Reducing high-order perineal laceration during operative vaginal delivery

Objective This study was undertaken to assess the impact of a focused intervention on reducing high-order (third and fourth degree) perineal lacerations during operative vaginal delivery. Study Design The following recommendations for clinical management were promulgated by departmental lectures, distribution of pertinent articles and manuals, training of physicians, and prominent display 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 episiotomy if episiotomy was deemed necessary; (4) flexion of the fetal head and maintenance of axis traction; (5) early disarticulation of forceps; 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 = .36). High-order laceration with operative vaginal delivery declined from 41% to 26% ( P = .02), coincident with increased use of vacuum (16% vs 29% of operative vaginal deliveries, P = .02); fewer high-order lacerations after episiotomy (63% vs 22%, P = .003); a nonsignificant reduction in performance of episiotomy (30% vs 23%, P = .22); and a nonsignificant increase in mediolateral episiotomy (14% vs 30% of episiotomies, P = .19). Conclusion Introduction of formal practice recommendations and performance review was associated with diminished high-order perineal injury with operative vaginal delivery.