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Clinical and methodological aspects on perineal laceration diagnostics at childbirth
Region Östergötland, Barn- och kvinnocentrum, Kvinnokliniken i Linköping. Linköpings universitet, Institutionen för klinisk och experimentell medicin, Avdelningen för barns och kvinnors hälsa. Linköpings universitet, Medicinska fakulteten.
2019 (engelsk)Doktoravhandling, med artikler (Annet vitenskapelig)
Abstract [en]

Background: Obstetric perineal lacerations are common after vaginal birth. The degree of obstetric perineal laceration is defined by the extent of tissue involved in the laceration. When a perineal laceration has occurred after vaginal delivery, the examination for correct diagnostics is essential before primary suturing. Standard immediate postpartum care is an inspection and palpation of the obstetric perineal laceration. The aim of this thesis was to explore the diagnostics of obstetric perineal lacerations, and to examine how the methods of bidigital perineal palpation and transperineal ultrasound postpartum can contribute to the clinical diagnostic decisions before primary repair.

Material and Methods: Study I is a methodological study of transperineal ultrasound of the anovaginal distance. The learning curve and inter-observer agreement of the method is studied between three examiners in an outpatient gynaecological setting. Study II is a prospective observational study of 150 primiparous women with suspected perineal laceration of degree 2-3 immediately after childbirth and the association between bidigital palpation of the perineal height, the anovaginal distance and the final diagnosis of the perineal laceration. Study III is a retrospective observational study with data from the Swedish national Perineal Laceration Registry, studying maternal and obstetric risk factors for internal anal sphincter injury in 3,333 women with external sphincter injury. Study IV is a follow-up study focusing on the implementation strategies and outcome when introducing a new method, (the Diagnostics After DELivery – DADEL concept) for examining perineal lacerations at a maternity ward. The DADEL concept consists of a combination of bidigital palpation of the perineal tissues and transperineal ultrasound in order to determine the degree of perineal lacerations.

Results and conclusions: In study I, the method of transperineal ultrasound measurement of anovaginal distance revealed a short learning period and high interobserver agreement. This indicated that the method can be taught and reliably used in further research and clinical practice. In study II, women with external sphincter injury had a shorter anovaginal distance compared to women without this injury. The palpatory perineal thickness was associated with the anovaginal distance. Study III showed that 33% of primiparous women with an external anal sphincter injury also had an internal anal sphincter injury diagnosed immediately after delivery. When the infant was born with a hand or arm beside the head, there was an increased risk for internal anal sphincter injury. Perineal palpatory thickness of less than 10 mm was significantly associated with an internal anal sphincter injury. In the follow-up study of diagnostic methods showed a significantly higher use of bidigital palpation five years after introduction of the DADEL concept. The use of transperineal ultrasound showed no significant change during the same period.

sted, utgiver, år, opplag, sider
Linköping: Linköping University Electronic Press, 2019. , s. 68
Serie
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1715
HSV kategori
Identifikatorer
URN: urn:nbn:se:liu:diva-162580DOI: 10.3384/diss.diva-162580ISBN: 9789179299620 (tryckt)OAI: oai:DiVA.org:liu-162580DiVA, id: diva2:1376169
Disputas
2020-01-17, Belladonna, University Hospital Campus, Linköping, 09:00 (svensk)
Opponent
Veileder
Tilgjengelig fra: 2019-12-09 Laget: 2019-12-09 Sist oppdatert: 2020-01-08bibliografisk kontrollert
Delarbeid
1. Interobserver agreement in perineal ultrasound measurement of the anovaginal distance: a methodological study
Åpne denne publikasjonen i ny fane eller vindu >>Interobserver agreement in perineal ultrasound measurement of the anovaginal distance: a methodological study
2018 (engelsk)Inngår i: International Urogynecology Journal, ISSN 0937-3462, E-ISSN 1433-3023, Vol. 29, nr 5, s. 697-701Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Objective outcome measures of the extent of laceration at delivery are needed. In this study we evaluated and describe here a method for learning perineal ultrasound measurement of the anovaginal distance (AVD). The learning period needed for examiners proficient in vaginal ultrasound examination and the interobserver agreement after reaching proficiency in AVD measurement were determined. The hypothesis was that the method is feasible to learn and reproducible for use in further research. The method was taught by an examiner experienced in perineal ultrasonography. The distance between the mucosal margin of the internal anal sphincter was measured with a vaginal probe. The studied examiners measured the AVD until similar results (+/- 5 mm) were achieved. The AVD in 40 women was then measured and documented by two examiners who were blinded to each others results. Interobserver agreement was calculated using the kappa score. Examiners with previous experience in vaginal ultrasonography had learned the method after performing five sets of comeasurements. The AVD measurements after the learning period showed almost perfect agreement (kappa = 0.87) between the examiners. The method for perineal ultrasound measurement of AVD was learned quickly with high interobserver agreement. The method is feasible to learn and reproducible for use in further research.

sted, utgiver, år, opplag, sider
Springer London, 2018
Emneord
Perineal ultrasound examination; Anovaginal distance; Perineum; Interobserver agreement; Validation
HSV kategori
Identifikatorer
urn:nbn:se:liu:diva-147921 (URN)10.1007/s00192-017-3392-6 (DOI)000430703900011 ()28624920 (PubMedID)2-s2.0-85020507347 (Scopus ID)
Tilgjengelig fra: 2018-05-23 Laget: 2018-05-23 Sist oppdatert: 2019-12-09bibliografisk kontrollert
2. Anovaginal distance and obstetric anal sphincter injury: a prospective observational study
Åpne denne publikasjonen i ny fane eller vindu >>Anovaginal distance and obstetric anal sphincter injury: a prospective observational study
2019 (engelsk)Inngår i: International Urogynecology Journal, ISSN 0937-3462, E-ISSN 1433-3023, Vol. 30, nr 6, s. 939-944Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Introduction and Hypothesis

No measurements are available for diagnosing the extent of obstetric lacerations. The primary aim of this study was to evaluate the relation between the anovaginal distance (AVD) measured with transperineal ultrasound immediately after delivery and external anal sphincter injury. A secondary aim was to assess whether the palpated perineal thickness was associated with the AVD.

Methods

A prospective observational study of 150 primiparous women at the University Hospital, Linköping, Sweden. After vaginal delivery, initial inspection and palpation of the perineal thickness were performed by the midwife. The women were then divided into subgroups depending on the degree of the suspected perineal laceration. Transperineal ultrasound of the AVD was performed by a physician. Diagnostics of the perineal laceration were done according to standard care.

Results

Women with an external sphincter injury had a shorter AVD and shorter palpatory perineal thickness compared with women without anal sphincter injury. No external sphincter injuries were diagnosed when the AVD and/or palpation height was > 20 mm. The mean AVD in the group with probable second-degree laceration (n = 85) was 18.8 mm (95% CI 17.8–19.8), in suspected third-degree laceration (n = 33) 15.7 mm (95% CI 13.7–17.7) and in probable third-degree laceration (n = 32) 11.8 mm (95% CI 9.7–13.9) (p < 0.001).

Conclusions

A short AVD could be a warning sign postpartum and should increase the awareness of possible external sphincter injury before suturing. An AVD of 20 mm seems to indicate a cutoff level of the occurrence of external sphincter injury, but this needs further evaluation.

sted, utgiver, år, opplag, sider
Springer London, 2019
Emneord
Anovaginal distance; Obstetrical anal sphincter injury; Perineal laceration; Transperineal ultrasound
HSV kategori
Identifikatorer
urn:nbn:se:liu:diva-157515 (URN)10.1007/s00192-018-3838-5 (DOI)000467656700011 ()30535980 (PubMedID)2-s2.0-85058189785 (Scopus ID)
Merknad

Funding Agencies|Ostergotland Region

Tilgjengelig fra: 2019-06-23 Laget: 2019-06-23 Sist oppdatert: 2019-12-09bibliografisk kontrollert
3. Internal anal sphincter injury in the immediate postpartum period; Prevalence, risk factors and diagnostic methods in the Swedish perineal laceration registry
Åpne denne publikasjonen i ny fane eller vindu >>Internal anal sphincter injury in the immediate postpartum period; Prevalence, risk factors and diagnostic methods in the Swedish perineal laceration registry
2020 (engelsk)Inngår i: European Journal of Obstetrics, Gynecology, and Reproductive Biology, ISSN 0301-2115, E-ISSN 1872-7654, Vol. 245, s. 1-6Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Risk factors for obstetric external anal sphincter injury are well known. Maternal and obstetric risk factors for internal anal sphincter injury are not extensively studied.

The rationale of this study was to evaluate the proportion of internal anal sphincter injury in women with external anal sphincter injury, diagnosed immediately after delivery.

This study will assess whether there are additional risks for obstetric internal anal sphincter injury.

Objectives

The primary aim was to assess the proportion of internal anal sphincter injury immediately in women with an external sphincter injury and to evaluate maternal and obstetric risk factors for internal anal sphincter injury in women with an external anal sphincter injury only.

A secondary aim was to relate the diagnostic methods used for obstetric perineal lacerations to the presence of an internal anal sphincter injury.

Study Design

A registry study with data from the Swedish Perineal Laceration Registry 2014–2018.

From the registry, the maternal and obstetric characteristics of 3,333 primiparous women with isolated external (N = 2,236) versus both external and internal (N = 1,097) anal sphincter injuries were studied, as were the methods used for examining the obstetric anal sphincter injuries.

Results

In 32.9 % (1,097/3,333) of primiparous women with an external anal sphincter injury, an internal anal sphincter injury was diagnosed immediately after delivery. A perineal palpatory thickness of less than 10 mm was a diagnostic sign for internal sphincter injury. Well-known risk factors associated with obstetric anal sphincter injuries could not be confirmed as independent risk factors for internal sphincter injury. When the infant is born with an arm beside the head, there is an almost two-fold increased risk for internal sphincter injury.

Conclusions

Our main finding is that 32.9 % of women with external anal sphincter injury also have an internal anal sphincter injury. A palpable perineal thickness of less than 10 mm, a degree 4-laceration and an infant born with a hand by the head increases the risk of internal sphincter injury and should be a clinical warning sign.

sted, utgiver, år, opplag, sider
Amsterdam: Elsevier, 2020
Emneord
Obstetric perineal laceration, internal anal sphincter injury
HSV kategori
Identifikatorer
urn:nbn:se:liu:diva-162583 (URN)10.1016/j.ejogrb.2019.11.030 (DOI)31825790 (PubMedID)2-s2.0-85075878318 (Scopus ID)
Tilgjengelig fra: 2019-12-09 Laget: 2019-12-09 Sist oppdatert: 2019-12-16bibliografisk kontrollert

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