Risk factors tied to prognosis of obstetric anal sphincter injuries

SCOTTSDALE, ARIZ. – Certain factors portend a rockier course for women who have serious obstetric anal sphincter injuries, a cohort study has found.

In the study, known as FORCAST (For Optimal Recovery, Care After Severe Tears), researchers prospectively followed 180 women who sustained a third- or fourth-degree injury during a term vaginal delivery between 2011 and 2013.

Overall, 18% developed a postpartum wound infection, 24% developed postpartum wound breakdown, and 9% developed postpartum depression, Dr. Kimberly Kenton reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

None of a variety of factors assessed independently predicted the development of wound infections. But women had a sharply elevated risk of wound breakdown if they had an operative vaginal delivery (relative risk, 3.07; P = .04), which was mainly via forceps in the cohort, and a sharply elevated risk of postpartum depression if they had a fourth-degree tear (relative risk, 4.59; P = .01).

"Obstetric anal sphincter injury is associated with high rates of wound complications and postpartum depression," she commented. The investigators hope that this new information can be applied to improve outcomes in this patient population, added Dr. Kenton, a urogynecologist and pelvic reconstructive surgeon at Northwestern Memorial Hospital in Chicago.

Session attendee Dr. Rebecca Rogers of the University of New Mexico in Albuquerque said, "I’m wondering how we can use these data to try to influence the pressure on training programs to support forceps delivery with their residencies, because I think we have a growing body of evidence that this can cause serious sequelae for our patients."

"The Accreditation Council for Graduate Medical Education still tracks forceps and vacuum deliveries, but then they collapse them into a combined category," Dr. Kenton replied. "So [a training program] won’t get a citation as long as you have the right number of operative vaginal deliveries, but it can be either forceps or vacuum."

Attendee Dr. Mikio Nihira of the University of Oklahoma in Oklahoma City noted that he and his colleagues are also studying severe perineal lacerations after obstetric delivery. "One finding that I found very interesting about your presentation was this association with depression, because we are getting this feeling when we work with these patients that it may actually interfere with their bonding with their children," he said at the meeting, which was jointly sponsored by the American College of Surgeons.

"Anecdotally, based on my clinical experience, I think that makes a lot of sense," Dr. Kenton commented. "I have seen a lot of these women and had to take a lot of them back to the OR. When you finally see them back 3 or 4 months later when they are healed, one of the first things they tell you is how much better they are doing and how they can finally get on with their lives and enjoy their baby."

Attendee Dr. Carl Zimmerman, director of female pelvic medicine and reconstructive surgery at Vanderbilt University in Nashville, asked which service repaired the lacerations.

"We have actively reached out to the obstetrical service and invited them to consult us for severe lacerations – sulcus tears, fourth degrees, and so on. And we believe that it has resulted in a better initial repair," he commented.

Dr. Kenton said that the obstetric service performed the laceration repairs and noted that practice variation may have some role in outcomes. "One of the biggest things that we have found is, surprisingly, nobody gives antibiotics around the time of the third- or fourth-degree tear. So maybe there is room for obtaining some level 1 evidence about randomizing women to antibiotics or no antibiotics to see if that would improve healing rates," she commented.

"Right, there are multiple things that just haven’t been looked at here," Dr. Zimmerman agreed. "And this really seems like a window of opportunity to address some of these issues at the front end rather than waiting till 20 or 30 years down the road."

Providing some background to the research, Dr. Kenton noted that each year, about 37,500 women in the United States develop anal incontinence after experiencing sphincter injury during childbirth, underscoring the importance of this complication.

The women in FORCAST had clinical follow-up in the urogynecology clinic at 1, 2, 6, and 12 weeks post partum and annually thereafter, with perineal evaluation, completion of the Patient Health Questionnaire as a depression screen, and assessment of pain on a visual analog scale.

On average, they were 32 years old and had a body mass index of 29 kg/m², according to Dr. Kenton. The majority were primiparous (87%) and had an operative delivery (72%).

In addition to identifying operative delivery as a risk factor for wound breakdown and identifying fourth-degree tear as a risk factor for depression, analyses showed that the women experiencing wound infection or breakdown had significantly higher levels of pain than did peers with an intact perineum (mean, 35 vs. 23 points on a scale from 0 to 100; P = .03).

Dr. Kenton disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Certain factors portend a rockier course for women who have serious obstetric anal sphincter injuries, a cohort study has found.

In the study, known as FORCAST (For Optimal Recovery, Care After Severe Tears), researchers prospectively followed 180 women who sustained a third- or fourth-degree injury during a term vaginal delivery between 2011 and 2013.

Overall, 18% developed a postpartum wound infection, 24% developed postpartum wound breakdown, and 9% developed postpartum depression, Dr. Kimberly Kenton reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

None of a variety of factors assessed independently predicted the development of wound infections. But women had a sharply elevated risk of wound breakdown if they had an operative vaginal delivery (relative risk, 3.07; P = .04), which was mainly via forceps in the cohort, and a sharply elevated risk of postpartum depression if they had a fourth-degree tear (relative risk, 4.59; P = .01).

"Obstetric anal sphincter injury is associated with high rates of wound complications and postpartum depression," she commented. The investigators hope that this new information can be applied to improve outcomes in this patient population, added Dr. Kenton, a urogynecologist and pelvic reconstructive surgeon at Northwestern Memorial Hospital in Chicago.

Session attendee Dr. Rebecca Rogers of the University of New Mexico in Albuquerque said, "I’m wondering how we can use these data to try to influence the pressure on training programs to support forceps delivery with their residencies, because I think we have a growing body of evidence that this can cause serious sequelae for our patients."

"The Accreditation Council for Graduate Medical Education still tracks forceps and vacuum deliveries, but then they collapse them into a combined category," Dr. Kenton replied. "So [a training program] won’t get a citation as long as you have the right number of operative vaginal deliveries, but it can be either forceps or vacuum."

Attendee Dr. Mikio Nihira of the University of Oklahoma in Oklahoma City noted that he and his colleagues are also studying severe perineal lacerations after obstetric delivery. "One finding that I found very interesting about your presentation was this association with depression, because we are getting this feeling when we work with these patients that it may actually interfere with their bonding with their children," he said at the meeting, which was jointly sponsored by the American College of Surgeons.

"Anecdotally, based on my clinical experience, I think that makes a lot of sense," Dr. Kenton commented. "I have seen a lot of these women and had to take a lot of them back to the OR. When you finally see them back 3 or 4 months later when they are healed, one of the first things they tell you is how much better they are doing and how they can finally get on with their lives and enjoy their baby."

Attendee Dr. Carl Zimmerman, director of female pelvic medicine and reconstructive surgery at Vanderbilt University in Nashville, asked which service repaired the lacerations.

"We have actively reached out to the obstetrical service and invited them to consult us for severe lacerations – sulcus tears, fourth degrees, and so on. And we believe that it has resulted in a better initial repair," he commented.

Dr. Kenton said that the obstetric service performed the laceration repairs and noted that practice variation may have some role in outcomes. "One of the biggest things that we have found is, surprisingly, nobody gives antibiotics around the time of the third- or fourth-degree tear. So maybe there is room for obtaining some level 1 evidence about randomizing women to antibiotics or no antibiotics to see if that would improve healing rates," she commented.

"Right, there are multiple things that just haven’t been looked at here," Dr. Zimmerman agreed. "And this really seems like a window of opportunity to address some of these issues at the front end rather than waiting till 20 or 30 years down the road."

Providing some background to the research, Dr. Kenton noted that each year, about 37,500 women in the United States develop anal incontinence after experiencing sphincter injury during childbirth, underscoring the importance of this complication.

The women in FORCAST had clinical follow-up in the urogynecology clinic at 1, 2, 6, and 12 weeks post partum and annually thereafter, with perineal evaluation, completion of the Patient Health Questionnaire as a depression screen, and assessment of pain on a visual analog scale.

On average, they were 32 years old and had a body mass index of 29 kg/m², according to Dr. Kenton. The majority were primiparous (87%) and had an operative delivery (72%).

In addition to identifying operative delivery as a risk factor for wound breakdown and identifying fourth-degree tear as a risk factor for depression, analyses showed that the women experiencing wound infection or breakdown had significantly higher levels of pain than did peers with an intact perineum (mean, 35 vs. 23 points on a scale from 0 to 100; P = .03).

Dr. Kenton disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Certain factors portend a rockier course for women who have serious obstetric anal sphincter injuries, a cohort study has found.

In the study, known as FORCAST (For Optimal Recovery, Care After Severe Tears), researchers prospectively followed 180 women who sustained a third- or fourth-degree injury during a term vaginal delivery between 2011 and 2013.

Overall, 18% developed a postpartum wound infection, 24% developed postpartum wound breakdown, and 9% developed postpartum depression, Dr. Kimberly Kenton reported at the annual scientific meeting of the Society of Gynecologic Surgeons.

None of a variety of factors assessed independently predicted the development of wound infections. But women had a sharply elevated risk of wound breakdown if they had an operative vaginal delivery (relative risk, 3.07; P = .04), which was mainly via forceps in the cohort, and a sharply elevated risk of postpartum depression if they had a fourth-degree tear (relative risk, 4.59; P = .01).

"Obstetric anal sphincter injury is associated with high rates of wound complications and postpartum depression," she commented. The investigators hope that this new information can be applied to improve outcomes in this patient population, added Dr. Kenton, a urogynecologist and pelvic reconstructive surgeon at Northwestern Memorial Hospital in Chicago.

Session attendee Dr. Rebecca Rogers of the University of New Mexico in Albuquerque said, "I’m wondering how we can use these data to try to influence the pressure on training programs to support forceps delivery with their residencies, because I think we have a growing body of evidence that this can cause serious sequelae for our patients."

"The Accreditation Council for Graduate Medical Education still tracks forceps and vacuum deliveries, but then they collapse them into a combined category," Dr. Kenton replied. "So [a training program] won’t get a citation as long as you have the right number of operative vaginal deliveries, but it can be either forceps or vacuum."

Attendee Dr. Mikio Nihira of the University of Oklahoma in Oklahoma City noted that he and his colleagues are also studying severe perineal lacerations after obstetric delivery. "One finding that I found very interesting about your presentation was this association with depression, because we are getting this feeling when we work with these patients that it may actually interfere with their bonding with their children," he said at the meeting, which was jointly sponsored by the American College of Surgeons.

"Anecdotally, based on my clinical experience, I think that makes a lot of sense," Dr. Kenton commented. "I have seen a lot of these women and had to take a lot of them back to the OR. When you finally see them back 3 or 4 months later when they are healed, one of the first things they tell you is how much better they are doing and how they can finally get on with their lives and enjoy their baby."

Attendee Dr. Carl Zimmerman, director of female pelvic medicine and reconstructive surgery at Vanderbilt University in Nashville, asked which service repaired the lacerations.

"We have actively reached out to the obstetrical service and invited them to consult us for severe lacerations – sulcus tears, fourth degrees, and so on. And we believe that it has resulted in a better initial repair," he commented.

Dr. Kenton said that the obstetric service performed the laceration repairs and noted that practice variation may have some role in outcomes. "One of the biggest things that we have found is, surprisingly, nobody gives antibiotics around the time of the third- or fourth-degree tear. So maybe there is room for obtaining some level 1 evidence about randomizing women to antibiotics or no antibiotics to see if that would improve healing rates," she commented.

"Right, there are multiple things that just haven’t been looked at here," Dr. Zimmerman agreed. "And this really seems like a window of opportunity to address some of these issues at the front end rather than waiting till 20 or 30 years down the road."

Providing some background to the research, Dr. Kenton noted that each year, about 37,500 women in the United States develop anal incontinence after experiencing sphincter injury during childbirth, underscoring the importance of this complication.

The women in FORCAST had clinical follow-up in the urogynecology clinic at 1, 2, 6, and 12 weeks post partum and annually thereafter, with perineal evaluation, completion of the Patient Health Questionnaire as a depression screen, and assessment of pain on a visual analog scale.

On average, they were 32 years old and had a body mass index of 29 kg/m², according to Dr. Kenton. The majority were primiparous (87%) and had an operative delivery (72%).

In addition to identifying operative delivery as a risk factor for wound breakdown and identifying fourth-degree tear as a risk factor for depression, analyses showed that the women experiencing wound infection or breakdown had significantly higher levels of pain than did peers with an intact perineum (mean, 35 vs. 23 points on a scale from 0 to 100; P = .03).

Dr. Kenton disclosed no relevant conflicts of interest.