Obstetrical anal sphincter injury describes a severe injury to the perineum and perianal muscles after birth. Obstetrical anal sphincter injury occurs in approximately 4.4% of vaginal births in the ...United States; however, racial and ethnic inequities in the incidence of obstetrical anal sphincter injury have been shown in several high-income countries. Specifically, an increased risk of obstetrical anal sphincter injury in individuals who identify as Asian vs those who identify as White has been documented among residents of the United States, Australia, Canada, Western Europe, and the Scandinavian countries. The high rates of obstetrical anal sphincter injury among the Asian diaspora in these countries are higher than obstetrical anal sphincter injury rates reported among Asian populations residing in Asia. A systematic review and meta-analysis of studies in high-income, non-Asian countries was conducted to further evaluate this relationship.
MEDLINE, Ovid, Embase, EmCare, and the Cochrane databases were searched from inception to March 2023 for original research studies.
Observational studies using keywords and controlled vocabulary terms related to race, ethnicity and obstetrical anal sphincter injury. All observational studies, including cross-sectional, case-control, and cohort were included. 2 reviewers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Meta-analysis of Observational Studies in Epidemiology recommendations.
Meta-analysis was performed using RevMan (version 5.4; Cochrane Collaboration, London, United Kingdom) for dichotomous data using the random effects model and the odds ratios as effect measures with 95% confidence intervals. Subgroup analysis was performed among Asian subgroups. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal tools. Meta-regression was used to determine sources of between-study heterogeneity.
A total of 27 studies conducted in 7 countries met the inclusion criteria encompassing 2,337,803 individuals. The pooled incidence of obstetrical anal sphincter injury was higher among Asian individuals than White individuals (pooled odds ratio, 1.64; 95% confidence interval, 1.48–1.80). Subgroup analyses showed that obstetrical anal sphincter injury rates were highest among South Asians and among population-based vs hospital-based studies. Meta-regression showed that moderate heterogeneity remained even after accounting for differences in studies by types of Asian subgroups included, study year, mode of delivery included, and study setting.
Obstetrical anal sphincter injury is more frequent among Asian versus white birthing individuals in multiple high-income, non-Asian countries. Qualitative and quantitative research to elucidate underlying causal mechanisms responsible for this relationship are warranted.
Several studies have investigated the importance of maternal, fetal factors and intrapartum characteristics in predicting severe perineal lacerations. The purpose of the present systematic review is ...to accumulate current evidence and provide estimated effect sizes for the various risk factors described. We reviewed Medline, Scopus, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL and Google Scholar for published studies in the field for observational studies as well as randomized controlled trials. Two researchers independently assessed the included studies and documented outcomes. Data extraction was performed using a modified data form that was based in Cochrane`s data collection form for intervention reviews for RCTs and non-RCTs. Forty-three articles were selected for inclusion in the present systematic review. The analyzed population reached 716,031 parturient of whom 22,280 (3,1%) sustained third- and fourth-degree perineal lacerations. Several risk factors were identified. Instrumental delivery RR 3.38 (2.21, 5.18), midline episiotomy RR 2.88 (1.79, 4.65) and a persistent occiput posterior position RR 2.73 (2.08, 3.58) were associated with the higher risk of developing severe perineal lacerations. Mediolateral episiotomy did not increase, but was also not protective against perineal lacerations RR 1.55 (0.95, 2.53). Several factors contribute to the development of severe perineal lacerations. The present meta-analysis presents accumulated data that may help physicians estimate risks and provide appropriate patient counseling.
Introduction: Rates of caesarean section deliveries are increasing worldwide including India. The reasons for this increasing trend are many. Caesarean section being a major operative procedure is ...associated with various complications. Instrumental vaginal delivery has the advantage of reducing these complications associated with caesarean delivery. As of today, there is no clear consensus regarding the safest and most effective mode of intervention in second stage of labour. Aim: To compare foetal and maternal outcomes between instrumental vaginal delivery and caesarean section in second stage of labour. Materials and Methods: It was a hospital-based prospective interventional study, conducted over a period of 18 months. A total of 104 mothers with live, singleton, term foetuses in vertex presentation who required intervention in second stage of labour were included in the study. The entire study population was divided into two groups depending on the type of intervention used in second stage- instrumental vaginal delivery (n=52) and caesarean section (n=52). Maternal outcomes of Postpartum Haemorrhage (PPH), perineal lacerations, febrile illness, blood transfusion and wound infection were compared using Chi-square test. Neonatal outcomes like birth weight, need for resuscitation, Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score, neonatal jaundice, sepsis and mortality were compared using Chi-square test and t-test. Results: Females undergoing caesarean section had more atonic PPH (5.8%), need for blood transfusion (19.2%), postpartum wound infection (17.3%) and febrile illness (26.9%, p=0.010). Third and fourth degree perineal lacerations were more common in the instrumental delivery group (19.2%, p=0.001). Mean weight of babies born by caesarean section (3127 g) was higher than those by instrumental delivery (2962 g). Composite neonatal outcome was not significantly different in both groups. Conclusion: Caesarean section in second stage of labour leads to increased maternal morbidity as compared to instrumental vaginal delivery. In skilled hands, these instruments can aid in smooth delivery of a healthy baby and can avoid the risks associated with second stage caesarean section.
Perineal trauma at the time of vaginal delivery is common, and when the anal sphincter is included, these injuries can be associated with additional morbidity including incontinence, pelvic pain, and ...sexual dysfunction.
The aim of this systematic review with meta-analysis was to evaluate whether a hands-on technique during vaginal delivery results in less incidence of perineal trauma than a hands-off technique.
Electronic databases were searched from their inception until June 2018. No restrictions for language or geographic location were applied. The reference lists of identified articles were examined to identify studies not captured by electronic searches. Randomized controlled trials comparing a hands-on technique of perineal support during vaginal delivery (i.e. intervention group) with a hands-off technique (i.e. control group) were included in the meta-analysis. Hands-on was defined as involving one hand on the fetal head, applying pressure to control expulsion, with the other hand applying pressure on the maternal perineum. The primary outcome was severe perineal trauma, defined as either third- or fourth-degree lacerations. The meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of relative risk (RR) with 95% confidence interval (CI).
Five trials, including 7287 women, were analyzed. All studies included singleton gestations with cephalic presentation at term undergoing spontaneous vaginal delivery. Women randomized to the hands-on technique had similar incidence of severe perineal trauma (1.5 versus 1.3%; RR 2.00, 95% CI 0.56-7.15). There was no significant between-group difference in the incidence of intact perineum, first-, second- and fourth-degree laceration. Hands-on technique was associated with increased risk of third-degree lacerations (2.6 versus 0.7%; RR 3.41, 95% CI 1.39-8.37) and of episiotomy (13.6 versus 9.8%, RR 1.59, 95% CI 1.14-2.22) compared to the hands-off technique.
Hands-on technique during spontaneous vaginal delivery of singleton gestations results in similar incidence of several perineal traumas compared to a hands-off technique. The incidence of third-degree lacerations and of episiotomy increases with the hands-on technique. Key Message A hands-on technique during vaginal delivery results in similar incidence of severe lacerations compared to hands-off.
Perineal lacerations could lead to substantial morbidities for women. A reliable prediction model for perineal lacerations has the potential to guide the prevention. Although several prediction ...models have been developed to estimate the risk of perineal lacerations, especially third- and fourth-degree perineal lacerations, the evidence about the model quality and clinical applicability is scarce.
To systematically review and critically appraise the existing prediction models for perineal lacerations.
Seven databases (PubMed, Embase, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, SinoMed, China National Knowledge Infrastructure, and Wanfang Data) were systematically searched from inception to July 2022. Studies that developed prediction models for perineal lacerations or performed external validation of existing models were considered eligible to include in the systematic review. Two reviewers independently conducted data extraction according to the Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies. The risk of bias and the applicability of the included models were assessed with the Prediction Model Risk of Bias Assessment Tool. A narrative synthesis was performed to summarize the characteristics, risk of bias, and performance of existing models.
Of 4345 retrieved studies, 14 studies with 22 prediction models for perineal lacerations were included. The included models mainly aimed to estimate the risk of third- and fourth-degree perineal lacerations. The top five predictors used were operative vaginal birth (72.7 %), parity/previous vaginal birth (63.6 %), race/ethnicity (59.1 %), maternal age (50.0 %), and episiotomy (40.1 %). Internal and external validation was performed in 12 (54.5 %) and seven (31.8 %) models, respectively. 13 studies (92.9 %) assessed model discrimination, with the c-index ranging from 0.636 to 0.830. Seven studies (50.0 %) evaluated the model calibration using the Hosmer–Lemeshow test, Brier score, or calibration curve. The results indicated that most of the models had fairly good calibration. All the included models were at higher risk of bias mainly due to unclear or inappropriate methods for handling missing data and continuous predictors, external validation, and model performance evaluation. Six models (27.3 %) showed low concerns about applicability.
The existing models for perineal lacerations were poorly validated and evaluated, among which only two have the potential for clinical use: one for women undergoing vaginal birth after cesarean delivery, and the other one for all women undergoing vaginal birth. Future studies should focus on robust external validation of existing models and the development of novel models for second-degree perineal laceration.
CRD42022349786.
The existing models for perineal lacerations during childbirth need external validation and updating. Tools are needed for second-degree perineal laceration.
This study was designed to evaluate the modified Goetz-one-stage repair technique for reconstruction of third-degree perineal lacerations (TDPLs) in female camels. Fifteen female dromedary camels ...with TDPL were surgically reconstructed using the modified Goetz one-stage repair using the three-line closure technique. The surgical outcomes, the interval between repair and breeding, and the postoperative conception of the operated female camels were recorded and analyzed. During the 12-month postoperative follow-up period, TDPLs in 14 female camels (93.33%) healed completely by the first intention with mild inflammatory edema and infection in 2 female camels. One camel (6.67%) had a rectovaginal fistula, which was successfully repaired with suturing through the vaginal approach. Of the 15 female camels, 13 (86.67%) subsequently became pregnant through natural mating within 3 to 6 months postoperatively; however, 2 (13.33%) were barren and were referred for gynecological treatment. The modified Goetz one-stage repair technique was successful in 14 of the 15 female camels after a single surgery, with a low incidence of postoperative complications. This technique is efficient for the repair of TDPLs in female camels, with promising results for subsequent fertility.
The amount of tissue trauma within second-degree perineal tears varies widely. Therefore, subcategorization of second-degree tears and a better understanding of their occurrence and risk factors are ...needed. The aim of this study was to assess the occurrence of perineal tears when second-degree tears were subcategorized. Furthermore, we aimed to assess the association between variables related to perineal anatomy and other potential risk factors, with second-degree tear subcategories.
This prospective cohort study included 880 primiparous and multiparous women giving birth to one child vaginally. Perineal tears were categorized using the classification system recommended by the Royal College of Obstetricians and Gynaecologists. In addition, second-degree tears were subcategorized as 2A, 2B, or 2C according to the percentage of damage to the perineal body. Selected variables related to perineal anatomy were as follows: length of genital hiatus; perineal body length; and previous perineal trauma. Risk factors for second-degree tear subcategories were analyzed using a multinominal regression model.
Perineal tears occurred as follows: first-degree: 35.6% (n = 313), 2A: 16.3% (n = 143), 2B: 9.1% (n = 80), 2C: 6.6% (n = 58), and third- or fourth-degree: 1.6% (n = 14). In total, 169/880 participants underwent an episiotomy. When episiotomies were excluded, the risk for 2B, or 2C tears increased with smaller genital hiatus, larger perineal body, previous perineal trauma, primiparity, higher gestational age, instrumental vaginal delivery and fetal presentation other than occiput anterior.
The occurrence of second-degree tear subcategories was 16.3% for 2A tears, 9.1% for 2B tears, and 6.6% for 2C tears. Factors related to perineal anatomy increased the odds for experiencing a second-degree tear in a more severe subcategory.
Please cite this paper as: Hirayama F, Koyanagi A, Mori R, Zhang J, Souza J, Gülmezoglu A. Prevalence and risk factors for third‐ and fourth‐degree perineal lacerations during vaginal delivery: a ...multi‐country study. BJOG 2012;119:340–347.
Objective To investigate the prevalence and risk factors of third‐ and fourth‐degree perineal lacerations in 24, mainly developing, countries.
Design Analysis using cross‐sectional data from the WHO Global Survey on Maternal and Perinatal Health.
Setting Seven African, nine Asian and eight Latin American countries.
Population Women at admission to hospital for delivery in 373 facilities between 2004 and 2008.
Methods We estimated the country‐wise prevalence of third‐ and fourth‐degree perineal lacerations, and conducted region‐wise multivariate logistic regression analyses to identify its risk factors.
Main outcome measures Prevalence and risk factors of third‐ and fourth‐degree perineal lacerations.
Results A total of 214 599 women who underwent vaginal delivery were analysed. The prevalence of third‐ and fourth‐degree perineal lacerations ranged widely across countries from 0.1% (China, Cambodia, India) to 15.0% (Philippines) and facilities (from null to 76.3%). After the deletion of facilities reporting no third‐ or fourth‐degree perineal lacerations, and also highly outlying facilities, the range in prevalence was 0.1% (Uganda) to 1.4% (Japan). Forceps‐assisted delivery, nulliparity and high birthweight were significant risk factors in all three regions. Vacuum‐assisted delivery was also a significant risk factor in Africa and Asia.
Conclusions Misdiagnosis of third‐ and fourth‐degree perineal lacerations in developing countries may be common. Correct recognition and diagnosis may lead to timely treatment and fewer sequelae. Risk factors of third‐ and fourth‐degree perineal lacerations in developing countries were similar to those previously reported from developed countries.
A male in his early 30s was transported to the emergency room after being hit by a vehicle while inebriated and lying in the street. His general condition was stable; however, he had a perineal ...laceration that extended to the coccyx. Due to the proximity of the wound margin to the anus, we were concerned regarding the potential contamination and opted not to suture it. Therefore, we refrained from suturing the wound and kept the wound open after irrigation and debridement. Additionally, we performed a transverse colostomy. On day 4, we initiated negative pressure wound therapy for 40 days, during which sufficient wound granulation occurred. The patient was discharged, and the colostomy was closed approximately 4 months after the injury. Our case illustrates the effectiveness of negative pressure wound therapy in managing perineal lacerations.
Aims and objectives
To evaluate and quantify the best available evidence regarding risk factors for severe perineal lacerations.
Background
Many studies have evaluated the risk factors for severe ...perineal lacerations. However, the results of those studies are inconsistent, and meta‐analysis which thoroughly evaluates the risk factors for severe perineal lacerations is still lacking.
Design
Systematic review and meta‐analysis of cohort studies based on the PRISMA guideline.
Methods
PubMed, Embase, the Cochrane Library, CINAHL, ClinicalTrials.gov, CNKI, Wanfang Data, VIP and SinoMed were systematically searched for cohort studies reporting at least one risk factor for severe perineal lacerations from 1 January 2000 to 2 June 2021. Two reviewers independently conducted quality appraisal by NOS scale and extracted data. Data synthesis was conducted via RevMan 5.3 using a random‐effects or fixed‐effects model.
Results
A total of 47 studies with 7,043,218 women were included. The results showed that prior caesarean delivery (OR: 1.46, 95% CI 1.12–1.92) and pre‐pregnant underweight (OR: 1.31, 95% CI 1.22–1.41) significantly increased the risk of severe perineal lacerations. The results also demonstrated that episiotomy was protective against severe perineal lacerations in forceps delivery (OR: 0.56, 95% CI 0.42–0.74), but not spontaneous vaginal delivery (OR: 1.30, 95% CI 0.81–2.07) or vacuum delivery (OR: 0.76, 95% CI 0.45–1.28). Nulliparity, foetus in occipitoposterior or occipitotransverse position, and midline episiotomy were also independent risk factors for severe perineal lacerations.
Conclusions
Severe perineal lacerations are associated with many factors, and evidence‐based risk assessment tools are needed to guide the midwives and obstetricians to estimate women's risk of severe perineal lacerations.
Relevance to clinical practice
This systematic review and meta‐analysis identified some important risk factors for severe perineal lacerations, which provides comprehensive insights to guide the midwives to assess women's risk for severe perineal lacerations and take appropriate preventive measures to decrease the risk.
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