andrew bisits, royal hospital for women, sydney - clinical considerations: perineal trauma

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

obstetric malpractice conference 3

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

obstetric malpractice conference 4

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

obstetric malpractice conference 5

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

obstetric malpractice conference 7

Incidence

Royal Hospital for Women

2008-2012

Data source – obstetrix

Public sector births

obstetric malpractice conference 8

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

obstetric malpractice conference 19

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

obstetric malpractice conference 21

Perineal warm compresses and SPT

Albers et al. 2005; Dahlen et al. 2007 (n=1525)

22

Intrapartum perineal massage and SPT

Albers et al. (2005); Stamp et al. (2001) (n=2147)

23

Hands off or poised and SPT

De Costa, et al. (2006); Mayerhofer et al. (2002) McCandlish et al. (1998)(n=6547)

24

Ritgen’s manoeuvre

Jonsson et al. (2008) (n=15750)

25

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

30

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

obstetric malpractice conference 33

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

obstetric malpractice conference 34

obstetric malpractice conference 35

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

obstetric malpractice conference 37

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

obstetric malpractice conference 38