Dendini Mohammad, Aldossari Sara K, AlQassab Hydar A, Aldraihem Othman O, Almalki Amwaj
Urogynecology and Reconstructive Pelvic Surgery, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, SAU.
Medicine, College of Dentistry, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, SAU.
Cureus. 2024 Mar 28;16(3):e57132. doi: 10.7759/cureus.57132. eCollection 2024 Mar.
A perineal tear is a rupture of the skin or muscle between the vagina and anus (perineum). A third-degree tear is one type of extended perineal tear (EPT), and it involves the penetration of the anal sphincter muscle. Another type of EPT is a fourth-degree laceration, which penetrates deeper into the lining of the anus or rectum. The stretching of the perineum during childbirth may result in perineal trauma. Invasive surgical interventions are required for the treatment of EPTs. For this reason, the reduction of their incidence can be achieved by fully comprehending the risk aspects associated with them.
The aim of this study is to contribute to the body of knowledge by providing insight into the various risk factors that are associated with extended perineal trauma. By following this path, this study aims to contribute to and advance Saudi Arabia's development of evidence-oriented obstetric care recommendations.
The current study is a case-control study where a review of 5000 vaginal delivery records was carried out between March 1, 2018, and March 19, 2023. For the study, cases (n = 71) were female patients who had documented greater than second-degree perineal injury. The control group (n = 238) was randomly chosen from women who had vaginal delivery but with less or equal to a second-degree perineal laceration. For each patient, we reviewed medical and obstetrics records for the following characteristics: age of diagnosis, gestational age, parity, labor induction, second-stage labor duration, mode of delivery, infant birth weight, epidural use and episiotomy indication, healthcare worker (HCW) experience, and APGAR (appearance, pulse, grimace, activity, and respiration) score.
From the 5000 births analyzed, the cases were 71 patients (1.42% of 5000 births). The mean age at diagnosis in our sample was (28.05 ± 4.66 years). The study's results showed that the following variables significantly affected the occurrence of EPTs: birth weight, labor durations, parity, HCW experience, and mode of delivery. The odds for tears were 3.69 (95% CI: 0.156-0.469) higher in nulliparous patients relative to multiparous patients. Instrumental deliveries resulted in more tears than non-instrumental deliveries with an odds ratio (OR) of 5.901 (95% CI: 2.443-14.525). This study also found that prolonged second-stage labor seems to be associated with an increased risk of perineal damage. HCW experience was looked at in relation to the increased incidence of EPTs, which showed that midwives had a lower incidence rate than physicians with an OR of 2.25 (95% CI: 1.169-4.366). Epidural usage has also been significantly associated with a lesser incidence of perineal tears, which indicates that using epidural could protect against the occurrence of EPTs.
In conclusion, the occurrence of perineal lacerations could be prevented during childbirth by taking preventative measures and having more precise judgments. Epidural was a protective factor in our study against the incidence of extensive perineal tearing. Furthermore, as compared to midwives, our study showed that the majority of EPTS occurred in cases of physicians (residents/consultants). Further research, proper documentation, and the development of evidence-based guidelines are needed to improve perineal care and reduce EPT incidence.
会阴撕裂是指阴道与肛门（会阴）之间的皮肤或肌肉破裂。三度撕裂是会阴扩展性撕裂（EPT）的一种类型，它涉及肛门括约肌肌肉的穿透。另一种EPT类型是四度撕裂，它更深地穿透肛门或直肠的黏膜。分娩期间会阴的拉伸可能导致会阴创伤。EPT的治疗需要侵入性手术干预。因此，通过充分了解与之相关的风险因素可以降低其发生率。
本研究的目的是通过深入了解与会阴扩展性创伤相关的各种风险因素，为知识体系做出贡献。通过这条途径，本研究旨在为沙特阿拉伯循证产科护理建议的制定和推进做出贡献。
本研究是一项病例对照研究，对2018年3月1日至2023年3月19日期间的5000份阴道分娩记录进行了回顾。在该研究中，病例组（n = 71）为有记录显示会阴损伤大于二度的女性患者。对照组（n = 238）是从阴道分娩但会阴撕裂小于或等于二度的女性中随机选取的。对于每位患者，我们回顾了医疗和产科记录，以了解以下特征：诊断年龄、孕周、产次、引产、第二产程时长、分娩方式、婴儿出生体重、硬膜外麻醉使用情况和会阴切开术指征、医护人员（HCW）经验以及阿氏（外观、脉搏、 grimace、活动和呼吸）评分。
在分析的5000例分娩中，病例组为71例患者（占5000例分娩的1.42%）。我们样本中的诊断平均年龄为（28.05 ± 4.66岁）。研究结果表明，以下变量对EPT的发生有显著影响：出生体重、产程时长、产次、HCW经验和分娩方式。相对于经产妇，初产妇发生撕裂的几率高出3.69倍（95%可信区间：0.156 - 0.469）。器械助产导致的撕裂比非器械助产更多，优势比（OR）为5.901（95%可信区间：2.443 - 14.525）。本研究还发现，第二产程延长似乎与会阴损伤风险增加有关。研究了HCW经验与EPT发生率增加的关系，结果显示助产士的发生率低于医生，OR为2.25（95%可信区间：1.169 - 4.366）。硬膜外麻醉的使用也与会阴撕裂发生率显著降低相关，这表明使用硬膜外麻醉可以预防EPT的发生。
总之，通过采取预防措施和进行更精确判断，可以在分娩期间预防会阴撕裂的发生。在我们的研究中，硬膜外麻醉是预防广泛会阴撕裂发生率的一个保护因素。此外，与助产士相比，我们的研究表明大多数EPT发生在医生（住院医师/顾问医师）的病例中。需要进一步研究、妥善记录并制定循证指南，以改善会阴护理并降低EPT发生率。
