of 168 137 primiparous women with term, singleton, cephalic, vaginal delivery between 2008 and 2014. The main outcome measure was obstetric anal sphincter injury. A multivariate regression model was used to identify risk and protective factors.ResultsAge >19 years, birthweight >4000 g, and operative vaginal delivery were independent risk factors for obstetric anal sphincter injuries. Mediolateral episiotomy increased the risk for obstetric anal sphincter injuries in spontaneous vaginal birth (number needed to harm 333), whereas it was protective in vacuum delivery (number needed to treat 50). From 2008 to 2014, there was an increase in the rate of obstetric anal sphincter injuries (2.1% vs 3.1%, P < .01), vacuum deliveries (12.1% vs 12.8%, P < .01), and cesarean delivery after labor (17.1% vs 19.4%, P < .01), while forceps deliveries (0.4% vs 0.1%, P < .01) and episiotomy rate decreased (35.9% vs 26.4%, P < .01).ConclusionsEpisiotomy may be a risk or protective factor depending on the type of episiotomy and the clinical setting in which it is used. Our study supports a restrictive use of mediolateral episiotomy in spontaneous vaginal deliveries. In vacuum deliveries mediolateral episiotomy may help prevent obstetric anal sphincter injuries.

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Section: Discussionsupporting

confidence: 89%

“…This is supported by Loewenberg‐Weisband et al38 who also found that epidural analgesia is not associated with severe perineal lacerations, once confounding factors were controlled for. Other studies found a protective effect of epidural analgesia and therefore suggest epidural should not be considered an independent risk factor 28, 30…”

Section: Discussionmentioning

confidence: 94%

Risk and protective factors for obstetric anal sphincter injuries: A retrospective nationwide study

Marschalek

Worda

Kuessel

et al. 2018

Birth

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“…Finally, of 812 initial reports, 15 articles encompassing 350 764 vacuum deliveries were included in the meta-analysis. [13][14][15][16][17][18][19][20][21][22][23][24][25][26][27] Table 1 summarises the characteristics of the studies. Fourteen articles described studies that were observational cohorts in nature, with only one study involving prospective data acquisition, 20 and one additional article describing case-control analysis.…”

Section: Resultsmentioning

confidence: 99%

“…25 Removal of the two obvious outliers in the forest plot reduced the statistical heterogeneity (P = 0.65, I 2 = 0%) and led to an increase in the pooled estimate, but not reaching statistical significance (OR 0.93, 95% CI 0.83-1.01). 25,27 We also ran an analysis in which each study was removed, in turn, to examine whether any one study had a large effect on the pooled estimate. The pooled estimate varied from 0.62 to 0.80 when we did this, with most yielding statistical insignificance according to the 95% CI.…”

Section: Resultsmentioning

confidence: 99%

Morbidity associated with episiotomy in vacuum delivery: a systematic review and meta‐analysis

Sagi‐Dain

Sagi

2015

BJOG

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Background The role of episiotomy in vacuum deliveries is controversial.Objectives To perform a meta-analysis of the literature examining this subject.Search strategy The search was conducted in four databases.Selection criteria Two investigators independently selected original research examining the effects of episiotomy on any neonatal and maternal outcomes during vacuum delivery.Data collection and analysis The effect estimates were presented as odds ratios (ORs) with 95% confidence intervals (95% CIs).Main results Fifteen articles were included, encompassing a total of 350 764 vacuum deliveries. A non-significant relationship was shown between mediolateral episiotomy and obstetric anal sphincter injuries (OASIS) in nulliparous women (OR 0.68, 95% CI 0.43-1.07; six studies), whereas an increased risk was demonstrated in parous women (OR 1.27, 95% CI 1.05-1.53; two reports). A higher risk of OASIS with median episiotomy use was shown in nulliparous (OR 5.11,; two studies) as well as in parous (OR 89.4, 95% CI 11.8-677.1; one study) women. Lateral episiotomy was related to lower OASIS risk in nullipara (OR 0.59, 95% CI 0.49-0.70; single paper). Mediolateral episiotomy was linked to increased rates of postpartum haemorrhage (OR 1.82, 95% CI 1.16-2.86) and analgesia use (OR 2.10, 95% CI 1.39-3.17; two reports). Overall, the quality of evidence was rated as low to very low.Author's conclusions Mediolateral and median episiotomy in parous woman may increase the rate of OASIS at vacuum delivery, whereas lateral episiotomy in nulliparous women could be associated with a decreased risk of OASIS. The suboptimal quality of the available evidence necessitates high-quality welldesigned randomised trials.Keywords Episiotomy, obstetric anal sphincter injury, vacuum extraction delivery.Tweetable abstract Episiotomy in vacuum delivery does not appear to be of benefit, and might even increase maternal morbidity.

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“…9 OASIS have been linked with a number of long-term complications such as faecal incontinence, urinary incontinence, perineal pain, dyspareunia, embarrassment and low self-esteem. 10 Instrumental delivery, increasing birthweight and prolonged second stage are all recognised risk factors for OASIS; 6,8,[11][12][13][14] however, the role of ethnicity remains uncertain.…”

Section: Introductionmentioning

confidence: 99%

The Great Divide: Country of birth as a risk factor for obstetric anal sphincter injuries

Brown

Kapurubandara

Gibbs

et al. 2017

Aust NZ J Obst Gynaeco

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BackgroundObstetric anal sphincter injuries (OASIS) can complicate up to 6% of births and are a major contributor to preventable maternal morbidity. Asian women have a risk of third and fourth degree perineal tears up to four times greater than women of other ethnicities in the same community, but the lack of differentiation of Asian women into regional groups has limited insight into the reasons behind their increased risk.AimsTo investigate risk of OASIS associated with country of birth.MethodsThis was a retrospective cohort study of all women with a singleton, nulliparous pregnancy who delivered vaginally by spontaneous vaginal birth or an instrumental delivery between 1 January 2009 and 31 December 2015. The demographics of women who experienced OASIS were compared with those women who had minor perineal trauma.ResultsFrom January 2009 to December 2015 there were 10 750 singleton, nulliparous and natural vaginal birth (NVB), forceps or vacuum deliveries. Of these deliveries, 581 (5.4%) werehad third degree tears and 36 (0.3%) fourth degree tears. Women born in South Asia were at a much higher risk of OASIS than other groups, including women born in other Asian countries, compared to the Australian/New Zealand cohort. One in every 10 nulliparous South Asian women having a singleton vaginal or instrumental delivery will sustain an OASIS.ConclusionsOur study further confirms the role of Asian ethnicity in the risk of OASIS, and is the second to confirm that South Asian women are at a dramatically increased risk.

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Modifiable risk factors of obstetric anal sphincter injury in primiparous women: a population–based cohort study

Cited by 131 publications

References 32 publications

Risk and protective factors for obstetric anal sphincter injuries: A retrospective nationwide study

Risk and protective factors for obstetric anal sphincter injuries: A retrospective nationwide study

Morbidity associated with episiotomy in vacuum delivery: a systematic review and meta‐analysis

The Great Divide: Country of birth as a risk factor for obstetric anal sphincter injuries

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