Importance of Individual Elements for Perineal Protection in Childbirth: An Interventional, Prospective Trial

Abstract

Objective To analyze the association between each element of a hands-on intervention in childbirth and the incidence of obstetric anal sphincter injuries (OASIS).

Study Design We conducted a prospective, interventional quality improvement project and implemented a care bundle with five elements at an obstetric department in Denmark with 3,000 deliveries annually. We aimed at reducing the incidence of OASIS. In the preintervention period, 355 vaginally delivering nulliparous women were included. Similarly, 1,622 nulliparous women were included in the intervention period. The association of each element with the outcome was estimated using a regression analysis.

Results The incidence of OASIS went down from 7.0 to 3.4% among nulliparous women delivering vaginally (p = 0.003; relative risk = 0.48; 95% confidence interval [CI]: 0.30–0.76). Number needed to treat was 28. Logistic regression analysis showed that using hand on the head of the child significantly reduced the risk of OASIS (odds ratio = 0.28; 95% CI: 0.14–0.58).

Conclusion Using a quality improvement framework, we documented the individual elements of the intervention. Hand on the infant's head reduced the risk of OASIS.

Keywords

vaginal delivery - obstetric anal sphincter injury - hands-on - quality improvement

• References

• 1 Turner CE, Young JM, Solomon MJ, Ludlow J, Benness C, Phipps H. Vaginal delivery compared with elective caesarean section: the views of pregnant women and clinicians. BJOG 2008; 115 (12) 1494-1502
• 2 Desseauve D, Proust S, Carlier-Guerin C, Rutten C, Pierre F, Fritel X. Evaluation of long-term pelvic floor symptoms after an obstetric anal sphincter injury (OASI) at least one year after delivery: a retrospective cohort study of 159 cases. Gynecol Obstet Fertil 2016; 44 (7-8): 385-390
• 3 Halle TK, Salvesen KÅ, Volløyhaug I. Obstetric anal sphincter injury and incontinence 15-23 years after vaginal delivery. Acta Obstet Gynecol Scand 2016; 95 (08) 941-947
• 4 Meister MRL, Cahill AG, Conner SN, Woolfolk CL, Lowder JL. Predicting obstetric anal sphincter injuries in a modern obstetric population. Am J Obstet Gynecol 2016; 215 (03) 310.e1-310.e7
• 5 Ramm O, Woo VG, Hung Y-Y, Chen H-C, Ritterman Weintraub ML. Risk factors for the development of obstetric anal sphincter injuries in modern obstetric practice. Obstet Gynecol 2018; 131 (02) 290-296
• 6 Thiagamoorthy G, Johnson A, Thakar R, Sultan AH. National survey of perineal trauma and its subsequent management in the United Kingdom. Int Urogynecol J Pelvic Floor Dysfunct 2014; 25 (12) 1621-1627
• 7 Laine K, Skjeldestad FE, Sandvik L, Staff AC. Incidence of obstetric anal sphincter injuries after training to protect the perineum: cohort study. BMJ Open 2012; 2 (05) e001649
• 8 Laine K, Pirhonen T, Rolland R, Pirhonen J. Decreasing the incidence of anal sphincter tears during delivery. Obstet Gynecol 2008; 111 (05) 1053-1057
• 9 Hals E, Øian P, Pirhonen T. , et al. A multicenter interventional program to reduce the incidence of anal sphincter tears. Obstet Gynecol 2010; 116 (04) 901-908
• 10 Leenskjold S, Høj L, Pirhonen J. Manual protection of the perineum reduces the risk of obstetric anal sphincter ruptures. Dan Med J 2015; 62 (05) A5075
• 11 Basu M, Smith D, Edwards R. ; STOMP project team. Can the incidence of obstetric anal sphincter injury be reduced? The STOMP experience. Eur J Obstet Gynecol Reprod Biol 2016; 202: 55-59
• 12 Bulchandani S, Watts E, Sucharitha A, Yates D, Ismail KM. Manual perineal support at the time of childbirth: a systematic review and meta-analysis. BJOG 2015; 122 (09) 1157-1165
• 13 Aasheim V, Nilsen ABV, Reinar LM, Lukasse M. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev 2017; 6: CD006672
• 14 McCandlish R, Bowler U, van Asten H. , et al. A randomised controlled trial of care of the perineum during second stage of normal labour. Br J Obstet Gynaecol 1998; 105 (12) 1262-1272
• 15 Mayerhofer K, Bodner-Adler B, Bodner K. , et al. Traditional care of the perineum during birth. A prospective, randomized, multicenter study of 1,076 women. J Reprod Med 2002; 47 (06) 477-482
• 16 Foroughipour A, Firuzeh F, Ghahiri A, Norbakhsh V, Heidari T. The effect of perineal control with hands-on and hand-poised methods on perineal trauma and delivery outcome. J Res Med Sci 2011; 16 (08) 1040-1046
• 17 Rezaei R, Saatsaz S, Chan YH, Nia HS. A comparison of the “hands-off” and “hands-on” methods to reduce perineal lacerations: a randomised clinical trial. J Obstet Gynaecol India 2014; 64 (06) 425-429
• 18 Rasmussen OB, Yding A, Anhøj J, Sander Andersen C, Boris J. Reducing the incidence of Obstetric Sphincter Injuries using a hands-on technique: an interventional quality improvement project. BMJ Qual Improv Rep 2016; 5 (01) 217936
• 19 Sultan AH. Obstetric perineal injury and anal incontinence. Clin Risk 1999; 5: 193-196
• 20 Murray D. What should we do when traditional research fails?. Anaesthesia 2017; 72 (09) 1059-1063
• 21 Albers LL, Sedler KD, Bedrick EJ, Teaf D, Peralta P. Factors related to genital tract trauma in normal spontaneous vaginal births. Birth 2006; 33 (02) 94-100
• 22 Poots AJ, Reed JE, Woodcock T, Bell D, Goldmann D. How to attribute causality in quality improvement: lessons from epidemiology. BMJ Qual Saf 2017; 26 (11) 933-937
• 23 Andrews V, Sultan AH, Thakar R, Jones PW. Risk factors for obstetric anal sphincter injury: a prospective study. Birth 2006; 33 (02) 117-122
• 24 Frieden TR. Evidence for health decision making - beyond randomized, controlled trials. N Engl J Med 2017; 377 (05) 465-475
• 25 Boutron I, Altman DG, Moher D, Schulz KF, Ravaud P. ; CONSORT NPT Group. CONSORT statement for randomized trials of nonpharmacologic treatments: a 2017 update and a CONSORT extension for nonpharmacologic trial abstracts. Ann Intern Med 2017; 167 (01) 40-47