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Objective: To investigate whether perineal wound complications in the first birth, alone or in conjunction with obstetric anal sphincter injury (OASI), is associated with an increased risk of OASI in the second birth., Design: Nationwide population-based cohort study., Setting: Sweden., Population: Women (n = 411 317) with first and second singleton vaginal births in Sweden, 2001-2019., Methods: Data on diagnostic codes and surgical procedures were retrieved from the Swedish Medical Birth Register and the Swedish Patient Register. A perineal wound complication was defined as wound infection, dehiscence or perineal haematoma within 2 months of childbirth., Main Outcome Measures: Associations between wound complications in the first birth and OASI in the second birth were investigated with logistic regression and presented as adjusted odds ratios (aORs) with 95% confidence intervals (95% CIs)., Results: In total, 2619 (0.6%) women had a wound complication in the first birth, and 5318 (1.3%) had an OASI in the second birth. Women with a wound complication but no OASI in the first birth had more than doubled odds of OASI in the second birth (aOR 2.73, 95% CI 2.11-3.53). Women with OASI and a wound complication in the first birth had almost tenfold odds (aOR 9.97, 95% CI 6.53-15.24) of recurrent OASI., Conclusions: Perineal wound complication in the first birth increases the likelihood of OASI in a subsequent birth., (© 2024 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)

Background: Obstetric anal sphincter injury is the most common cause of anal incontinence for women, which often has profound impacts on women's lives. GPs offer a first line of contact for many women, but we know that very few women experiencing anal incontinence postnatally report discussing it with their GPs., Aim: To identify key ways in which GPs can support women with anal incontinence caused by childbirth injuries., Design and Setting: A qualitative study investigating women's experiences with their GP, and GPs' perspectives about providing such care., Method: This qualitative study combined two phases: first, a series of in-depth semi-structured interviews with women experiencing anal incontinence caused by childbirth injuries ( n = 41); and second, focus groups with GPs ( n = 13) stratified by experience. Thematic analysis was conducted and relevant themes from across the two datasets were examined., Results: Mediating factors in GP care for women with anal incontinence caused by childbirth injuries centred around three key themes: the role of the GP, access and pathways, and communication., Conclusion: The findings demonstrate multifactorial challenges in identifying the problem and supporting women experiencing anal incontinence after childbirth injury in primary care settings. Many GPs lacked confidence in their role in supporting women, and women were often reluctant to seek help. Those women who did seek help often experienced frustrations consulting with their GPs. In a context where women are often reluctant to ask for help, their concerns are not always taken seriously, and where GPs do not routinely ask about anal incontinence, potential anal incontinence after childbirth injury appears to be often missed in a primary care setting., (© The Authors.)

Background: Incidence of complications following obstetrical anal sphincter injury (OASI) during vaginal delivery are poorly defined. They are only studied in high level maternities, small cohorts, all stages of perineal tear or in low-income countries. The aim of our study was to describe complications after primary OASI repair following a vaginal delivery in all French maternity wards at short and midterm and to assess factors associated with complication occurrence., Methods: We conducted a historical cohort study using the French nationwide claim database (PMSI) from January 2013 to December 2021. All women who sustained an OASI repair following a vaginal delivery were included and virtually followed-up for 2 years. Then, we searched for OASIS complications. Finally, we evaluated factors associated with OASIS complication repaired or not and OASIS complication repairs., Results: Among the 61,833 included women, 2015 (2.8%) had an OASI complication and 842 (1.16%) underwent an OASI complication repair. Women were mainly primiparous (71.6%) and 44.3% underwent an instrumental delivery. During a follow-up of 2 years, 0.6% (n = 463), 0.3% (n = 240), 0.2% (n = 176), 0.1% (n = 84), 0.06% (n = 43) and 0.01% (n = 5) of patients underwent second surgery for a perineal repair, a fistula repair, a sphincteroplasty, a perineal infection, a colostomy and a sacral nervous anal stimulation, respectively. Only one case of artificial anal sphincter was noticed. Instrumental deliveries (OR = 1.56 CI95%[1.29;1.9]), private for-profit hospitals (OR = 1.42 [1.11;1.82], reference group "public hospital"), obesity (OR = 1.36 [1;1.84]), stage IV OASIS (OR = 2.98 [2.4;3.72]), perineal wound breakdown (OR = 2.8 [1.4;5.48]), ages between 25 and 29 years old (OR = 1.59 [1.17;2.18], refence group "age between 13 and 24 years old") and 30 and 34 years old (OR = 1.57 [1.14; 2.16], refence group "age between 13 and 24 years old") were factors associated with OASIS complication repairs., Conclusions: Maternal age, stage IV OASIS, obesity, instrumental deliveries and private for-profit hospitals seemed to predict OASIS complications. Understanding factors associated with OASIS complications could be beneficial for the patient to inform them and to influence the patient's follow-up in order to prevent complications, repairs and maternal distress., (© 2024. The Author(s).)

Objective: Prevalence of obesity in reproductive age and pregnant women has been on the rise during the past several decades. The relationship between body mass index (BMI) and obstetric anal sphincter injuries (OASIS) or episiotomy has not yet been thoroughly investigated. The objective of this study was to shed light on this issue., Methods: This retrospective cohort study was performed using electronic database of an obstetrics department at a university-affiliated tertiary medical center. All spontaneous singleton vaginal deliveries at term between January 2015 and December 2021 were included. The primary outcome was the incidence of OASIS (third- and fourth-degree perineal tears) and obesity. These were compared across three BMI categories: normal (BMI below 25 kg/m 2 ), overweight (BMI 25.0-29.9 kg/m 2 ), and obesity (BMI of 30 kg/m 2 and over)., Results: Of the overall 13,932 spontaneous vaginal deliveries identified, 34.7 % had BMI in the normal range, 43.1 % were overweight, and 25.4 % were obese. Multivariate analysis demonstrated lower rates of OASIS in obese (OR 0.2, 95 %CI 0.04-0.9) and in overweight (OR 0.3, 95 %CI 0.1-0.99) women, as compared to the normal-weight cohort. In addition, lower rates of episiotomy were noted in the obese cohort (OR 0.7, 95 %CI 0.6-0.8)., Conclusions: Decreased incidence of OASIS was noted in women with obesity, in conjunction with lower use of episiotomy. These findings imply that obstetrics clinics might consider a more conservative approach to episiotomy in obese patients., 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 © 2024. Published by Elsevier B.V.)

Objectives: The Healthy Recovery after Childbirth Clinic (HRCC) in Nova Scotia provides postpartum care to patients who experience obstetric anal sphincter injuries (OASIS). The purpose of this study was to describe characteristics associated with HRCC attendance, characteristics associated with a trial of labour in a subsequent delivery, and OASIS recurrence by HRCC attendance status., Methods: A retrospective cohort study using the Atlee Perinatal Database and clinical record review included primiparous individuals who sustained an OASIS at IWK Health in Halifax between 2013 and 2020. The χ 2 and Fisher exact tests were performed to compare groups., Results: Of the 1041 individuals included, 67% attended HRCC. Attendance increased from 58% in 2013-2015 to 77% in 2019-2020. Younger age (<25 years) and smoking were associated with lower HRCC attendance (P = 0.07 and <0.01, respectively). Other characteristics, including area-level income and driving distance to HRCC, were not associated with attendance (P > 0.05). Of the 439 individuals who had a subsequent delivery, 92% had a trial of labour. Individuals with fourth-degree injury were less likely to attempt a trial of labour than those with third-degree injury (73% vs. 94%, P < 0.01). Of those who delivered vaginally, OASIS recurrence was similar in those who did and did not attend the HRCC (7.5% vs. 6.5%, P = 0.84)., Conclusions: HRCC attendance was high, but the disparity by age and smoking status suggests some barriers to access that should be explored. Although we found no difference in OASIS recurrence by HRCC attendance, more research with larger samples with adjustment for confounders is needed., (Copyright © 2024 The Society of Obstetricians and Gynaecologists of Canada/La Société des obstétriciens et gynécologues du Canada. Published by Elsevier Inc. All rights reserved.)

Introduction: Efforts to reduce primary cesarean birth may include supporting longer second stages of labor. Although midwifery-led care is associated with lower cesarean use, little has been published on associated outcomes of prolonged second stage (≥3 hours of pushing) for nulliparous individuals in US hospital-based midwifery care. Epidural analgesia and the role of passive descent in midwifery-led care are also underexplored in relation to the second stage. In this study, we report the incidence of prolonged second stage stratified by epidural analgesia and/or passive descent. Secondary aims included calculating the odds of cesarean birth, obstetric anal sphincter injury (OASI), postpartum hemorrhage (PPH), and neonatal complications., Methods: Data were collected prospectively from a single academic center in the United States from 2012 through 2019. Our cohort analysis of labors attended by midwives for nulliparous, term, singleton, and vertex pregnancies included both descriptive and inferential statistics comparing outcomes between prolonged versus nonprolonged pushing groups. We stratified the sample and quantified second stage outcomes by epidural analgesia and by use of passive descent., Results: Of the 1465 births, 17% (n = 247) included prolonged pushing. Cesarean ranged from 2.2% without prolonged pushing to 26.7% with prolonged pushing. Fetal malposition, epidural analgesia, and longer passive descent were more common among those with prolonged active pushing. Despite these factors, neither odds for PPH nor poor neonatal outcomes were associated with prolonged pushing. Those with more than one hour of passive descent in the second stage who also had prolonged active pushing had lower odds for cesarean but higher odds for OASI relative to those who had little passive descent before pushing for more than 3 hours., Discussion: Prolonged pushing occurred in nearly 2 of 10 nulliparous labors. Fetal malposition, epidural analgesia, and prolonged pushing were commonly observed with longer passive descent, cesarean, and OASI. Passive descent in these data likely reflects individualized midwifery care strategies when pushing was complicated by fetal malposition or other complexities., (© 2024 by the American College of Nurse‐Midwives.)

Objective: Obstetric anal sphincter injuries (OASIS) are severe complications to vaginal births with potential long-term consequences. Maternal origin has been proposed to affect the overall risk, but the association and underlying explanation are uncertain. The objective was to assess the association between maternal country of birth and OASIS., Methods: A Swedish nationwide cohort study including singleton term vaginal births during 2005-2016. Data were extracted from the Swedish Medical Birth Registry and Statistics Sweden. Modified Poisson regression analyses were performed to obtain crude and adjusted risk ratios (RRs). Adjustments were made in four cumulative steps. Sub-analyses were performed to investigate the risk of OASIS associated with female genital circumcision (FGC)., Results: In all, 988 804 births were included. The rate of OASIS in Swedish-born women was 3.5%. Women from East/Southeast Asia had an increased risk of OASIS (adjusted RR [aRR] 1.71, 95% confidence interval [CI] 1.60-1.83), as did women born in Sub-Saharan Africa (aRR 1.60, 95% CI 1.49-1.72). The risk remained significantly increased also after adjustment for maternal height. By contrast, women from South/Central America had a decreased risk of OASIS (aRR 0.65, 95% CI 0.56-0.76). FGC was associated with an increased risk of OASIS (aRR 3.05, 95% CI 2.60-3.58). Episiotomy appeared to have an overall protective effect (aRR 0.95, 95% CI 0.92-0.98), but not significantly more protective among women with female genital mutilation., Conclusions: Country of birth plays an important role in the risk of OASIS. Women from East/Southeast Asia and Sub-Saharan Africa are at significantly increased risk as compared with Swedish-born women, whereas women from South/Central America are at lower risk. FGC is also a significant risk factor for OASIS., (© 2024 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Introduction: Data concerning the mechanical properties of the perineum during delivery are very limited. In vivo experiments raise ethical issues. The aim of the study was to describe some of the biomechanical properties of each perineal tissue layer collected from sows in order to better understand perineal tears during childbirth., Material and Methods: Samples of each perineal tissue layer were obtained from the skin, the vagina, the external anal sphincter (EAS), the internal anal sphincter (IAS), and the anal mucosa of fresh dead sows. They were tested in quasi-static uniaxial tension using the testing machine Mach-1®. Tests were performed at a displacement velocity of 0.1 mm·s -1 . Stress-strain curves of each perineal tissue layer before the first damage for each sow were obtained and modeled using a hyperelastic Yeoh model described by three coefficients: C1, C2, and C3. Pearson correlation coefficients were calculated to measure the correlation between the C1 hyperelastic coefficient and the duration between the first microfailure and the complete rupture for each perineal tissue layer. Pearson correlation was computed between C1 and the number of microfailures before complete rupture for each tissue., Results: Ten samples of each perineal tissue layer were analyzed. Mean values of C1 and corresponding standard deviations were 46 ± 15, 165 ± 60, 27 ± 10, 19 ± 13, 145 ± 28 kPa for the perineal skin, the vagina, the EAS, the IAS, and the anal mucosa, respectively. According to this same sample order, the first microfailure in the population of 10 sows appeared at an average of 54%, 27%, 70%, 131%, and 22% of strain. A correlation was found between C1 hyperelastic coefficient and the duration between the first microfailure and the complete rupture (r = 0.7, p = 0.02) or the number of microfailures before complete rupture only for the vagina (r = 0.7, p = 0.02)., Conclusions: In this population of fresh dead sow's perineum, the vagina and the anal mucosa were the stiffest tissues. The IAS and EAS were more extensible and less stiff. A significantly positive correlation was found between C1 and the duration between the first microfailure and the complete rupture of the vagina, and the duration between the first microfailure and the complete rupture of the vagina., (© 2024 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).)

Objective: To create a sensorised surgical glove that can accurately identify obstetric anal sphincter injury to facilitate timely repair, reduce complications and aid training., Design: Proof-of-concept., Setting: Laboratory., Sample: Pig models., Methods: Flexible triboelectric pressure/force sensors were mounted onto the fingertips of a routine surgical glove. The sensors produce a current when rubbed on materials of different characteristics which can be analysed. A per rectum examination was performed on the intact sphincter of pig cadavers, analogous to routine examination for obstetric anal sphincter injuries postpartum. An anal sphincter defect was created by cutting through the vaginal mucosa and into the external anal sphincter using a scalpel. The sphincter was then re-examined. Data and signals were interpreted., Main Outcome Measures: Sensitivity and specificity of the glove in detecting anal sphincter injury., Results: In all, 200 examinations were performed. The sensors detected anal sphincter injuries in a pig model with sensitivities between 98% and 100% and a specificity of 100%. The current produced when examining an intact sphincter and sphincter with a defect was significantly different (p < 0.001)., Conclusion: In this preliminary study, the sensorised glove accurately detected anal sphincter injury in a pig model. Future plans include its clinical translation, starting with an in-human study on postpartum women, to determine whether it can accurately detect different types of obstetric anal sphincter injury in vivo., (© 2024 The Authors. BJOG: An International Journal of Obstetrics and Gynaecology published by John Wiley & Sons Ltd.)

Background: Maternal injury with any form of perineal trauma following vaginal delivery is very common which ranges globally from 16.2 to 90.4%. The frequency of Obstetric anal sphincter Injuries and the incidence of cervical laceration increases rapidly. However, in Ethiopia, there is limited evidence on the prevalence of maternal birth trauma and its determinant factors after vaginal delivery., Objective: To assess the magnitude and associated factors of Maternal Birth Trauma after vaginal delivery at University of Gondar Comprehensive Specialized Hospital, Gondar, North-West Ethiopia, 2022., Methods: An Institution based cross-sectional study was conducted among mothers with singleton vaginal delivery at University of Gondar Comprehensive Specialized Hospital from 9th May to 9th August 2022 among 424 study participants. Pre-tested semi-structured questioner was utilized. Epi-Data version 4.6 was used for data entry and exported to SPSS version 25 for data management and analysis. To identify the determinant factors, binary logistic regression model was fitted and variables with p-value < 0.2 were considered for the multivariable binary logistic regression analysis. In the multivariable binary logistic regression analysis, Variables with P-value < 0.05 were considered to have statistical significant association with the outcome variable. The Adjusted Odds Ratio (AOR) with 95% CI was reported to declare the statistical significance and strength of association between Maternal Birth Trauma and independent variables., Results: A total of 424 mothers who delivered vaginally were included. The mean age of participants was 26.83 years (± 5.220 years). The proportion of birth trauma among mothers after vaginal delivery was47.4% (95%CI: 43.1, 51.7). Of different forms of perineal trauma, First degree tear in 42.8%, OASIs in 1.5% and Cervical laceration in 2.5% study participants. In the multivariable binary logistic regression analysis being primiparous (AOR = 3.00; 95%CI: 1.68, 5.38), Gestational age ≥ 39 weeks at delivery (AOR = 2.96; 95%CI: 1.57, 5.57), heavier birth weight (AOR = 12.3; 95%CI: 7.21, 40.1), bigger head circumference (AOR = 5.45; 95%CI: 2.62, 11.31), operative vaginal delivery (AOR = 6.59; 95%CI: 1.44, 30.03) and delivery without perineum and/or fetal head support (AOR = 6.30; 95%CI: 2.21, 17.94) were significantly associated with the presence of maternal birth trauma., Conclusion and Recommendation: Maternal birth trauma following vaginal delivery was relatively high in this study. Prim parity, gestational age beyond 39 weeks at delivery, heavier birth weight, bigger head circumference, operative vaginal delivery and delivery without perineum and/or fetal head supported were factors affecting perineal outcome. The Ministry of Health of Ethiopia should provide regular interventional training as to reduce maternal birth trauma., (© 2024. The Author(s).)

Background: Obstetric anal sphincter injury is a complication of vaginal delivery, if left untreated, causes significant maternal morbidities; urinary problems and fecal/ flatus incontinence. The aim of this study was to determine the incidence and describe the obstetric characteristics and functional outcomes of women who had vaginal delivery at Paropakar Maternity and Women's Hospital Nepal and sustained Obstetric anal sphincter injury., Methods: This retrospective descriptive study included women who had vaginal delivery, irrespective of parity, in the labor room or birthing unit of Paropakar Maternity and Women's Hospital from April 2018 to September 2020, and sustained Grade III or IV Obstetric anal sphincter injury after 28 weeks period of gestation. Maternal characteristics, obstetric details and perineal status after vaginal delivery were noted after review of hospital records. The patients were further inquired via telephone for their current status of fecal and/or urinary incontinence., Results: The incidence of OASI was 106 (0.33%) among 31, 786 Nepalese women with vaginal birth over a 2-year period. The mean age women with Obstetric anal sphincter injury was 24.6 ± 4.3 years and 45(52.9%) cases belonged to Janajati ethnicity. Fifty two (61.2 %) were primipara and 77 (90.6%) had spontaneous vaginal deliveries. Episiotomy was not performed on most of the patients (63, 74.1%). Problems with flatus holding, stool holding and urine holding was reported by 28.3%, 13.2% and 22.6% women respectively., Conclusions: The incidence of Obstetric anal sphincter injury among Nepalese women with vaginal birth over a 2-year period was 0.33%, which was lower than other South Asian studies. Grade III Obstetric anal sphincter injury was the frequent most type. The injuries were more common in women with Janajati ethnicity, primipara and women who did not have episiotomy. Problems with flatus holding and urine holding were present in almost one-fourth of the women with Obstetric anal sphincter injury at follow up.

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.)

Perineal injuries can occur during vaginal delivery and they are harmful to anal function, sexuality, and overall quality of life of patients. Among the feared complications, anal incontinence, often difficult to address for both patients and caregivers, has a significant impact and must be looked for during the medical history. Clinical examination of the perineum and additional tests such as endoanal ultrasound and anorectal manometry confirm the diagnosis and guide the management. Treatment often relies on multiple modalities and depends on the interval between obstetric trauma and symptom onset. When indicated, perineal reconstruction surgery restores anatomy and function., Competing Interests: Les auteurs n’ont déclaré aucun conflit d’intérêts en relation avec cet article.

Introduction and Hypothesis: Obstetric anal sphincter injury (OASI) is a major complication associated with vacuum-assisted vaginal delivery (VAVD). The aim of this study was to evaluate risk factors related to vacuum extraction that are associated with OASI., Methods: This was a case-control study performed at a tertiary university teaching hospital. Included were patients aged 18-45 years who had a singleton pregnancy resulting in a live, term, VAVD. The study group consisted of women diagnosed with OASI following vacuum extraction. The control group included women following VAVD without OASI. Matching at a ratio of 1:2 was performed. Groups were compared regarding demographic, obstetric. and labor-related parameters, specifically focusing on variables related to the vacuum procedure itself., Results: One hundred and ten patients within the study group and 212 within the control group were included in the final analysis. Patients in the OASI group were more likely to undergo induction of labor, use of oxytocin during labor, increased second stage of labor, higher likelihood of the operator being a resident, increased number of pulls, procedure lasting under 10 min, occipito-posterior head position at vacuum initiation, episiotomy, increased neonatal head circumference, and birthweight. Multivariate logistic regression analysis revealed that increased week of gestation (OR 1.67, 95% CI 1.25-2.22, p < 0.001), unsupervised resident performing the procedure (OR 4.63, 95% CI 2.17-9.90), p < 0.001), indication of VAVD being fetal distress (OR 2.72, 95% CI 1.04-7.10, p = 0.041), and length of procedure under 10 min (OR 4.75, 95% CI 1.53-14.68, p = 0.007) were associated with OASI. Increased maternal age was associated with lower risk of OASI (OR 0.9, 95% CI 0.84-0.98, p = 0.012)., Conclusions: When performing VAVD, increased week of gestation, unsupervised resident performing the procedure, fetal distress as vacuum indication, and vacuum procedure under 10 min were associated with OASI. In contrast, increased maternal age was shown to be a protective factor., (© 2024. The International Urogynecological Association.)

Birth related perineal trauma (BRPT) and obstetric anal sphincter injuries (OASIS) are leading causes of anal incontinence in women, which negatively impacts on their quality of life, resulting in low self-esteem and abandonment. In low resource countries (LRC), the true incidence is not known and since most births are unattended or occur in community-based health care systems, one can anticipate that it is a significant problem. Dissemination of information to women, education of traditional birth attendants, improvement of resources and transport, and training of health professionals on the detection and appropriate surgical management of these injuries will reduce morbidity and improve outcome. Intrapartum measures such as controlled head descent and perineal support, correct episiotomy techniques and selective use of instruments to assist vaginal births is pivotal in avoiding these injuries. Policy makers should prioritize maternity care in LRC, and research is urgently needed to address all aspects of BRPT., Competing Interests: Declaration of competing interest All Authors have no conflicts of interest to declare., (Copyright © 2024. Published by Elsevier Ltd.)

Objective: We aimed to investigate changes in the elastic properties of levator ani muscle (LAM) and external anal sphincter (EAS) during pregnancy using shear wave elastography (SWE). Our secondary objective was to examine the association between the elastic properties of pelvic floor muscles (PFM) and perineal tears at childbirth., Methods: This was a prospective monocentric study, including nulliparous women. Three visits were planned (14-18, 24-28, and 34-38 weeks) with a SWE assessment of the LAM and EAS at rest and during Valsalva maneuver. Then, we collected data about the delivery's characteristics. Assessments were performed using an Aixplorer V12 ® device (SL 18-5 linear probe) using a transperineal approach, reporting the shear modulus in kPa. We looked for changes in PFM's elastic properties during pregnancy using one-way ANOVA for repeated measures. We compared the mean shear modulus in late pregnancy for each muscle and condition between women with an intact perineum at delivery and those with a perineal tear using Student's t test., Results: Forty-seven women were considered. Forty-five women had vaginal delivery of which 38 (84.4%) had perineal tears. We did not report any significant changes in the elastic properties of PFM during pregnancy. Women with an intact perineum at delivery had a stiffer EAS at Valsalva maneuver in late pregnancy (27.0 kPa vs. 18.2 kPa; p < 0.005)., Conclusions: There were no significant changes in the elastic properties of the PFM in pregnancy. Stiffer EAS in late pregnancy appears to be associated with a lower incidence of perineal tears., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Importance: Social media is a powerful outlet for the dissemination of health care information. Adoption of a hashtag ontology-a standardized list of terms-may help better organize information and improve access to educational materials for health care providers (HCPs) and patients., Objectives: The primary objective was to create a hashtag ontology specific to obstetric anal sphincter injuries (OASIS) based on Twitter usage. Secondary objectives included (1) performing a thematic analysis of OASIS-related tweet content and (2) reporting the type of users posting about OASIS., Study Design: This study was an analysis of tweets related to OASIS posted between June 1, 2019, and June 1, 2022. Symplur Signals (a Twitter analytics software) (Symplur LLC, Los Angeles, CA) was used to identify relevant tweets based on predetermined search terms. Hashtags were reviewed by social media influencers to create a finalized ontology list. The top 100 tweets underwent thematic analysis and were grouped based on emergent themes. Types of users posting about OASIS were also analyzed., Results: Symplur identified 660 tweets related to OASIS. The final ontology included the following 8 hashtags: #OASIS, #perinealtrauma, #birthtrauma, #3rddegreetear, #4thdegreetear, #episiotomy, #operativedelivery, and #postpartumbody. Major tweet content themes included education, self-promotion, patient experience, medical-legal, research, and opinions. Educational tweets surrounded prevention, risk factors, complications, and educational events related to OASIS and perineal trauma. Of the educational tweets, only 30% were posted by HCPs., Conclusion: This study created a standardized hashtag ontology related to OASIS. Less than one third of educational tweets were posted by HCPs., Competing Interests: Disclosures: The authors have no pertinent conflicts of interest to disclose., (Copyright © 2024 American Urogynecologic Society. All rights reserved.)

Introduction: In this study, the aim is to discuss the cases of lower extremity and perianal burns at the burn center in the southeast Anatolia of Turkey. Material and methods: A 4-year retrospective study was conducted on 775 patients who had been admitted to Gazi Yaşargil Training and Research Hospital Burn Centre with lower extremity and perianal burn injuries between January 2016 and January 2020. Results: Of the patients, 427 were male and 348 were female. Scald burns are most commonly affect the perianal and lower extremities. The right lower extremity was affected in 602 (77.7%) patients, the left lower extremity was affected in 574 (74.1%) patients and the perineum was affected in 70 (9.0%) patients. Most burn injuries occur in individuals between 0 to 4 years old, and the rate of burn injuries gradually decreases in individuals outside of this age range. No patient underwent colostomy for perianal burns. Conclusion: Early, aggressive and extensive debridement, in addition to adequate antimicrobial therapy, should be performed as the basis of treatment., Competing Interests: Declaration of Conflicting InterestsThe author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Objective: To identify risk factors for obstetric anal sphincter injuries (OASIS) for primiparous women who gave birth vaginally and to compare recovery by OASIS status in three domains as follows: (1) physical health and functioning, (2) mental health, and (3) healthcare utilization., Study Design: This secondary analysis used data from 2,013 vaginal births in the First Baby Study, a prospective cohort study of women with first births between 2009 and 2011. Interview data at multiple time points were linked to birth certificate and hospital discharge data. The key exposure of interest was OASIS (3rd or 4th degree perineal laceration, identified in the hospital discharge data; n  = 174) versus no OASIS ( n  = 1,839). We used multivariable logistic regression models to examine the association between OASIS and a range of outcomes including physical health and functioning, depression, and health care utilization, assessed at 1 month and 6 months postpartum., Results: Eight percent of women had OASIS. In adjusted models, there were no differences in general physical health and functioning measures by OASIS (such as fatigue and overall self-rated health), but women with OASIS had higher rates of reporting perineal pain ( p  < 0.001), accidental stool loss ( p  = 0.001), and bowel problems ( p  < 0.001) at 1-month postpartum. By 6-month postpartum, there were no differences in reported physical health and functioning. There were no differences in probable depression at 1- or 6-month postpartum. Women with OASIS were more likely to attend a comprehensive postpartum visit, but there were no other differences in health care utilization by OASIS., Conclusion: Women with OASIS were at increased risk of accidental stool loss, bowel problems, and perineal pain in the immediate postpartum period. Women who had OASIS had similar physical functioning across a range of general health outcomes to women who gave birth vaginally without OASIS., Key Points: · Higher risk of bowel problems and accidental stool loss 1-month postpartum with OASIS.. · Higher risk of perineal pain 1-month postpartum with OASIS.. · No differences in health outcomes at 6-months postpartum by OASIS.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objectives: To quantify variation in the association between episiotomy and obstetric anal sphincter injury (OASI) by maternity care provider in spontaneous and operative vaginal deliveries (SVDs and OVDs)., Methods: Population-based retrospective cohort study of vaginal, term deliveries among nullipara in Canada (2004-2015). Adjusted rate ratios (ARRs) and 95% CIs were estimated using log-binomial regression to quantify the associations between episiotomy and OASI, stratified by care provider (obstetrician [OB], family physician [FP], or registered midwife [RM]) while adjusting for potential confounders., Results: The study included 631 642 deliveries. Episiotomy use varied by provider: among SVDs, the episiotomy rate was 19.6%, 14.4%, and 8.4% in the OB, FP, and RM groups, respectively. The rate of OASI was higher among SVDs with versus without episiotomy (5.8% vs 4.6%). Conversely, OASI occurred less frequently in operative vaginal deliveries with episiotomy (15.3%) compared with those without (16.7%). In all provider groups, the ARR for OASI was increased with episiotomy in SVD and decreased with episiotomy with forceps delivery. No differences in these associations were observed by provider except among vacuum delivery (ARR with episiotomy vs. without, OB: 0.88, 95% CI 0.84-0.92; FP: 0.89, 95% CI 0.83-0.96, RM: 1.22, 95% CI 1.02-1.48)., Conclusions: In nullipara, irrespective of maternity care provider, there is a positive association between episiotomy and OASI among SVDs and an inverse association between episiotomy and deliveries with forceps. The relationship between episiotomy and OASI is modified by maternity care providers among vacuum deliveries., (Copyright © 2024 The Author. Published by Elsevier Inc. All rights reserved.)

Objective: Data available at admission to delivery of nulliparous has rarely been investigated for prediction of obstetric anal sphincter injury (OASI). The aim of the present study was to study risk factors for OASI in nulliparous based on information available at admission., Methods: A retrospective study of all nulliparous women undergoing labor, during March 2011 to January 2021 was performed. We compared women with OASI following delivery to those without by univariate and multivariable regression., Results: A total of 30 262 deliveries were included and 4181 (13.4%) of those were delivered by an emergent cesarean delivery. OASI followed 453 (1.5%) deliveries. Women in the OASI group were younger 29 ± 4.4 versus 30 ± 4.8, P = 0.001. In a multivariable regression analysis, higher sonographic estimated fetal weight was positively associated with OASI occurrence (aOR, 95% CI: 1.13 [1.00-1.29]). Maternal age was inversely associated with OASI occurrence (adjusted odds ratio [aOR], 95% confidence interval [CI] 0.95 [0.92-0.97])., Conclusion: Sonographic fetal weight estimation is an independent risk factor for OASI occurrence that may be available at admission for delivery among nulliparous women., (© 2023 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Introduction and Hypothesis: The objective was to evaluate the prevalence of levator ani avulsion (LAA) among primiparous women with obstetric anal sphincter injury (OASI) and how this association could affect future pelvic floor dysfunction., Methods: Three electronic databases (MEDLINE/PubMed/EMBASE) were searched in December 2018 and again in October 2022. Nine full-text articles were included in the analysis. The exclusion criteria were language other than English, studies not based on primiparous women only, conference abstracts, and evaluation without ultrasound or MRI., Results: The overall prevalence of LAA was 24% (95% CI: 18-30%). Those with OASI, were at a higher risk of LAA, OR 3.49 (95% CI: 1.46 to 8.35). In women with LAA + OASI versus OASI alone, Three of Five studies showed worsened AI symptoms. Three of Five studies assessing urinary incontinence (UI) reported no significant difference in UI, whereas two reported increased UI. All studies that looked at pelvic organ prolapse reported a higher incidence of symptomatic prolapse and reduced pelvic floor muscle strength in women with LAA + OASI compared with those without LAA., Conclusion: Levator ani avulsion is prevalent following vaginal birth and is strongly associated with OASI. Incidence of AI does not increase in women with LAA and OASI, but they had greater symptom bother. OASI with LAA appears to increase the incidence of pelvic floor weakness and pelvic organ prolapse. There is no consensus agreement on the effect of LAA + OASI on UI., (© 2024. Crown.)

Objective: This study aimed to determine whether a trial of labor after cesarean section (TOLAC) with a macrosomic neonate is associated with adverse outcomes., Study Design: A retrospective cohort study was conducted in a population motivated for TOLAC. Women attempting TOLAC with a neonatal birth weight >4,000 g were compared with women attempting TOLAC with neonatal birth weights between 3,500 and 4,000 g. The primary outcome was TOLAC success. Secondary outcomes included mode of delivery, uterine rupture, postpartum hemorrhage (PPH), shoulder dystocia, obstetric anal sphincter injury (OASI), Apgar's score <7 at 5 minutes, and umbilical artery pH <7.1. Data were analyzed using Fisher's exact test and Chi-square test., Results: Overall, 375 women who underwent TOLAC with a neonate weighing >4,000 g comprised the study group. One thousand seven hundred and eighty-three women attempting TOLAC with a neonate weighing 3,500 to 4,000 g comprised the control group. There were no clinically significant differences between the groups for maternal age, gestational age, parity, and vaginal birth after cesarean (VBAC) rate. There were no significant differences in the rates of successful TOLAC (94 vs. 92.3%, p  = 0.2, odds ratio [OR] = 0.8, 95% confidence interval [CI]: 0.5, 1.2), operative vaginal delivery (7.4 vs. 5.3%, p  = 0.18, OR = 0.7, 95% CI: 0.4, 1.1), uterine rupture (0.4 vs. 0%, p  = 0.6), PPH (3.2 vs. 2.3%, p  = 0.36, OR = 1.4, 95% CI: 0.7, 2.7), OASI (0.8 vs. 0.2%, p  = 0.1, OR = 3.6, 95% CI: 0.8, 1.6), Apgar's score <7 at 5 minutes (0 vs. 0.4%, p  = 0.37), and umbilical artery pH <7.1 (0.5 vs. 0.7%, p  = 1.0, OR = 0.73, 95% CI: 0.2, 3.2). Women with a neonate weighing >4,000 g had a significantly increased risk of shoulder dystocia (4 vs. 0.4%, p  < 0.05, OR = 9.2 95% CI: 3.9, 22) CONCLUSION:  Women attempting TOLAC with a macrosomic neonate are not at increased risk for failed TOLAC, operative vaginal delivery, uterine rupture, PPH, or OASI but are at risk of shoulder dystocia. This information may aid in prenatal counseling for women considering TOLAC with a macrosomic fetus., Key Points: · TOLAC with fetal macrosomia does not increase the risk of uterine rupture.. · TOLAC with fetal macrosomia is associated with high chances of VBAC.. · TOLAC with fetal macrosomia is not associated with adverse neonatal outcomes.., Competing Interests: None declared., (Thieme. 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.)

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.)

Pelvic floor disorders after childbirth have distressing lifelong consequences for women, requiring more than 300,000 women to have surgery annually. This represents approximately 10% of the 3 million women who give birth vaginally each year. Vaginal birth is the largest modifiable risk factor for prolapse, the pelvic floor disorder most strongly associated with birth, and is an important contributor to stress incontinence. These disorders require 10 times as many operations as anal sphincter injuries. Imaging shows that injuries of the levator ani muscle, perineal body, and membrane occur in up to 19% of primiparous women. During birth, the levator muscle and birth canal tissues must stretch to more than 3 times their original length; it is this overstretching that is responsible for the muscle tear visible on imaging rather than compression or neuropathy. The injury is present in 55% of women with prolapse later in life, with an odds ratio of 7.3, compared with women with normal support. In addition, levator damage can affect other aspects of hiatal closure, such as the perineal body and membrane. These injuries are associated with an enlarged urogenital hiatus, now known as antedate prolapse, and with prolapse surgery failure. Risk factors for levator injury are multifactorial and include forceps delivery, occiput posterior birth, older maternal age, long second stage of labor, and birthweight of >4000 g. Delivery with a vacuum device is associated with reduced levator damage. Other steps that might logically reduce injuries include manual rotation from occiput posterior to occiput anterior, slow gradual delivery, perineal massage or compresses, and early induction of labor, but these require study to document protection. In addition, teaching women to avoid pushing against a contracted levator muscle would likely decrease injury risk by decreasing tension on the vulnerable muscle origin. Providing care for women who have experienced difficult deliveries can be enhanced with early recognition, physical therapy, and attention to recovery. It is only right that women be made aware of these risks during pregnancy. Educating women on the long-term pelvic floor sequelae of childbirth should be performed antenatally so that they can be empowered to make informed decisions about management decisions during labor., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Objective: To examine the postnatal psychological health and parenting adjustment of primiparous women experiencing perineal trauma., Study Design: Longitudinal cohort study assessing body image, perceptions of traumatic birth, psychological distress, perineal pain, impact upon parental tasks and mother-infant bonding at 6-12 weeks (n = 103) and 6-10 months postnatally (n = 91). Primiparous women were recruited following vaginal birth and perineal suturing in a UK-based maternity hospital. al. Comparisons made according to the objective classification of perineal trauma experienced; 1st/2nd degree tear, episiotomy, and Obstetric Anal Sphincter Injuries (OASI)., Results: At 6-12 weeks women with an episiotomy reported a more negative perception of their body image than those with OASI. Women with OASI or an episiotomy were more likely to have experienced birth as traumatic, and those with OASI reported more avoidance symptoms of post-traumatic stress and a greater negative impact on parenting tasks. At 6-10 months significantly more avoidance symptoms continued to be reported by those with OASI, whereas those with an episiotomy reported more anxiety related symptoms in general than those with OASI., Conclusions: OASI, whilst associated with traumatic birth and some early parenting impacts, may not be linked to general negative psychological outcomes when specialist routine follow-up care is provided. Psychological impacts for women with episiotomy may merit further input than currently provided. Consideration should be given with regards to widening the access to postnatal perineal care by extending the criteria for specialist follow up beyond those sustaining OASI., 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 © 2024 The Authors. Published by Elsevier B.V. All rights reserved.)

Introduction: There are many risk factors for obstetric anal sphincter injury (OASIS) and the interaction between these risk factors is complex and understudied. The many observational studies that have shown a reduction of OASIS rates after implementation of perineal support have short follow-up time. We aimed to study the effect of integration of active perineal support and lateral episiotomy on OASIS rates over a 15-year period and to study interactions between risk factors known before delivery., Material and Methods: We performed a historical cohort study over the periods 1999-2006 and 2007-2021 at Stavanger University Hospital, Norway. The main outcome was OASIS rates. Women without a previous cesarean section and a live singleton fetus in cephalic presentation at term were eligible. The department implemented in 2007 the Finnish concept of active perineal protection, which includes support of perineum, control of fetal expulsion, good communication with the mother and observation of perineal stretching. The practice of mediolateral episiotomy was replaced with lateral episiotomy when indicated. We analyzed the OASIS rates in groups with and without episiotomy stratified for delivery mode, fetal position at delivery and for parity, and adjusted for possible confounders (maternal age, gestational age, oxytocin augmentation and epidural analgesia)., Results: We observed a long-lasting reduction in OASIS rates from 4.9% to 1.9% and an increase in episiotomy rates from 14.4% to 21.8%. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with instrumental vaginal deliveries and occiput anterior (OA) position; 3.4% vs 10.1% (OR 0.31; 95% CI: 0.24-0.40) and 6.1 vs 13.9% (OR 0.40; 95% CI: 0.19-0.82) in women with occiput posterior (OP) position. Lateral episiotomy was also associated with lower OASIS rates in nulliparous women with spontaneous deliveries and OA position; 2.1% vs 3.2% (OR 0.62; 95% CI: 0.49-0.80). The possible confounders had little confounding effects on the risk of OASIS in groups with and without episiotomy., Conclusions: We observed a long-lasting reduction in OASIS rates after implementation of preventive procedures. Lateral episiotomy was associated with lower OASIS rates in nulliparous women with an instrumental delivery. Special attention should be paid to deliveries with persistent OP position., (© 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).)

Aim: Obstetric anal sphincter injuries (OASIS) occur in approximately 3%-6% of vaginal deliveries and are the leading risk factor for late-onset faecal incontinence, which is an underdiagnosed pathology. The aim of this work was to use a validated scoring system to quantify the effect of irritable bowel syndrome (IBS) on the severity of faecal incontinence symptoms after primary repair of major OASIS (Grade IIIb-IV)., Method: A prospective cohort study was performed on all women who underwent primary repair of major OASIS over a 6-year period. They were assessed with ultrasonography within 12 weeks. Two control groups (who did not have OASIS) were women who underwent elective caesarean section and primigravid women. Questionnaires were sent at least 12 months after delivery, or at first consultation for primigravids, which generated the main outcome measures: Cleveland Clinic faecal incontinence severity scores and the presence of IBS based on Rome III criteria., Results: There was a total of 211 patients included in the three groups and the mean follow-up time was 26 months after sphincter repair. Ultrasonographic sphincter defects were detected in 37% but did not affect the faecal incontinence score (p = 0.47), except in patients with IBS. Within each group, patients with IBS had significantly worse faecal incontinence than those without. Women with both OASIS and IBS had the most severe faecal incontinence scores., Conclusion: OASIS has a limited negative effect on faecal incontinence, independent of whether residual ultrasonographic sphincter defects are present. However, the presence of IBS has a significant compounding effect on faecal incontinence in OASIS patients. The effect of IBS on faecal incontinence is also notable in caesarean section patients and primigravids, suggesting that IBS is an independent risk-factor that should have its place in predelivery assessment and counselling., (© 2024 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Objectives: There is a progressive reduction in the rate of episiotomies since the recommendations of the French college of gynaecologists. Our objective was to study the evolution of the rate of episiotomies and Obstetric Anus Sphincter Injury (OASI) since the restriction of episiotomies in our department., Methods: Observational monocentric retrospective study performed at the Rouen University Hospital. The inclusion criteria were monofetal pregnancies, delivery at a term greater than or equal to 37 weeks of amenorrhea of a living, viable child and by cephalic presentation. We compared two periods corresponding to before and after the 2018 recommendations. We used logistic regression modelling to identify factors associated with the risk of episiotomies and of obstetrical anal injuries, overall and in case of instrumental delivery., Results: We included 3329 patients for the 1st period and 3492 for the 2nd period, and the rate of instrumental deliveries were respectively of 16.4% (n=547) and 17.9% (n=626). Multivariate analysis showed a significant decrease in the rate of episiotomies in the 2nd period (OR 0.14, CI 95% [0.12; 0.16], P<0.0001). Main factors associated with the risk of OASI were primiparity (OR 6.21, CI 95% [3.19; 12.11]) and the use of forceps (OR 4.23, CI 95% [2.17; 8.27]) overall; and instrumental delivery using forceps (OR 3.25, CI 95% [1.69; 6.22]) and delivery during the 2nd period (OR 1.98, CI 95% [1.01; 3.88]) in case of instrumental delivery., Conclusions: Our study confirms that the voluntary reduction in the episiotomy rate does not seem to be associated with an increased risk of OASI, overall and in case of instrumental delivery. However, we show an increase in the rate of OASI in case of instrumental delivery since the latest recommendations., (Copyright © 2024 Elsevier Masson SAS. All rights reserved.)

Aim: The incidence of obstetric anal sphincter injuries (OASIS) has increased in the past two decades despite improved awareness of the risk factors. This study aimed to define the incidence of OASIS in women with different features (instrumental delivery or other variables)., Methods: A systematic review was conducted on articles reporting the incidence of OASIS. This review aims to examine the association of instrumentation and OASIS by performing a formal systematic review of the published literature. Databases used for the research were MEDLINE, Embase, CINAHL and 'Maternity and infant care' databases., Results: Two independent reviewers screened the selected articles. 2326 duplicates were removed from the total of 4907 articles. The remaining 2581 articles were screened for title and abstract. 1913 articles were excluded due to irrelevance. The remaining 300 were screened as full text. Primiparity associated with the use of forceps were the features associated with the highest incidence of OASIS in the selected articles (19.4%). OASIS in all women had an overall incidence of 3.8%. The incidence of OASIS in all women by geographical region was the highest (6.5%) in North America., Conclusions: There are various factors that impact on the incidence of OASIS and the combination of some of these, such as the use of forceps in primiparas, resulted in the highest incidence of OASIS. The lack of international consensus is limiting the improvements that can be done to reduce OASIS rates and improve best clinical practice., (© 2023 Association of Coloproctology of Great Britain and Ireland.)

Aim: The role of colorectal surgeons in the management of acute obstetric anal sphincter injury (OASI) is an ongoing debate. Their expertise in operating in the anorectal region lends itself to assisting in OASI repair. The aim of this study was to establish the current involvement and recommended management of acute OASI by colorectal surgeons., Method: An online survey of consultant colorectal surgeons was sent to members of the Pelvic Floor Society to assess current involvement in acute OASI management and repair., Results: Forty completed surveys were collated and analysed. Sixty-five per cent of respondents had seen an acute OASI since being a consultant and 50% stated they were involved in the repair of OASI less than once per year. 37.5% felt that a de-functioning stoma was still necessary sometimes. Many agreed with current guidelines for OASI repair in terms of antibiotics, laxatives and follow-up., Conclusions: Colorectal surgeons have varied opinions on the management of OASI. We suggest that multidisciplinary training of obstetricians and colorectal surgeons could lead to more collaboration regarding the management of women with acute OASI., (© 2023 The Authors. Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Background and Objective: Childbirth trauma is a major health concern that affects millions of women worldwide. Severe degrees of perineal trauma, designated as obstetric anal sphincter injuries (OASIS), and levator ani muscle (LAM) injuries are associated with long-term morbidity. While significant research has been conducted on LAM avulsions, less attention has been given to perineal trauma and OASIS, which affect up to 90% and 11% of vaginal deliveries, respectively. Despite being widely discussed, childbirth trauma remains unpredictable. This work aims to enhance the modeling of the maternal musculature during childbirth, with a particular focus on understanding the mechanisms underlying the often overlooked perineal injuries., Methods: A geometrical model of the pelvic floor muscles (PFM) and perineum (including the perineal body, ischiocavernosus, bulbospongiosus, superficial and deep transverse perineal muscles) was created. The muscles were characterized by a transversely isotropic visco-hyperelastic constitutive model. Two simulations of vaginal delivery were conducted with the fetus in the vertex presentation and occipito-anterior position, with and without the perineum., Results: The simulation that considered the perineum exhibited higher stresses over an extended area of the PFM, which suggests that including additional structures can impact the obtained results. The maximum stretch of the urogenital hiatus was 2.94 and the maximum stress was 23.86 kPa. The perineal body reached a maximum stretch of 1.95, which was more pronounced near the urogenital hiatus, where perineal tears may occur. The external anal sphincter's transverse diameter decreased by 51% and the maximum principal stresses were observed in the area close to the perineal body, where OASIS can occur., Conclusions: The present study emphasizes the importance of including most structures involved in vaginal delivery in its biomechanical analysis and represents another step further in the understanding of perineal injuries and OASIS. The superior region of the perineal body and its connection to the urogenital hiatus and anal sphincter have been identified as the most critical regions, highly susceptible to injury., 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 The Author(s). Published by Elsevier B.V. All rights reserved.)

Background: Bullfighting festivals are commonly performed at Spain. Perineal trauma due to bull-horn injury is associated with high morbidity due to sphincteric associated lesions METHODS: We report a case of 37-year-old male patient with anal trauma due to a bull-horn injury involving the sphincter complex, treated in our Emergency department RESULTS: Urgent surgery was performed with primary sphincteroplasty, without performing a colostomy. The associated complication was a partial dehiscence of the surgical wound (Clavien-Dindo I). No transfusions, re-interventions or readmissions were registered. The degree of incontinence at discharge and after 12 month follow-up, according to the Wexner scale was 8 points and 2 points, respectively., Conclusions: The main treatment of bull-horn injuries is extensive surgical debridement, antibiotic therapy, and lavage of the area. In cases involving the anal sphincter, primary sphincteroplasty is recommended. The modern trend does not include the systematic performance of a colostomy however, it has been described in cases with catastrophic wounds and urological lesions associated., (© 2023. Springer Nature Switzerland AG.)

Objective: To evaluate trends in the incidence of women with obstetric anal sphincter injuries (OASIS) over a 10-year period comparing spontaneous vaginal delivery (SVD) and operative vaginal delivery (OVD)., Methods: A retrospective study was performed in which all women who underwent vaginal delivery over a 10-year period (n = 86 242, 2009-2018) at the Rotunda Hospital were reviewed. The overall incidence of OASIS was compared with incidence rates stratified by parity and type of vaginal birth., Results: The 10-year vaginal delivery rate was 69% (n = 59 187) where 24 580 women (42%) were primiparous and 34 607 women (58%) were multiparous. SVD rate was 74% and OVD rate was 26%. The overall incidence of OASIS was 2.9%. The incidence of OASIS in OVD was 5.5% and the incidence in SVD was 2%. Of 498 multipara who sustained OASIS, 366 (73%) had an SVD without episiotomy compared with 14 (3%) who had an episiotomy. There was a significant reduction of OASIS over the 10-year period in primipara who had an OVD but no reduction in the other groups., Conclusion: The primiparous OVD group had a significant reduction of OASIS. Continued education around perineal protection and episiotomy at SVD could positively impact further reduction in OASIS, particularly in the SVD groups., (© 2023 International Federation of Gynecology and Obstetrics.)

Purpose of Review: Perineal wound complications occur in up to 25% of postpartum patients. Wound complications are most common after obstetric anal sphincter injuries (OASIS) but can occur after any laceration. It is imperative that any provider caring for postpartum patients understand the best evidence-based practices to recognize and manage these complications. We present a review of the available literature on the management of postpartum perineal wound complications., Recent Findings: There is a paucity of new publications on the management of postpartum perineal wound complications, despite an increased emphasis on postpartum recovery in women's health. The role of topical estrogen in healing of perineal wounds was investigated in a pilot study, demonstrating that granulation tissue does express estrogen receptors, and the use of estrogen increases cell proliferation. Progression of perineal wound healing by secondary intention was evaluated in an observational study. Wound healing was delayed in 30% of women, with the initial wound area, perimeter, bacterial colonization, and OASIS being associated with delayed healing., Summary: Evidence based practices on timing of follow-up, addressing wound care and analgesia, administrating antibiotics, timing secondary repair, and surgical technique all play a role in optimizing recovery and reducing morbidity in patients with postpartum perineal wound complications., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Introduction and Hypothesis: Perineal trauma during vaginal delivery is very common. Training in diagnosis and repair of trauma, including obstetric anal sphincter injuries, varies in the UK. We aimed to investigate the current knowledge and training received by obstetric physicians., Methods: A national, validated survey was conducted online, using Qualtrics. The National Trainees Committee distributed the survey. It was also sent directly to consultants via email., Results: A total of 302 physicians completed the survey and were included in the analysis. 3.9% of participants described their training in obstetric perineal trauma as "very poor" or "poor". 20.5% said they have not received training. 8.6% of physicians practising for more than 10 years had not had training for over 10 years. 70.5% responded "somewhat agree" or "strongly agree" when asked if they would like more training. Identification of first, second, third-, and fourth-degree tears from images and descriptions was very good (more than 80% correct for all categories). Classification of other perineal trauma was less consistent, with many incorrectly using the Sultan Classification. "Manual perineal support" and "Controlled or guided delivery" were the most frequently selected methods for the prevention of obstetric anal sphincter injury (OASI)., Conclusions: Training experience for physicians in obstetric perineal trauma varies. Further improvement in training and education in perineal trauma, particularly in OASI, is needed for physicians. Perineal trauma that is not included in the Sultan Classification is often misclassified., (© 2023. Crown.)

Objective: The use of episiotomy during operative vaginal birth (OVB) is rather debated among operators and in literature. It is also important to evaluate the indications for which episiotomy is performed. In fact, the consequences of an episiotomy can be invalidating for patients with long-lasting results. The aim of this study is the evaluation of the role of episiotomy during OVB with the vacuum extractor and its correlation with Obstetric Anal Sphincter Injuries (OASIs). Methods: On of 9165 vaginal births, a total of 498 OVB (5.4%) were enrolled in a longitudinal prospective observational study. The incidence of OASIs was evaluated in our population after OVB performed with the vacuum extractor, during which the execution of episiotomy was performed indicated by clinician in charge. Results: OASIs occurred in 4% of the patients ( n  = 20). Episiotomy was performed in 39% of them ( n  = 181). OASIs incidence was 6% ( n  = 17) in the No Episiotomy and 1.8% ( n  = 3) in Episiotomy group ( p <.001). Performance of episiotomy during OVB determined a protective effect against OASIs ( p  = 0.025 in full cohort and p  = 0.013 in the primiparous group). An expulsive phase under one hour was an almost significant protective factor ( p  = 0.052). Conclusions: The use of episiotomy during OVB was associated with much lower OASIs rates in nulliparous women with a vacuum extraction; OR 0.23 (CI 95% 0.07-0.81) p  = 0.037 in nulliparous women and the number necessary to treat was 18 among nulliparous women to prevent 1 OASIs. A further risk factor that emerged from the analysis is a prolonged expulsive period, whereas fundal pressure does not seem to have a statistically significant influence.

Purpose: Levator ani muscle (LAM) avulsion affects up to 35% of women. Unlike obstetric anal sphincter injury, LAM avulsion is not diagnosed immediately after vaginal delivery, however, has a profound impact on quality of life. The management of pelvic floor disorders is in growing demand yet the significance of LAM avulsion in the context of pelvic floor dysfunction (PFD) is poorly understood. This study collates information on success of treatment for LAM avulsion to establish the best options for management of women., Methods: MEDLINE ® , MEDLINE ® In-Process, EMBASE, PubMed, CINAHL and The Cochrane Library were searched for articles that evaluated the management techniques used to treat LAM avulsion. The protocol was registered with PROSPERO (CRD42021206427)., Results: Natural healing of LAM avulsion occurs in 50% of women. Conservative measures, including pelvic floor exercises and pessary use are poorly studied. Pelvic floor muscle training for major LAM avulsions was of no benefit. Post-partum pessary use was only of benefit in the first three months for women. Surgeries for LAM avulsion are poorly researched but studies suggest they may provide benefit for 76-97% of patients., Conclusions: Whilst some women with PFD secondary to LAM avulsion improve spontaneously, 50% continue to have pelvic floor symptoms 1 year following delivery. These symptoms result in a significant negative impact on quality of life, however, it is not clear whether conservative or surgical methods are helpful. There is a pressing need for research to find effective treatments and explore appropriate surgical repair techniques for women with LAM avulsion., (© 2023. Crown.)

Introduction and Hypothesis: The objective was to identify modifiable risk factors for obstetric anal sphincter injury (OASI) in primiparous women., Methods: This was a retrospective cohort study of primiparous women with a singleton vaginal delivery. Main outcome measures were incidence of OASI and odds ratios for possible risk factors: maternal age, body mass index and height, fetal birthweight and head circumference, gestational age, epidural analgesia, mediolateral episiotomy, and instrumental deliveries. Univariate and multivariate logistic regressions were performed using forward methods for variable selection., Results: Of 19,786 primiparous women with a singleton vaginal delivery, 369 sustained an OASI (1.9%). Risk factors were identified: vacuum extraction (adjusted OR 2.06, 95% CI, 1.59-2.65, p < 0.001), increased fetal weight (aOR 1.06, 95% CI, 1.02-1.11, p = 0.002, per 100-g increments); head circumference (aOR 1.24, 95% CI, 1.13-1.35, p < 0.001, per 1-cm increments); gestational week (aOR 1.11, 95% CI, 1.02-1.2, p = 0.012, per week). Protective factors: mediolateral episiotomy (aOR 0.75, 95% CI, 0.59-0.94, p = 0.013) particularly in vacuum deliveries (aOR 0.50, 95% CI, 0.29-0.97, p = 0.040); epidural analgesia (aOR 0.64, 95% CI, 0.48-0.84, p = 0.001); maternal height ≥157 cm (aOR 0.97, 95% CI, 0.96-0.98, p = 0.006, risk decreases by 2.6% per 1 cm increase in height)., Conclusions: Mediolateral episiotomy was protective against OASI in both spontaneous and instrumental deliveries of primiparae. Increased fetal weight and large fetal head circumference, particularly in short women, were significant risk factors. These findings support the performance of ultrasound to acquire updated fetal measures before admission to the labor ward., (© 2023. The International Urogynecological Association.)

Obstetric anal sphincter injury (OASI) in the absence of concurrent injury to the perineal skin is not a common diagnosis. A primiparous woman delivered a healthy male infant by spontaneous vertex delivery. At time of delivery, a compound presentation of the fetal hand with the head was noted. Initial examination revealed a presumed second-degree tear; however, a small laceration above the anal verge was noted, which on exploration revealed a perineal injury through the anal sphincter complex. In the operating theatre, the perineal skin was incised to reveal a 3c OASI, which was repaired appropriately. While atypical OASI has been reported previously, this specific injury has never been described in detail in the literature. Awareness of atypical perineal injuries is needed and while careful perineal examination is required in all cases, this is especially important where the perineal skin appears intact to ensure appropriate diagnosis of any concurrent OASI., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: The primary objective was to perform a systematic review of predictive factors for obstetric anal sphincter injury (OASI) occurrence at first vaginal delivery, with the diagnosis made by ultrasound (US-OASI). The secondary objective was to report on incidence rates of sonographic anal sphincter (AS) trauma, including trauma that was not clinically reported at childbirth, among the studies providing data for our primary objective., Methods: We conducted a systematic search of MEDLINE, EMBASE, Web of Science, CINAHL, The Cochrane Library and ClinicalTrials.gov databases. Both observational cohort studies and interventional trials were eligible for inclusion. Study eligibility was assessed independently by two authors. Random-effects meta-analyses were performed to pool effect estimates from studies reporting on similar predictive factors. Summary odds ratio (OR) or mean difference (MD) is reported with 95% CI. Heterogeneity was assessed using the I 2 statistic. Methodological quality was assessed using the Quality in Prognosis Studies tool., Results: A total of 2805 records were screened and 21 met the inclusion criteria (16 prospective cohort studies, three retrospective cohort studies and two interventional non-randomized trials). Increasing gestational age at delivery (MD, 0.34 (95% CI, 0.04-0.64) weeks), shorter antepartum perineal body length (MD, -0.60 (95% CI, -1.09 to -0.11) cm), labor augmentation (OR, 1.81 (95% CI, 1.21-2.71)), instrumental delivery (OR, 2.13 (95% CI, 1.13-4.01)), in particular forceps extraction (OR, 3.56 (95% CI, 1.31-9.67)), shoulder dystocia (OR, 12.07 (95% CI, 1.06-137.60)), episiotomy use (OR, 1.85 (95% CI, 1.11-3.06)) and shorter episiotomy length (MD, -0.40 (95% CI, -0.75 to -0.05) cm) were associated with US-OASI. When pooling incidence rates, 26% (95% CI, 20-32%) of women who had a first vaginal delivery had US-OASI (20 studies; I 2  = 88%). In studies reporting on both clinical and US-OASI rates, 20% (95% CI, 14-28%) of women had AS trauma on ultrasound that was not reported clinically at childbirth (16 studies; I 2  = 90%). No differences were found in maternal age, body mass index, weight, subpubic arch angle, induction of labor, epidural analgesia, episiotomy angle, duration of first/second/active-second stages of labor, vacuum extraction, neonatal birth weight or head circumference between cases with and those without US-OASI. Antenatal perineal massage and use of an intrapartum pelvic floor muscle dilator did not affect the odds of US-OASI. Most (81%) studies were judged to be at high risk of bias in at least one domain and only four (19%) studies had an overall low risk of bias., Conclusion: Given the ultrasound evidence of structural damage to the AS in 26% of women following a first vaginal delivery, clinicians should have a low threshold of suspicion for the condition. This systematic review identified several predictive factors for this. © 2023 International Society of Ultrasound in Obstetrics and Gynecology., (© 2023 International Society of Ultrasound in Obstetrics and Gynecology.)

Introduction: Pelvic floor pain and dyspareunia are both important entities of postpartum pelvic pain, often concomitant and associated with perineal tears during vaginal delivery. The association between postpartum sonographic anal sphincter defects, pelvic floor pain, and dyspareunia has not been fully established. We aimed to determine the prevalence of postpartum anal sphincter defects using three-dimensional endoanal ultrasonography (3D-EAUS) and evaluate their association with symptoms of pelvic floor pain and dyspareunia., Material and Methods: This prospective cohort study followed 239 primiparas from birth to 12 months post delivery. Anal sphincters were assessed with 3D-EAUS 3 months postpartum, and self-reported pelvic floor function data were obtained using a web-based questionnaire distributed 1 year after delivery. Descriptive statistics were compared between the patients with and without sonographic defects, and the association between sonographic sphincter defects and outcomes were analyzed using logistic regression., Results: At 3 months postpartum, 48/239 (20%) patients had anal sphincter defects on 3D-EAUS, of which 43 (18%) were not clinically diagnosed with obstetric anal sphincter injury at the time of delivery. Patients with sonographic defects had higher fetal weight than those without defects, and a perineum <2 cm before the suture was a risk factor for defects (odds ratio [OR], 6.9). Patients with sonographic defects had a higher frequency of dyspareunia (OR, 2.4), and pelvic floor pain (OR, 2.3) than those without defects., Conclusions: Our results suggest an association between postpartum sonographic anal sphincter defects, pelvic floor pain, and dyspareunia. A perineal height <2 cm, measured by bidigital palpation immediately postdelivery, was a risk factor for sonographic anal sphincter defect. We suggest offering pelvic floor sonography around 3 months postpartum to high- risk women to optimize diagnosis and treatment of perineal tears and include perineum <2 cm prior to primary repair as a proposed indication for postpartum follow-up sonography., (© 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).)

Objective: To present clinical and instrumental sequelae after obstetric anal sphincter injuries (OASIS), evaluating correlations between intrapartum severity of lesions, postpartum symptoms, and sonographic and manometric findings; outcomes during subsequent deliveries were also evaluated., Methods: This retrospective study evaluated all consecutive women who sustained an OASIS between 2015 and 2020. Postpartum symptoms, anorectal manometry (ARM), and three-dimensional endoanal ultrasonography (3D-EAUS) were analyzed., Results: A total of 107 women underwent OASIS primary repair; 84 (78.5%) of them were asymptomatic after 1 month. The presence and severity of symptoms showed a great correlation with instrumental outcomes in terms of maximum resting pressure, squeeze pressure increment (SPI), circumferential extension of defect for both external anal sphincter (EAS) and internal anal sphincter (IAS), and EAS, IAS and total Starck scores. There was a significant correlation between ARM and 3D-EAUS findings, with the exception of SPI, for which the abnormalities were not predictable based on EAUS results., Conclusion: Both ARM and EAUS findings after OASIS are directly related to each other, and associated with symptoms. These instrumental tools may be useful for OASIS assessment and counseling., (© 2023 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Background: Obstetric anal sphincter injury (OASI) describes severe injury to the perineum and perineum and perianal muscles following birth and occurs in 4.4% to 6.0% of vaginal births in Canada. Studies from high-income countries have identified an increased risk of OASI in individuals who identify as Asian race versus those who identify as white. This protocol outlines a systematic review and meta-analysis which aims to determine the incidence of OASI in individuals living in high-income countries who identify as Asian versus those of white race/ethnicity. We hypothesize that the pooled incidence of OASI will be higher in Asian versus white birthing individuals., Methods: We will search MEDLINE, OVID, Embase, Emcare and Cochrane databases from inception to 2022 for observational studies using keywords and controlled vocabulary terms related to race, ethnicity and OASI. Two reviewers will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and Meta-analysis of Observational Studies (MOOSE) recommendations. Meta-analysis will be performed using RevMan for dichotomous data using the random effects model and the odds ratio (OR) as effect measure with a 95% confidence interval (CI). Subgroup analysis will be performed based on Asian subgroups (e.g., South Asian, Filipino, Chinese, Japanese individuals). Study quality assessment will be performed using The Joanna Briggs Institute Critical Appraisal tools., Discussion: The systematic review and meta-analysis that this protocol outlines will synthesize the extant literature to better estimate the rates of OASI in Asian and white populations in non-Asian, high-income settings and the relative risk of OASI between these two groups. This systematic summary of the evidence will inform the discrepancy in health outcomes experienced by Asian and white birthing individuals. If these findings suggest a disproportionate burden among Asians, they will be used to advocate for future studies to explore the causal mechanisms underlying this relationship, such as differential care provision, barriers to accessing care, and social and institutional racism. Ultimately, the findings of this review can be used to frame obstetric care guidelines and inform healthcare practices to ensure care that is equitable and accessible to diverse populations., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Park et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)