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International Urogynecology Journal

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01-03-2020 | Care | Original Article

Are women attending a midwifery-led birthing center at increased risk of anal sphincter injury?

Authors: Bobby D. O’Leary, Vineta Ciprike

Published in: International Urogynecology Journal | Issue 3/2020

Abstract

Introduction and hypothesis

In recent years there has been renewed interest in midwifery-led care for women, with studies reporting similar neonatal outcomes despite lower rates of intervention in midwifery-led birthing centers. Research into obstetric anal sphincter injuries (OASI) in these birthing centers is scarce. The objective of this study was to compare the rate of OASI after spontaneous vaginal delivery in nulliparous women in consultant or midwifery-led units over a ten-year period.

Methods

All spontaneous vaginal deliveries in nulliparous women from 2008 to 2017 were analyzed in a single-center retrospective study. Women who had neuraxial analgesia were excluded. The primary endpoint was OASI. Labor characteristics in both groups were compared, and a multiple regression model was created.

Results

During the study period, there were 3260 spontaneous vaginal deliveries in nulliparous women; 75.7% (2467/3260) delivered in the consultant-led unit and 24.3% (793/3260) in the midwifery-led unit (MLU). Women delivering in the MLU had a greater risk of anal sphincter injury than those delivering in the CLU (4.9% [39/793] vs 2.5% [62/2467], OR 2.01, 95% CI 1.32 – 3.01). Significant risk factors that increased the risk of OASI on regression analysis were birthweight and delivery in the midwifery-led unit.

Conclusions

Women delivering in the midwifery-led unit appear to be at double the risk of OASI when compared to those delivering in the consultant-led unit. These results are in contrast to previous studies in midwifery-led centers. This difference may be site-specific and further research is required before these results form part of patient counseling.

Sultan AH, Kamm MA, Hudson CN, et al. Anal-sphincter disruption during vaginal delivery. N Engl J Med. 1993;329:1905–11. https://doi.org/10.1056/NEJM199312233292601.CrossRefPubMed

Mahony R, Behan M, Daly L, et al. Internal anal sphincter defect influences continence outcome following obstetric anal sphincter injury. Am J Obstet Gynecol 196:217.e1–5. 2007. https://doi.org/10.1016/j.ajog.2006.09.012.

Sultan AH, Thakar R, Ismail KM, et al. The role of mediolateral episiotomy during operative vaginal delivery. Eur J Obstet Gynecol Reprod Biol. 2019;240:192–6. https://doi.org/10.1016/j.ejogrb.2019.07.005.CrossRefPubMed

Gurol-Urganci I, Cromwell D, Edozien L, et al. Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG Int J Obstet Gynaecol. 2013;120:1516–25. https://doi.org/10.1111/1471-0528.12363.CrossRef

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:e001649. https://doi.org/10.1136/bmjopen-2012-001649.CrossRefPubMedPubMedCentral

Meister MRL, Cahill AG, Conner SN, et al. Predicting obstetric anal sphincter injuries in a modern obstetric population. Am J Obstet Gynecol. 2016;215:310.e1–7. https://doi.org/10.1016/j.ajog.2016.02.041.CrossRef

Birthplace in England Collaborative Group, Brocklehurst P, Hardy P, et al. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ. 2011;343:d7400. https://doi.org/10.1136/bmj.d7400.CrossRef

Dencker A, Smith V, McCann C, Begley C. Midwife-led maternity care in Ireland – a retrospective cohort study. BMC Pregnancy Childbirth. 2017;17:. doi:https://doi.org/10.1186/s12884-017-1285-9.

Sandall J, Soltani H, Gates S, et al. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev. 2016;4:CD004667. https://doi.org/10.1002/14651858.CD004667.pub5.CrossRefPubMed

10.

Kelly P, Yong L, Langdon R, et al. A comparison of the outcomes of partnership caseload midwifery and standard hospital care in low risk mothers. Aust J Adv Nurs. 2005;22:21.PubMed

11.

Bodner-Adler B, Kimberger O, Griebaum J, et al. A ten-year study of midwife-led care at an Austrian tertiary care center: a retrospective analysis with special consideration of perineal trauma. BMC Pregnancy Childbirth. 2017;17:1–7. https://doi.org/10.1186/s12884-017-1544-9.CrossRef

12.

Preston HL, Alfirevic Z, Fowler GE, Lane S. Does water birth affect the risk of obstetric anal sphincter injury? Development of a prognostic model. Int Urogynecology J. 2019;30:909–15. https://doi.org/10.1007/s00192-019-03879-z.CrossRef

13.

Da Silva A, Thiagamoorthy G, Flint R, et al. Position, where and how? Does delivery position, place and mode of delivery affect the risk of Obstetric Anal Sphincter Injuries (OASIS). Int Urogynecology J. 29:35–6. https://doi.org/10.1007/s00192-018-3752-x.

14.

Walsh D, Downe SM. Outcomes of Free-Standing, Midwife-Led Birth Centers: A Structured Review. Birth. 2004;31:222–9. https://doi.org/10.1111/j.0730-7659.2004.00309.x.CrossRefPubMed

15.

Cheung NF, Mander R, Wang X, et al. Clinical outcomes of the first midwife-led normal birth unit in China: a retrospective cohort study. Midwifery. 2011;27:582–7. https://doi.org/10.1016/j.midw.2010.05.012.CrossRefPubMed

16.

Trochez R, Waterfield M, Freeman RM. Hands on or hands off the perineum: a survey of care of the perineum in labour (HOOPS). Int Urogynecology J. 2011;22:1279–85. https://doi.org/10.1007/s00192-011-1454-8.CrossRef

17.

Ampt AJ, de Vroome M, Ford JB. Perineal management techniques among midwives at five hospitals in New South Wales – A cross-sectional survey. Aust N Z J Obstet Gynaecol. 2015;55:251–6. https://doi.org/10.1111/ajo.12330.CrossRefPubMedPubMedCentral

18.

Lindgren HE, Brink Å, Klinberg-Allvin M. Fear causes tears - Perineal injuries in home birth settings. A Swedish interview study. BMC Pregnancy Childbirth. 2011;11:6. https://doi.org/10.1186/1471-2393-11-6.CrossRefPubMedPubMedCentral

19.

Hals E, Oian P, Pirhonen T, et al. A multicenter interventional program to reduce the incidence of anal sphincter tears. Obstet Gynecol. 2010;116:901–8. https://doi.org/10.1097/AOG.0b013e3181eda77a.CrossRefPubMed

20.

Pirhonen JP, Grenman SE, Haadem K, et al. Frequency of anal sphincter rupture at delivery in Sweden and Finland--result of difference in manual help to the baby’s head. Acta Obstet Gynecol Scand. 1998;77:974–7. https://doi.org/10.1034/j.1600-0412.1998.771005.x.CrossRefPubMed

21.

Stedenfeldt M, Øian P, Gissler M, et al. Risk factors for obstetric anal sphincter injury after a successful multicentre interventional programme. BJOG Int J Obstet Gynaecol. 2014;121:83–91. https://doi.org/10.1111/1471-0528.12274.CrossRef

22.

Bidwell P, Thakar R, Sevdalis N, et al. A multi-centre quality improvement project to reduce the incidence of obstetric anal sphincter injury (OASI): study protocol. BMC Pregnancy Childbirth. 2018; 18:. doi:https://doi.org/10.1186/s12884-018-1965-0.

23.

Forster DA, McLachlan HL, Davey M-A, et al. Continuity of care by a primary midwife (caseload midwifery) increases women’s satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial. BMC Pregnancy Childbirth. 2016;16:28. https://doi.org/10.1186/s12884-016-0798-y.CrossRefPubMedPubMedCentral

24.

Biró MA, Waldenström U, Brown S, Pannifex JH. Satisfaction with Team Midwifery Care for Low- and High-Risk Women: A Randomized Controlled Trial. Birth. 2003;30:1–10. https://doi.org/10.1046/j.1523-536X.2003.00211.x.CrossRefPubMed

25.

Naidu M, Sultan AH, Thakar R. Reducing obstetric anal sphincter injuries using perineal support: our preliminary experience. Int Urogynecology J. 2017;28:381–9. https://doi.org/10.1007/s00192-016-3176-4.CrossRef

26.

Royal College of Obstetricians and Gynaecologists. The Management of Third- and Fourth-Degree Perineal Tears, Third. London: Royal College of Obstetricians and Gynaecologists; 2015.

27.

Murphy DJ, Macleod M, Bahl R, et al. A randomised controlled trial of routine versus restrictive use of episiotomy at operative vaginal delivery: a multicentre pilot study. BJOG Int J Obstet Gynaecol. 2008;115:1695–702; discussion 1702-1703. https://doi.org/10.1111/j.1471-0528.2008.01960.x.CrossRef

28.

Lowder JL, Burrows LJ, Krohn MA, Weber AM. Risk factors for primary and subsequent anal sphincter lacerations: a comparison of cohorts by parity and prior mode of delivery. Am J Obstet Gynecol. 2007;196:344.e1–5. https://doi.org/10.1016/j.ajog.2006.10.893.CrossRef

29.

Valsky DV, Lipschuetz M, Bord A, et al. Fetal head circumference and length of second stage of labor are risk factors for levator ani muscle injury, diagnosed by 3-dimensional transperineal ultrasound in primiparous women. Am J Obstet Gynecol. 2009;201:91.e1–7. https://doi.org/10.1016/j.ajog.2009.03.028.CrossRef

30.

Caughey AB, Cahill AG, Guise J-M, Rouse DJ. Safe prevention of the primary cesarean delivery. Am J Obstet Gynecol. 2014;210:179–93. https://doi.org/10.1016/j.ajog.2014.01.026.CrossRefPubMed

31.

van Delft K, Sultan A, Thakar R, et al. The relationship between postpartum levator ani muscle avulsion and signs and symptoms of pelvic floor dysfunction. BJOG Int J Obstet Gynaecol. 2014;121:1164–72. https://doi.org/10.1111/1471-0528.12666.CrossRef

32.

Richter HE, Brumfield CG, Cliver SP, et al. Risk factors associated with anal sphincter tear: A comparison of primiparous patients, vaginal births after cesarean deliveries, and patients with previous vaginal delivery. Am J Obstet Gynecol. 2002;187:1194–8. https://doi.org/10.1067/mob.2002.126977.CrossRefPubMed

Title: Are women attending a midwifery-led birthing center at increased risk of anal sphincter injury?
Authors: Bobby D. O’Leary
Vineta Ciprike
Publication date: 01-03-2020
Publisher: Springer International Publishing
Keywords: Care
Episiotomy
Published in: International Urogynecology Journal / Issue 3/2020
Print ISSN: 0937-3462
Electronic ISSN: 1433-3023
DOI: https://doi.org/10.1007/s00192-019-04218-y

At a glance: The STEP trials

Springer Medicine

Are women attending a midwifery-led birthing center at increased risk of anal sphincter injury?

Abstract

Introduction and hypothesis

Methods

Results

Conclusions

At a glance: The STEP trials

Springer Medicine

Abstract

Introduction and hypothesis

Methods

Results

Conclusions

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