Incidence of and risk factors for perineal trauma: a prospective observational study

BMC Pregnancy and Childbirth

Ethel E Burns²  Vanessa Simonite³  Natalia Price¹  Lesley A Smith² 

[1] Department of Obstetrics & Gynaecology, Women’s Centre, Oxford University Hospitals Trust, Oxford, OX3 9DU, UK;Department Social Work and Public Health, Faculty of Health and Life Sciences, Oxford Brookes University, Jack Straws Lane, Marston, Oxford, OX3 0FL, UK;Department of Mechanical Engineering and Mathematical Sciences, Faculty of Technology, Design and Environment, Oxford Brookes University, Wheatley Campus, Wheatley, Oxford, OX33 1HX, UK

关键词: Prospective study;    OASIS;    Perineal trauma;    Vaginal delivery;   

Others  :  1138171
DOI  :  10.1186/1471-2393-13-59

 received in 2012-10-16, accepted in 2013-02-20,  发布年份 2013

【 摘 要 】

Background

Our aim was to describe the range of perineal trauma in women with a singleton vaginal birth and estimate the effect of maternal and obstetric characteristics on the incidence of perineal tears.

Methods

We conducted a prospective observational study on all women with a planned singleton vaginal delivery between May and September 2006 in one obstetric unit, three freestanding midwifery-led units and home settings in South East England. Data on maternal and obstetric characteristics were collected prospectively and analysed using univariable and multivariable logistic regression. The outcome measures were incidence of perineal trauma, type of perineal trauma and whether it was sutured or not.

Results

The proportion of women with an intact perineum at delivery was 9.6% (125/1,302) in nulliparae, and 31.2% (453/1,452) in multiparae, with a higher incidence in the community (freestanding midwifery-led units and home settings). Multivariable analysis showed multiparity (OR 0.52; 95% CI: 0.30–0.90) was associated with reduced odds of obstetric anal sphincter injuries (OASIS), whilst forceps (OR 4.43; 95% CI: 2.02–9.71), longer duration of second stage of labour (OR 1.49; 95% CI: 1.13–1.98), and heavier birthweight (OR 1.001; 95% CI: 1.001–1.001), were associated with increased odds. Adjusted ORs for spontaneous perineal truama were: multiparity (OR 0.42; 95% CI: 0.32–0.56); hospital delivery (OR 1.48; 95% CI: 1.01–2.17); forceps delivery (OR 2.61; 95% CI: 1.22–5.56); longer duration of second stage labour (OR 1.45; 95% CI: 1.28–1.63); and heavier birthweight (OR 1.001; 95% CI: 1.000–1.001).

Conclusions

This large prospective study found no evidence for an association between many factors related to midwifery practice such as use of a birthing pool, digital perineal stretching in the second stage, hands off delivery technique, or maternal birth position with incidence of OASIS or spontaneous perineal trauma. We also found a low overall incidence of OASIS, and fewer second degree tears were sutured in the community than in the hospital settings. This study confirms previous findings of overall high incidence of perineal trauma following vaginal delivery, and a strong association between forceps delivery and perineal trauma.

【 授权许可】

   
2013 Smith et al; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Kettle C, Tohill S: Perineal care. Clin Evid (Online) 2008. [http://www.ncbi.nlm.nih.gov/pubmed/19445799 webcite] (accessed 20th June 2012)
• [2]Harkin R, Fitzpatrick M, O'Connell PR, O'Herlihy C: Anal sphincter disruption at vaginal delivery: is recurrence predictable? Eur J Obstet Gynecol Reprod Biol 2003, 109:149-152.
• [3]Dudding TC, Vaizey CJ, Kamm MA: Obstetric anal sphincter injury: incidence, risk factors, and management. Ann Surg 2008, 247:224-237.
• [4]Lindgren HE, Radestad IJ, Christensson K, Hildingsson IM: Outcome of planned home births compared to hospital births in Sweden between 1992 and 2004. A population-based register study. Acta Obstet Gynecol Scand 2008, 87:751-759.
• [5]Revicky V, Nirmal D, Mukhopadhyay S, Morris EP, Nieto JJ: Could a mediolateral episiotomy prevent obstetric anal sphincter injury? Eur J Obstet Gynecol Reprod Biol 2010, 150:142-146.
• [6]Hals E, Oian P, Pirhonen T, Gissler M, Hjelle S, Nilsen EB, Severinsen AM, Solsletten C, Hartgill T, Pirhonen J: A multicenter interventional program to reduce the incidence of anal sphincter tears. Obstet Gynecol 2010, 116:901-908.
• [7]Gottvall K, Allebeck P, Ekeus C: Risk factors for anal sphincter tears: the importance of maternal position at birth. BJOG 2007, 114:1266-1272.
• [8]Laine K, Pirhonen T, Rolland R, Pirhonen J: Decreasing the incidence of anal sphincter tears during delivery. Obstet Gynecol 2008, 111:1053-1057.
• [9]Pretlove SJ, Thompson PJ, Toozs-Hobson PM, Radley S, Khan KS: Does the mode of delivery predispose women to anal incontinence in the first year postpartum? A comparative systematic review. BJOG 2008, 115:421-434.
• [10]Borello-France D, Burgio KL, Richter HE, Zyczynski H, Fitzgerald MP, Whitehead W, Fine P, Nygaard I, Handa VL, Visco AG: Fecal and urinary incontinence in primiparous women. Obstet Gynecol 2006, 108:863-872.
• [11]Fenner DE, Genberg B, Brahma P, Marek L, DeLancey JO: Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States. Am J Obstet Gynecol 2003, 189:1543-1549. discussion 1549–1550
• [12]Poen AC, Felt-Bersma RJ, Dekker GA, Deville W, Cuesta MA, Meuwissen SG: Third degree obstetric perineal tears: risk factors and the preventive role of mediolateral episiotomy. BJOG 1997, 104:563-566.
• [13]Mous M, Muller SA, de Leeuw JW: Long-term effects of anal sphincter rupture during vaginal delivery: faecal incontinence and sexual complaints. BJOG 2008, 115:234-238.
• [14]Sultan AH, Kamm MA, Hudson CN, Bartram CI: Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ 1994, 308:887-891.
• [15]Thom DH, Rortveit G: Prevalence of postpartum urinary incontinence: a systematic review. Acta Obstet Gynecol Scand 2010, 89:1511-1522.
• [16]Brubaker L, Handa VL, Bradley CS, Connolly A, Moalli P, Brown MB, Weber A: Sexual function 6 months after first delivery. Obstet Gynecol 2008, 111:1040-1044.
• [17]Signorello LB, Harlow BL, Chekos AK, Repke JT: Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort study of primiparous women. Am J Obstet Gynecol 2001, 184:881-888.
• [18]Barrett G, Pendry E, Peacock J, Victor C, Thakar R, Manyonda I: Women's sexual health after childbirth. BJOG 2000, 107:186-195.
• [19]Andrews V, Thakar R, Sultan AH, Jones PW: Evaluation of postpartum perineal pain and dyspareunia-a prospective study. Eur J Obstet Gynecol Reprod Biol 2008, 137:152-156.
• [20]Radestad I, Olsson A, Nissen E, Rubertsson C: Tears in the vagina, perineum, sphincter ani, and rectum and first sexual intercourse after childbirth: a nationwide follow-up. Birth 2008, 35:98-106.
• [21]de Leeuw JW, Struijk PC, Vierhout ME, Wallenburg HC: Risk factors for third degree perineal ruptures during delivery. BJOG 2001, 108:383-387.
• [22]Dahl C, Kjolhede P: Obstetric anal sphincter rupture in older primiparous women: a case-control study. Acta Obstet Gynecol Scand 2006, 85:1252-1258.
• [23]Voldner N, Froslie KF, Haakstad LA, Bo K, Henriksen T: Birth complications, overweight, and physical inactivity. Acta Obstet Gynecol Scand 2009, 88:550-555.
• [24]Prager M, Andersson KL, Stephansson O, Marchionni M, Marions L: The incidence of obstetric anal sphincter rupture in primiparous women: a comparison between two European delivery settings. Acta Obstet Gynecol Scand 2008, 87:209-215.
• [25]Lowder JL, Burrows LJ, Krohn MA, Weber AM: Risk factors for primary and subsequent anal sphincter lacerations: a comparison of cohorts by parity and prior mode of delivery. Am J Obstet Gynecol 2007, 196(344):e341-345.
• [26]Kalis V, Chaloupka P, Turek J, Rokyta Z: [Risk factors for 3rd and 4th degree perineal ruptures during delivery]. Ceska Gynekol 2005, 70:30-36.
• [27]Groutz A, Hasson J, Wengier A, Gold R, Skornick-Rapaport A, Lessing JB, Gordon D: Third- and fourth-degree perineal tears: prevalence and risk factors in the third millennium. Am J Obstet Gynecol 2010, 204(347):e341-344.
• [28]Rognant S, Benoist G, Creveuil C, Dreyfus M: Obstetrical situations with a high risk of anal sphincter laceration in vacuum-assisted deliveries. Acta Obstet Gynecol Scand 2012, 91:862-868.
• [29]Landy HJ, Laughon SK, Bailit JL, Kominiarek MA, Gonzalez-Quintero VH, Ramirez M, Haberman S, Hibbard J, Wilkins I, Branch DW: Characteristics associated with severe perineal and cervical lacerations during vaginal delivery. Obstet Gynecol 2011, 117:627-635.
• [30]Shorten A, Donsante J, Shorten B: Birth position, accoucheur, and perineal outcomes: informing women about choices for vaginal birth. Birth 2002, 29:18-27.
• [31]Andrews V, Sultan AH, Thakar R, Jones PW: Risk factors for obstetric anal sphincter injury: a prospective study. Birth 2006, 33:117-122.
• [32]Carroli G, Belizan J: Episiotomy for vaginal birth. Cochrane Database Syst Rev 2012, Issue 1 Art No:CD000081. (accessed 20th June 2012)
• [33]Murphy DJ, Macleod M, Bahl R, Goyder K, Howarth L, Strachan B: A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study. BJOG 2008, 115:1695-1702.
• [34]Dahlen HG, Ryan M, Homer CS, Cooke M: An Australian prospective cohort study of risk factors for severe perineal trauma during childbirth. Midwifery 2007, 23:196-203.
• [35]Wheeler J, Davis D, Fry M, Brodie P, Homer CS: Is Asian ethnicity an independent risk factor for severe perineal trauma in childbirth? A systematic review of the literature. Women Birth 2011, 25:107-113.
• [36]Dahlen H, Homer C: Perineal trauma and postpartum perineal morbidity in Asian and non-Asian primiparous women giving birth in Australia. J Obstet Gynecol Neonatal Nurs 2008, 37:455-463.
• [37]Meyvis I, Van Rompaey B, Goormans K, Truijen S, Lambers S, Mestdagh E, Mistiaen W: Maternal position and other variables: effects on perineal outcomes in 557 births. Birth 2012, 39:115-120.
• [38]Peduzzi P, Concato J, Kemper E, Holford TR, Feinstein AR: A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol 1996, 49:1373-1379.
• [39]Royal College of Obstetricians and Gynaecologists: The management of third and fourth degree perineal tears. Green Top Guideline 2007., no 29[http://www.rcog.org.uk/files/rcog-corp/GTG2911022011.pdf webcite] (accessed 20th June 2012)
• [40]Anim-Somuah M, Smyth R, Jones L: Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev Issue 4 Art No:CD000331. (Accessed 20th June 2012)
• [41]Bick DE, Ismail KM, Macdonald S, Thomas P, Tohill S, Kettle C: How good are we at implementing evidence to support the management of birth related perineal trauma? A UK wide survey of midwifery practice. BMC Pregnancy Childbirth 2012, 12:57. BioMed Central Full Text
• [42]Sultan AH, Kamm MA: Obstetric perineal trauma: An audit of training. J Obstet Gynaecol 1995, 15:19-23.
• [43]Elharmeel SM, Chaudhary Y, Tan S, Scheermeyer E, Hanafy A, van Driel ML: Surgical repair of spontaneous perineal tears that occur during childbirth versus no intervention. Cochrane Database Syst Rev 2011, Issue 8 Art No:CD008534. (accessed 20th June 2012)
• [44]Hodnett E, Downe S, Edwards N, Walsh D: Alternative versus conventional institutional settings for birth. Cochrane Database Syst Rev 2010, Issue 9 Art No:CD000012. (accessed 20th June 2012)
• [45]Brocklehurst P, Hardy P, Hollowell J, Linsell L, Macfarlane A, Mccourt C, Marlow N, Miller A, Newburn M, Petrou S, Puddicombe D, Redshaw M, Rowe R, Sandall J, Silverton L, Stewart M: Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ 2011, 343:d7400.
• [46]Laws PJ, Tracy SK, Sullivan EA: Perinatal outcomes of women intending to give birth in birth centers in Australia. Birth 2010, 37:28-36.
• [47]Hatem M, Sandall J, Devane D, Soltani H, Gates S: Midwife-led versus other models of care for childbearing women. Cochrane Database Syst Rev 2008, Issue 4 Art No:CD004667. (accessed 20th June 2012)
• [48]Hodnett E, Gates S, Hofmeyr G, Sakala C: Continuous support for women during childbirth. Cochrane Database Syst Rev 2011, Issue 3 Art No:CD003766. (accessed 20th June 2012)
• [49]National Institute for Health and Clinical Excellence: Intrapartum care of healthy women and babies during childbirth. 2007. [http://www.nice.org.uk/nicemedia/pdf/IPCNICEGuidance.pdf webcite] (accessed 20th June 2012)
• [50]Gupta JK, Hofmeyr GJ, Shehmar M: Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev 2012, Issue 5 Art No:CD002006. (accessed 20th June 2012)
• [51]Altman D, Ragnar I, Ekstrom A, Tyden T, Olsson SE: Anal sphincter lacerations and upright delivery postures-a risk analysis from a randomized controlled trial. Int Urogynecol J Pelvic Floor Dysfunct 2007, 18:141-146.
• [52]Thies-Lagergren L, Kvist LJ, Christensson K, Hildingsson I: No reduction in instrumental vaginal births and no increased risk for adverse perineal outcome in nulliparous women giving birth on a birth seat: results of a Swedish randomized controlled trial. BMC Pregnancy Childbirth 2011, 11:22. BioMed Central Full Text
• [53]Albers LL, Sedler KD, Bedrick EJ, Teaf D, Peralta P: Factors related to genital tract trauma in normal spontaneous vaginal births. Birth 2006, 33:94-100.
• [54]Prins M, Boxem J, Lucas C, Hutton E: Effect of spontaneous pushing versus Valsalva pushing in the second stage of labour on mother and fetus: a systematic review of randomised trials. BJOG 2011, 118:662-670.
• [55]Aasheim V, Nilsen AB, Lukasse M, Reinar LM: Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 2011, Issue 12 Art No:CD006672. (accessed 1st March 2013)
• [56]Andrews V, Sultan AH, Thakar R, Jones PW: Occult anal sphincter injuries-myth or reality. BJOG 2006, 113:195-200.