Objective
The assessment of risk factors, including mediolateral episiotomy (MLE), for the recurrence of obstetric anal sphincter injury (rOASI).
Design
Population‐based cohort study.
Setting
Data ...from the nationwide database of the Dutch Perinatal Registry (Perined).
Population
A cohort of 391 026 women at term, of whom 9943 had an OASI in their first delivery and had a second vaginal delivery of a liveborn infant in cephalic position.
Methods
Possible risk factors were tested for statistical significance using univariate and multivariate logistic regression analysis.
Main outcome measures
Rate of rOASI.
Results
The rate of rOASI was 5.8%. Multivariate analysis identified a birthweight of ≥4000 g (adjusted OR, aOR, 2.1, 95% CI 1.6–2.6) and a duration of second stage of ≥30 minutes (aOR 1.8, 95% CI 1.4–2.3) as statistically significant risk factors for rOASI. Mediolateral episiotomy was associated with a statistically significant lower rate of rOASI in spontaneous vaginal delivery (SVD) (aOR 0.4, 95% CI 0.3–0.5) and in operative vaginal delivery (OVD) (aOR 0.2, 95% CI 0.1–0.5).
Conclusions
Women with a history of OASI have a higher rate of OASI in their next delivery. Duration of the second stage of ≥30 minutes and a birthweight of ≥4000 g are significantly associated with an increased rate of rOASI. Mediolateral episiotomy is associated with a significantly lower rate of rOASI in both SVD and OVD.
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Mediolateral episiotomy is associated with a significant lower recurrence rate of OASI in women with an OASI in their first delivery.
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Mediolateral episiotomy is associated with a significant lower recurrence rate of OASI in women with an OASI in their first delivery.
Objective
To assess the costs of labour induction with oral misoprostol versus Foley catheter.
Design
Economic evaluation alongside a randomised controlled trial.
Setting
Obstetric departments of six ...tertiary and 23 secondary care hospitals in the Netherlands.
Population
Women with a viable term singleton pregnancy in cephalic presentation, intact membranes, an unfavourable cervix (Bishop score <6) without a previous caesarean section, were randomised for labour induction with oral misoprostol (n = 924) or Foley catheter (n = 921).
Methods
We performed economic analysis from a hospital perspective. We estimated direct medical costs associated with healthcare utilisation from randomisation until discharge. The robustness of our findings was evaluated in sensitivity analyses.
Main outcome measures
Mean costs and differences were calculated per women induced with oral misoprostol or Foley catheter.
Results
Mean costs per woman in the oral misoprostol group and Foley catheter group were €4470 versus €4158, respectively mean difference €312, 95% confidence interval (CI) –€508 to €1063. Multiple sensitivity analyses did not change these conclusions. However, if cervical ripening for low‐risk pregnancies in the Foley catheter group was carried out in an outpatient setting, with admittance to labour ward only at start of active labour, the difference would be €4470 versus €3489, respectively (mean difference €981, 95% CI €225–1817).
Conclusions
Oral misoprostol and Foley catheter generate comparable costs. Cervical ripening outside labour ward with a Foley catheter could potentially save almost €1000 per woman.
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Oral misoprostol or Foley catheter for induction of labour generates comparable costs.
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Oral misoprostol or Foley catheter for induction of labour generates comparable costs.
Objective
To assess whether the current condition‐specific sexual function questionnaire provides full insight into sexual function following pelvic floor surgery.
Design
Prospective, mixed ...quantitative and qualitative study.
Setting
Urogynaecology clinic in a large university hospital.
Population
Thirty‐seven women undergoing surgery for pelvic organ prolapse (POP) and/or stress urinary incontinence (SUI).
Methods
Women were seen before surgery and 3 months postoperatively. At both visits the Pelvic Organ Prolapse/Urinary Incontinence Sexual Function Questionnaire (PISQ) was completed and a qualitative face‐to‐face semi‐structured interview was conducted. PISQ total and domain scores, as well as the change in the preoperative and postoperative score, were calculated and analysed using Wilcoxon signed rank test and one‐sample t‐test. The qualitative data were systematically analysed using data‐matrices.
Main outcome measures
The impact of pelvic floor surgery on female sexual function.
Results
Significant improvement was seen for PISQ total score (P = 0.003) as well as Physical (P < 0.001) and Partner‐related (P = 0.002) domains, but not for the Behavioural/Emotive domain (P = 0.220). Analysis of qualitative data showed that improvement in sexual function was a result of cure of POP and SUI symptoms. Deterioration of sexual function was due to dyspareunia, fear of causing damage to the surgical result, new symptoms and a disappointing result of surgery.
Conclusions
Our qualitative data show that PISQ is limited in the assessment of sexual function after pelvic floor surgery as it does not assess most surgery‐specific negative effects on sexual function.
Objective To determine the risk factors for anal sphincter injuries during operative vaginal delivery.
Setting and design A population‐based observational study.
Population All 21 254 women ...delivered with vacuum extraction and 7478 women delivered with forceps, derived from the previously validated Dutch National Obstetric Database from the years 1994 to 1995.
Methods Anal sphincter injury was defined as any injury, partial or complete, of the anal sphincters. Risk factors were determined with multivariate logistic regression analysis.
Main outcome measures Individual obstetric factors, e.g. fetal birthweights, duration of second stage, etc.
Results Anal sphincter injury occurred in 3.0% of vacuum extractions and in 4.7% of forceps deliveries. Primiparity, occipitoposterior position and fetal birthweight were associated with an increased risk for anal sphincter injury in both types of operative vaginal delivery, whereas duration of second stage was associated with an increased risk only in vacuum extractions. Mediolateral episiotomy protected significantly for anal sphincter damage in both vacuum extraction (OR 0.11, 95% CI 0.09–0.13) and forceps delivery (OR 0.08, 95% CI 0.07–0.11). The number of mediolateral episiotomies needed to prevent one sphincter injury in vacuum extractions was 12, whereas 5 mediolateral episiotomies could prevent one sphincter injury in forceps deliveries.
Conclusions Primiparity and occipitoposterior presentation are strong risk factors for the occurrence of anal sphincter injury during operative vaginal delivery. The highly significant protective effect of mediolateral episiotomies in both types of operative vaginal delivery warrants the conclusions that this type of episiotomy should be used routinely during these interventions to protect the anal sphincters.
Please cite this paper as: Kalis V, Laine K, de Leeuw J, Ismail K, Tincello D. Classification of episiotomy: towards a standardisation of terminology. BJOG 2012;119:522–526.
Seven episiotomy ...incisions are described in the literature, although only midline, mediolateral or lateral episiotomies are commonly used. Recent research has demonstrated variations in both site and direction of the incision, and differences between the angle of incision at the time of crowning of the fetal head and the angle of the scar once the wound has been repaired. We review this evidence and suggest that this variation may undermine the reliability of much published work. We suggest a standardised definition of each type of episiotomy to establish uniformity going forward, so that future studies are amenable to comparison and meta‐analysis.
The present paper is the result of a workshop sponsored by the DFG Research Center/Cluster of Excellence MARUM "The Ocean in the Earth System", the International Graduate College EUROPROX, and the ...Alfred Wegener Institute for Polar and Marine Research. The workshop brought together specialists on organic matter degradation and on proxy-based environmental reconstruction. The paper deals with the main theme of the workshop, understanding the impact of selective degradation/preservation of organic matter (OM) in marine sediments on the interpretation of the fossil record. Special attention is paid to (A) the influence of the molecular composition of OM in relation to the biological and physical depositional environment, including new methods for determining complex organic biomolecules, (B) the impact of selective OM preservation on the interpretation of proxies for marine palaeoceanographic and palaeoclimatic reconstruction, and (C) past marine productivity and selective preservation in sediments. It appears that most of the factors influencing OM preservation have been identified, but many of the mechanisms by which they operate are partly, or even fragmentarily, understood. Some factors have not even been taken carefully into consideration. This incomplete understanding of OM breakdown hampers proper assessment of the present and past carbon cycle as well as the interpretation of OM based proxies and proxies affected by OM breakdown. To arrive at better proxy-based reconstructions "deformation functions" are needed, taking into account the transport and diagenesis-related molecular and atomic modifications following proxy formation. Some emerging proxies for OM degradation may shed light on such deformation functions. The use of palynomorph concentrations and selective changes in assemblage composition as models for production and preservation of OM may correct for bias due to selective degradation. Such quantitative assessment of OM degradation may lead to more accurate reconstruction of past productivity and bottom water oxygenation. Given the cost and effort associated with programs to recover sediment cores for paleoclimatological studies, as well as with generating proxy records, it would seem wise to develop a detailed sedimentological and diagenetic context for interpretation of these records. With respect to the latter, parallel acquisition of data that inform on the fidelity of the proxy signatures and reveal potential diagenetic biases would be of clear value.
Objective To determine the long‐term effects of obstetric anal sphincter rupture on the frequency of faecal incontinence and sexual complaints.
Design Retrospective case–control study.
Setting ...Department of Gynaecology and Obstetrics, Ikazia Hospital, The Netherlands.
Population All 171 women operated for anal sphincter rupture between 1971 and 1990 and 171 controls matched for parity and date of delivery.
Methods Postal questionnaires regarding faecal incontinence were sent in 1996 and 2005 to all cases and controls with questions regarding sexual complaints added to the questionnaire in 2005.
Main outcome measures Anorectal complaints defined as any form of faecal incontinence including faecal urgency and faecal soiling. Sexual complaints defined as dyspareunia or faecal incontinence during intercourse.
Results Sixty‐one percent of the women responded to both questionnaires. Anorectal complaints were reported by 38% of case versus 16% of controls in 1996 (risk difference: 0.22, 95% CI 0.10–0.34) and by 61% of cases versus 22% of controls in 2005 (risk difference: 0.41, 95% CI 0.29–0.53). In contrast to the control group, the increase of anorectal complaints in the case group between 1996 and 2005 was highly significant (P < 0.0001). Postmenopausal state was not associated with an increased risk for faecal incontinence. Dyspareunia was reported by 29% of cases versus 13% of controls (P = 0.01). Faecal incontinence during intercourse was reported by 13% of cases versus 1% of controls (P = 0.005).
Conclusions Obstetric anal sphincter rupture is an important risk factor for sexual complaints and for faecal incontinence increasing with age irrespective of menopausal state.
Please cite this paper as: Withagen M, Milani A, de Leeuw J, Vierhout M. Development of de novo prolapse in untreated vaginal compartments after prolapse repair with and without mesh: a secondary ...analysis of a randomised controlled trial. BJOG 2012;119:354–360.
Objective To compare the de novo prolapse rate in the untreated vaginal compartments following conventional vaginal prolapse repair and tension‐free vaginal mesh repair.
Design Secondary analysis of a randomised controlled trial.
Setting Thirteen centres in the Netherlands.
Population Women with recurrent pelvic organ prolapse stage II or higher.
Methods Random assignment to either conventional vaginal native tissue repair or vaginal mesh insertion.
Main outcome measures Primary outcome: de novo pelvic organ prolapse stage II or higher in the untreated vaginal compartments at 12 months after surgery. Secondary outcomes: de novo pelvic organ prolapse at and beyond the hymen, de novo prolapse beyond the hymen and prolapse domain scores of the Urogenital Distress Inventory.
Results At 12 months ten of 59 women (17%) in the conventional group versus 29 of 62 women (47%) in the mesh group were diagnosed with a de novo pelvic organ prolapse stage II or higher in the untreated compartment (P < 0.001, odds ratio 4.3, 95% confidence interval 1.9–10.0). Additional apical support to a mesh‐augmented anterior repair significantly reduced the de novo prolapse rate. Women with a de novo prolapse in the mesh‐treated group demonstrated significantly higher mean bother scores on the domain genital prolapse of the Urogenital Distress Inventory score (13.1 ± 24.2) compared with those without de novo prolapse (2.9 ± 13.9) (P = 0.03).
Conclusion Mesh‐augmented prolapse repair in only one vaginal compartment is associated with a higher de novo prolapse rate in the untreated compartments compared with conventional vaginal native tissue repair in women with recurrent pelvic organ prolapse.
Molecularly-uncharacterized organic matter comprises most reduced carbon in soils, sediments and natural waters. The origins, reactions and fates of these ubiquitous materials are relatively obscure, ...in large part because the rich vein of geochemical information that typically derives from detailed structural and stereochemical analysis is yet to be tapped. This discussion highlights current knowledge about the origins and characteristics of molecularly uncharacterized organic matter in the environment and outlines possible means by which this structurally uncharted frontier might best be explored.
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