European Journal of Obstetrics & Gynecology and Reproductive Biology
The rate of obstetric anal sphincter injuries in Finnish obstetric units as a patient safety indicator
Introduction
Over the past two decades patient safety has become one of the most prominent issues in health policy. To provide accurate and reliable data we need patient safety indicators that are easily measurable, comparable and preferably under mandatory reporting systems. Patient safety indicators need to be easy to gather without violating patient confidentiality and privacy. Every second year the Organization for Economic Co-operation and Development (OECD) publishes a new edition of the “Health at Glance” report [1], which includes a number of general patient safety indicators with comparable data within the OECD countries. In the field of obstetrics the selected indicators were obstetric trauma (3rd or 4th degree anal sphincter injury in vaginal delivery with or without instrument) and birth trauma (injury to neonate).
Obstetric anal sphincter injuries (OASIS) are serious complications of vaginal delivery and may have significant and long-term consequences for women's health later in life [2], [3]. There have been several studies aimed at identifying risk factors for OASIS and it has been shown that in addition to maternal and neonatal variables many obstetric practices have an impact on the OASIS rate [4], [5], [6], [7], [8], [9], [10]. Hence, it has been suggested that by employing appropriate labour management and care standards the OASIS rate can be reduced [10], [11], [12] and therefore it would be a suitable indicator for patient safety.
In Finland the OASIS rate is below the Nordic average, but the rate has been on a steady rise during the last decade, reaching the average of 1.0% in 2010 with a great variation between the delivery units. At the same time, there have been significant changes in obstetric interventions: the use of epidural analgesia (39.0% in 2000 and 44.9% in 2010) and vacuum assistance (6.1% in 2000 and 8.6% in 2010) has increased while the use of episiotomy has decreased (41.8% in 2000 and 24.1% in 2010) [13], [14].
The aim of this study was to analyse whether there are significant differences in the OASIS rate between different sized delivery units in Finland. We focused on the low-risk population and studied if Robson's “ten groups” classification is useful in the inter-hospital comparison.
Section snippets
Materials and methods
Obstetric anal sphincter injury (OASIS) encompasses both 3rd and 4th degree sphincter rupture. A 3rd degree rupture is defined as a partial or complete disruption of the anal sphincter muscles, which may involve either or both the external (EAS) and internal (IAS) anal sphincter muscles. A 4th degree rupture is defined as a disruption of the anal sphincter muscles with a breach of the rectal mucosa. The 3rd degree rupture is further subclassified to grade III a, b or c depending on the severity
Results
The main finding was the elevated risk of OASIS in the largest (OR 1.46, 95% CI 1.11–1.92) and in the smallest (OR 1.33, 95% CI 1.22–1.45, both adjusted by maternal age and parity) delivery units (Fig. 1). The OASIS rates in the mid-sized units showed no differences, and they were merged in one group and used as a reference group. In the largest units the risk of OASIS was elevated both in instrumental (OR 1.26, 95% CI 1.10–1.45) and in non-instrumental vaginal deliveries (OR 1.64, 95% CI
Comments
In Finland the total OASIS rate has increased and obstetric practices have changed markedly during the last decade. Obstetric practices have been reported to contribute strongly to the risk of OASIS [1], [22]. The present study showed that the risk of OASIS also depended on hospital size. The trend in Finland has been towards fewer but larger delivery units. Hemminki et al. questioned this, reporting no significant benefits from centralizing births, if high-risk pregnancies are successfully
Acknowledgements
Apart from the authors stated on the title page no other person, agency or institution has participated in the study. None of the authors have any potential conflicts of interest to be disclosed. There was no special funding for the study.
References (23)
- et al.
Risk factors for perineal injury during delivery
Obstetrics and Gynecology
(2003) - et al.
Risk factors for third degree perineal ruptures during delivery
British Journal of Obstetrics and Gynaecology
(2001) Can we reduce the caesarean section rate?
Best Practice and Research. Clinical Obstetrics and Gynaecology
(2001)- et al.
Hospital-based lateral episiotomy and obstetric anal sphincter injury rates: a retrospective population-based register study
American Journal of Obstetrics and Gynecology
(2012) Health at a glance 2011: OECD indicators
(2011)- et al.
Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair
BMJ
(1994) - et al.
Anal incontinence after vaginal delivery: a five-year prospective cohort study
Obstetrics and Gynecology
(2004) - et al.
The role of mediolateral episiotomy during labour. Analysis of risk factors for obstetric anal sphincter tears
Acta Obstetricia et Gynecologica Scandinavica
(2006) - et al.
Episiotomy characteristics and risks for obstetric anal sphincter injuries: a case–control study
BJOG
(2012) - et al.
Prevalence and risk factors for third- and fourth-degree perineal lacerations during vaginal delivery: a multi-country study
BJOG
(2012)
Characteristics associated with severe perineal and cervical lacerations during vaginal delivery
Obstetrics and Gynecology
Cited by (10)
Episiotomy and severe perineal trauma among Eastern African immigrant women giving birth in public maternity care: A population based study in Victoria, Australia
2017, Women and BirthCitation Excerpt :In general, the use of episiotomy and perineal tear are considered as measurable indicators of the quality of maternity care.23 For example, severe perineal trauma (third and fourth degree tear) is routinely included in the reports of the Organization for Economic Co-operation and Development as a quality care indicator,24 and in the performance Indicator reports published by a number of countries.25–29 The use of episiotomy and occurrence of perineal tear has rarely been examined however, for international migrants in developed countries, despite increasing international migration, and substantially increased numbers of births to immigrants.
Effectiveness of episiotomy to prevent OASIS in nulliparous women at term
2023, International Journal of Gynecology and ObstetricsA step towards better audit: The Robson Ten Group classification system for outcomes other than cesarean section
2022, Acta Obstetricia et Gynecologica ScandinavicaThe Great Divide: Country of birth as a risk factor for obstetric anal sphincter injuries
2018, Australian and New Zealand Journal of Obstetrics and GynaecologyVariations in rates of severe perineal tears and episiotomies in 20 European countries: a study based on routine national data in Euro-Peristat Project
2016, Acta Obstetricia et Gynecologica Scandinavica