Schmitz Thomas, Alberti Corinne, Andriss Béatrice, Moutafoff Constance, Oury Jean-François, Sibony Olivier
AP-HP, Hôpital Robert Debré, Service de Gynécologie Obstétrique, 75019 Paris, France; Université Paris Diderot, Sorbonne Paris Cité, 75019 Paris, France.
Université Paris Diderot, Sorbonne Paris Cité, 75019 Paris, France; AP-HP, Hôpital Robert Debré, Unité d'Epidémiologie Clinique, 75019 Paris, France; Inserm, CIE 5, 75019 Paris, France.
Eur J Obstet Gynecol Reprod Biol. 2014 Nov;182:11-5. doi: 10.1016/j.ejogrb.2014.08.031. Epub 2014 Aug 29.
To evaluate the frequency and to identify the risk factors of severe perineal lacerations and the subgroup of women exposed to the highest risk for these complications.
We conducted a case-control study in a large cohort of women for which vaginal delivery management consisted in systematic perineal support and restrictive use of mediolateral episiotomy. The case group comprised women with severe perineal lacerations while the control group comprised women without severe perineal lacerations. Maternal, labor, delivery and neonatal characteristics were analyzed in logistic regression models and a classification and regression tree (CART) was constructed.
Between 2000 and 2009, 19,442 women delivered vaginally in our centre, 88 of whom had severe perineal lacerations (0.5%). Instrumental delivery (aOR 4.17, 95% CI 2.51-6.90), nulliparity (aOR 2.58, 95% CI 1.55-4.29), persistent posterior orientation (aOR 2.24, 95% CI 1.02-4.94) and increased birth weight (aOR 1.28, 95% CI 1.03-1.60) were independent risk factors of severe perineal lacerations whereas mediolateral episiotomy had a protective effect (aOR 0.38, 95% CI 0.23-0.63). CART identified instrumental delivery of neonates smaller than 4500 g in persistent posterior orientation in nullipara without mediolateral episiotomy as the clinical situation associated with the highest risk of severe perineal lacerations (12.5%). Conversely, patients with the lowest risk (0.1%) were those delivering spontaneously, neonates larger than 3200 g after mediolateral episiotomy.
Instrumental delivery, nulliparity, persistent posterior orientation and increased birth weight are independently associated with severe perineal lacerations. Restrictive use of mediolateral episiotomy protects against severe perineal lacerations especially in case of instrumental delivery.
评估严重会阴裂伤的发生率，确定其危险因素以及面临这些并发症风险最高的女性亚组。
我们在一大群女性中开展了一项病例对照研究，这些女性的阴道分娩管理包括系统性会阴支撑和有限使用会阴侧切术。病例组包括患有严重会阴裂伤的女性，对照组包括没有严重会阴裂伤的女性。在逻辑回归模型中分析产妇、产程、分娩和新生儿特征，并构建分类回归树（CART）。
2000年至2009年期间，我们中心有19442名女性经阴道分娩，其中88名患有严重会阴裂伤（0.5%）。器械助产（调整后比值比[aOR] 4.17，95%置信区间[CI] 2.51 - 6.90）、初产（aOR 2.58，95% CI 1.55 - 4.29）、持续性枕后位（aOR 2.24，95% CI 1.02 - 4.94）和出生体重增加（aOR 1.28，95% CI 1.03 - 1.60）是严重会阴裂伤的独立危险因素，而会阴侧切术具有保护作用（aOR 0.38，95% CI 0.23 - 0.63）。CART确定，在未行会阴侧切术的初产妇中，以持续性枕后位分娩体重小于4500 g的新生儿是与严重会阴裂伤风险最高相关的临床情况（12.5%）。相反，风险最低（0.1%）的患者是那些经阴道侧切术后自然分娩体重超过3200 g新生儿的产妇。
器械助产、初产、持续性枕后位和出生体重增加与严重会阴裂伤独立相关。有限使用会阴侧切术可预防严重会阴裂伤，尤其是在器械助产的情况下。
