| 1. |
- Ankarcrona, Victoria, et al.
(författare)
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Attitudes and knowledge regarding episiotomy use and technique in vacuum extraction : A web-based survey among doctors in Sweden
- 2022
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Ingår i: European Journal of Obstetrics, Gynecology, and Reproductive Biology. - : Elsevier. - 0301-2115 .- 1872-7654. ; 269, s. 62-70
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Tidskriftsartikel (refereegranskat)abstract
- Objectives: Correct episiotomy use and technique may prevent obstetric anal sphincter injuries. We aimed to explore the attitudes, use, and technique regarding episiotomy among doctors in Sweden, and their willingness to contribute to a randomized controlled trial of lateral episiotomy or no episiotomy in vacuum extraction in nulliparous women.Study design: A web-based survey was sent to members of the Swedish Society of Obstetrics and Gynecology (n = 2140). The survey included 31 questions addressing personal characteristics, use of episiotomy, a two-dimensional picture on which the respondents drew an episiotomy, and questions regarding attitudes towards episiotomy and participation in a randomized controlled trial. We calculated the proportion of supposedly protective episiotomies (fulfilling criteria of a lateral or mediolateral episiotomy and a length >= 30 mm). We compared the results between obstetricians, gynecologists, and residents using Chi-square and Kruskal-Wallis tests for differences between groups, and logistic regression to estimate the odds ratio (OR) of drawing a protective episiotomy.Results: We received 432 responses. Doctors without a vacuum delivery in the past year were excluded, leaving 384 respondents for further analyses. In all, 222 (57.8%) doctors reported use of episiotomy in<50% of vacuum extractions. We obtained 308 illustrated episiotomies with a median angle of 53 degrees, incision point distance from the midline of 21 mm, and length of 36 mm, corresponding to a lateral episiotomy. Few doctors combined these parameters correctly resulting in 167 (54.2%) incorrectly drawn episiotomies. Residents drew shorter episiotomies than obstetricians and gynecologists. Doctors ranked episiotomy the least important intervention to prevent obstetric anal sphincter injuries in vacuum extraction. Doctors contributing to an ongoing randomized controlled trial of lateral episiotomy or no episiotomy in vacuum extraction were more able to draw a protective episiotomy (OR 3.69, 95% confidence interval 1.94-7.02).Conclusions: Doctors in Sweden reported restrictive use of episiotomy in vacuum extraction and depicted lateral type episiotomies, although the majority were incorrectly drawn. Preventive episiotomy was ranked of low importance. Our results imply a need for education, training, and guidelines to increase uptake of correct episiotomy technique, which could result in improved prevention of obstetric anal sphincter injuries.
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| 2. |
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| 3. |
- Ankarcrona, Victoria, et al.
(författare)
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Delivery outcome after trial of labor in nulliparous women 40 years or older-A nationwide population-based study
- 2019
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Ingår i: Acta Obstetricia et Gynecologica Scandinavica. - : WILEY. - 0001-6349 .- 1600-0412. ; 98:9, s. 1195-1203
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Tidskriftsartikel (refereegranskat)abstract
- Introduction The number of women postponing childbirth until an advanced age is increasing. Our aim was to study the outcome of labor in nulliparous women >= 40 years, compared with women 25-29 years, after both spontaneous onset and induction of labor. Material and methods The nationwide population-based Swedish Medical Birth Register was used to study the perinatal outcome in nulliparous women with a singleton, term (gestational weeks 37-44), live fetus in cephalic presentation and a planned vaginal delivery from 1992 to 2011. We included 7796 nulliparous women >= 40 years and 264 262 nulliparous women 25-29 years. Prevalence and risk of intrapartum cesarean section, operative vaginal delivery, obstetric anal sphincter injury and a 5-minute Apgar score <7 were calculated for women >= 40 years stratified for spontaneous onset and induction of labor, using women 25-29 years as the reference in both strata. Crude and adjusted odds ratios (aOR) were calculated by unconditional logistic regression and presented with 95% confidence intervals (CI). Results Overall, 79% of women >= 40 years with a trial of labor reached a vaginal delivery. After spontaneous onset, intrapartum cesarean section was performed in 15.4% of women >= 40 years compared with 5.4% of women 25-29 years (aOR 3.07, 95% CI 2.81-3.35). Operative vaginal delivery was performed in 22.3% of women >= 40 years compared with 14.2% of women 25-29 years (aOR 1.71, 95% CI 1.59-1.85). After induction of labor, an intrapartum cesarean section was performed in 37.2% women >= 40 years compared with 20.2% women 25-29 years (aOR 2.51, 95% CI 2.24-2.81). Operative vaginal delivery was performed in 22.6% of women >= 40 years compared with 18.4% women 25-29 years (aOR 1.45, 95% CI 1.28-1.65). The risk of obstetric anal sphincter injury or a 5-minute Apgar score <7 was not increased in women >= 40 years, regardless of onset of labor. Conclusions Trial of labor ended in vaginal delivery in 79% of nulliparous women >= 40 years. The risks of intrapartum cesarean section and operative vaginal delivery were higher in women >= 40 years compared with women 25-29 years, after both spontaneous onset and induction of labor. The risk of obstetric anal sphincter injury or a 5-minute Apgar score <7 was not increased.
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| 4. |
- Ankarcrona, Victoria, et al.
(författare)
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Episiotomy in vacuum extraction, do we cut the levator ani muscle? : A prospective cohort study
- 2022
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Ingår i: International Urogynecology Journal. - : Springer Nature. - 0937-3462 .- 1433-3023. ; 33:12, s. 3391-3399
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Tidskriftsartikel (refereegranskat)abstract
- Introduction and hypothesis Vaginal delivery may lead to levator ani muscle (LAM) injury or avulsion. Episiotomy may reduce obstetric anal sphincter injury in operative vaginal delivery, but may increase the risk of LAM injury. Our aim was to assess whether lateral episiotomy in vacuum extraction (VE) in primiparous women causes LAM injury. Methods A prospective cohort study of 58 primiparous women with episiotomy nested within an ongoing multicenter randomized controlled trial of lateral episiotomy versus no episiotomy in VE (EVA trial) was carried out in Sweden. LAM injury was evaluated using 3D endovaginal ultrasound 6-12 months after delivery and Levator Ani Deficiency (LAD) score. Episiotomy scar properties were measured. Characteristics were described and compared using Chi-squared tests. We stipulated that if a lateral episiotomy cuts the LAM, >= 50% would have a LAM injury. Among those, >= 50% would be side specific. We compared the observed prevalence with a test of one proportion. Results Twelve (20.7%, 95% CI 10.9-32.9) of 58 women had a LAD (p < 0.001, compared with the stipulated 50%). Six (50.0%, 95% CI 21.1% to 78.9%) of 12 women had a LAD on the episiotomy side, including those with bilateral LAD (p = 1.00). Two (16.7%, 95% CI 2.1% to 48.4%) of 12 women had a LAD exclusively on the episiotomy side (p = 0.02). Conclusions There was no excessive risk of cutting the LAM while performing a lateral episiotomy. LAD was not seen in women with episiotomies shorter than 18 mm.
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| 5. |
- Ankarcrona, Victoria, et al.
(författare)
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Obstetric anal sphincter injury after episiotomy in vacuum extraction: an epidemiological study using an emulated randomized trial approach
- 2021
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Ingår i: BJOG : an international journal of obstetrics and gynaecology. - : Wiley. - 1471-0528 .- 1470-0328. ; 128:10, s. 1663-1671
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Tidskriftsartikel (refereegranskat)abstract
- To emulate a randomized controlled trial investigating if lateral or mediolateral episiotomy compared to no episiotomy reduces the prevalence of obstetric anal sphincter injury (OASIS) in nulliparous women delivered with vacuum extraction.A population-based observational study.Sweden.63 654 nulliparous women delivered with vacuum extraction derived from the Swedish Medical Birth Register 2000-2011, with a live singleton baby without known malformations in cephalic presentation in gestational week ≥34+0, and subject to lateral or mediolateral episiotomy or no episiotomy.The effect of episiotomy was calculated using a causal doubly robust estimation method based on propensity scores. Results are presented as the average treatment effect and numbers needed to treat (NNT).OASIS (third- and fourth-degree perineal injury) in nulliparous women delivered with vacuum extraction.Episiotomy was associated with a reduction in OASIS from 15.5% to 11.8%, average treatment effect -3.66% (95% CI -4.31 to -3.01) and NNT 27. Third-degree perineal injuries were reduced from 14.0% to 10.9% (-3.08, 95% CI -3.71 to -2.42) with NNT 32. Fourth-degree perineal injuries were reduced from 1.6% to 1.0 % (-0.58%, 95% CI -0.79 to -0.37) with NNT 172.Lateral or mediolateral episiotomy reduced the prevalence of OASIS in nulliparous women delivered with vacuum extraction, compared to women with no episiotomy.
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| 6. |
- Ankarcrona, Victoria
(författare)
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To cut or not to cut? Episiotomy in vacuum extraction
- 2022
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- BACKGROUND AND AIMS: Obstetric anal sphincter injury (OASIS) may cause anal incontinence, as well as sexual dysfunction and psychological trauma. Mediolateral and lateral episiotomy have been shown to be protective against OASIS in nulliparous women delivered by vacuum extraction (VE). The technique and trigonometric properties of an episiotomy may be important for its protective effect. The aim of the thesis was to explore episiotomy in Sweden. Firstly, we aimed at investigating the effect of episiotomy in nulliparous women at VE. Secondly, we aimed at exploring the attitudes towards, and knowledge about, episiotomy among doctors. Finally, we wanted to find out if an episiotomy might cause injury to the levator ani muscles (LAM). The impact of advanced maternal age on delivery outcome was also explored. METHODS AND MAIN RESULTS: Study I and II are register-based cohort studies based on data from the Swedish Medical Birth Register. In study I delivery outcome in women ≥40 years was explored. We compared nulliparous women ≥40 years (n=7796) with nulliparous women 25-29 years (n=264 262) after spontaneous onset and induction of labor between 1992-2011. The rate of OASIS, episiotomy, and low Apgar score was also investigated. We found a significantly higher rate of intrapartum cesarean section among women ≥40 years, both after spontaneous onset of labor (adjusted odds ratio (aOR) 3.07, 95%CI 2.81-3.35) and induction of labor (aOR 2.51, 95%CI 2.24-2.81). The risk of VE was also increased in women ≥40 years, both after spontaneous onset (aOR 1.71 95%CI 1.59-1.85), and induction of labor (aOR 1.45, 95%CI 1.28-1.65). We found no significant difference in rate of OASIS, episiotomy or low Apgar score. Overall, 79% of women ≥40 years had a vaginal delivery compared with 93% of women 25-29 years. In study II nulliparous women delivered by VE between 2000-2011 were included. Women without episiotomy (n=43 853) were compared to women with a lateral or mediolateral episiotomy (n=19 801). After statistical balancing using propensity score, episiotomy was associated with a reduction in OASIS from 15.5% to 11.8%, ie an average treatment effect -3.7% (95% CI -4.3 to -3.0). The numbers needed to treat (NNT) to prevent one OASIS was 27. The third-degree perineal injuries alone were reduced from 14.0% to 10.9% (-3.1, 95% CI -3.7 to -2.4) with NNT 32. The fourth-degree perineal injuries alone were reduced from 1.6% to 1.0 % (-0.6%, 95% CI -0.8 to -0.4). Fourth-degree perineal injuries required NNT 172. Study III was a web-based questionnaire sent to the members of the Swedish Society of Obstetrics and Gynecology with a registered email in 2019 (n=2140). The response rate was 25% (n=432). The questionnaire addressed different aspects of VE and episiotomy and contained a picture of a crowning fetal head in which the respondents were asked to depict the episiotomy they would perform in the delivery room. The drawn episiotomies were translated into coordinates in a diagram. The episiotomies were categorized as lateral, mediolateral, midline or unclassifiable. In total, 57.8% (n=222) doctors reported performing episiotomy in less than 50% of VE deliveries. We found that only 54% of the doctors drew what could be considered a protective episiotomy. Furthermore, doctors in Sweden rated episiotomy as the least important measure to prevent OASIS in VE. Study IV was a descriptive prospective cohort study, examining if lateral episiotomy causes an iatrogenic LAM injury. Sixty-three women delivered by VE who received a standardized lateral episiotomy were examined by 3D endovaginal ultrasound about one year after delivery. Five images were not possible to retrieve due to a broken hard drive, thus 58 women were included. Of these 58 women, 12 had a visible LAM injury (20.7%, 95%CI 10.9-32.9). This is a significantly lower proportion than the stipulated 50% (p<0.001) of women. Two (16.7%, 95% CI 2.1-48.4) of 12 women had an ipsilateral LAD (p=0.02, compared with the stipulated proportion of 50%). CONCLUSION: In conclusion, trial of labor may be worthwhile in women ≥ 40 years. Episiotomy seems to have a protective effect of OASIS in a Swedish population of nulliparous women with VE. A small majority of doctors in Sweden could depict a protective episiotomy. Our studies support that doctors are able to continue performing lateral episiotomies without risk of cutting the LAM.
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| 7. |
- Bergendahl, Sandra, et al.
(författare)
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Lateral episiotomy or no episiotomy in vacuum assisted delivery in nulliparous women (EVA) : multicentre, open label, randomised controlled trial
- 2024
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Ingår i: BMJ. British Medical Journal. - : BMJ Publishing Group Ltd. - 0959-8146 .- 0959-535X. ; 385, s. e079014-
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Tidskriftsartikel (refereegranskat)abstract
- Objective: To assess the effect of lateral episiotomy, compared with no episiotomy, on obstetric anal sphincter injury in nulliparous women requiring vacuum extraction. Design: A multicentre, open label, randomised controlled trial.Setting: Eight hospitals in Sweden, 2017-23.Participants: 717 nulliparous women with a single live fetus of 34 gestational weeks or more, requiring vacuum extraction were randomly assigned (1:1) to lateral episiotomy or no episiotomy using sealed opaque envelopes. Randomisation was stratified by study site.Intervention: A standardised lateral episiotomy was performed during the vacuum extraction, at crowning of the fetal head, starting 1-3 cm from the posterior fourchette, at a 60° (45-80°) angle from the midline, and 4 cm (3-5 cm) long. The comparison was no episiotomy unless considered indispensable.Main outcome measures: The primary outcome of the episiotomy in vacuum assisted delivery (EVA) trial was obstetric anal sphincter injury, clinically diagnosed by combined visual inspection and digital rectal and vaginal examination. The primary analysis used a modified intention-to-treat population that included all consenting women with attempted or successful vacuum extraction. As a result of an interim analysis at significance level P<0.01, the primary endpoint was tested at 4% significance level with accompanying 96% confidence interval (CI).Results: From 1 July 2017 to 15 February 2023, 717 women were randomly assigned: 354 (49%) to lateral episiotomy and 363 (51%) to no episiotomy. Before vacuum extraction attempt, one woman withdrew consent and 14 had a spontaneous birth, leaving 702 for the primary analysis. In the intervention group, 21 (6%) of 344 women sustained obstetric anal sphincter injury, compared with 47 (13%) of 358 women in the comparison group (P=0.002). The risk difference was -7.0% (96% CI -11.7% to -2.5%). The risk ratio adjusted for site was 0.47 (96% CI 0.23 to 0.97) and unadjusted risk ratio was 0.46 (0.28 to 0.78). No significant differences were noted between groups in postpartum pain, blood loss, neonatal outcomes, or total adverse events, but the intervention group had more wound infections and dehiscence.Conclusions: Lateral episiotomy can be recommended for nulliparous women requiring vacuum extraction to significantly reduce the risk of obstetric anal sphincter injury. Trial registration: ClinicalTrials.gov NCT02643108.
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| 8. |
- Bergendahl, Sandra, et al.
(författare)
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Lateral episiotomy versus no episiotomy to reduce obstetric anal sphincter injury in vacuum-assisted delivery in nulliparous women : Study protocol on a randomised controlled trial
- 2019
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Ingår i: BMJ Open. - : BMJ. - 2044-6055. ; 9:3
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Tidskriftsartikel (refereegranskat)abstract
- Introduction Obstetric anal sphincter injury (OASIS) occurs in 5%-7% of normal deliveries and increases with vacuum extraction (VE) to 12%-14% in nulliparous women in Sweden. Lateral/mediolateral episiotomy may reduce the prevalence of OASIS at VE in nulliparous women. The current use of episiotomy is restrictive. The protective effect and consequences are uncertain. This trial will investigate if lateral episiotomy can reduce the prevalence of OASIS and assess short-term and long-term effects. Methods and analysis This is a multicentre randomised controlled trial of lateral episiotomy versus no episiotomy in nulliparous women with a singleton, live fetus, after gestational week 34+0 with indication for VE. A lateral episiotomy of 4 cm is cut at crowning, 1-3 cm from the midline, at a 60° angle. The primary outcome is OASIS by clinical diagnosis analysed according to intention to treat. To demonstrate a 50% reduction in OASIS prevalence (from 12.4% to 6.2%), 710 women will be randomised at a 1:1 ratio. Secondary outcomes are pain, blood loss, other perineal injuries, perineal complications, Apgar score, cord pH and neonatal complications. Web-based questionnaires at baseline, 2 months, 1 and 5 years will be used to assess pain, incontinence, prolapse, sexual function, quality of life and childbirth experience. A subset of women will receive follow-up by pelvic floor sonography and pelvic examination. Mode of delivery and recurrence of OASIS/episiotomy in subsequent pregnancies will be assessed at 5 and 10 years using register data. Ethics and dissemination The trial is open for enrolment. The trial has received ethical approval from the Regional Ethical Review Board of Stockholm and full funding from the Swedish Research Council. Women are interested in participation. The predominant restrictive view on episiotomy may limit recruitment. Results are of global interest and will be disseminated in peer-reviewed journals and at international congresses.
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