Effect of the “shoulder-up” bundle on the incidence of spontaneous perineal injury after vaginal delivery: comparison of 2 historic cohorts after propensity score matching
Perineal injury following vaginal delivery represents a major cause of long-term maternal morbidity, and its prevention is among the priorities of modern obstetrical practice. This study aimed to investigate whether the systematic implementation of a bundle of maneuvers to prevent perineal injury (i...
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| Veröffentlicht in: | American journal of obstetrics & gynecology MFM 2023-08, Vol.5 (8), p.101038-101038, Article 101038 |
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| creator | Morganelli, Giovanni Fieni, Stefania Dall'Asta, Andrea di Pasquo, Elvira Capozzi, Vito Andrea Valenti, Alissa Pezzani, Alessandra Kiener, Ariane Jeanne Odette Ghi, Tullio |
| description | Perineal injury following vaginal delivery represents a major cause of long-term maternal morbidity, and its prevention is among the priorities of modern obstetrical practice.
This study aimed to investigate whether the systematic implementation of a bundle of maneuvers to prevent perineal injury (ie, the “shoulder-up” bundle) may reduce the rate of spontaneous perineal tears in women delivering at a single tertiary maternity unit.
This was a single-center retrospective intervention study including all vaginal deliveries between April 1, 2020 and March 31, 2022. On March 1, 2021, a bundle focused on perineal injury prevention in vaginal deliveries was implemented and introduced as a standard of care. The “shoulder-up” bundle includes the addition of a hands-on technique for the delivery of the posterior shoulder, which is slowly lifted up under the direct visualization of the perineal body, immediately after the disengagement of the anterior shoulder. The labor ward staff underwent dedicated training to acquire expertise on the “shoulder-up” bundle. Little changes in terms of medical and midwifery staffing were recorded during the study period.
The incidence of spontaneous second-degree or higher perineal tears was compared between the patients who gave birth before the clinical implementation of the bundle (standard-care group) and those who were delivered following the implementation of the bundle (shoulder-up group). A 1:1 propensity score matching of the 2 groups was done for the variables that proved to be independently associated with the perineal outcome.
From April 1, 2020 to March 31, 2022, 3671 patients had a vaginal birth at our tertiary care unit (1786 in the standard-care group and 1885 in the “shoulder-up” group) and were enrolled in the study population. Of these, 1191 (32.4%) had a spontaneous second-degree or higher perineal tear. At univariate analysis, nulliparity (59.6% vs 39.1%; P |
| doi_str_mv | 10.1016/j.ajogmf.2023.101038 |
| format | Article |
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This study aimed to investigate whether the systematic implementation of a bundle of maneuvers to prevent perineal injury (ie, the “shoulder-up” bundle) may reduce the rate of spontaneous perineal tears in women delivering at a single tertiary maternity unit.
This was a single-center retrospective intervention study including all vaginal deliveries between April 1, 2020 and March 31, 2022. On March 1, 2021, a bundle focused on perineal injury prevention in vaginal deliveries was implemented and introduced as a standard of care. The “shoulder-up” bundle includes the addition of a hands-on technique for the delivery of the posterior shoulder, which is slowly lifted up under the direct visualization of the perineal body, immediately after the disengagement of the anterior shoulder. The labor ward staff underwent dedicated training to acquire expertise on the “shoulder-up” bundle. Little changes in terms of medical and midwifery staffing were recorded during the study period.
The incidence of spontaneous second-degree or higher perineal tears was compared between the patients who gave birth before the clinical implementation of the bundle (standard-care group) and those who were delivered following the implementation of the bundle (shoulder-up group). A 1:1 propensity score matching of the 2 groups was done for the variables that proved to be independently associated with the perineal outcome.
From April 1, 2020 to March 31, 2022, 3671 patients had a vaginal birth at our tertiary care unit (1786 in the standard-care group and 1885 in the “shoulder-up” group) and were enrolled in the study population. Of these, 1191 (32.4%) had a spontaneous second-degree or higher perineal tear. At univariate analysis, nulliparity (59.6% vs 39.1%; P<.001), higher gestational age at delivery (39.8±1.28 vs 39.4±1.97 weeks; P<.001), epidural analgesia (40.6% vs 31.2%; P<.001), vacuum-assisted delivery (9.6% vs 4.0%; P<.001), and birthweight >4 kg (11.0% vs 6.3%; P<.001) were independently associated with the perineal outcome. Following propensity score matching for the above cited factors, the 1703 patients of each group were compared. A significant increase in the rate of intact perineum (71.0% vs 64.1%; P=.014) and a reduction in the incidence of second- (27.2% vs 32.9%; P=.006) and third to fourth-degree perineal tears (1.3% vs 3.0%; P<.001) was demonstrated in the “shoulder-up” group. Among the subgroup of patients undergoing vacuum-assisted delivery, a borderline significant reduction in the rate of obstetrical anal sphincter injury (10.4% vs 2.9%; P=.052) was also observed.
Our study showed that the clinical implementation of the “shoulder-up” bundle at vaginal delivery is associated with a significant reduction in the incidence of spontaneous second-degree or higher perineal tears.]]></description><identifier>ISSN: 2589-9333</identifier><identifier>EISSN: 2589-9333</identifier><identifier>DOI: 10.1016/j.ajogmf.2023.101038</identifier><identifier>PMID: 37245605</identifier><language>eng</language><publisher>United States: Elsevier Inc</publisher><subject>Delivery, Obstetric - adverse effects ; Delivery, Obstetric - methods ; Female ; Humans ; Incidence ; Infant ; intrapartum perineal care ; obstetrical anal sphincter injuries ; perineal injury ; Perineum - injuries ; Pregnancy ; Propensity Score ; Retrospective Studies ; Shoulder ; shoulder delivery ; vaginal birth</subject><ispartof>American journal of obstetrics & gynecology MFM, 2023-08, Vol.5 (8), p.101038-101038, Article 101038</ispartof><rights>2023 Elsevier Inc.</rights><rights>Copyright © 2023 Elsevier Inc. All rights reserved.</rights><lds50>peer_reviewed</lds50><woscitedreferencessubscribed>false</woscitedreferencessubscribed><cites>FETCH-LOGICAL-c311t-5d311b72855fbf4615b95ca36a0d0e5b825c2b49ba2c30862d8389adcd6c789a3</cites><orcidid>0000-0002-0429-729X</orcidid></display><links><openurl>$$Topenurl_article</openurl><openurlfulltext>$$Topenurlfull_article</openurlfulltext><thumbnail>$$Tsyndetics_thumb_exl</thumbnail><link.rule.ids>314,780,784,27924,27925</link.rule.ids><backlink>$$Uhttps://www.ncbi.nlm.nih.gov/pubmed/37245605$$D View this record in MEDLINE/PubMed$$Hfree_for_read</backlink></links><search><creatorcontrib>Morganelli, Giovanni</creatorcontrib><creatorcontrib>Fieni, Stefania</creatorcontrib><creatorcontrib>Dall'Asta, Andrea</creatorcontrib><creatorcontrib>di Pasquo, Elvira</creatorcontrib><creatorcontrib>Capozzi, Vito Andrea</creatorcontrib><creatorcontrib>Valenti, Alissa</creatorcontrib><creatorcontrib>Pezzani, Alessandra</creatorcontrib><creatorcontrib>Kiener, Ariane Jeanne Odette</creatorcontrib><creatorcontrib>Ghi, Tullio</creatorcontrib><title>Effect of the “shoulder-up” bundle on the incidence of spontaneous perineal injury after vaginal delivery: comparison of 2 historic cohorts after propensity score matching</title><title>American journal of obstetrics & gynecology MFM</title><addtitle>Am J Obstet Gynecol MFM</addtitle><description><![CDATA[Perineal injury following vaginal delivery represents a major cause of long-term maternal morbidity, and its prevention is among the priorities of modern obstetrical practice.
This study aimed to investigate whether the systematic implementation of a bundle of maneuvers to prevent perineal injury (ie, the “shoulder-up” bundle) may reduce the rate of spontaneous perineal tears in women delivering at a single tertiary maternity unit.
This was a single-center retrospective intervention study including all vaginal deliveries between April 1, 2020 and March 31, 2022. On March 1, 2021, a bundle focused on perineal injury prevention in vaginal deliveries was implemented and introduced as a standard of care. The “shoulder-up” bundle includes the addition of a hands-on technique for the delivery of the posterior shoulder, which is slowly lifted up under the direct visualization of the perineal body, immediately after the disengagement of the anterior shoulder. The labor ward staff underwent dedicated training to acquire expertise on the “shoulder-up” bundle. Little changes in terms of medical and midwifery staffing were recorded during the study period.
The incidence of spontaneous second-degree or higher perineal tears was compared between the patients who gave birth before the clinical implementation of the bundle (standard-care group) and those who were delivered following the implementation of the bundle (shoulder-up group). A 1:1 propensity score matching of the 2 groups was done for the variables that proved to be independently associated with the perineal outcome.
From April 1, 2020 to March 31, 2022, 3671 patients had a vaginal birth at our tertiary care unit (1786 in the standard-care group and 1885 in the “shoulder-up” group) and were enrolled in the study population. Of these, 1191 (32.4%) had a spontaneous second-degree or higher perineal tear. At univariate analysis, nulliparity (59.6% vs 39.1%; P<.001), higher gestational age at delivery (39.8±1.28 vs 39.4±1.97 weeks; P<.001), epidural analgesia (40.6% vs 31.2%; P<.001), vacuum-assisted delivery (9.6% vs 4.0%; P<.001), and birthweight >4 kg (11.0% vs 6.3%; P<.001) were independently associated with the perineal outcome. Following propensity score matching for the above cited factors, the 1703 patients of each group were compared. A significant increase in the rate of intact perineum (71.0% vs 64.1%; P=.014) and a reduction in the incidence of second- (27.2% vs 32.9%; P=.006) and third to fourth-degree perineal tears (1.3% vs 3.0%; P<.001) was demonstrated in the “shoulder-up” group. Among the subgroup of patients undergoing vacuum-assisted delivery, a borderline significant reduction in the rate of obstetrical anal sphincter injury (10.4% vs 2.9%; P=.052) was also observed.
Our study showed that the clinical implementation of the “shoulder-up” bundle at vaginal delivery is associated with a significant reduction in the incidence of spontaneous second-degree or higher perineal tears.]]></description><subject>Delivery, Obstetric - adverse effects</subject><subject>Delivery, Obstetric - methods</subject><subject>Female</subject><subject>Humans</subject><subject>Incidence</subject><subject>Infant</subject><subject>intrapartum perineal care</subject><subject>obstetrical anal sphincter injuries</subject><subject>perineal injury</subject><subject>Perineum - injuries</subject><subject>Pregnancy</subject><subject>Propensity Score</subject><subject>Retrospective Studies</subject><subject>Shoulder</subject><subject>shoulder delivery</subject><subject>vaginal birth</subject><issn>2589-9333</issn><issn>2589-9333</issn><fulltext>true</fulltext><rsrctype>article</rsrctype><creationdate>2023</creationdate><recordtype>article</recordtype><sourceid>EIF</sourceid><recordid>eNp9kc9u1DAQxi0EolXpGyDkI5csjh1nEw5IqCp_pEpc4Gw59njjKLGD7ay0tz5IeQbeqU-CQxbEidOMZr5vxuMfQi9LsitJWb8ZdnLwh8nsKKFsLRHWPEGXlDdt0TLGnv6TX6DrGAdCCC2ritP6Obpge1rxmvBL9PPWGFAJe4NTD_jx_iH2fhk1hGKZH-9_4G5xegTs3e--dcpqcApWQ5y9S9KBXyKeIVgHcsyKYQknLE2CgI_yYF0uahjtEcLpLVZ-mmWwMc_LEyjubUw-WJUbvQ8pno1z8DO4aNMJR-UD4Ekm1Vt3eIGeGTlGuD7HK_Ttw-3Xm0_F3ZePn2_e3xWKlWUquM6h29OGc9OZqi5513IlWS2JJsC7hnJFu6rtJFWMNDXVDWtaqZWu1T4n7Aq93ubml3xfICYx2ahgHLd7BW0oYazmvMrSapOq4GMMYMQc7CTDSZRErLTEIDZaYqUlNlrZ9uq8Yekm0H9Nf9hkwbtNAPnOo4UgorLr32sbMjKhvf3_hl-SCq1A</recordid><startdate>202308</startdate><enddate>202308</enddate><creator>Morganelli, Giovanni</creator><creator>Fieni, Stefania</creator><creator>Dall'Asta, Andrea</creator><creator>di Pasquo, Elvira</creator><creator>Capozzi, Vito Andrea</creator><creator>Valenti, Alissa</creator><creator>Pezzani, Alessandra</creator><creator>Kiener, Ariane Jeanne Odette</creator><creator>Ghi, Tullio</creator><general>Elsevier Inc</general><scope>CGR</scope><scope>CUY</scope><scope>CVF</scope><scope>ECM</scope><scope>EIF</scope><scope>NPM</scope><scope>AAYXX</scope><scope>CITATION</scope><scope>7X8</scope><orcidid>https://orcid.org/0000-0002-0429-729X</orcidid></search><sort><creationdate>202308</creationdate><title>Effect of the “shoulder-up” bundle on the incidence of spontaneous perineal injury after vaginal delivery: comparison of 2 historic cohorts after propensity score matching</title><author>Morganelli, Giovanni ; Fieni, Stefania ; Dall'Asta, Andrea ; di Pasquo, Elvira ; Capozzi, Vito Andrea ; Valenti, Alissa ; Pezzani, Alessandra ; Kiener, Ariane Jeanne Odette ; Ghi, Tullio</author></sort><facets><frbrtype>5</frbrtype><frbrgroupid>cdi_FETCH-LOGICAL-c311t-5d311b72855fbf4615b95ca36a0d0e5b825c2b49ba2c30862d8389adcd6c789a3</frbrgroupid><rsrctype>articles</rsrctype><prefilter>articles</prefilter><language>eng</language><creationdate>2023</creationdate><topic>Delivery, Obstetric - adverse effects</topic><topic>Delivery, Obstetric - methods</topic><topic>Female</topic><topic>Humans</topic><topic>Incidence</topic><topic>Infant</topic><topic>intrapartum perineal care</topic><topic>obstetrical anal sphincter injuries</topic><topic>perineal injury</topic><topic>Perineum - injuries</topic><topic>Pregnancy</topic><topic>Propensity Score</topic><topic>Retrospective Studies</topic><topic>Shoulder</topic><topic>shoulder delivery</topic><topic>vaginal birth</topic><toplevel>peer_reviewed</toplevel><toplevel>online_resources</toplevel><creatorcontrib>Morganelli, Giovanni</creatorcontrib><creatorcontrib>Fieni, Stefania</creatorcontrib><creatorcontrib>Dall'Asta, Andrea</creatorcontrib><creatorcontrib>di Pasquo, Elvira</creatorcontrib><creatorcontrib>Capozzi, Vito Andrea</creatorcontrib><creatorcontrib>Valenti, Alissa</creatorcontrib><creatorcontrib>Pezzani, Alessandra</creatorcontrib><creatorcontrib>Kiener, Ariane Jeanne Odette</creatorcontrib><creatorcontrib>Ghi, Tullio</creatorcontrib><collection>Medline</collection><collection>MEDLINE</collection><collection>MEDLINE (Ovid)</collection><collection>MEDLINE</collection><collection>MEDLINE</collection><collection>PubMed</collection><collection>CrossRef</collection><collection>MEDLINE - Academic</collection><jtitle>American journal of obstetrics & gynecology MFM</jtitle></facets><delivery><delcategory>Remote Search Resource</delcategory><fulltext>fulltext</fulltext></delivery><addata><au>Morganelli, Giovanni</au><au>Fieni, Stefania</au><au>Dall'Asta, Andrea</au><au>di Pasquo, Elvira</au><au>Capozzi, Vito Andrea</au><au>Valenti, Alissa</au><au>Pezzani, Alessandra</au><au>Kiener, Ariane Jeanne Odette</au><au>Ghi, Tullio</au><format>journal</format><genre>article</genre><ristype>JOUR</ristype><atitle>Effect of the “shoulder-up” bundle on the incidence of spontaneous perineal injury after vaginal delivery: comparison of 2 historic cohorts after propensity score matching</atitle><jtitle>American journal of obstetrics & gynecology MFM</jtitle><addtitle>Am J Obstet Gynecol MFM</addtitle><date>2023-08</date><risdate>2023</risdate><volume>5</volume><issue>8</issue><spage>101038</spage><epage>101038</epage><pages>101038-101038</pages><artnum>101038</artnum><issn>2589-9333</issn><eissn>2589-9333</eissn><abstract><![CDATA[Perineal injury following vaginal delivery represents a major cause of long-term maternal morbidity, and its prevention is among the priorities of modern obstetrical practice.
This study aimed to investigate whether the systematic implementation of a bundle of maneuvers to prevent perineal injury (ie, the “shoulder-up” bundle) may reduce the rate of spontaneous perineal tears in women delivering at a single tertiary maternity unit.
This was a single-center retrospective intervention study including all vaginal deliveries between April 1, 2020 and March 31, 2022. On March 1, 2021, a bundle focused on perineal injury prevention in vaginal deliveries was implemented and introduced as a standard of care. The “shoulder-up” bundle includes the addition of a hands-on technique for the delivery of the posterior shoulder, which is slowly lifted up under the direct visualization of the perineal body, immediately after the disengagement of the anterior shoulder. The labor ward staff underwent dedicated training to acquire expertise on the “shoulder-up” bundle. Little changes in terms of medical and midwifery staffing were recorded during the study period.
The incidence of spontaneous second-degree or higher perineal tears was compared between the patients who gave birth before the clinical implementation of the bundle (standard-care group) and those who were delivered following the implementation of the bundle (shoulder-up group). A 1:1 propensity score matching of the 2 groups was done for the variables that proved to be independently associated with the perineal outcome.
From April 1, 2020 to March 31, 2022, 3671 patients had a vaginal birth at our tertiary care unit (1786 in the standard-care group and 1885 in the “shoulder-up” group) and were enrolled in the study population. Of these, 1191 (32.4%) had a spontaneous second-degree or higher perineal tear. At univariate analysis, nulliparity (59.6% vs 39.1%; P<.001), higher gestational age at delivery (39.8±1.28 vs 39.4±1.97 weeks; P<.001), epidural analgesia (40.6% vs 31.2%; P<.001), vacuum-assisted delivery (9.6% vs 4.0%; P<.001), and birthweight >4 kg (11.0% vs 6.3%; P<.001) were independently associated with the perineal outcome. Following propensity score matching for the above cited factors, the 1703 patients of each group were compared. A significant increase in the rate of intact perineum (71.0% vs 64.1%; P=.014) and a reduction in the incidence of second- (27.2% vs 32.9%; P=.006) and third to fourth-degree perineal tears (1.3% vs 3.0%; P<.001) was demonstrated in the “shoulder-up” group. Among the subgroup of patients undergoing vacuum-assisted delivery, a borderline significant reduction in the rate of obstetrical anal sphincter injury (10.4% vs 2.9%; P=.052) was also observed.
Our study showed that the clinical implementation of the “shoulder-up” bundle at vaginal delivery is associated with a significant reduction in the incidence of spontaneous second-degree or higher perineal tears.]]></abstract><cop>United States</cop><pub>Elsevier Inc</pub><pmid>37245605</pmid><doi>10.1016/j.ajogmf.2023.101038</doi><tpages>1</tpages><orcidid>https://orcid.org/0000-0002-0429-729X</orcidid></addata></record> |
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| ispartof | American journal of obstetrics & gynecology MFM, 2023-08, Vol.5 (8), p.101038-101038, Article 101038 |
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| source | MEDLINE; Alma/SFX Local Collection |
| subjects | Delivery, Obstetric - adverse effects Delivery, Obstetric - methods Female Humans Incidence Infant intrapartum perineal care obstetrical anal sphincter injuries perineal injury Perineum - injuries Pregnancy Propensity Score Retrospective Studies Shoulder shoulder delivery vaginal birth |
| title | Effect of the “shoulder-up” bundle on the incidence of spontaneous perineal injury after vaginal delivery: comparison of 2 historic cohorts after propensity score matching |
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