Cora A. Fanning

A Prospective Observational Study of 1000 Vacuum Assisted Deliveries With the OmniCup Device

OBJECTIVE To determine the maternal and perinatal outcomes associated with delivery by the rigid plastic OmniCup vacuum delivery device. METHODS We conducted a prospective observational study of 1000 consecutive vacuum-assisted deliveries using the OmniCup vacuum device in singleton pregnancies. The relationship of the cup application to the flexion point was independently observed after delivery and related to the neonatal outcome, including scalp trauma. RESULTS Of the 1000 women, 70% were nulliparous and 30% parous (> or = para 1). In 87.1% of the women, vacuum-assisted delivery was completed; spontaneous or forceps delivery occurred in 10.9%, and Caesarean section was performed in 2%. The vacuum was applied for < or = 10 minutes in 97.4% of deliveries, < or = 3 pulls were required in 95.6%, and < or = 25 lb traction force was required in 85.7% of cases. There was a statistically significant relationship between unfavourable cup applications (deflexing and paramedian) and scalp trauma in infants born to nulliparous women (P < 0.01). Four cases of neonatal intracranial hemorrhage (0.4%) were identified, and three of these infants were subsequently neurodevelopmentally normal. There was one subgaleal hemorrhage. CONCLUSIONS There is a relationship between unfavourable cup application during vacuum assisted delivery and neonatal scalp trauma in infants born to nulliparous women.

Overlapping compared with end-to-end repair of third- and fourth-degree obstetric anal sphincter tears: a randomized controlled trial.

OBJECTIVE: To compare overlapping repair with end-to-end repair of obstetric tears and to investigate which procedure results in a higher rate of flatal incontinence. METHODS: One-hundred forty-nine primiparous women sustaining a complete third- or a fourth-degree tear of the perineum were assigned randomly to a primary sphincter repair using either an end-to-end (n=75) or an overlapping surgical technique (n=74) using 3–0 polyglyconate. Outcome measures at 6 months included rates of flatal and fecal incontinence, quality-of-life scores, integrity of the internal and external anal sphincters by anal ultrasonography, and anal sphincter function as reflected by anal manometry. RESULTS: Women who underwent overlapping repair compared with end-to-end repair had higher rates of flatal incontinence, 61% compared with 39% (odds ratio [OR] 2.44, confidence interval [CI] 1.2–5.0). The rate of fecal incontinence was also higher, 15% compared with 8% (OR 1.97, CI 0.62–6.3) but did not attain statistical significance. Rates of internal and external anal sphincter defects did not differ significantly between groups and did not correlate with anal incontinence symptoms. Fecal incontinence was higher when there was a defect in both sphincter muscles. Anal sphincter function as assessed by manometry did not differ significantly between groups. CONCLUSION: End-to-end repair of third- or fourth-degree obstetric anal sphincter tears is associated with lower rates of anal incontinence when compared with overlapping repair. Clinical Trial Registration: ISRCTN Register, isrctn.org, ISRCTN04149919. LEVEL OF EVIDENCE: I

Overlapping compared with end-to-end repair of complete third-degree or fourth-degree obstetric tears: three-year follow-up of a randomized controlled trial.

OBJECTIVE: To report on a 3-year follow-up of women who underwent overlapping repair of a complete third-degree or fourth-degree obstetric tear. METHODS: Primiparous women sustaining a complete third-degree or a fourth-degree tear of the perineum were randomized to a primary sphincter repair using either an end-to-end or an overlapping surgical technique. At 1, 2, and 3 years, questionnaires on rates of flatal and fecal incontinence were mailed to participants. RESULTS: At 1 year, women who underwent an end-to-end repair reported lower rates of flatal and fecal incontinence than women who had an overlapping repair. For flatal incontinence the rates were 31% compared with 56% (95% confidence interval for the rate difference 6–43%, P=.012). For fecal incontinence, the rates were 7% compared with 16% (95% confidence interval for the rate difference −4% to 21%, P=.17). The difference between the two methods of surgical repair had largely disappeared by the end of year 2. CONCLUSION: At 1-year follow-up, end-to-end repair of complete third-degree or fourth-degree obstetric anal sphincter tears is associated with significantly lower rates of anal incontinence when compared with overlapping repair. There is no long-term benefit associated with either technique over the other. CLINICAL TRIAL REGISTRATION: ISRCTN Register, http://isrctn.org, ISRCTNO 4149919. LEVEL OF EVIDENCE: I

Women's ability to assess their urinary incontinence type using the QUID as an educational tool

Introduction and hypothesisLittle evidence is available concerning the ability of women with urinary incontinence (UI) to properly assess their problem. This study compared women’s assessments of their UI type with physicians’ diagnoses.MethodsWomen referred to a urogynecology clinic for UI were asked to anonymously answer a short validated Questionnaire for Urinary Incontinence Diagnosis (QUID) before their physician visit. Women completed the QUID and read a brief explanation of its interpretation, after which they were asked to choose their UI type: stress, urge, or mixed. Physicians, blinded to patients’ answers, conducted routine examinations and indicated their diagnoses of incontinence types. Sample size was representative of typical clinic volumes. Levels of agreement among physician diagnoses, QUID scores, and patient self-assessments of UI type were calculated with kappa (κ) statistics. Physician diagnosis was the gold standard.ResultsWe had 497 patients return the questionnaire; 338 met inclusion criteria. Mean age was 53 (±13) years. Levels of agreement among physician diagnoses and patients’ assessments of UI type (κ = 0.411, p < 0.01) and QUID scores (κ = 0.378, p < 0.01) were significant. Significant level of agreement was found among QUID scores and patients’ assessments of UI type (κ = 0.497, p < 0.001).ConclusionsWith aid of a brief standardized questionnaire, women can accurately assess their UI type. This suggests women could be educated about UI via good-quality Internet health sites and choose appropriate conservative management options.

Neonatal Outcome Following Failed Kiwi OmniCup Vacuum Extraction

OBJECTIVE To evaluate neonatal outcomes following failed vacuum extraction using the Kiwi OmniCup vacuum device. METHODS We conducted a retrospective study of 288 failed vacuum deliveries using the OmniCup device. The neonatal morbidity was recorded for each delivery. RESULTS Of the 288 women involved, 82.3% were nulliparous. In 245 cases (85.1%), failed vacuum was followed by successful forceps delivery; failed vacuum and failed forceps was followed by Caesarean section in 5.9%; failed vacuum was followed by spontaneous vaginal delivery in 3.8%; and failed vacuum was followed by Caesarean section in 5.2%. Cephalhematoma was diagnosed in 19.8% of the 288 infants delivered. There were no cases of neonatal intracranial or subgaleal hemorrhage. CONCLUSION Although the method of delivery following failed vacuum extraction is controversial, and most national guidelines warn of increased neonatal morbidity with subsequent use of forceps, the low morbidity in this study is reassuring. In our cohort, low forceps delivery (station > 2 cm) following failed vacuum extraction was not associated with serious neonatal morbidity.

Overlapping Compared With End-to-End Repair of Complete Third-Degree or Fourth-Degree Obstetric Tears: Three-Year Follow-up of a Randomized Controlled Trial

Overlapping compared with end-to-end repair of complete third-degree or fourth-degree obstetric tears: three-year follow-up of a randomized controlled trial - Obstetrics and Gynecology - Vol. 120, 4 - ISBN: 1873-233X - p.803-808

Overlapping Compared With End-to-End Repair of Third- and Fourth-Degree Obstetric Anal Sphincter Tears: A Randomized Controlled Trial

The traditional procedure in obstetric practice used to repair external anal sphincter defects has been an end-to-end technique. Clinicians have been concerned, however, by reports of high rates of external anal sphincter defects and associated symptoms of anal incontinence with this technique. In a small retrospective study, another procedure, overlapping repair, lowered the rate of postoperative defects and improved anal function leading to suggestions that the traditional end-to-end surgical repair technique does not restore normal anatomy or function. As a result, some investigators believe that overlapping repair should replace the end-to-end technique as the standard of care. A Cochrane review of 3 randomized trials comparing the overlapping and end-to-end repair techniques reported no difference in flatal or fecal incontinence rates but a lower rate of fecal urgency and a lower anal incontinence scores in the overlapping group. Although these data suggest some advantage of the overlapping repair technique, the 3 trials were limited by deficiencies in design. Limitations included lack of reporting surgeon experience, inclusion of multiparous women and women with partial tears of the external anal sphincter, and lack of clarity in regard to interpreting outcome measures. This randomized controlled trial compared the use of overlapping repair and end-to-end repair of obstetric tears and investigated which of these procedures is associated with a higher rate of flatal incontinence. The study subjects—149 primiparous women who had sustained a complete third- or a fourth-degree tear of the perineum—were randomly assigned to overlapping (n = 74) or end-to-end (n = 75) external anal sphincter repair. The study was conducted at a tertiary care academic center between 2001 and 2007. All participants and follow-up assessment personnel were blinded as to the surgical procedure performed. At the 6-month follow-up, outcome measures examined included rates of flatal and fecal incontinence, rates of internal and external anal sphincter defects using ultrasonography, anal function using anal manometry, and quality-of-life scores. Compared with end-to-end repair, overlapping repair was associated with higher rates of flatal incontinence (61 % vs. 39%); the odds ratio was 2.44, with a 95% confidence interval of 1.2-5.0 (P = 0.015). The rate of fecal incontinence was also higher with overlapping repair (15% vs. 8%) but not statistically significant (P = 0.243). The difference between groups in rates of internal and external anal sphincter defects was not significant. The presence of a defect in both sphincter muscles was associated with a higher rate of fecal incontinence. There was no significant difference in anal sphincter function between the surgical groups. These findings indicate that overlapping repair of third- or fourth-degree obstetric anal sphincter tears is more likely to result in anal incontinence compared with the traditional end-to-end repair procedure. The investigators recommend use of the traditional end-to-end procedure for repair of these tears.