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Dr Andrew Bisits, Obstetrician, Royal Hospital for Women, Sydney delivered this presentation at the 2013 Obstetric Malpractice Conference. This is the only national conference for the prevention, management and defence of obstetric negligence claims. For more information, go to http://www.healthcareconferences.com.au/obstetric13
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obstetric malpractice conference 1
PERINEAL TRAUMA
Clinical Considerations
• Encountering post- natal morbidity can leave women feeling inadequate and distraught. This can have a devastating effect on family life, relationships and ability to return to work. (kettle et al 2001)
• As these issues are normally of a sensitive nature they can often be overlooked unless the patient is directly asked a by a trained health professional.
Outline
Objectives
Definitions
Background
Incidence
Prevention
The role of episiotomy
Management
Contentious issues
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Objective
Focus will be on the major perineal trauma meaning damage to the anal sphincter or anal sphincter and rectum
Current clinical evidence and perspective of relevance to medico legal considerations
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Definitions
First degree tear
Second degree tear
Third degree tear 3a tear < 50%
3b tear >50%
3c tear complete tear
4th degree tear – tear of sphincter and the rectum
OASIS- obstetric anal sphincter injury service
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Anatomy review…
1. http://education.yahoo.com/reference/gray/illustrations/figure?id=408 2. Anatomy: A Regional Atlas of the Human Body, 4th Edition, by Carmine Clemente, 1997 3. http://www.nva.org/vulvarAnatomy.html
Background
Increasing interest and concern in the last 20 years
Increased recognition
?Increased incidence
Increased knowledge about longer term consequences
Increasing prevalence of caesarean section
Attracts medico legal attention
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Incidence
Royal Hospital for Women
2008-2012
Data source – obstetrix
Public sector births
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Mode Birth 2008 2009 2010 2011 2012
Caesarean section 888 938 897 903 881
% 27.79 29.22 28.12 26.91 25.6
Instrumental 472 456 514 615 643
% 14.77 14.21 16.11 18.33 18.68
Spontaneous 1,835 1,816 1,779 1,838 1,918
% 57.43 56.57 55.77 54.77 55.72
Instrumental births
Vacuum births 55% to 45%
Forceps 45% to 55%
Major perineal trauma 2008-2012
2008 2009 2010 2011 2012 Total
no major pt 2,767 2,718 2,673 2,748 2,886 13,792
95.98 95.87 95.64 95.05 96.46 95.8
major pt 116 117 122 143 106 604
4.02 4.13 4.36 4.95 3.54 4.2
No significant trend
Major perineal trauma public sector
majpt 2008 2009 2010 2011 2012 Total
0 2,202 2,175 2,185 2,333 2,474 11,369
95.45 95.73 95.29 95.11 96.6 95.65
MPT 105 97 108 120 87 517
4.55 4.27 4.71 4.89 3.4 4.35
No significant trend
Grading of perineal trauma
2008 2009 2010 2011 2012 3a 24 75 77 53
66.67 64.1 55 56.38
3b 10 34 49 33 27.78 29.06 35 35.11
3c 2 8 14 8 5.56 6.84 10 8.51
4thDegree 6 3 5 4 13
Major perineal trauma spontaneous
2008 2009 2010 2011 2012
no major pt 1,771 1,752 1,722 1,772 1,865
96.51 96.48 96.8 96.41 97.24
Major perineal trauma 64 64 57 66 53
3.49 3.52 3.2 3.59 2.76 No significant trend
Major perineal trauma instrumental
majpt 2008 2009 2010 2011 2012
No major perineal trauma 431 423 463 561 609
91.31 92.76 90.08 91.22 94.71
Major perineal trauma 41 33 51 54 34
8.69 7.24 9.92 8.78 5.29
Major perineal trauma forceps
2008 2009 2010 2011 2012
No major perineal trauma 189 216 238 280 330
86.7 91.14 85.92 88.61 93.22
Major perineal trauma 29 21 39 36 24
13.3 8.86 14.08 11.39 6.78
* significant trend*
Major perineal trauma vacuum
2008 2009 2010 2011 2012
no perineal trauma 242 207 225 281 279
95.28 94.52 94.94 93.98 96.54
Major perineal trauma 12 12 12 18 10
4.72 5.48 5.06 6.02 3.46
Episiotomy
2008 2009 2010 2011 2012
no episiotomy 2,758 2,776 2,719 2,820 2,864
86.32 86.48 85.24 84.03 83.21
episiotomy 437 434 471 536 578
13.68 13.52 14.76 15.97 16.79
Risk factors
primiparity ,
instrumental birth,
baby>4kg,
long second stage
?epidural
Race – Asian
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Summary
Major perineal trauma a steady 4% of vaginal births
Most of these are 3a tears
Increased number of 4th degree tears in 2012.
Risk factors primiparity , instrumental birth, baby>4kg, long second stage
Consistent with figures from other hospitals
Can we prevent this?
Controlled birth of the head , perineal support(Laine et al
Warm compresses
Fewer instrumental births
No midline episiotomies
Properly directed episiotomy when needed
?Avoiding vertical positions for birth?
Medio-lateral episiotomies with forceps birth
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Perineal warm compresses and SPT
Albers et al. 2005; Dahlen et al. 2007 (n=1525)
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Intrapartum perineal massage and SPT
Albers et al. (2005); Stamp et al. (2001) (n=2147)
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Hands off or poised and SPT
De Costa, et al. (2006); Mayerhofer et al. (2002) McCandlish et al. (1998)(n=6547)
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Ritgen’s manoeuvre
Jonsson et al. (2008) (n=15750)
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Authors recommendations
“The use of warm compresses on the perineum is associated with a decreased occurrence of perineal trauma. The procedure has shown to be acceptable to women and midwives. This procedure may therefore be offered to women.”
26
Aasheim V, Nilsen ABV, Lukasse M, Reinar LM. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD006672. DOI: 10.1002/14651858.CD006672.pub2.
Antenatal digital perineal massage
Cochrane Database Systematic Review (Beckman & Stock, 2013). Four trials (n=2497 women)
A 9% reduction in the incidence of perineal trauma requiring suturing (NNT=15).
Less likely to have an episiotomy (16%) (NNT 21).
This was only statistically significant for primips.
Only women who had birthed vaginally before had reduced pain at three months following the birth (55%) (NNT13)
No statistically significant differences were seen in the incidence of first, second, third and fourth degree tears
Beckmann MM, Stock OM. Antenatal perineal massage for reducing perineal trauma. Cochrane Database of Systematic Reviews 2013, Issue 4. Art. No.: CD005123. DOI: 10.1002/14651858.CD005123.pub3
Antenatal perineal massage using a massaging device…
Two RCTs Ruckhaberle et al. 2009 (n=276) Episiotomy (41.1% vs 50.5%, p=0.11) Intact perineum(37.4% vs 25.7%,
p=0.05) Severe perineal trauma (5.6% vs 4.8%,
p=0.51)
Shek et al. 2011 (n=200) Examined the risk of levator trauma (6%
vs 13%, p=0.19) Episiotomy (29% vs 22%, p=0.40) Perineal tears (26% vs 36%, p=0.18) Major perineal tear (1% vs 6%, p=0.09)
Pelvic Floor Muscle Training
RCT (Salvesen & Morkved, 2004) (n=301)
Quasi Cluster RCT Leon (unpublished thesis) (n= 466)
Women randomised to the pelvic floor exercises had a lower rate of prolonged second stage of labour (greater than 60 minutes) than women allocated to no training
Fewer women had breech presentations in the pelvic floor muscle training group (1 vs 9) and episiotomies (51% vs 64%) (NNT 7).
There was no difference between the rates of operative delivery.
pelvic floor training programme that included: daily perineal massage and pelvic floor exercises from 32 weeks of pregnancy until birth.
31.63% reduction in episiotomy (50.56% vs 82.19%)
Fewer third and fourth degree-tears (4.10% vs 5.6%)
Coached vs uncoached pushing
Simpson & James 2005 (n=45) (delayed with epidural)
Perineal lacerations (13 vs 5, p=0.01)
Shaffer et al. 2005 (n=128)
No difference in perineal lacerations
Decreased bladder capacity and first urge to void
Bloom et al. (2005) (n=320)
No difference in perineal outcomes
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Immersion in water
A Cochrane Systematic review (Cluett et al. 2012) 12 trials 3243 women)
Significant reduction in use of epidural.
Less maternal pain
No significant differences in the numbers of instrumental births, episiotomies, second degree tears and severe perineal trauma, Apgar scores, infection.
Upright position / supine or lithotomy positions
Cochrane review(Gupta et a., 2012) (22 trials ) (n=7280 women)
A reduction in assisted deliveries (RR 0.78; CI 0.68-0.90)
A reduction in episiotomies (RR 0.79; CI 0.70-0.90)
An increase in second degree perineal tears (RR1.32; CI 1.20-1.52).
An increase in estimated blood loss greater than 500mLs (RR 1.65; CI 1.32-2.60)
Fewer abnormal fetal heart rate patterns (RR 0.46; CI 0.22-0.93)
Accepted standards
Controlled birth of the head
Properly directed Episiotomy if the skin is blanching as it stretches
Properly directed Episiotomy with forceps or more difficult vacuum birth
Attention to the length of second stage
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Management
Recognition Rectal examination where there is any
perineal trauma Good light 3a tear – repair birthing suite or operating
theatre 3b and above – operating theatre Consultant /senior registrar ?colorectal Techniques of repair –direct or overlap Antibiotics Follow up- physio, obstetrician , colorectal
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Longer term outcomes
The risk of faecal incontinence at 6 months PN following OASIS is 2 fold higher than with out an OASIS ( 17% vs 8.2%) (Borello 2006)
At 3 months post partum 25% will have Flatal Incontinence at 3/12 and 34.2% faecal urgency ( Marsh et al 2010)
At 4 years post OASIS:
37% will suffer some type of anal incontinence ( including flatal incontinence.)
of these women, 53% reported having to alter their life style ( Kumar 2012)
Various
Contentious Areas
The Role of episiotomy
Episiotomy in assisted vaginal births Evidence for and against
Birth position -birth stool or squatting
Epi no
Role of caesarean section-?
Role of colorectal surgeon in repair
Recurrence rates and advice
Symptoms prior to birth
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Conclusions
A very important consideration
More recognition recently
Complex interplay of factors
Long term consequences
Contentious areas
Majority of women recover
Opportunities for prevention
Standards for prevention, recognition and management
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