Fødselsdynamikk og sfinkterrupturer hvilke risikofaktorer er relevante?

Transcription

1 Fødselsdynamikk og sfinkterrupturer hvilke risikofaktorer er relevante? Finn Egil Skjeldestad Forskningsgruppe for kvinnehelse og perinatologi, Institutt for klinisk medisin, Universitetet i Tromsø Norges arktiske universitet Tromsø

2 K.Laine 2013 OASIS in Nordic countries, updated 4,5 4 3,5 3 2,5 2 1,5 1 0,5 0 OASIS (%), all vaginal deliveries Denmark Sweden Norway Finland Oslo Fredrikstad K. Laine 2013

3 Forklaringen til nedgangen i AOSR? The impact of an intervention programme employing a handson technique to reduce the incidence of anal sphincter tears: interrupted time-series reanalysis Fretheim A, Odgaard-Jensen J, Røttingen J-A, et al. BMJ Open 2013;3:e doi: /bmjopen Conclusions: The intervention programme was associated with a significant reduction in the incidenceof obstetric anal sphincter tears. Still, the findings should be interpreted with caution as they seem to contradict the findings from randomised controlled studies of similar interventions.

4 Figure 2: Monthly incidence rates of anal sphincter tears in the five intervention hospitals with fitted segmented regression lines (full model). Fretheim A, Odgaard-Jensen J, Røttingen J-A, et al. BMJ Open 2013;3:e doi: /bmjopen

5 Vaginal parity INDUCTION ANES MODE of DELIVERY BW Duration 2nd Stage EPISIOTOMY AOSR HEAD CF ETNICITY AGE/Marital st. Figuromriss: Maternal foetal - obstetric Fødselsdynamikk og risiko for spinkterruptur

6 Fødselsdynamikk og risiko for spinkterruptur Hvordan er sammenhengen mellom faktorene? Paritet Induksjon Stimulering Epidural Fødselsfaser - varighet av aktiv trykketid Episiotomi Hodets innstilling Instrumentell forløsning FV Hvilke faktorer ligger i samme årsakskjede det ene betinger det andre?

7 Effect modificaton and AOSR confounding and interaction Risk for AOSR Group OR aor Group OR (95% CI) Vacuum/forceps 0 1,0 0/0 1,0 1/0 2,2 (1,9-2,6) 1 2,3 2,2 0/1 2,5 (1,9-3,1) 1/1 5,0 (4,0-6,3) BW >= 4000 g 0 1,0 1 2,4

8 Vaginal parity INDUCTION Duration 1st Stage Epidural Duration 2nd Stage EPISIOTOMY Bishop score <= 5 modning av cervix/ Bishop score > 5 induksjon av fødsel/rier Indikasjoner Overtidig svangerskap Preeklampsi/hypertensjon/PIH (Pregnancy Induced Hypertension) Diabetes mellitus Intrauterin tilveksthemning Vannavgang uten oppstart av rier Tvillingsvangerskap ved termin Polyhydramnion/oligohydramnion Andre medisinske/sosiale indikasjoner MODE of DELIVERY HEAD CF BW AOSR Perineum anal sphincters - rectum

9 Inductions Norway data from MBR Para-0 Para ,3 11, ,5 11, ,1 10, ,3 12, ,3 15, ,2 17, ,7 12,6

10 INDUCTION Obstetric risk factors OR aor (95% CI) Induction ( ) Abnormal 1 st stage ( ) Considerable confounding/ Episiotomy ( ) Not tested for interaction Forceps ( ) Vaccum ( ) Adjusted for: Parity, CD, age, race, education, medical insurance, BW, GA, fetal distress, prolonged 2 nd stage, shoulder dystocia, maternal diabetes. Handa VL, Denielsen BH, Gilbert Wm. Obstetric anal sphincter lacerations. Obstet Gynecol 2001;98: Overadjustment relevant risk factors? INDUCTION Episiotomy Vacuum Forceps AOSR

11 Vaginal parity Duration 1st Stage Time Time is no risk factor Epidural Duration 2nd Stage EPISIOTOMY MODE of DELIVERY HEAD CF BW AOSR Perineum anal sphincters - rectum

12 Vaginal parity Epidural Duration 2nd Stage EPISIOTOMY MODE of DELIVERY HEAD CF BW AOSR Perineum anal sphincters - rectum

13 Epidural etter paritet tidsperioder- MFR-data Para-0 Para ,3 7, ,6 8, ,8 16, ,7 17, ,7 18, ,8 20, ,8 13,8

14 Vaginal parity Epidural Duration of active 2nd Stage Duration 2nd Stage EPISIOTOMY MODE of DELIVERY HEAD CF BW AOSR Perineum anal sphincters - rectum

15 Use of oxytocin for augmentation of contractions Stavanger universitetshospital Para-0 Duration of active 2 nd stage 1-29 m 30-59m >=60 m % % % Consistent finding increasing from 1/3 in the 1-29 min. group to nearly 2/3 in the >= 60 min group over years. More use of oxytocin the longer active 2 nd stage last

16 Prevalence of instrumental deliveries Stavanger universitetshospital Para-0 Duration of active second stage 1-29m 30-59m 60+m Consistent finding the longer active 2 nd stage the more instrumental deliveries

17 Instrumentel forløsning etter paritet tidsperioder- MFR-data Para -0 Para-1+ Forceps Vacuum Forceps Vacuum % % % % ,4 10,0 1,0 2, ,3 12,4,8 2, ,2 14,1,7 2, ,6 16,0,6 3, ,3 17,4,7 3, ,5 18,4,9 4,1 Total 3,8 14,1,8 3,0

18 Vaginal parity Epidural Associated to use of oxytocin/instrumental delivery Duration of active 2nd Stage Time EPISIOTOMY MODE of DELIVERY HEAD CF BW AOSR Perineum anal sphincters - rectum

19 Vaginal parity Epidural EPISIOTOMY MODE of DELIVERY BW Occiput posterior HEAD CF AOSR Perineum anal sphincters - rectum

20 Occiput posterier (n=769:15493(4,6%)) Stavanger university hospital Para-0 Duration of active second stage 1-29m 30-59m 60+m A consistent strong association between occiput posterior position and use of oxytocin/instrumental deliveries

21 Why so many divergent results from studies on risk factors of OASR? Misjustment..because there overadjustment is no clear understanding for factors of the that causal measure pathway the of same OASR - interrelated and what even takes worse place during adjustment last part for of factors active 2 nd that phase! are not in the causal pathway!!!!!! Occiput posterior Episiotomy MODE of DELIVERY BW VF (-) BW (-) VF (+) BW (-) VF (+) BW (+) VF (-) BW (+) Parity Etnisity Age AOSR Epidural Induction Duration 1st phase Duration active 2nd phase

22 Final model Episiotomy VF (-) BW (-) VF (+) BW (-) VF (+) BW (+) VF (-) BW (+) AOSR Epidural Conclusion: Hands on must be evaluated in stratified analysis by the 3 intervention factors; Instrumental delivery, episiotomy, stimulation and BW estimation in light of epidural anestesia. By evalutating total quality of care more AOSRs prevented.

23 Velkommen til vårmøtet i Tromsø april 2014