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Background: Various interventions have been applied to reduce perineal trauma and obstetric anal sphincter injuries (OASIS). The efficacy of warm compresses during the second stage of labor for reducing the occurrence of perineal tears is controversial., Objective: We aimed to compare rates of spontaneous perineal tears requiring suturing, between women who received warm compresses plus perineal massage vs perineal massage alone., Study Design: Women admitted to a single tertiary university-affiliated hospital between June 2023 and January 2024 were randomized to receive warm compresses and perineal massage (n=206) or perineal message only (n=206) during the second stage of labor. Excluded were women with a history of third-degree perineal tear, nut allergy, fetal death, Crohn's disease with perineal involvement, or delivery number >5. Participant allocation was concealed until the second stage of labor. The allocated perineal management was implemented at the time of active fetal descent and when the participant felt the need to push. During active maternal pushing, gentle perineal massage with almond oil was performed in both study groups. In 1 group, warm compresses were applied between contractions, for a minimum of 10 minutes and a maximum of 30. The temperature of the warm compresses was kept in the range of 45°C to 59°C. The perineum was protected during delivery with a hands-on technique. After delivery, the perineum was assessed by an intervention-blinded senior midwife and rectal examination was performed for ruling out OASIS. The primary outcome was the rate of perineal tears requiring suturing. Secondary outcomes included the rates of OASIS and episiotomies. A sub-analysis according to parity and an intention-to-treat analysis were performed., Results: Similar proportions of women treated and not treated with warm compresses had spontaneous perineal tears requiring suturing: 43.7% vs 45.1%, P value=.766. The groups did not differ in the proportions with first-degree tears, 22.8% vs 21.4%, P value=.722; second-degree tears, 21.4% vs 23.8%, P value=.566; and OASIS rates, 0.5% in each. In a sub-analysis according to parity, the proportion with perineal tears did not differ between the 2 groups., Conclusion: For women treated during the second stage of labor with warm compresses and perineal massage, compared to perineal massage alone, the rate of spontaneous perineal tears requiring suturing was similar. El resumen está disponible en Español al final del artículo., Competing Interests: Declaration of competing interest The authors declare no conflicts of interest related to this work., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Objective: The purpose of this guideline is to promote recognition and preventive strategies for obstetrical anal sphincter injuries. Furthermore, it provides guidance on primary repair and immediate postpartum management for obstetrical anal sphincter tears in order to minimize further negative sequelae., Target Population: All patients having a vaginal delivery and those who have sustained an obstetrical anal sphincter injury., Outcomes: Certain preventive strategies have been associated with lower rates of obstetrical anal sphincter injuries (e.g., fetal head flexion and control, appropriate use of mediolateral episiotomy). Management strategies, including appropriate diagnosis and repair of obstetrical anal sphincter injuries, antibiotic prophylaxis, and bowel and bladder function management can decrease associated short- and long-term complications., Benefits, Harms, and Costs: Implementation of the recommendations in this guideline may increase detection, prevention, and appropriate management of obstetrical anal injuries, thus limiting the future burden associated with these injuries. Implementation of the recommended classification of obstetrical anal sphincter injuries will improve national and international research efforts., Evidence: Published literature was retrieved through searches of PubMed, Ovid, Medline, Embase, Scopus, and the Cochrane Library from September 1, 2014, through November 30, 2023, using appropriate MeSH terms (delivery, obstetrics, obstetric surgical procedures, obstetric labor complications, anal canal, episiotomy) and keywords (OASIS, obstetrical anal sphincter injury, anal injury, anal sphincter, vaginal delivery, suture, fecal incontinence, anal incontinence, overlap repair, end-to-end repair, bladder protocol, analgesia). Results were restricted to systematic reviews, meta-analyses, randomized controlled trials/controlled clinical trials, observational studies, and clinical practice guidelines. Results were limited to English- or French-language materials. Evidence was supplemented with references from the 2015 Society of Obstetricians and Gynaecologists of Canada guideline no. 330., Validation Methods: The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional recommendations)., Intended Audience: Obstetrical care providers., Tweetable Abstract: Updated Canadian guideline on recognition, prevention and management of obstetrical anal sphincter injuries (OASIS)., Summary Statements: RECOMMENDATIONS., (Copyright © 2024. Published by Elsevier Inc.)

Introduction and Hypothesis: Guidelines recommend episiotomy for instrumental vaginal delivery with an optimal incision angle of 60° to protect the anal sphincter. The "Episiometer" is a new device promising a 60° incision angle. We compared the incidence of obstetric anal sphincter injury (OASI) and post-repair suture angle of episiotomies made with conventional "eyeballing" versus Episiometer guided during instrumental delivery., Methods: We conducted this randomized controlled trial in a tertiary care teaching institute in southern India after ethical committee approval, trial registration, and informed consent. We randomized (block) 328 pregnant women aged 18 years and above with term, singleton fetuses delivered by instruments into Episiometer-guided (164) or conventional episiotomy (164) groups (allocation concealed). We compared the OASI (identified clinically) and the suture angle measured from the midline (assessor blinded) in the two groups. We followed up on the subjects at 6 and 12 weeks to assess perineal pain and fecal/flatus incontinence., Results: The incidence of OASI of 0.61% in the Episiometer group was significantly lower compared with 4.88% in the eyeballing group (Chi-squared = 5.6; p = 0.02; adjusted risk ratio = 5.9; CI 0.7-46.1; p = 0.09). A significantly higher proportion of subjects (59.1%) in the Episometer group had a post-suture angle between 36 and 40° compared with 36.6% in the eyeballing group (Chi-squared = 21.8, p < 0.001). We found no significant difference in the perineal pain or Wexner score during follow-up., Conclusion: The Episiometer-guided episiotomy during instrumental delivery resulted in a significantly higher suture angle and lower obstetric anal sphincter injuries than with conventional eyeballing., Competing Interests: Declarations. Ethics Approval: Institute Ethics Review Board approval was given. Approval certificate number IEC: JIP/IEC/2020/086. Approved by the Jawaharlal Institute of Postgraduate Medical Education and Research Ethics Committee, JIPMER. Puducherry, India. Conflicts of Interest: The authors declare that there are no conflicts of interest. None of the authors has any disclosures to make., (© 2024. The International Urogynecological Association.)

Background: Birth tears are common after vaginal birth with a prevalence of up to 85%, especially in vaginal-assisted births. Because birth trauma can cause physical and psychological short-term and long-term maternal morbidity, it is essential to improve maternal outcomes at birth., Objective: This study aimed to evaluate the effect of a perineal protection device on the rate of spontaneous birth tears in the posterior compartment in vacuum-assisted births and the feasibility and safety of the device., Study Design: In a prospective, randomized controlled interventional trial from July 2020 to October 2022, we evaluated the application of a perineal protection device in vacuum-assisted vaginal births in a tertiary care center. A total of 1998 patients were asked to participate, and 1574 patients with singletons at ≥36 weeks of gestation gave their informed consent before birth. Ultimately, 209 were included according to a power calculation, performed in advance, with a statistical power of 80% and a significance level of 5% for an expected reduction in the rate of the primary composite outcome of 20%. The primary composite outcome was the rate of low-grade perineal and/or vaginal tears in the posterior compartment. Secondary outcomes were the rate of high-grade perineal tears and episiotomies, the feasibility of the device, and its safety for the mother and child. Descriptive statistics and a logistic regression analysis were performed in an intention-to-treat, a per-protocol, and an as-treated analysis, using SPSS, version 29.0.0.0, and R. A P value of <.05 was considered statistically significant., Results: Of the 1574 patients, 249 (15.8%) had an indication for vacuum-assisted vaginal birth, and 217 (13.8%) of those were randomized. An addition 8 patients (0.5%) were excluded because the birth ended without vacuum assistance. Of the remaining 209 patients, 105 formed the intervention group (application of the device), whereas 104 formed the control group (without application of the device). No differences in primary and secondary outcomes were found in the intention-to-treat and per-protocol analysis. In the intention-to-treat analysis, 79 patients (75.2%) in the intervention group and 73 patients (70.2%) in the control group (P=.4) met the primary endpoint. In the per-protocol analysis, the primary composite outcome was seen 53 patients (77.9%) in the intervention group and in 73 patients (70.2%) in the control group (P=.27). For the as-treated analysis, 68 of the 105 patients (65%) remained in the intervention group after exclusion of 37 (35%) patients with failed application of the device. Consequently, 141 formed the control group. In the as-treated analysis, there was also no difference in the primary composite outcome between the 2 groups (53 patients [77.9%] in the intervention group and 99 patients [70.2%] in the control group). However, within the secondary outcomes, we found a significantly lower rate of mediolateral episiotomies in the intervention group (29% vs 45%; P=.034). No adverse outcomes for the mother and child were seen. In one-third of cases, the device was difficult to place correctly and/or to keep correctly in place., Conclusion: The perineal protection device was not able to reduce the primary composite outcome of the study among women who gave birth by vacuum assistance. Although this was not the primary end point, a lower rate of mediolateral episiotomies was observed when the device was used correctly. As a limitation, difficulties with the application of the device occurred in 33% of cases. Nevertheless, no adverse events in association with the device were observed for either mother or child in our cohort., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: To assess the association between the decrease in the use of episiotomy and the incidence of obstetric anal sphincter injuries (OASIS) over a 10-year period and understand their reasons by interviewing obstetricians and midwives., Design: Mixed-methods study., Setting: A tertiary university public maternity hospital, Paris, France., Population: All patients who delivered vaginally between January 2012 and December 2021 in the maternity hospital and 20 interviews with obstetrician-gynaecologists and midwives., Methods: Quantitative data analysis using a multivariate logistic regression model, stratifying on the mode of delivery. Semi-structured interview with 20 obstetricians and midwives, with an interview guide., Main Outcome Measures: Obstetric anal sphincter injuries., Results: The quantitative study of 37 942 women (16.1% of whom had an episiotomy and 1.4% OASIS) shows that, the incidence of episiotomy decreased from 25% to 7.6% over this 10-year period. Allow on the known risk factors for OASIS, we demonstrate that its incidence rose (adjusted odds ratio 1.35, 95% confidence interval 1.09-1.67) for the years in which the episiotomy incidence fell below 10% for the overall population. The interviews showed professionals' apparent awareness that the decreased incidence in episiotomy (achieved by changes in departmental policy, redefining its benefit/risk balance and acquiring new skills to manage the expulsion phase) could lead to an increased incidence of OASIS., Conclusions: Decreasing the episiotomy incidence appears to be associated with a rising incidence of OASIS. The optimal incidence of episiotomy remains controversial in the literature and among professionals., (© 2024 The Author(s). BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)

Background: Perineal trauma after vaginal birth is common and can be associated with short- and long-term health problems. Perineal hyaluronidase (HAase) injection has been widely used to reduce perineal trauma, perineal pain and the need for episiotomy since the 1950s. The administration of HAase is considered to be a simple, low risk, low cost and effective way to decrease perineal trauma without causing adverse effects., Objectives: To assess the effectiveness and safety of perineal HAase injection for reducing perineal trauma, episiotomy and perineal pain during vaginal delivery., Search Methods: To identify studies for inclusion in this review, we searched the Cochrane Central Register of Controlled Trials, Ovid MEDLINE, Embase, CINAHL (EBSCOhost), ClinicalTrials.gov and WHO International Clinical Trials Registry Platform (ICTRP) in November 2023., Selection Criteria: Randomised and quasi-randomised controlled trials comparing women giving birth to their first baby receiving perineal HAase injection compared to placebo injection or no intervention during vaginal delivery of a single foetus with vertex foetal presentation (foetus with head engaging the maternal pelvis)., Data Collection and Analysis: We used standard methodological procedures expected by Cochrane. Two review authors independently assessed trials for inclusion, extracted and checked data, and evaluated the risk of bias in the studies. Our primary outcomes were perineal trauma (tears or episiotomy, or both), episiotomy and perineal pain. Our secondary outcomes were first and second degree perineal lacerations, third and fourth degree perineal lacerations, perineal oedema 1 hour after vaginal delivery, perineal oedema 24 hours after vaginal delivery and neonatal Apgar scores of less than 7 at five minutes after birth (Apgar score is a measure of the health status of a newborn). We assessed the certainty of the evidence using the GRADE approach., Main Results: We included five randomised controlled trials involving a total of 747 women (data were available for 743 women). The dosage of HAase used in the perineal injection varied from 750 turbidity-reducing units to 5000 international units. The certainty of the evidence was largely low (ranging from very low to moderate). Perineal HAase injection versus placebo injection Data from three trials involving 426 women provided low-certainty evidence that there may be no difference between the HAase and placebo groups in the incidence of perineal trauma (tears or episiotomy, or both) (RR 0.94, 95% CI 0.87 to 1.03; 426 participants, 3 studies), episiotomy (RR 0.91, 95% CI 0.71 to 1.15; 427 participants, 3 studies), first and second degree perineal lacerations (RR 1.02, 95% CI 0.87 to 1.18; 341 participants, 3 studies), third and fourth degree perineal lacerations (RR 0.46, 95% CI 0.11 to 2.05; 426 participants, 3 studies), and perineal oedema one hour after vaginal delivery (RR 0.99, 95% CI 0.78 to 1.25; 303 participants, 2 studies). Moreover, perineal HAase injection during the second stage of labour likely resulted in a reduction in incidence of perineal oedema 24 hours after vaginal delivery compared with placebo injection (RR 0.42, 95% CI 0.26 to 0.70; 303 participants, 2 studies; moderate-certainty evidence). There may be no difference between groups in Apgar scores less than 7 at five minutes (RR 5.00, 95% CI 0.24 to 105.95; 148 participants, 1 study; low-certainty evidence). Perineal HAase injection versus no intervention Data from three trials involving 373 women suggested that perineal HAase injection during the second stage of labour may result in a lower incidence of perineal trauma (tears or episiotomy, or both) (RR 0.61, 95% CI 0.42 to 0.88; 373 participants, 3 studies; low-certainty evidence) compared with no intervention. The evidence is very uncertain for episiotomy (RR 0.79, 95% CI 0.44 to 1.42; 373 participants, 3 studies), first and second degree perineal lacerations (RR 0.59, 95% CI 0.30 to 1.18; 373 participants, 3 studies) and perineal oedema one hour after vaginal delivery (RR 0.32, 95% CI 0.01 to 7.71; 139 participants, 1 study), all very low certainty evidence. No third and fourth degree perineal lacerations, perineal oedema 24 hours after vaginal delivery or Apgar scores less than 7 at five minutes were reported in these three trials. No side effects were reported in the included trials., Authors' Conclusions: Perineal HAase injection during the second stage of labour may result in a lower incidence of perineal trauma (tears or episiotomy, or both) compared with no intervention, but not compared with placebo injection, in women having a vaginal delivery. Meanwhile, perineal HAase injection likely reduces the incidence of perineal oedema 24 hours after vaginal delivery compared with placebo injection. The potential use of perineal HAase injection as a method to reduce perineal trauma and perineal oedema remains to be determined as the number of high-quality trials and outcomes reported was too limited to draw conclusions on its effectiveness and safety. Further rigorous randomised controlled trials are required to evaluate the role of perineal HAase injection in vaginal deliveries, including evaluating whether there is any differential effect based on the dose, frequency and positioning of HAase injection., (Copyright © 2024 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.)

Rationale: Postpartum haemorrhage (PPH) is responsible for around 27% of global maternal deaths. Perineal tears are common in vaginal births and a significant contributor to excessive blood loss. A diversity of perineal techniques are utilised to prevent perineal trauma and reduce the incidence of PPH; however, they lack evidence-based comparisons to understand their effects., Objectives: To assess the effect of perineal techniques during the second stage of labour on the incidence of and morbidity associated with perineal trauma to prevent postpartum complications., Search Methods: We searched four databases and two trial registers up to 16 April 2024. We checked references, searched citations and contacted study authors to identify additional studies., Eligibility Criteria: We included randomised controlled trials (RCTs) of women in the second stage of labour who intended to give birth vaginally, comparing any perineal techniques with control or another perineal technique. We excluded studies that performed perineal techniques outside the second stage of labour., Outcomes: Our critical outcomes were second-, third- and fourth-degree tears measured immediately after birth, and PPH ≥ 500 mL measured within 24 hours after birth., Risk of Bias: We used the Cochrane risk of bias 2 tool to assess bias in the included RCTs., Synthesis Methods: We synthesised results for each outcome within each comparison using meta-analysis where possible. Where this was not possible due to the nature of the data, we synthesised results narratively. We used GRADE to assess the certainty of evidence for each outcome., Included Studies: We included a total of 17 studies with 13,695 participants., Synthesis of Results: Hands off (or poised) versus hands on Hands off (poised) may result in little to no difference in second-degree tears (risk ratio (RR) 0.73, 95% confidence interval (CI) 0.32 to 1.64; 2 studies; low-certainty evidence) and third- or fourth-degree tears when data are combined (RR 1.27, 95% CI 0.81 to 1.99; 2 studies; low-certainty evidence). The evidence is very uncertain about the effect of hands off (poised) on third-degree tears and fourth-degree tears when reported separately (RR 0.50, 95% CI 0.05 to 5.27; 1 study; very low-certainty evidence and RR 3.00, 95% CI 0.13 to 71.22; 1 study; very low-certainty evidence). Hands off (poised) may result in little to no difference in PPH ≥ 500 mL (RR 1.16, 95% CI 0.92 to 1.47; 1 study; low-certainty evidence). Hands off (poised) probably results in little to no difference in breastfeeding two days after birth (RR 1.02, 95% CI 0.99 to 1.06; 1 study; moderate-certainty evidence) and perineal pain (RR 0.98, 95% CI 0.94 to 1.01; 1 study; moderate-certainty evidence). Vocalisation versus control Vocalisation may result in a reduction in second-degree tears (RR 0.56, 95% CI 0.23 to 1.38; 1 study; low-certainty evidence) and third-degree tears (RR 0.13, 95% CI 0.01 to 2.32; 1 study; low-certainty evidence), but the CIs are wide and include the possibility of no effect. No events were reported for fourth-degree tears (low-certainty evidence). Vocalisation may increase maternal satisfaction (RR 1.19, 95% CI 0.93 to 1.51; 1 study; low-certainty evidence). The evidence is very uncertain about the effect of vocalisation on perineal pain (RR 1.44, 95% CI 0.81 to 2.58; 1 study; very low-certainty evidence). Warm compress on the perineum versus control (hands off or no warm compress) Warm compress on the perineum may result in little to no difference in second-degree tears (RR 0.94, 95% CI 0.72 to 1.21; 2 studies; low-certainty evidence), but likely results in a reduction in third- or fourth-degree tears (RR 0.46, 95% CI 0.27 to 0.79; 3 studies; moderate-certainty evidence). Evidence from two smaller studies is very uncertain about the effect of warm compress on the perineum on third-degree tears (RR 0.51, 95% CI 0.04 to 7.05; 2 studies; very low-certainty evidence) or fourth-degree tears (RR 0.11, 95% CI 0.01 to 2.06; 2 studies; very low-certainty evidence) when reported separately. Warm compress likely results in a large reduction in perineal pain (mean difference (MD) -0.81, 95% CI -1.18 to -0.44; 1 study; moderate-certainty evidence). The evidence is very uncertain about the effect of warm compress on the perineum on maternal satisfaction and PPH ≥ 500 mL. Massage of the perineum versus control (hands off or no usual care) Massage of the perineum may have little to no effect on second-degree tears (RR 1.04, 95% CI 0.89 to 1.21; 4 studies; low-certainty evidence). The evidence is very uncertain about the effect of massage of the perineum on third-degree tears (RR 0.57, 95% CI 0.16 to 2.02; 4 studies; very low-certainty evidence). Massage of the perineum may reduce fourth-degree tears but the CIs are wide and include the possibility of no effect (RR 0.26, 95% CI 0.04 to 1.61; 4 studies; low-certainty evidence). The evidence suggests that massage likely results in little to no difference in perineal pain (RR 0.97, 95% CI 0.90, 1.05; 1 study; moderate-certainty evidence). One study reported 10 participants with postpartum haemorrhage across three interventions (warm compress, massage, control). Combined warm compress and massage of the perineum versus control Combined warm compress and massage of the perineum likely results in a reduction in second-degree tears when compared to a control (RR 0.63, 95% CI 0.46 to 0.86; 1 study; moderate-certainty evidence), but the evidence is very uncertain about the effect on third-degree tears (RR 2.92, 95% CI 0.12 to 70.72; 1 study; very low-certainty evidence). The intervention may result in a reduction in PPH ≥ 500 mL but the CIs are wide and include the possibility of no effect (RR 0.43, 95% CI 0.14 to 1.35; 1 study; low-certainty evidence). Combined warm compress and massage likely results in an increase in maternal satisfaction (MD 0.4, 95% CI -0.01 to 0.81; 1 study; moderate-certainty evidence). Combined warm compress and massage of the perineum versus massage alone Combined warm compress and massage of the perineum may result in little to no difference in second-degree tears (RR 0.95, 95% CI 0.86 to 1.06; 1 study; low-certainty evidence) when compared to massage alone, but the evidence is very uncertain about the effect on third- or fourth-degree tears (RR 0.98, 95% CI 0.06 to 15.49; 1 study; very low-certainty evidence). It may also result in little to no difference in PPH ≥ 500 mL (RR 1.10, 95% CI 0.59 to 2.07; 1 study; low-certainty evidence). The evidence suggests that combined warm compress and massage may result in little to no difference in maternal satisfaction (1 study; low-certainty evidence). Other perineal techniques We also assessed evidence on the following comparisons, but since they are used less frequently in global clinical practice to optimise birth outcomes, we have not presented the results summary here: Ritgen's manoeuvre versus standard care; primary delivery of posterior versus anterior shoulder; massage with enriched oil on the perineum versus massage with liquid wax; petroleum jelly on the perineum versus control; and perineal protection device versus control., Authors' Conclusions: Overall, the evidence for the effectiveness of perineal techniques to reduce perineal trauma and postpartum haemorrhage is very uncertain. Very few studies reported rates of postpartum haemorrhage, adverse events, women's or health workers' experience or other important outcomes that allow us to understand the effectiveness and acceptability of perineal techniques to reduce perineal trauma. Prior to any further large trials, research is needed to clarify the types of interventions, including a clear description of the process of development and involvement of relevant stakeholders. There is a need to clarify how the intervention is proposed to achieve its effects. Trials would benefit from process evaluation alongside, to explore context, mechanisms and effects., Funding: This Cochrane review was funded (in part) by WHO (APW 2024/1475460). TF, VL and the CIDG editorial base are funded by UK aid from the UK government for the benefit of low- and middle-income countries (project number 300342-104). The views expressed do not necessarily reflect the UK government's official policies., Registration: Registration and protocol: PROSPERO, CRD42024537252. Available from: https://www.crd.york.ac.uk/prospero/display&#95;record.php?ID=CRD42024537252., (Copyright © 2024 The Authors. Cochrane Database of Systematic Reviews published by John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration.)

Skin tears are common injuries that result from mechanical forces. Older people with fragile skin are at greater risk of this type of wound. They are usually categorised as acute wounds that typically heal in 7-21 days but the healing process can be disrupted, leading to chronic, non-healing wounds. They have the potential to compromise quality of life and disrupt daily activities, so it is important to identify risk factors and implement prevention strategies for those at risk. An interdisciplinary approach has a pivotal role in promptly and precisely identifying skin tears, and the use of evidence-based interventions for efficient skin damage management can enhance the recovery process. This article adopts a case study approach to explore the prevention, evaluation and treatment of skin tears, using the case of an individual living with a skin tear in a community setting., Competing Interests: None declared, (© 2024 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Background: There is a growing body of evidence indicating that second-degree tears cause both short- and long-term consequences. Very few preventative measures have been found to reduce the incidence of these tears., Objective: This study aimed to investigate whether the use of a perineal protection device during vaginal birth reduces severe perineal tearing (grade ≥2 tear) in primiparous women compared with routine manual perineal support., Study Design: A single-center randomized controlled trial was conducted in Sweden from 2019 to 2021. Primiparous women at term were randomly allocated to the intervention group (n=43), where a perineal protection device was used, or to the routine care group (n=49). The primary outcome was grade of perineal tear. The secondary outcomes were vaginal and labial tearing. Continuous data were analyzed using the Student t test or Mann-Whitney U test. Dichotomous data were analyzed using the Pearson X 2 test, Fisher exact test, and ordinal logistic regression., Results: Women in the intervention group had a significantly lower risk of sustaining more extensive perineal tearing than those in the control group. The use of the perineal protection device decreased the risk of grade ≥2 tears in relation to grade 0 to 1 tears (odds ratio, 0.40; 95% confidence interval, 0.17-0.94). Ordinal logistic regression analyses revealed an odds ratio of 0.36 (95% confidence interval, 0.16-0.81) per incremetn of grade injury using the perineal protection device vs routine care (P=.013). The number needed to treat using the perineal protection device was 4.3 to avoid 1 grade ≥2 tear. Women in the treatment group showed less labial tearing (P=.016). No adverse effect was detected., Conclusion: The use of a perineal protection device reduced the risk of grade ≥2 perineal tearing by 60% and labial tearing. El resumen está disponible en Español al final del artículo., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objective: This study aimed to evaluate if induction of labor (IOL) is associated with an increased risk of severe perineal laceration., Data Sources: A systematic search was conducted in MEDLINE, Ovid, Scopus, ClinicalTrials.gov, Cochrane Central Register of Controlled Trials, and CINHAL using a combination of keywords and text words related to "induction of labor," "severe perineal laceration," "third-degree laceration," "fourth-degree laceration," and "OASIS" from inception of each database until January 2023., Study Eligibility Criteria: We included all randomized controlled trials (RCTs) comparing IOL to expectant management of a singleton, cephalic pregnancy at term gestation that reported rates of severe perineal laceration., Study Appraisal and Synthesis and Methods: The primary outcome of interest was severe perineal laceration, defined as 3rd- or 4th-degree perineal lacerations. We conducted meta-analyses using the random effects model of DerSimonian and Laird to determine the relative risks (RR) or mean differences with 95% confidence intervals (CIs). Bias was assessed using guidelines established by Cochrane Handbook for Systematic Reviews of Interventions., Results: A total of 11,187 unique records were screened and ultimately eight RCTs were included, involving 13,297 patients. There was no statistically significant difference in the incidence of severe perineal lacerations between the IOL and expectant management groups (209/6655 [3.1%] vs 202/6641 [3.0%]; RR 1.03, 95% CI 0.85, 1.26). There was a statistically significant decrease in the rate of cesarean birth (1090/6655 [16.4%] vs 1230/6641 [18.5%], RR 0.89, 95% CI 0.82, 0.95) and fetal macrosomia (734/2696 [27.2%] vs 964/2703 [35.7%]; RR 0.67: 95% CI 0.50, 0.90) in the IOL group., Conclusion: There is no significant difference in the risk of severe perineal lacerations between IOL and expectant management in this meta-analysis of RCTs. Furthermore, there is a lower rate of cesarean births in the IOL group, indicating more successful vaginal deliveries with similar rates of severe perineal lacerations. Patients should be counseled that in addition to the known benefits of induction, there is no increased risk of severe perineal lacerations., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Purpose: Injuries of the nasal vestibular skin caused by the rotating burr shafts can represent a tedious complication following endonasal drilling and is experienced sooner or later by every rhino-surgeon., Material and Methods: To protect the nasal entrance from laceration by the free rotating drill shaft we position an otology speculum in the nasal entrance. The speculum is held in place by the scrub nurse during the critical phase of bone drilling., Results: Following the introduction of the ear speculum protection, we successfully treated our dacryocystostamia procedures (n = 27) and median maxillectomia procedures (n = 6) without any further soft tissue erosions., Discussion: Preventive measures for injuries by endonasal drilling procedures are not reported extensively in literature. This stands in contrast to the fact that these injuries are prone to cause significant suffering as amply described in the case of nostril laceration due to nasogastric intubation or nasogastric feeding tubes., Conclusion: The use of a readily available, reusable ear speculum in endonasal drill application eliminated the complication of nasal entrance lacerations throughout our institution, hitherto., Competing Interests: Declaration of competing interest All authors declare that they do neither have a conflict of interest nor items on the financial disclosure, (Copyright © 2024 Elsevier Inc. All rights reserved.)

Skin tears are a major problem for patients and the health care professionals who treat them. Although opinions on their prevalence differ, it is estimated that they are encountered more frequently than pressure sores but are overlooked. Recommendations based on strong evidence were presented for the prevention and treatment of skin tears as classified by the International Skin Tear Advisory Panel. This case series includes the clinical status of 3 patients who developed skin tears while receiving care in the hospital, and the corrective and preventive practices related to skin tears. This article will contribute to raising the awareness of health care professionals in predicting, preventing, evaluating, and treating skin tears., (Copyright © 2024 Wolters Kluwer Health, Inc. All rights reserved.)

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., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: funding from the Swedish Research Council (2016-00526), the Stockholm Region (FoUI-960261/2021), and the Uppsala-Örebro Research Council (RFR-939428); no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: The complex process of pregnancy and childbirth significantly influences the well-being of both mother and child. Today all pregnant women without medical contraindications are recommended to start or continue regular aerobic and strength training for at least 150 min per week to prevent pregnancy-related diseases and conditions. Urinary incontinence in pregnancy, episiotomy and third- or fourth-degree perineal tear during labor can greatly impact womens' health, quality of life and ability to be physically active. The aim of this study was to examine the efficacy of pelvic floor muscle training (PFMT) during pregnancy in the prevention of urinary incontinence, episiotomy, and third- or fourth-degree perineal tear., Material and Methods: A systematic review and meta-analysis (CRD42022370600) was performed. Only randomized clinical trials published between 2010 and 2023 were included. The following databases were examined: EBSCO (including Academic Search Premier, Education Resources Information Center, MEDLINE, SPORTDiscus and OpenDissertations databases), Clinicaltrials.gov, Web of Science, Scopus, Cochrane Database of Systematic Reviews and Physiotherapy Evidence Database (PEDro). Three meta-analyses to investigate the effect of PFMT exclusively or implemented as a section within a physical activity program during pregnancy on urinary incontinence, episiotomy, and third- or fourth-degree perineal tear were conducted., Results: Thirty studies were analyzed (N = 6691). An effective preventive action of PFMT was found for urinary incontinence (z = 3.46; p < 0.0005; relative risk [RR] = 0.72, 95% confidence interval [CI]: 0.59, 0.87, I 2  = 59%) and third- or fourth-degree perineal tear (z = 2.89; p = 0.004; RR = 0.50, 95% CI: 0.31, 0.80, I 2  = 48%) but not for episiotomy (z = 0.80; p = 0.42; RR = 0.95, 95% CI: 0.85, 1.07, I 2  = 75%)., Conclusions: PFMT during pregnancy proves to be an effective preventive intervention for reducing the risk of urinary incontinence and the occurrence of third- or fourth-degree perineal tears. These findings highlight the importance of incorporating PFMT into antenatal care and training programs to improve maternal well-being and overall childbirth outcomes., (© 2023 The Authors. Acta Obstetricia et Gynecologica Scandinavica published by John Wiley & Sons Ltd on behalf of Nordic Federation of Societies of Obstetrics and Gynecology (NFOG).)

Pelvic floor dysfunction (PFD) is common to be associated with pregnancy and birth. To date, no research has been done to understand whether the perineal massage and warm compresses technique has an impact on pelvic floor dysfunction. To assess the impact of perineal massage and warm compresses technique during the second stage of labor in pelvic floor dysfunction at 3 and 6 months postpartum. Of the 800 women recruited to randomised controlled trial to prevent perineal trauma, 496 were included in the study, with 242 (48.8%) assigned to the Perineal Massage and Warm Compresses (PeMWaC) group and 254 (51.2%) to the control group (hands-on). Used the Pelvic Floor Distress Inventory-20 (PFDI-20). The questionnaire is divided into three subscales: Urinary (UDI), Colorectal-Anal (CRADI), and Pelvic Organ Prolapse Distress Inventory (POPDI). The PeMWaC group had a significantly higher frequency of intact perineum (p < 0.001) and low-severity vaginal tears (tears without any other degree of perineal trauma) (p = 0.031) compared to the control group, while the control group had significantly more patients who suffered high-severity vaginal/perineal trauma (second degree perineal tears) (p = 0.031) and patients without spontaneous perineal trauma or vaginal tears who underwent episiotomy (p < 0.001). In addition, at 3 months postpartum, women in the control group had a higher Urinary Distress Inventory (UDI) score and global score, compared to the PeMWaC group, and after controlling for confounding variables, the perineal massage and warm compresses technique was associated with lower UDI scores at 3 months postpartum compared to control group. At 6 months postpartum, there were no differences in the UDI or global scores, indicating general recovery from perineal trauma. In addition to reducing perineal trauma during birth, the perineal massage and warm compresses technique was associated with a lower prevalence of early PFD symptoms, mainly urinary distress, at 3 months.Trial registration http://www.ClinicalTrials.gov NCT05854888, retrospectively registered., (© 2023. The Author(s), under exclusive licence to Society for Reproductive Investigation.)

Objective: Obstetric anal sphincter injuries are feared perineal injuries that are associated with increased pelvic floor disorders. The knowledge of influencing factors as the mode of delivery is therefore important. The aim of this study is to compare the rate of obstetric anal sphincter injuries in primiparae after water and bed deliveries., Study Design: In this retrospective cohort study 3907 primiparae gave birth in water or on a bed in a Swiss teaching hospital. The diagnosis of obstetric anal sphincter injuries was confirmed by a consultant of obstetrics and gynecology and treated by them. The rates of these injuries after water and bed births were compared. Subgroup analysis was performed to detect possible associative factors, such as birth weight, episiotomy, use of oxytocin in first and second stage of labor., Results: 1844 (47.2 %) of the primiparae had a water delivery and 2063 (52.8 %) a bed delivery. 193 (4.94 %) were diagnosed with obstetric anal sphincter injuries, of which 68 (3.7 %) had a water delivery and 125 (6.1 %) a bed delivery, p < 0.001. Subgroup analysis revealed that, in the first and second stage of labor, the rate of obstetric anal sphincter injuries with oxytocin was significantly lower in water than in bed deliveries; p = 0.025, p < 0.017, respectively. The rate of obstetric anal sphincter injuries in the birth weight or episiotomy subgroups did not reach significance., Conclusions: In a teaching hospital setting with standardized labor management, primiparae with a water delivery have the lowest risk for obstetric anal sphincter injuries., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%. The incidence of obstetrical anal sphincter injury is approximately 3%, with a significantly higher rate in primiparous than in multiparous women (6% vs 2%). Obstetrical anal sphincter injury is a significant risk factor for the development of anal incontinence, with approximately 10% of women developing symptoms within a year following vaginal birth. Obstetrical anal sphincter injuries have significant medicolegal implications and contribute greatly to healthcare costs. For example, in 2013 and 2014, the economic burden of obstetrical anal sphincter injuries in the United Kingdom ranged between £3.7 million (with assisted vaginal birth) and £9.8 million (with spontaneous vaginal birth). In the United States, complications associated with trauma to the perineum incurred costs of approximately $83 million between 2007 and 2011. It is therefore crucial to focus on improvements in clinical care to reduce this risk and minimize the development of perineal trauma, particularly obstetrical anal sphincter injuries. Identification of risk factors allows modification of obstetrical practice with the aim of reducing the rate of perineal trauma and its attendant associated morbidity. Risk factors associated with second-degree perineal trauma include increased fetal birthweight, operative vaginal birth, prolonged second stage of labor, maternal birth position, and advanced maternal age. With obstetrical anal sphincter injury, risk factors include induction of labor, augmentation of labor, epidural, increased fetal birthweight, fetal malposition (occiput posterior), midline episiotomy, operative vaginal birth, Asian ethnicity, and primiparity. Obstetrical practice can be modified both antenatally and intrapartum. The evidence suggests that in the antenatal period, perineal massage can be commenced in the third trimester of pregnancy to increase muscle elasticity and allow stretching of the perineum during birth, thereby reducing the risk of tearing or need for episiotomy. With regard to the intrapartum period, there is a growing body of evidence from the United Kingdom, Norway, and Denmark suggesting that the implementation of quality improvement initiatives including the training of clinicians in manual perineal protection and mediolateral episiotomy can reduce the incidence of obstetrical anal sphincter injury. With episiotomy, the International Federation of Gynecology and Obstetrics recommends restrictive rather than routine use of episiotomy. This is particularly the case with unassisted vaginal births. However, there is a role for episiotomy, specifically mediolateral or lateral, with assisted vaginal births. This is specifically the case with nulliparous vacuum and forceps births, given that the use of mediolateral or lateral episiotomy has been shown to significantly reduce the incidence of obstetrical anal sphincter injury in these groups by 43% and 68%, respectively. However, the complications associated with episiotomy including perineal pain, dyspareunia, and sexual dysfunction should be acknowledged. Despite considerable research, interventions for reducing the risk of perineal trauma remain a subject of controversy. In this review article, we present the available data on the prevention of perineal trauma by describing the risk factors associated with perineal trauma and interventions that can be implemented to prevent perineal trauma, in particular obstetrical anal sphincter injury., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Introduction and Hypothesis: Evidence suggests that episiotomies reduce the risk for obstetric anal sphincter injuries (OASIs) in operative vaginal deliveries (OVDs). However, there is limited evidence on the importance of episiotomy technique in this context. The primary objective of this study was to assess if an episiotomy suture angle >45° from the median line would be associated with a lower risk for OASIs at the time of OVD., Methods: This was an ancillary study from the multicentre prospective cohort INSTRUMODA study. Of the 2,620 patients who had an OVD with a concomitant episiotomy between April 2021 and March 2022, a total of 219 fulfilled the inclusion criteria. Post-suturing photographs were used to assess episiotomy characteristics., Results: Based on suture angles of ≤45° and >45° the study cohort was categorized into groups A (n = 155) and B (n = 64) respectively. The groups had comparable demographic and birth-related characteristics. The mean episiotomy length was significantly longer in group A than in group B (3.21 cm vs 2.84 cm; p = 0.009). Senior obstetricians performed more acute angled episiotomies than junior residents (p = 0.016). The total prevalence of OASIS was 2.3%, with no significant difference in rate of OASI between the two study groups. Birthweight was significantly higher in OASI births (p = 0.018) and spatula-assisted births were associated with higher risk for OASIs than ventouse or forceps (p = 0.0039)., Conclusions: This study did not demonstrate a significant reduction in risk for OASI at the time of OVD when the episiotomy suture angle was >45° from the median line. However, these results should be interpreted with caution owing to the low prevalence of OASIs in our cohort., (© 2023. The International Urogynecological Association.)

Skin tears are traumatic wounds caused by mechanical forces, which can be caused by the removal of adhesive dressing. Although they are common - especially in individuals with vulnerable skin, such as older people - their prevalence is underestimated, they are often misdiagnosed and they have a high risk of developing into complex, chronic wounds. However, skin tears are largely preventable. There are a number of intrinsic and extrinsic factors relating to skin tears and preventive strategies that may be undertaken. Health professionals, patients and caregivers/family members should aim to manage modifiable intrinsic and extrinsic factors to promote and maintain skin integrity to prevent skin tears. Where a skin tear does occur, an evidence-based approach should be taken to management, with referral to specialist care if necessary.

Skin tears are acute wounds caused by mechanical forces resulting in the separation of the skin's outer layers. Skin tears are more likely to occur in vulnerable people such as older people and people with neurodegenerative conditions. Rising life expectancy means that the number of patients with skin tears is expected to increase. This article describes the characteristics of skin tears, details the risk factors for skin tears and explains the importance of using a holistic, evidence-based and person-centred approach to skin tear prevention, assessment and treatment. The article outlines the crucial role of nurses as part of the multidisciplinary team in the management of skin tears., Competing Interests: None declared, (© 2023 RCN Publishing Company Ltd. All rights reserved. Not to be copied, transmitted or recorded in any way, in whole or part, without prior permission of the publishers.)

Background: Perineal lacerations could lead to substantial morbidities for women. A reliable prediction model for perineal lacerations has the potential to guide the prevention. Although several prediction models have been developed to estimate the risk of perineal lacerations, especially third- and fourth-degree perineal lacerations, the evidence about the model quality and clinical applicability is scarce., Objectives: To systematically review and critically appraise the existing prediction models for perineal lacerations., Methods: Seven databases (PubMed, Embase, The Cochrane Library, Cumulative Index to Nursing and Allied Health Literature, SinoMed, China National Knowledge Infrastructure, and Wanfang Data) were systematically searched from inception to July 2022. Studies that developed prediction models for perineal lacerations or performed external validation of existing models were considered eligible to include in the systematic review. Two reviewers independently conducted data extraction according to the Checklist for critical Appraisal and data extraction for systematic Reviews of prediction Modelling Studies. The risk of bias and the applicability of the included models were assessed with the Prediction Model Risk of Bias Assessment Tool. A narrative synthesis was performed to summarize the characteristics, risk of bias, and performance of existing models., Results: Of 4345 retrieved studies, 14 studies with 22 prediction models for perineal lacerations were included. The included models mainly aimed to estimate the risk of third- and fourth-degree perineal lacerations. The top five predictors used were operative vaginal birth (72.7 %), parity/previous vaginal birth (63.6 %), race/ethnicity (59.1 %), maternal age (50.0 %), and episiotomy (40.1 %). Internal and external validation was performed in 12 (54.5 %) and seven (31.8 %) models, respectively. 13 studies (92.9 %) assessed model discrimination, with the c-index ranging from 0.636 to 0.830. Seven studies (50.0 %) evaluated the model calibration using the Hosmer-Lemeshow test, Brier score, or calibration curve. The results indicated that most of the models had fairly good calibration. All the included models were at higher risk of bias mainly due to unclear or inappropriate methods for handling missing data and continuous predictors, external validation, and model performance evaluation. Six models (27.3 %) showed low concerns about applicability., Conclusions: The existing models for perineal lacerations were poorly validated and evaluated, among which only two have the potential for clinical use: one for women undergoing vaginal birth after cesarean delivery, and the other one for all women undergoing vaginal birth. Future studies should focus on robust external validation of existing models and the development of novel models for second-degree perineal laceration., Prospero Registration Number: CRD42022349786., Tweetable Abstract: The existing models for perineal lacerations during childbirth need external validation and updating. Tools are needed for second-degree perineal laceration., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier Ltd. All rights reserved.)

Background: Numerous interventions to reduce perineal trauma during childbirth have been studied in recent years, including perineal massage., Objective: To determine the efficacy of perineal massage during the second stage of labor to prevent perineal damage., Search Strategy: Systematic search in PubMed, Pedro, Scopus, Web of Science, ScienceDirect, BioMed, SpringerLink, EBSCOhost, CINAHL, and MEDLINE with the terms Massage, Second labor stage, Obstetric delivery, and Parturition., Selection Criteria: The articles must have been published in the last 10 years; the perineal massage was administered to the study sample; and the experimental design consisted of randomized controlled trial., Data Collection and Analysis: Tables were used to describe both the studies' characteristics and the extracted data. The PEDro and Jadad scales were used to assess the quality of studies., Main Results: Of the 1172 total results identified, nine were selected. Seven studies were included in the meta-analysis and indicated a statistically significant decreased number of episiotomies in perineal massage., Conclusions: Massage during the second stage of labor appears to be effective in preventing episiotomies and reducing the duration of the second stage of labor. However, it does not appear to be effective in reducing the incidence and severity of perineal tears., (© 2023 International Federation of Gynecology and Obstetrics.)

Background: Most women suffer from perineal trauma during childbirth, whether it is natural tears or episiotomy., Objectives: To perform a systematic review and network meta-analysis investigating the effectiveness of different PFMT relevant strategies in the prevention of perineal trauma., Search Strategy: PubMed, Embase, the Cochrane Library, CINAHL, CNKI, CBM, WANFANG DATABASE, and ClinicalTrials.gov were searched for citations published in any language from inception to 1 July 2021., Selection Criteria: Randomized controlled trials (RCTs) of PFMT relevant prevention strategies for preventing perineal trauma during childbirth., Data Collection and Analysis: Data were independently extracted by two reviewers. Relative treatment effects were estimated using network meta-analysis (NMA)., Main Results: Of 12 632 citations searched, 21 RCTs were included. Comparing with usual care, "PFMT combine with perineal massage" and PFMT alone showed more superiority in intact perineum (RR = 5.37, 95% CI: 3.79 to 7.60, moderate certainty; RR = 2.58, 95% CI 1.34-4.97, moderate certainty, respectively), episiotomy (RR = 0.26, 95% CI 0.14-0.49, very low certainty; RR = 0.63, 95% CI 0.45-0.90, very low certainty, respectively), and OASIS (RR = 0.35, 95% CI 0.16-0.78, moderate certainty; RR = 0.49, 95% CI 0.28-0.85, high certainty, respectively). "PFMT combine with perineal massage" showed superiority in reducing perineal tear (RR = 0.41, 95% CI 0.20-0.85, moderate certainty)., Conclusions: In view of the results, antenatal "PFMT combine with perineal massage" and PFMT were effective strategies for the prevention of perineal trauma., (© 2022. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Background: Periorbital laceration can result in complex, permanent scars, and even lead to serious complications such as cicatricial ectropion. Early intervention with laser devices has been suggested as a novel modality to reduce scar formation. However, no consensus exists regarding the optimal treatment parameters for scar management. This study evaluated the efficacy and safety of ultrapulse fractional CO 2 laser (UFCL) with different fluences and densities in preventing periorbital surgical scars., Objective: To assess the efficacy and safety of UFCL with different fluences and densities in the prevention of periorbital laceration scars., Methods: A prospective, randomized, blinded study was conducted on 90 patients with periorbital laceration scars of 2 weeks old. Four treatment sessions of UFCL were administered to each half of the scar at 4-week intervals, with halves treated with high fluences with low density versus low fluences with low-density treatment. Vancouver Scar Scale was used to assess the 2 portions of each individual scar at baseline, final treatment, and 6 months. The patient's 4-point satisfaction scale was used to evaluate the patient's satisfaction at baseline and 6 months. Safety was evaluated by registration of adverse events., Results: Eighty-two of 90 patients completed the clinical trial and follow-up. There was no significant difference in Vancouver Scar Scale and satisfaction score between different laser settings between the two groups ( P > 0.05). Adverse events were minor and no long-term side effects were noted., Conclusions: Early application of UFCL is a safe, strategy to significantly improve the final traumatic periorbital scar appearance. Objective evaluation of scars did not identify differences in scar appearance between high fluences with low density versus low fluences with low density of UFCL treatment., Level of Evidence: Level III., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 by Mutaz B. Habal, MD.)

Aim: To investigate the effectiveness of interventions to prevent the occurrence of perineal trauma in parturients., Methods: A bibliographic search was carried out in Cochrane Library, MEDLINE via PUBMED, LILACS via Virtual Health Library (VHL), Embase, Scopus, CINAHL, Scielo, Web of Science, and PEDro databases. Randomized clinical trials evaluating the effects of any intervention to prevent perineal trauma during pregnancy and/or childbirth were included. There were no temporal or language restrictions. The risk of bias assessment was performed using the Revised Cochrane Risk-of-bias Tool for Randomized Trials., Results: Fifty studies, with a total of 17,221 participants, were included in this meta-analysis. No intervention during childbirth was effective for the prevention of perineal trauma (RR = 1.07, 95% CI [0.98.1.18], p < 0.01, I 2  = 83%) when compared to no intervention. However, a lower risk of perineal laceration was verified with techniques performed during pregnancy, when compared to no intervention (RR = 0.81, 95% CI [0.71, 0.93], p = 0.05, I 2  = 47%). Among them, highlight the effects of perineal massage in preventing lacerations (RR = 0.69, 95% CI [0.54, 0.87], p < 0.01) when compared to no intervention., Conclusions: The techniques performed during pregnancy, especially perineal massage, are associated with a lower risk of perineal laceration., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Aim and Objective: To summarize the evidence on the effects of different techniques during the second stage of labour on reducing perineal laceration depending on available systematic reviews to provide optimal evidence for decision-making., Background: Preventing perineal laceration has been considered an important part of improving women's health. Various techniques have been used to prevent perineal laceration during the second stage of labour. However, systematic reviews evaluating the effects of different techniques on reducing perineal laceration show inconsistent results., Design: Overview of systematic reviews., Methods: Five English and four Chinese databases were systematically searched for relevant systematic reviews and meta-analyses published between 1 January 2016 and 31 August 2021. The quality of the included reviews was assessed by the AMSTAR 2 tool. A narrative synthesis was conducted to report the results of moderate-to-high quality systematic reviews. The overview was reported according to the PRISMA statement., Results: Eighteen reviews were included, of which four reviews had moderate-to-high methodological quality. Perineal massage and warm compresses significantly decreased the incidence of third- or fourth-degree perineal laceration (moderate-quality evidence). Hands-off technique had no impact on perineal laceration (low-to-moderate quality evidence). Ritgen's manoeuvre could reduce the incidence of first-degree perineal laceration but increase the incidence of second-degree perineal laceration (very low-quality evidence). Spontaneous pushing (low-quality evidence) and delayed pushing (moderate-quality evidence) had no impact on the incidence of third- or fourth-degree perineal laceration. Upright positions did not increase the risk of third- or fourth-degree perineal laceration (very low- to low-quality evidence) but increased the risk of second-degree perineal laceration for women without epidural analgesia (low-quality evidence)., Conclusions: Perineal massage and warm compresses could be the better choice for preventing perineal laceration in the second stage of labour., Relevance to Clinical Practice: Midwives and obstetricians could use perineal massage and warm compresses to prevent perineal laceration and should consider women's preferences and experience with perineal techniques., (© 2022 John Wiley & Sons Ltd.)

Background: A recent randomized controlled trial of prophylactic antibiotics for the prevention of infection following operative vaginal birth showed that women allocated prophylactic intravenous amoxicillin and clavulanic acid had a significantly lower risk of developing confirmed or suspected infection within 6 weeks after operative vaginal birth (risk ratio [RR], 0.58; 95% confidence interval [CI], 0.49-0.69; P < .001). Some international and national guidelines have subsequently been updated to include prophylactic antibiotics after operative vaginal birth. However, the generalizability of the trial results may be limited in settings where the episiotomy rate is lower (89% of women in the trial had an episiotomy). In addition, there was a high burden of infection in the prophylactic antibiotics group despite the administration of prophylactic antibiotics. It is essential to identify modifiable risk factors for infection after operative vaginal birth, including the timing of antibiotic administration., Objective: This study aimed to evaluate if the effectiveness of the prophylactic antibiotic in reducing confirmed or suspected infection was independent of perineal trauma, identify risk factors for infection after operative vaginal birth, and investigate variation in efficacy with the timing of antibiotic administration., Study Design: This study was a secondary analysis of 3225 women with primary outcome data from the prophylactic antibiotics for the prevention of infection following operative vaginal birth randomized controlled trial. Women were divided into subgroups according to the perineal trauma experienced (episiotomy and/or perineal tear). The consistency of the prophylactic antibiotics in preventing infection across the subgroups was assessed using log-binomial regression and the likelihood ratio test. Multivariable log-binomial regression was used to investigate factors associated with infection. The multivariable risk factor model was subsequently fitted to the group of women who received amoxicillin and clavulanic acid to investigate the timing of antibiotic administration., Results: Of the 3225 women included in the secondary analysis, 2144 (66.5%) had an episiotomy alone, 726 (22.5%) had an episiotomy and a tear, 277 (8.6%) had a tear alone, and 78 (2.4%) had neither episiotomy nor tear. Among women who experienced perineal trauma, amoxicillin and clavulanic acid administration was protective against infection in all subgroups compared with placebo with no significant interaction between subgroup and trial allocation (P=.17). Moreover, 2925 women were included in the multivariable risk factor analysis. The following were associated with adjusted risk ratios of infection: episiotomy, 2.94 (95% confidence interval, 1.62-5.31); forceps, 1.37 (95% confidence interval, 1.12-1.69) compared to vacuum extraction; primiparity, 1.34 (95% confidence interval, 1.05-1.70); amoxicillin and clavulanic acid administration, 0.60 (95% confidence interval, 0.51-0.72); body mass index of 25.0 to 29.9 kg/m 2 , 1.21 (95% confidence interval, 1.00-1.47), and body mass index of ≥30 kg/m 2 , 1.22 (95% confidence interval, 0.98-1.52) compared to body mass index of <25 kg/m 2 . Each 15-minute increment between birth and antibiotic administration was associated with a 3% higher risk of infection (adjusted risk ratio, 1.03; 95% confidence interval, 1.01-1.06)., Conclusion: Timely prophylactic antibiotics should be administered to all women after operative vaginal birth, irrespective of the type of perineal trauma. The use of episiotomy, forceps birth, primiparity, and overweight were associated with an increased risk of confirmed or suspected infection after operative vaginal birth., (Copyright © 2022 The Authors. Published by Elsevier Inc. All rights reserved.)

Objective: Obstetric anal sphincter injures (OASIS) have long-term implications on women's health. Administration of antibiotic prophylaxis and treatment following OASIS repair is controversial. We conducted a national survey to provide data about practice routines regarding antibiotic prophylaxis and treatment following OASIS repair in Israeli labor and delivery units., Methods: A national survey was performed among obstetricians and gynecologists from 24 university-affiliated delivery centers within the jurisdiction of the Israeli Ministry of Health during 2020. Representatives from each center completed the "Google form" electronic survey. For each questionnaire item, the most common answer was chosen to represent the center's answer., Results: The number of physicians who responded per center varied from 1 to 14 (median, 3.5). Preoperative and postoperative antibiotic treatment was given in 75% and 92% of the centers, respectively. While most centers (58.3%) recommend pelvic floor physical therapy on release, recommendations about functional radiologic tests vary. In all centers, there is a designated clinic for postpartum follow-up of OASIS. Most centers (83%) allow trial of vaginal delivery in the subsequent pregnancy, on an individual basis., Conclusion: Heterogeneity exists in managing OASIS in Israel, particularly regarding administration of antibiotics. Further studies are needed to examine the consequences of different management protocols., (© 2022 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Purpose: The primary aim of this study was to observe the change in obstetric anal sphincter tear rates in instrumental deliveries during one decade. Secondly, the changes in non-instrumental deliveries were followed., Methods: Data from all deliveries at Hudiksvall Hospital, Sweden 2010-2011 and 2016-2017 were collected. The change of OASIS rate during instrumental deliveries was the most important. Statistical significances were calculated by using chi-square test, test for relative proportions, and Students t-test, where appropriate., Results: The total incidence of OASIS decreased significantly (from 2.54% to 0.73%, p  < .001). Even the OASIS rate in instrumental deliveries decreased substantially from 15.1% to 3.0% ( p  = .002) but the decrease was statistically insignificant in spontaneous deliveries (from 1.22% to 0.60%, p  = .065)., Conclusion: Based on the results of our study the manual protection of the perineum reduces the risk of OASIS in instrumental delivery significantly.

Aim: To assess the effect of lubricants on reducing perineal trauma during vaginal delivery., Methods: PubMed, Embase, the Cochrane Library, CINAHL, China National Knowledge Infrastructure, China Biology Medicine disc, WanFang databases, and ClinicalTrials.gov, were searched for literature up to 25 June 2021. Randomized controlled trials published in English or Chinese that compared the vaginal application of lubricant with standard care for women were included. Two reviewers independently performed study screening, data extraction, risk of bias assessment, and certainty of evidence assessment. Pooled effect sizes and corresponding 95% confidence intervals (CI) were calculated using meta-analysis., Results: Nineteen trials enrolling 5445 pregnant women were included. Compared with standard care, women using lubricants had a lower incidence of perineal trauma (risk ratio [RR] 0.84, 95% CI 0.76-0.93; low certainty evidence), second-degree perineal laceration (RR 0.72, 95% CI 0.64-0.82; moderate certainty evidence) and episiotomy (RR 0.77, 95% CI 0.62-0.96; very low certainty evidence), and had a shorter duration of the second-stage labor (MD -13.72 min, 95% CI -22.68 to -4.77; very low certainty evidence)., Conclusion: Lubricants might reduce the incidence of perineal trauma, especially second-degree perineal laceration, and shorten the duration of the second-stage labor. More well-designed studies will continue developing high-quality evidence in this field., (© 2022 Japan Society of Obstetrics and Gynecology.)

Background and Purpose: Most women suffer some degree of perineal trauma during vaginal delivery. Second stage management strategies, including vocalization, to protect the perineum have been investigated., Objective: To compare the frequency and degree of perineal trauma at vaginal delivery, with and without use of the vocalization maneuver during the second stage of labor., Materials and Methods: This is an open-label, randomized controlled trial. We conducted the study at the Center for Normal Deliveries of IMIP. We included low-risk women without prior cesarean deliveries. Women who met the inclusion criteria and signed the informed consent form were randomized to one of two groups: Group A (experimental) and Group B (control). A physical therapist encouraged women in Group A to maintain an open glottis during pushing and to emit sounds when exhaling (vocalization). Women in Group B underwent routine humanized vaginal deliveries. The outcomes of the study were perineal integrity and degree of perineal laceration. These were measured by the study team immediately after completion of the third stage of labor., Results: Women in Group A tended to have less severe perineal tear (less second and third degree lacerations) and smaller lacerations than women in group B. The vocalization maneuver reduced the risk of a perineal tear greater than 2 cm by 68% (NNT 2.2). There was no difference in other outcomes., Conclusion: Encouraging women to follow a vocalization protocol coached by a physical therapist during the second stage of labor can be a helpful labor assistance technique, since this study showed that vocalization is associated with less extensive perineal tears., Clinical Trial Registration: This study was registered on ClinicalTrials.gov (www., Clinicaltrial: gov) registration number: NCT03605615., (Copyright © 2022 Elsevier B.V. All rights reserved.)

Background: The efficacy of perineal massage is controversial. The study was aimed at comparing the effects of perineal massage on perineal injury and complications., Methods: PubMed, Embase, the Cochrane Library, and ISI Web of Science were searched for literature on the relationship between prenatal perineal massage and postpartum perineal injury and complications until April 2022. Indicators included postpartum perineal tears, perineotomy, postpartum perineal pain, natural labour, and postpartum incontinence. Finally, RevMan5.4 software was used to analyze the extracted data., Results: A total of 6487 subjects in 16 studies were included, with 3211 who received perineal massage and 3276 did not. There was no significant difference in 1-2 degree perineal tearing between the intervention group and the control group (RR = 0.96, 95% CI [0.90, 1.03], P = 0.30), and there was no heterogeneity between studies ( P = 0.62, I 2 = 0%), indicating publication bias. Compared with the control group, prenatal perineal massage significantly reduced the incidence of 3-4 degree perineal tears (RR = 0.56, 95% CI [0.47, 0.67], P < 0.00001), and there was no heterogeneity between studies ( P = 0.16, I 2 = 30%), indicating publication bias. Compared with the control group, prenatal perineal massage reduced the risk of lateral perineal resection (RR = 0.87, 95% CI [0.80, 0.95], P = 0.001), and there was no heterogeneity between studies ( P = 0.14, I 2 = 31%), and there was no publication bias. Compared with the control group, prenatal perineal massage reduced the risk of postpartum pain at 3 months (RR = 0.64, 95% CI [0.51, 0.81], P = 0.0002). There was no significant heterogeneity among studies ( P = 0.23, I 2 = 31%)., Conclusion: Compared with no prenatal perineal massage, prenatal perineal massage can reduce the risk of perineal injury, the incidence of lateral perineal resection, and the incidence of long-term pain., Competing Interests: The authors have no conflicts of interest to declare., (Copyright © 2022 Qiuxia Chen et al.)

Background: To assess the effects of policy of selective versus routine episiotomy on mother and baby for women delivering vaginally in Shanghai and whether the hospital type has any effect on the outcomes., Method: This was a multi-center retrospective cohort study in Shanghai between March 2015 and May 2017. The study population were vaginal births with selective or routine episiotomy (n = 5478) in 20 secondary or tertiary hospitals. Main Outcome Measure was the incidence of severe perineal lacerations. The adjusted odds ratios (aOR) and 95% confidence intervals (CI) were estimated by logistic regression and presented as the effect sizes. All models were stratified by the utilization of level (secondary and tertiary) and type (general and Obstetric) of hospital., Results: The primary outcome was not significantly different between vaginal births with routine and selective episiotomy. Patients with selective episiotomy had a lower risk of postpartum hemorrhage, and newborns in the selective episiotomy group had a lower risk of shoulder dystocia and Neonatal Ward compared to those with routine episiotomy. Newborns in selective episiotomy group had a lower risk of birth injury in tertiary hospital. However, newborns in selective episiotomy group had a higher risk of birth injury in general hospitals., Conclusion: Selective episiotomy is safe and can be recommended over routine episiotomy in obstetric and tertiary hospital settings in China., (© 2022. The Author(s).)

Background: Pelvic floor muscle training (PFMT) is reportedly able to reduce risk factors for perineal trauma. However, the effects of these exercises on perineal injuries are unclear., Objective: To investigate the effectiveness of PFMT in the prevention of perineal laceration., Search Strategy: Searches were conducted in PubMed/Medline, LILACS, Scopus, Cochrane Library, Web of Science, and CINAHL. For search strategies, we combined the terms PFMT, tear, laceration, perineum, and delivery., Selection Criteria: We included randomized controlled trials that evaluated the effectiveness of PFMT for the prevention of perineal laceration during vaginal delivery. There were no period or language limitations., Data Collection and Analysis: We conducted data extraction and synthesis. We performed a quality appraisal, a qualitative synthesis, and for meta-analysis we used the Software R., Main Results: Nine studies were included. In most studies, PFMT was performed daily, with a wide range of the number of contractions and sustainability. Prevalence of perineal laceration had a wide range and information on laceration degree was limited. Meta-analysis showed that PFMT was not effective to prevent perineal laceration., Conclusion: Pelvic floor muscle training does not prevent perineal laceration. Further studies are needed to investigate different protocols and interventions., (© 2021 International Federation of Gynecology and Obstetrics.)

Objective: To investigate the effect of unique skill of perineum protection in forceps delivery on the maternal and neonatal morbidity., Methods: A case-control study was conducted. Singleton pregnancies with forceps-assisted and normal vaginal deliveries were recruited. The maternal and neonatal complications were compared between forceps and normal deliveries., Results: Five hundred forty participants were included. The prevalence of maternal anal sphincter injury, postpartum hemorrhage, vaginal hematoma, cervical laceration, perineal wound infection, perineal wound dehiscence, dyspareunia, urinary incontinence, and anal incontinence were not significantly different between forceps and normal deliveries ( p  > .05). However, the rate of neonatal facial injury was higher in the forceps group (2.9% versus 0, p  = .004)., Conclusions: Cooperation according to the tension of perineum and labor process between obstetrician and midwife is important for perineum protection. Forceps-assisted delivery concentrating on perineum protection is an effective alternative in decreasing maternal morbidity.

Background: To examine which elements of an obstetric anal sphincter injury (OASI) care bundle were protective for OASI. Several interventional trials showed that application of a care bundle involving a hands-on approach to perineal protection may reduce the risk of OASI. Previously, we found that only the element "hand on the fetal head" in itself was protective, although the risk of a type 2 error was calculated to be 50%., Methods: A prospective follow-up study in an obstetric department in Denmark with 3200 deliveries per year. We included a cohort of 10,383 women giving birth vaginally from gestational week 22 + 0 from 2016 through 2019. We documented on a person-level the five elements of the care bundle together with maternal and obstetrical characteristics. The elements were 1) communication, 2) visible perineum, 3) hand on fetal head, 4) perineal support and 5) certification. Regression analysis was used for analysis of associations. The primary outcome measure was OASI., Results: The total rate of OASI in vaginally delivering women was 1.9%. The incidence was 3.2% in nulliparous women giving birth vaginally. The rate of cesarean section was 16.5% and for episiotomy 2.4%. The reduction in the incidence of OASI was sustained since 2013. Hand on the fetal head and perineal support both were protective factors for OASI. In case of a nulliparous woman with a neonate weighing 3500 g giving birth spontaneously, the relative risk (RR) for OASI was 0.50 (95% CI 0.49- 0.51) with use of hand on the fetal head together with perineal support against no use. Similarly, with a nulliparous woman giving birth to a neonate of 3500 g by vacuum extraction, the RR for OASI was 0.65 (95% CI 0.62-0.68) against no use., Conclusions: Both hand on the fetal head and perineal support were associated with a reduced risk of OASI., (© 2021. The Author(s).)

Background: Bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) and laceration of the anterior mitral leaflet to prevent outflow obstruction (LAMPOON) reduce the risk of coronary and left ventricular outflow obstruction obstruction during transcatheter aortic valve replacement and transcatheter mitral valve replacement. Despite successful laceration, BASILICA or LAMPOON may fail to prevent obstruction caused by inadequate leaflet splay in patients having challenging anatomy such as very small valve-to-coronary distance, diffusely calcified, rigid leaflets, or undergoing transcatheter aortic valve replacement inside existing transcatheter aortic valve replacement. We describe a novel technique of balloon-augmented (BA) leaflet laceration to enhance leaflet splay., Methods: We measured the incremental leaflet splay from BA-BASILICA in vitro. From November 2019 to March 2021, 16 patients underwent BA-BASILICA and 4 BA-LAMPOON at 3 centers., Results: BA-BASILICA increased benchtop leaflet tip splay 17%, maximum splay angle 30%, and splay area 23%, resulting in a more rounded apex and larger effective area. Sixteen patients at risk for inadequate BASILICA leaflet splay, including 4 transcatheter aortic valve replacement inside existing transcatheter aortic valve replacement, underwent BA-BASILICA. All had successful leaflet laceration. One had coronary obstruction requiring immediate orthotopic stenting. Two underwent elective orthotopic coronary stenting through the transcatheter valve cells for leaflet prolapse without coronary ischemia. There were no deaths during the procedure or at 30 days. Four patients at risk for inadequate anterior mitral leaflet splay underwent BA-LAMPOON. All had successful target leaflet laceration without left ventricular outflow obstruction obstruction or procedural death. One died within 30 days., Conclusions: BA leaflet laceration enhances leaflet splay in vitro and may allow transcatheter aortic valve replacement and transcatheter mitral valve replacement in patients otherwise ineligible for traditional BASILICA or LAMPOON due to challenging anatomy. Graphic Abstract: A graphic abstract is available for this article.

Objective: The rate of perineal tears in Cameroonian primiparous women is reported to be up to 59.7%. The present study aimed to assess the relationship between perineal length and perineal tears., Methods: We conducted a prospective study of primiparous women with singleton pregnancies of at least 36 +6  weeks length. The admitting physician measured the length of the perineal body at the first stage of labor and this value was hidden from the delivery personnel until delivery occurred. The presence of perineal trauma and other delivery characteristics were recorded. Data were analyzed using univariate analyses and multiple logistic regression., Results: The mean perineal body length was 3.21 ± 0.75 cm (range 1.5-5.5 cm). 34 (33.0%) primiparous women sustained spontaneous perineal tears and 20 (19.4%) had episiotomies. No third- or fourth-degree perineal tears were observed. Perineal body length shorter than 2.5 cm was a significant (P < 0.04) predictor of spontaneous perineal lacerations (58.3% vs. 29.7% with relative risk 0.59). Both duration of second stage of labor longer than 60 min and occiput posterior presentation were associated with an increased risk of episiotomy in primiparous patients., Conclusion: Perineal body length less than 2.5 cm significantly predisposed to spontaneous perineal lacerations., (© 2021 International Federation of Gynecology and Obstetrics.)

Introduction and Hypothesis: Obstetric anal sphincter injury (OASI) is a severe form of perineal trauma that can occur during vaginal birth. Long-term morbidities include anal incontinence and psychosocial disorders. To reduce these injuries within England, Scotland and Wales, the OASI Care Bundle was introduced to 16 maternity units (January 2017-March 2018). The OASI Care Bundle comprises four elements: (1) antenatal information, (2) manual perineal protection, (3) medio-lateral episiotomy (when indicated) and 4) recognition and diagnosis of tears. As part of the project evaluation, a qualitative study was conducted to explore women's experiences of the OASI Care Bundle., Methods: Semi-structured interviews were conducted with women (n = 19) who received the OASI Care Bundle as part of their maternity care. This was to explore their experience of each element. A thematic analysis of the interview data was performed., Results: Three themes were identified: (1) memories of touch, whereby women reported that a 'hands-on' approach to perineal protection was a positive experience; (2) midwife as a supportive guide, where women reported that good communication facilitated a calm birth and post-birth diagnosis; (3) education: women need more information about perineal trauma., Conclusion: This study contributes to the literature through its exploration of women's experiences of perineal protection techniques and diagnosis of perineal trauma. Interviewed women indicated that they did not experience any of the care bundle elements as an intrusion of their physical integrity. Additionally, an urgent need was identified for more information about perineal trauma in terms of risk, prevention and recovery., (© 2021. The Author(s).)

Background: Interference screw is commonly used for graft fixation in anterior cruciate ligament (ACL) reconstruction. However, previous studies had reported that the insertion of interference screws significantly caused graft laceration. The purposes of this study were to (1) quantitatively evaluate the graft laceration from one single insertion of PEEK interference screws; and (2) determine whether different types of sutures reduced the graft laceration after one single insertion of interference screws in ACL reconstruction., Methods: The in-vitro ACL reconstruction model was created using porcine tibias and bovine extensor digitorum tendons of bovine hind limbs. The ends of grafts were sutured using three different sutures, including the bioabsorbable, Ethibond and ultra-high molecular weight polyethylene (UHMWPE) sutures. Poly-ether-ether-ketone (PEEK) interference screws were used for tibial fixation. This study was divided into five groups (n = 10 in each group): the non-fixed group, the non-sutured group, the absorbable suture group, the Ethibond suture group and the UHMWPE suture group. Biomechanical tests were performed using the mode of pull-to-failure loading tests at 10 mm/min. Tensile stiffness (newtons per millimeter), energy absorbed to failure (in joules) and ultimate load (newtons) were recorded for analysis., Results: All prepared tendons and bone specimens showed similar characteristics (length, weight, and pre-tension of the tendons, tibial bone mineral density) among all groups (P > 0.05). The biomechanical tests demonstrated that PEEK interference screws significantly caused the graft laceration (P < 0.05). However, all sutures (the bioabsorbable, Ethibond and UHMWPE sutures) did not reduce the graft laceration in ACL reconstruction (P > 0.05)., Conclusions: Our biomechanical study suggested that the ultimate failure load of grafts was reduced of approximately 25 % after one single insertion of a PEEK interference screw in ACL reconstruction. Suturing the ends of the grafts using different sutures (absorbable, Ethibond and UHMWPE sutures) did not decrease the graft laceration caused by interference screws.

Obstetric lacerations are a common complication of vaginal delivery. Lacerations can lead to chronic pain and urinary and fecal incontinence. Perineal lacerations are defined by the depth of musculature involved, with fourth-degree lacerations disrupting the anal sphincter and the underlying rectal mucosa and first-degree lacerations having no perineal muscle involvement. Late third-trimester perineal massage can reduce lacerations in primiparous women; perineal support and massage and warm compresses during the second stage of labor can reduce anal sphincter injury. Conservative care of minor hemostatic first- and second-degree lacerations without anatomic distortion reduces pain, analgesia use, and dyspareunia. Minor hemostatic lesions with anatomic disruption can be repaired with surgical glue. Second-degree lacerations are best repaired with a single continuous suture. Lacerations involving the anal sphincter complex require additional expertise, exposure, and lighting; transfer to an operating room should be considered. Limited evidence suggests similar results from overlapping and end-to-end external sphincter repairs. Postdelivery care should focus on controlling pain, preventing constipation, and monitoring for urinary retention. Acetaminophen and nonsteroidal anti-inflammatory drugs should be administered as needed. Opiates should be avoided to decrease risk of constipation; need for opiates suggests infection or problem with the repair. Osmotic laxative use leads to earlier bowel movements and less pain during the first bowel movement. Simulation models are recommended for surgical technique instruction and maintenance, especially for third- and fourth-degree repairs.

Background: Perineal trauma at the time of vaginal delivery is common, and when the anal sphincter is included, these injuries can be associated with additional morbidity including incontinence, pelvic pain, and sexual dysfunction., Objective: The aim of this systematic review with meta-analysis was to evaluate whether a hands-on technique during vaginal delivery results in less incidence of perineal trauma than a hands-off technique., Methods: Electronic databases were searched from their inception until June 2018. No restrictions for language or geographic location were applied. The reference lists of identified articles were examined to identify studies not captured by electronic searches. Randomized controlled trials comparing a hands-on technique of perineal support during vaginal delivery (i.e. intervention group) with a hands-off technique (i.e. control group) were included in the meta-analysis. Hands-on was defined as involving one hand on the fetal head, applying pressure to control expulsion, with the other hand applying pressure on the maternal perineum. The primary outcome was severe perineal trauma, defined as either third- or fourth-degree lacerations. The meta-analysis was performed using the random effects model of DerSimonian and Laird, to produce summary treatment effects in terms of relative risk (RR) with 95% confidence interval (CI)., Results: Five trials, including 7287 women, were analyzed. All studies included singleton gestations with cephalic presentation at term undergoing spontaneous vaginal delivery. Women randomized to the hands-on technique had similar incidence of severe perineal trauma (1.5 versus 1.3%; RR 2.00, 95% CI 0.56-7.15). There was no significant between-group difference in the incidence of intact perineum, first-, second- and fourth-degree laceration. Hands-on technique was associated with increased risk of third-degree lacerations (2.6 versus 0.7%; RR 3.41, 95% CI 1.39-8.37) and of episiotomy (13.6 versus 9.8%, RR 1.59, 95% CI 1.14-2.22) compared to the hands-off technique., Conclusions: Hands-on technique during spontaneous vaginal delivery of singleton gestations results in similar incidence of several perineal traumas compared to a hands-off technique. The incidence of third-degree lacerations and of episiotomy increases with the hands-on technique. Key Message A hands-on technique during vaginal delivery results in similar incidence of severe lacerations compared to hands-off.

Objective: To evaluate the impact of a care bundle (antenatal information to women, manual perineal protection and mediolateral episiotomy when indicated) on obstetric anal sphincter injury (OASI) rates., Design: Multicentre stepped-wedge cluster design., Setting: Sixteen maternity units located in four regions across England, Scotland and Wales., Population: Women with singleton live births between October 2016 and March 2018., Methods: Stepwise region by region roll-out every 3 months starting January 2017. The four maternity units in a region started at the same time. Multi-level logistic regression was used to estimate the impact of the care bundle, adjusting for time trend and case-mix factors (age, ethnicity, body mass index, parity, birthweight and mode of birth)., Main Outcome Measures: Obstetric anal sphincter injury in singleton live vaginal births., Results: A total of 55 060 singleton live vaginal births were included (79% spontaneous and 21% operative). Median maternal age was 30 years (interquartile range 26-34 years) and 46% of women were primiparous. The OASI rate decreased from 3.3% before to 3.0% after care bundle implementation (adjusted odds ratio 0.80, 95% CI 0.65-0.98, P = 0.03). There was no evidence that the effect of the care bundle differed according to parity (P = 0.77) or mode of birth (P = 0.31). There were no significant changes in caesarean section (P = 0.19) or episiotomy rates (P = 0.16) during the study period., Conclusions: The implementation of this care bundle reduced OASI rates without affecting caesarean section rates or episiotomy use. These findings demonstrate its potential for reducing perineal trauma during childbirth., Tweetable Abstract: OASI Care Bundle reduced severe perineal tear rates without affecting caesarean section rates or episiotomy use., (© 2020 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd on behalf of Royal College of Obstetricians and Gynaecologists.)

Objective: To examine the effectiveness of twice-daily moisturizer application for patients admitted to an acute care setting on reducing the incidence of skin tear (ST) injuries., Design, Setting, and Participants: This prospective, nonrandomized, case-control study identified an experimental and control ward equivalent in demography and patient acuity in a large hospital in regional Victoria, Australia. Patients 70 years or older admitted to the wards were invited to participate., Intervention: Twice-daily application of a commercially available skin and body lotion to the arms and legs of participants., Main Outcome Measures: The incidence of ST in the experimental and control settings in the pre-, intra-, and posttrial periods., Main Results: Although a decrease in ST incidence was observed over the study period (n = 128), this decrease was not significant pre- (median = 2.16, n = 73), intra- (median = 2.16, n = 73), or postintervention (median = 2.16, n = 69; χ[2, 152] = 0.502, P = .778). Similarly, there was no significant difference between wards (median = 9.86 [n = 152] vs median = 13.14 [n = 177]; U = 42.50, z = -1.198, r = 0.358, P = .231)., Conclusions: The moisturizer in this study did not have a direct influence on the frequency of STs in the study population, although the data would suggest an intermittent reduction in ST incidence. The authors postulate that this was correlated with behavior change effects from the study., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Over the last decade the incidence of obstetric anal sphincter injuries (OASIS) has been steadily increasing locally and internationally. Investigations into reducing rates, and the long-term complications, of OASIS are required., Aims: To determine if applying a new method of perineal guarding at the time of delivery reduces the incidence of OASIS at an Australian tertiary hospital., Materials and Methods: A retrospective audit was performed for the three  years prior to and following mandatory introduction of a new method of perineal guarding. The novel 'Please Squeeze' technique involved placement of the accoucheur's thumb and index finger just above the line of the posterior fourchette at crowning and bringing them firmly one centimetre postero-medially to reduce tension. Demographic data were extracted from the unit's obstetric database (ObstetriX)., Results: There were 9453 deliveries prior to, and 9805 deliveries following commencement of 'Please Squeeze', with no difference in the incidence of caesarean (30.4% vs 30.3% P = 0.87) or forceps (6.3% vs 5.8% P = 0.14) between groups. The incidence of primiparas (P = 0.005), ventouse (P < 0.001) and spontaneous vaginal deliveries (SVD) (P = 0.005) between groups. There was a clinically important 20% reduction in the incidence of OASIS across all vaginal deliveries from 3.5% to 2.8% (P = 0.006). In SVD, there was a 20% decrease in OASIS from 2.4% to 2.2% (P = 0.02), and a 14% decrease in OASIS with assisted vaginal delivery from 8% to 7.3% (P = 0.002). The incidence of episiotomy increased 16% (P < 0.001)., Conclusions: The novel 'Please Squeeze' perineal guarding method contributed to a reduced incidence of OASIS in an Australian tertiary hospital., (© 2020 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.)

Background: Instrumental deliveries are an unavoidable part of obstetric practice. Dedicated training is needed for each instrument. To identify when a trainee resident can be entrusted with instrumental deliveries by Suzor forceps by studying obstetric anal sphincter injuries., Methods: A French retrospective observational study of obstetric anal sphincter injuries due to Suzor forceps deliveries performed by trainee residents was conducted from November 2008 to November 2016 at Limoges University Hospital. Perineal lesion risk factors were studied. Sequential use of a vacuum extractor and then forceps was also analyzed., Results: Twenty-one residents performed 1530 instrumental deliveries, which included 1164 (76.1%) using forceps and 89 (5.8%) with sequential use of a vacuum extractor and then forceps. Third and fourth degree perineal tears were diagnosed in 82 patients (6.5%). Residents caused fewer obstetric anal sphincter injuries after 23.82 (+/- 0.8) deliveries by forceps (p = 0.0041), or after 2.36 (+/- 0.7) semesters of obstetrical experience (p = 0.0007). No obese patient (body mass index> 30) presented obstetric anal sphincter injuries (p = 0.0013). There were significantly fewer obstetric anal sphincter injuries after performance of episiotomy (p <  0.0001), and more lesions in the case of the occipito-sacral position (p = 0.028). Analysis of sequential instrumentation did not find any additional associated risk., Conclusion: Training in the use of Suzor forceps requires extended mentoring in order to reduce obstetric anal sphincter injuries. A stable level of competence was found after the execution of at least 24 forceps deliveries or after 3 semesters (18 months) of obstetrical experience.

Objective: This study aims to compare two techniques (External pop-out versus classic technique) for delivery of the fetal head during elective cesarean section (CS).The potential clinical predictors associated with unintended uterine incision extension during fetal head delivery among women delivered by elective CS were also assessed., Methods: A randomized clinical trial conducted at a tertiary University hospital between February 2017 and January 2019. Participants were randomly assigned to the classic head delivery technique (group I) or external Pop-out (EPO) technique (group II). The primary outcome was the incidence of unintended uterine incision extension during elective CS. A logistic regression model was utilized to examine the association between patient's characteristics and the occurrence of unintended uterine incision extension., Results: Participants in both groups (455 women in each group) had similar demographic characteristics. The EPO group had a significantly lower incidence of uterine incision extension than the classic group (p = 0.006). The operative time was significantly shorter in the EPO group (p = 0.000), which was also significantly easier than the classic technique (p = 0.001). The high body mass index (p = 0.004), previous delivery by CS (p = 0.010), high birth weight (p = 0.001) and the classic technique for head delivery (p = 0.002) were significant predictors for uterine incision tears., Conclusions: EPO technique is an easy technique for fetal head delivery during elective CS with a lower risk of uterine incision extension and shorter operative time., Competing Interests: Declaration of Competing Interest The authors report no conflicts of interest, (Copyright © 2020 Elsevier Masson SAS. All rights reserved.)

Objective: To compare neonatal intensive care unit (NICU) or special care nursery admission for deliveries with water immersion compared with deliveries in the matched control group without water immersion. Secondary outcomes included adverse neonatal diagnoses, maternal infections, and perineal lacerations., Methods: We conducted a retrospective study using electronic health record data (2014-2018) from two health systems (eight hospitals), with similar clinical eligibility, associated with low risks of intrapartum complications, and implementation policies for waterbirth. The water immersion group included women intending waterbirth. Water immersion was recorded prospectively during delivery. The comparison population were women who met the clinical eligibility criteria for waterbirth but did not experience water immersion during labor. Comparison cases were matched (1:1) using propensity scores. Outcomes were compared using Fischer's exact tests and logistic regression with stratification by stage of water immersion., Results: Of the 583 women with water immersion, 34.1% (199) experienced first-stage water immersion only, 65.9% (384) experienced second-stage immersion, of whom 12.0% (70) exited during second stage, and 53.9% (314) completed delivery in the water. Neonatal intensive care unit or special care nursery admissions were lower for second-stage water immersion deliveries than deliveries in the control group (odds ratio [OR] 0.3, 95% CI 0.2-0.7). Lacerations were lower in the second-stage immersion group (OR 0.5, 95% CI 0.4-0.7). Neonatal intensive care unit or special care nursery admissions and lacerations were not different between the first-stage immersion group and their matched comparisons. Cord avulsions occurred for 0.8% of second-stage water immersion deliveries compared with none in the control groups. Five-minute Apgar score (less than 7), maternal infections, and other adverse outcomes were not significantly different between either the first- or second-stage water immersion groups and their control group., Conclusion: Hospital-based deliveries with second-stage water immersion had lower risk of NICU or special care nursery admission and perineal lacerations than matched deliveries in the control group without water immersion.