Prevention of obstetric anal sphincter injuries with perineal support and lateral episiotomy: A historical cohort study

• Published in: Acta obstetricia et gynecologica Scandinavica 2024-03, Vol.103 (3), p.488-497
• Main Authors: Eggebø, Torbjørn M., Rygh, Astrid Betten, Brandis, Phillip, Skjeldestad, Finn Egil
• Format: Article
• Language: English
• Subjects: Anal Canal - injuries; Anus; Birth; Cesarean Section - adverse effects; Childbirth & labor; Cohort analysis; Cohort Studies; delivery mode; Delivery, Obstetric - methods; Episiotomy; Episiotomy - adverse effects; Female; fetal position; Health risks; Humans; Injuries; Lacerations - complications; OASIS; Obstetric Labor Complications - etiology; Obstetric Labor Complications - prevention & control; Obstetrics; Original; parity; Perineum - injuries; Pregnancy; Retrospective Studies; Risk Factors; Vagina
• ISSN: 0001-6349; 1600-0412; 1600-0412
• DOI: 10.1111/aogs.14742

Introduction There are many risk factors for obstetric anal sphincter injury (OASIS) and the interaction between these risk factors is complex and understudied. The many observational studies that have shown a reduction of OASIS rates after implementation of perineal support have short follow‐up time. We aimed to study the effect of integration of active perineal support and lateral episiotomy on OASIS rates over a 15‐year period and to study interactions between risk factors known before delivery. Material and methods We performed a historical cohort study over the periods 1999–2006 and 2007–2021 at Stavanger University Hospital, Norway. The main outcome was OASIS rates. Women without a previous cesarean section and a live singleton fetus in cephalic presentation at term were eligible. The department implemented in 2007 the Finnish concept of active perineal protection, which includes support of perineum, control of fetal expulsion, good communication with the mother and observation of perineal stretching. The practice of mediolateral episiotomy was replaced with lateral episiotomy when indicated. We analyzed the OASIS rates in groups with and without episiotomy stratified for delivery mode, fetal position at delivery and for parity, and adjusted for possible confounders (maternal age, gestational age, oxytocin augmentation and epidural analgesia). Results We observed a long‐lasting reduction in OASIS rates from 4.9% to 1.9% and an increase in episiotomy rates from 14.4% to 21.8%. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with instrumental vaginal deliveries and occiput anterior (OA) position; 3.4% vs 10.1% (OR 0.31; 95% CI: 0.24–0.40) and 6.1 vs 13.9% (OR 0.40; 95% CI: 0.19–0.82) in women with occiput posterior (OP) position. Lateral episiotomy was also associated with lower OASIS rates in nulliparous women with spontaneous deliveries and OA position; 2.1% vs 3.2% (OR 0.62; 95% CI: 0.49–0.80). The possible confounders had little confounding effects on the risk of OASIS in groups with and without episiotomy. Conclusions We observed a long‐lasting reduction in OASIS rates after implementation of preventive procedures. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with an instrumental delivery. Special attention should be paid to deliveries with persistent OP position. Obstetric anal sphincter injuries rates during the study period differentiated in accordance with the Robson ten‐group clas