IMPLEMENTATION OF A PERINEAL SUPPORTPROGRAM FOR REDUCTION OF OASIS: FIRST RESULTS AND PITFALLS
J. W. DE LEEUW1, N.KALJOUW 2, L. DE MEUTTER 1, H. BREMER 2,H. VAN DONGEN 2, A. L. MILANI 2;
1Obstetricsand Gynaecology, Ikazia Hosp., Rotterdam, Netherlands, 2Obstetricsand Gynaecology, Reinier de Graaf Groep, locatie Delft, Delft,Netherlands.
Introduction: Obstetric analsphincter injuries (OASIs) are the most extensive type of perinealtrauma that women may sustain during childbirth. It may have alifelong negative impact on the quality of life with complaints ofanal incontinence and dyspareunia. In the last two decades in manycountries the incidence of OASIs has risen significantly. In Norwayin 2004, by demand of its national health authorities, a nationwideprogram was initiated to reduce the rate of OASIs, which consequentlylead to a rapid reduction.1 In recent years similarprevention programs started in more hospitals in Europe. In thesehospitals a reduction in OASIs rate was seen, although the extent ofthe reduction varied considerably.2,3
Objective:To assess the impact of a perineal support program, inspired by theNorwegian intervention, on the OASIs rate in two large teachinghospitals, and to describe its potential setbacks andpitfalls.
Methods: An expert midwife from Norway visitedboth hospitals and trained all clinical midwives and obstetricians inperineal support according to the Norwegian program, both on trainingmodels as well as in women in labour, as described by Laine et al.1Training was both on technique of perineal support and on theoreticalbackground. Three midwives in each hospital received additionaltraining to serve as expert midwife-teachers to ensure continuationof training of colleagues (old and new) after the initial trainingperiod. Demographic and obstetric data were prospectively recordedusing the Dutch Perinatal Registry (Perined). Additional data werecollected on the grade of perineal trauma and on the indication ofepisiotomy, if used. For this study, data were collected from twoconsecutive periods of seven months after introduction of the programto assess a possible effect of habituation to the new technique inperiod 1 and to assess whether a possible beneficial effect lastedafter the first period of introduction in period 2. The yearpreceding the training program served as control period.
Results:Outcomes of OASIs rates in both hospitals were combined and numbersfollowing various modes of delivery are listed in the table. Thebaseline risk for the occurrence of OASIs in both spontaneous andventouse deliveries was relatively low compared to rates from othercountries.1-3 As expected, the OASIs rate in ventousedeliveries was almost twice as high as in spontaneous deliveries.After introduction of the program, the overall OASIs rate decreasedsignificantly in the first period of seven months. In the secondperiod after introduction the OASIs rate increased again to a levelof non-significant reduction in comparison with baseline. Thereduction of the OASIs rate in the (second) period after introductionwas only significant in women who delivered spontaneously. In thegroup of women who were delivered by ventouse the OASIs rate droppedwith almost 50%, but due to small numbers this didn’t reachsignificance. In the second period after introduction the OASIs rateincreased again in both groups. Although less pronounced, thereduction was still significant in those women who deliveredspontaneously.
Conclusions: A perineal support programdecreases OASIs rate in women delivering spontaneously, althoughcontinuous attention and training seems necessary to prevent afallback. More intense and persistent training is necessary toachieve a reduction of OASIS in women who are delivered byventouse.
References: 1. Laine K, Skjeldestad FE, SandvikL, Staff AC. Incidence of obstetric anal sphincter injuries aftertraining to protect the perineum: cohort study. BMJ Open. 2012 Oct17;2(5). pii: e001649. doi: 10.1136/bmjopen-2012-001649. 2.Leenskjold S, Høj L, Pirhonen J. Manual protection of the perineumreduces the risk of obstetric anal sphincter ruptures. Dan Med J.2015 May;62(5). pii: A5075. 3. Naidu M, Sultan AH, Thakar R. Reducingobstetric anal sphincter injuries using perineal support: ourpreliminary experience. Int Urogynecol J. 2016 Oct 19. [Epub ahead ofprint].
Numbers are listed as n (%), * p <0.01, ‡ p < 0.05, † NS