Obstetric Anal Sphincter InjurieS OASIS - can be reduced

Transcription

1 Obstetric Anal Sphincter InjurieS OASIS - can be reduced Katariina Laine, MD Consultant, Research fellow Department of of Obstetrics Oslo University Hospital, Ullevål Norway

2 Most important risk factor for female anal incontinence 30-60% suffer from anal incontinence Negative impact on Quality of life Diagnostics Primary repair Prevention Roos AM, Sultan AH, Thakar R. St.Mark's incontinence score for assessment of anal incontinence following obstetric anal sphincter injuries (OASIS). Int Urogynecol J Pelvic Floor Dysfunct Norderval et al. Anal incontinence after obstetric sphincter tears: Incidence in a Norwegian county. Acta Obstet Gynecol Scand 2004.

3 Oestfold Hospital Trust, Fredrikstad, Norway 3200 deliveries 22 ob-gyn doctors 60 midwives

4 Oslo University Hospital, Ullevål, Norway 7200 deliveries 55 ob-gyn doctors 140 midwives

5 OASIS in four Nordic countries 4,5 4 3,5 3 2,5 2 1,5 1 Denmark Finland Norway Sweden 0,5 0 Laine K, Gissler M, Pirhonen J. Changing incidence of anal sphincter tears in four Nordic countries through the last decades. EJOGRB

6 The Norwegian Directorate of Health Norwegian Board of Health Criticized the high OASIS rate in Norway National Plan to reduce OASIS rate: Recommended training and education in Improved delivery techniques Manual perineal protection Primary diagnosis Primary OASIS suture Required the hospitals, midwives and obstetricians to reduce the OASIS rate Ref: Sfinkterskader ved fødsel bør reduseres i Norge. Helsedirektoratet, 2006.

7 Perineal protection abandoned or forgotten? 4,5 4 3,5 3 2,5 2 1,5 1 0,5 0 OASIS in Nordic countries (%), all vaginal deliveries Trochez et al. Hands-on or hands-off the perineum: a survey of care of the perineum in labour (HOOPS). Int Urogynecol J Questionnaire to midwives about using handson or hands-off technique, 607 answered Of all midwives: 49 % preferred hands-off Midwives with <5 years experience: 72% hands-off Hands-off even in presence of OASR risk factors (primipara, macrosomia, history of OASR)

8 Manual perineal protection Not registered in perinatal databases or patient records Poor definitions Research: few publications RCT: difficult to conduct Traditions, subjective, individual decisions Standardized procedures not usual Do not forget the correct episiotomy technique = Active management of stage 2

9 Perineal protection abandoned or forgotten? Trochez et al. Hands-on or hands-off the perineum: a survey of care of the perineum in labour (HOOPS). Int Urogynecol J Questionnaire to midwives about using hands-on or hands-off technique, 607 answered Of all midwives: 49 % preferred hands-off Midwives with <5 years experience: 72% hands-off Hands-off even in presence of OASR risk factors (primipara, macrosomia, history of OASR) Similar findings with use of episiotomy Pirhonen et al. Frequency of anal sphincter rupture at delivery in Sweden and Finland - result of difference in manual help to the baby's head. AOGS Pirhonen et al. Experiences of expert midwives in a training program aimed at decreasing perineal tears. Int J of Nursing and Midwifery. 2011

10 National interventional program in Norway Norwegian Directory of Health Training programme in 5 hospitals: o Perineal protection o Including both midwives and doctors o Hands-on training o Standardization of the delivery technique 5 4,5 4 3,5 3 2,5 2 1,5 1 0,5 0 OASIS (%), all vaginal deliveries Fredrikstad, Lillehammer, Tromsø, Ålesund, Stavanger Laine K, Gissler M, Pirhonen J: Decreasing the incidence of anal sphincter tears during delivery. Obstet Gynecol Hals E, Øian P, Pirhonen T, Gissler M, Hjelle S, Nilsen EB, Severinsen AM, Solsletten C, Hartgill T, Pirhonen J: A Multicenter Interventional Program to Reduce the Incidence of Anal Sphincter Tears. Obstet Gynecol

11 Results from an interventional program Fredrikstad, Norway

12 OASIS in four Nordic countries, updated 4,5 4 3,5 3 2,5 2 1,5 1 0,5 0 OASIS (%), all vaginal deliveries Denmark Sweden Norway Finland

13 The four Nordic countries in 2010 Finland Norway Sweden Denmark OASR, % of vaginal deliveries, OASR, % of vaginal deliveries, Episiotomy, % of vaginal deliveries, Instrumental delivery, % of all deliveries Caesarean section rate, % of all deliveries Primiparous women, % of all deliveries Mean maternal age, all deliveries Macrosomia >4000g, % of all deliveries Source: Nordic medical birth registries

14 Norway: Differences in OASIS rate between hospitals p< N

15 OASIS in Oslo University Hospital, Ullevål ,6 19,8 21,2 21,8 21,5 18,1 19,4 19,6 19,3 19,3 20,3 19,7 17,5 14,6 11,9 12,7 10,5 10,9 9,7 7,4 6,6 6,6 5 5,3 5,4 4,1 4,3 4,5 3,6 3,8 3,8 3,8 3,6 3,1 3,3 3,3 2,9 2,9 3 2,8 2,9 2,6 2,4 2,1 1,8 1,9 1,9 1,6 1,6 1,4 1,4 1, Caesarean Ventouse All vaginal deliveries Spontaneous

16 OASIS in Oslo University Hospital, Ullevål Caesarean Ventouse Forceps All vaginal deliveries Spontaneous

17 Training program and hands-on technique Program: Expert midwives were trained Expert midwives teached rest of the staff (Everybody!!) Technique: Manually slowing down the delivery of the foetal head Perineal support/protection with the other hand Instructions to the delivering woman not to push Correcting the quality of episiotomy technique Laine et al: Decreasing the incidence of anal sphincter tears during delivery. Obstet Gynecol Hals et al: A Multicenter Interventional Program to Reduce the Incidence of Anal Sphincter Tears. Obstet Gynecol

18 Predicting OASIS not possible Is it possible to predict or prevent third degree tears? Byrd et al. Colorectal Dis Antenatal prediction of postpartum urinary and fecal incontinence. Chaliha et al. Obstet.Gynecol Objective methods cannot predict anal incontinence after primary repair of extensive anal tears. Goffeng et al. Acta Obstet.Gynecol.Scand Anal sphincter disruption at vaginal delivery: is recurrence predictable? Harkin et al. Eur.J.Obstet.Gynecol.Reprod.Biol Do routinely measured delivery variables predict anal sphincter outcome? Varma et al. Dis.Colon Rectum Risk scoring system for prediction of obstetric anal sphincter injury. Williams et al. BJOG. 2005

19 4 rules for active management of stage 2 1.Left hand slowing down the delivery of the head 2.Right hand protecting perineum 3.Mother NOT pushing when head is crowning (communicate, instructions!) 4.Think about EPISIOTOMY

20 K.Laine, IUGA

21 K.Laine, IUGA Delivery

22 K.Laine, IUGA Delivery

23 OASIS, Oslo versus Fredrikstad 5 OASIS (%), all vaginal deliveries 4,5 4 3,5 Oslo Fredrikstad 3 2,5 2 1,5 1 0, K.Laine, IUGA

24 Episiotomy, Oslo vs Fredrikstad 30 Episiotomy (%), all vaginal deliveries Oslo Fredrikstad K.Laine, IUGA

25 Oslo vs Fredrikstad (all vaginal deliveries) 5 4 OASR (%), all vaginal deliveries ,5 14,9 21,6 21,3 20,6 15, , , Episiotomy (%), all vaginal deliveries K.Laine, IUGA

26 Conclusion/question Hands-on delivery technique more important than episiotomy? K.Laine, IUGA

27 Discussion: Why did the OASIS rates fall in NORWAY? RCTs do not show effect on OASIS by perineal protection during 2nd stage of labour? A registration bias, underreporting? Is less OASIS rate due to too many episiotomies? Episiotomy (%), vaginal deliveries K.Laine, IUGA

28 Reduced number of women with OASIS in Norway Before 2005: Annually 2000 women with OASIS In 2011: 1000 women with OASIS During 7 years 4643 OASIS avoided Less anal incontinence? K.Laine, IUGA

29 Take home message It is possible to reduce OASR Use your hands! 4,5 4 3,5 3 2,5 2 1,5 1 0,5 0 OASIS (%), all vaginal deliveries Denmark Sweden Norway Finland Thank You Takk Dank U Kiitos