Reducing high-order perineal laceration
during operative vaginal delivery
Emmet Hirsch, MD; Elaine I. Haney, BS, MT; Trent E. J. Gordon, MS; Richard K. Silver, MD
OBJECTIVE:
This study was undertaken to assess the impact of a fo-
cused intervention on reducing high-order (third and fourth degree)
perineal lacerations during operative vaginal delivery.
STUDY DESIGN:
The following recommendations for clinical manage-
ment were promulgated by departmental lectures, distribution of perti-
nent articles and manuals, training of physicians, and prominent dis-
play of an instructional poster: (1) increased utilization of vacuum
extraction over forceps delivery; (2) conversion of occiput posterior to
anterior positions before delivery; (3) performance of mediolateral epi-
siotomy if episiotomy was deemed necessary; (4) flexion of the fetal
head and maintenance of axis traction; (5) early disarticulation of for-
ceps; and (6) reduced maternal effort at expulsion. Peer comparison
was encouraged by provision of individual and departmental statistics.
Clinical data were extracted from the labor and delivery database and
the medical record.
RESULTS:
One hundred fifteen operative vaginal deliveries occurred in
the 3 quarters preceding the intervention, compared with 100 afterward
(P ϭ .36). High-order laceration with operative vaginal delivery de-
clined from 41% to 26% (P ϭ .02), coincident with increased use of
vacuum (16% vs 29% of operative vaginal deliveries, P ϭ .02); fewer
high-order lacerations after episiotomy (63% vs 22%, P ϭ .003); a
nonsignificant reduction in performance of episiotomy (30% vs 23%,
P ϭ .22); and a nonsignificant increase in mediolateral episiotomy
(14% vs 30% of episiotomies, P ϭ .19).
CONCLUSION:
Introduction of formal practice recommendations and
performance review was associated with diminished high-order peri-
neal injury with operative vaginal delivery.
Key words: forceps, operative vaginal delivery, perineal injury,
vacuum extraction
Cite this article as: Hirsch E, Haney EI, Gordon TEJ, et al. Reducing high-order perineal laceration during operative vaginal delivery. Am J Obstet Gynecol 2008;198:
668.e1-668.e5.
V
aginal birth frequently causes
perineal laceration. These lacera-
tions are typically categorized in 4 de-
grees, with third-degree lacerations in-
volving, in addition to the vaginal
epithelium and tissues of the perineal
body, a partial or complete tear of the
anal sphincter complex. In fourth-de-
gree perineal lacerations, the above tis-
sues are disrupted along with the rectal
mucosa. In general, these “high-order”
(third- and fourth-degree) perineal in-
juries are associated with greater risks
of dysfunction than lower order lacer-
ations. For example, the risk of re-
ported fecal incontinence 6 months
postpartum in primiparous women is
2-fold higher after a recognized
sphincter tear than after a vaginal birth
without such a tear (17.0% vs 8.2%, ad-
justed odds ratio [AOR], 1.9; 95% con-
fidence interval [CI], 1.2 to 3.2).
1
In addition to fecal and flatal inconti-
nence, high-order perineal lacerations
are associated with pain (acute and
chronic), dyspareunia, and rectovaginal
fistula.
1-3
In recent years, perineal lacer-
ation has been viewed as a proxy for
quality of care in obstetrics by the Joint
Commission (formerly JCAHO)
4
and
the Agency for Healthcare Research
and Quality (AHRQ, http://www.
qualityindicators.ahrq.gov).
5
Data on
third- and fourth-degree lacerations
will soon be available to third-party
payers and to the public on the Inter-
net. Also, functional impairment after
perineal laceration continues to be a
significant impetus for legal claims.
6
Given these considerations, it follows
that reducing high-order perineal lacer-
ation while preserving maternal and fetal
outcomes should be an important goal in
clinical obstetrics. In this observational
study, we report the outcomes of a de-
partment-wide intervention, the objec-
tive of which was to reduce the rate of
high-order perineal laceration in the set-
ting of operative vaginal delivery (OVD)
(vacuum and forceps). This interven-
tion, which focused on clinical practice
recommendations, education of physi-
cians, and performance review, was in-
stituted as a quality improvement effort
when it became apparent that perineal
injury with OVD in our hospital ex-
ceeded national benchmarks. Physicians
were encouraged to adopt evidence-
based practices that have been shown to
reduce the rates of severe perineal
trauma in published studies or are gen-
erally accepted “best practices” based
primarily on authoritative opinion. Out-
comes from the 9-month period before
the quarter in which the intervention
was initiated were compared with results
from the 9 months after.
From the Department of Obstetrics and
Gynecology (Drs Hirsch and Silver, Ms
Haney and Mr Gordon), Evanston
Northwestern Healthcare, Evanston, IL, and
the Feinberg School of Medicine (Drs Hirsch
and Silver), Northwestern University,
Chicago, IL.
Presented in part at the 74th Annual Meeting of
the Central Association of Obstetricians and
Gynecologists, Chicago, IL, Oct. 17-20, 2007.
Received July 7, 2007; revised Nov. 20, 2007;
accepted Feb. 4, 2008.
Reprints not available from the authors.
0002-9378/$34.00
© 2008 Mosby, Inc. All rights reserved.
doi: 10.1016/j.ajog.2008.02.002
CAOG Papers
www.
AJOG
.org
668.e1
American Journal of Obstetrics & Gynecology JUNE 2008