REVIEW OF CLINICAL PRACTICE AFTERINTRODUCTION OF RISK REDUCING STRATEGIES TO PREVENT OASIS
N. BOYD, L. TOMLINSON;
Department of Obstetrics and Gynaecology, Middlemore Hosp.,Auckland, New Zealand.
Introduction: Obstetric analsphincter injury (OASIS) rates with vaginal delivery in our unit were4.9% for the standard primiparous patient without episiotomy in 2014and 2.2% with an episiotomy, both higher than the national averagefor that year. Overall OASIS rates for all vaginal births in our unithave remained static at between 2.1-3.0% since 2007, and in 2014occurred in 2.5% of all vaginal deliveries. Implementation oftraining programmes to improve perineal protection in labour havebeen shown to significantly reduce OASIS rates and the most recentRCOG guideline suggests that perineal support should be promoted inorder to protect the perineum. A perineal care policy was introducedat our institution in March 2016 with the aim of reducing perinealtrauma by providing guidelines for preventative strategies withvaginal delivery.
Objective: The aim of this retrospectiveobservational study was to identify if there have been any changes inclinical practice since the introduction of a perineal care policy inour unit, and to identify if this has translated into a reduction inthe rate of OASIS.
Methods: All accoucheurs involved withvaginal deliveries for the month of July 2014 were asked to completea form for each delivery classifying the type of delivery, degree ofperineal trauma and methods used to prevent perineal trauma as wellas basic demographic information. A perineal care policy wasintroduced in March 2016 with guidelines for preventative strategieswith vaginal delivery with the aim of reducing perineal trauma. Arepeat survey of clinical practice was performed for all vaginaldeliveries for the month of August 2016. Information obtained wascross-referenced with delivery records and electronic databases toobtain missing data where available.
Results: Data wasobtained on 372/407 (91.4%) vaginal deliveries in July 2014 and308/399 (77.2%) in August 2016. There was no significant differencein the ethnicity or parity distribution before and after theintroduction of the policy. The assisted vaginal delivery andepisiotomy rates were the same in each time period. There was anoverall significant difference between the two time periods (p-value<0.0001) in the perineal cares at time of delivery (table 1) with“hands off the perineum” falling from 15.9% to 6.3% ofdeliveries, and “hands on the head and guarding the perineum”increasing from 64.8% to 77.4% of deliveries between these two timeperiods. There was no difference in the rates of reported antenatalmassage, perineal massage and use of warm packs in the second stageof labour. There was an increase in the proportion of intactperineums (32.8% to 38.7%) and reduction in second degree tears(48.9% to 44.0%) but this was found to be not significant. Thesphincter injury rate remained unchanged between the two groups witha rate of 2.2% in July 2014 and 3.9% in August 2016 (p=0.19).
Handsoff the perineum
Handson the head only
Guardingthe perineum only
Handson and guarding
Conclusions:The introduction of a perineal care policy has led to a change in theclinical practice of accoucheurs in our unit. This has not howeverled to a reduction in the rate of anal sphincter injuries between thetwo time periods studied. Given the small numbers of sphincterinjuries in these groups it is possible that ongoing data collectionmay reveal a clinically relevant reduction in injury rates with time.The OASIS rate for all deliveries in our unit for the year of 2016was 2.8% which is unchanged from previous years. It is hoped thatrates of OASIS will start to decline in keeping with the reductionnoted after perineal care training in previous studies.
References:Laine K, Skeldestad FE, Sandvik L, et al. Incidence of obstetric analsphincter injuries after training to protect the perineum: cohortstudy. BMJ Open 2012;2:e001649.doi:10.1136/bmjopen-2012-001649.
Royal College of Obstetriciansand Gynaecologists. The Management of Third- and Fourth-DegreePerineal Tears. Green-Top Guideline No.29. London (UK): RCOG; June2015