Gillian E. Fowler

Bio: Gillian E. Fowler is an academic researcher. The author has contributed to research in topics: Urinary diversion & Nocturia. The author has an hindex of 2, co-authored 2 publications receiving 8 citations.

Factors predicting a failed primary repair of obstetric anal sphincter injury.

Abstract: INTRODUCTION The success of the primary repair of obstetric anal sphincter injury (OASI) is paramount in maintaining adequate fecal continence after childbirth. The factors determining the success or failure of primary repair are unclear. The aim of this study is to investigate modifiable factors determining the success or failure of the primary sphincter repair after OASI. MATERIAL AND METHODS Sixty women with OASI were investigated by endoanal ultrasound or magnetic resonance imaging, and with the Wexner incontinence questionnaire. Based on the findings, the women were divided in two groups; successful primary repair group (n = 41) and failed primary repair group (n = 19). RESULTS The primary repair failed in 31.7% of the tears. These included more tears repaired by less experienced personnel (p < 0.001) and more repairs performed during on-call hours (p = 0.039) than in the successful primary repair group. Significantly more pain medication was used in the failed group (p = 0.003), and the use of antibiotics and laxatives after the repair was more common in the successful group (p < 0.001). Sphincter injuries were repaired using the overlapping suture technique in 95.1% of the repairs in the successful group compared with 47.4% in the failed group (p = 0.03). The mean (SD) Wexner score was significantly higher in the failed group [5.92 (4.1) vs. 1.88 (4.2), p < 0.001], in agreement with the findings on endoanal ultrasound. CONCLUSIONS Postpartum perineal tears should be evaluated by personnel familiar with the diagnosis and repair of OASI. Delaying the primary repair until next morning is recommended if experienced personnel are unavailable during on-call hours.

The impact of first birth obstetric anal sphincter injury on the subsequent birth: a population-based linkage study

Abstract: With rising obstetric anal sphincter injury (OASI) rates, the number of women at risk of OASI recurrence is in turn increasing. Decisions regarding mode of subsequent birth following an OASI are complex, and depend on a variety of factors. We sought to identify the risk factors for OASI recurrence from first and subsequent births, and to investigate the effect of OASI birth factors on planned caesarean for the second birth. Using two linked population datasets from New South Wales, Australia, we selected women giving birth between 2001 and 2011 with a first birth OASI and a subsequent birth. Multivariable logistic regression was used to identify the association of first and second birth factors with OASI recurrence, and to determine which factors were associated with a planned pre-labour caesarean at the second birth. Of 6,380 women with a first birth OASI who proceeded to a subsequent birth, 75.4% had a vaginal second birth, 19.4% a pre-labour caesarean, and 5.2% an intrapartum caesarean. Although the OASI recurrence rate of 5.7% was significantly higher than the first birth OASI rate of 4.5% (p < 0.01), this may not reflect a clinically significant increase. Following adjustment for first and second birth factors, first birth diabetes and second birthweight ≥3.5 kg were associated with increased likelihood of OASI recurrence, while first birthweight ≥4.0 kg and second gestation at 37–38 weeks were associated with decreased likelihood. A fourth degree tear at the first birth was the strongest factor associated with planned caesarean at the second birth, with other factors including epidural, spinal or general anaesthetic, birthweight, gestation, country of birth and maternal age. Compared with previous reports, the low OASI recurrence rate (approximately one in twenty) may reflect appropriate decision-making about subsequent mode of delivery following first birth OASI. This assertion is supported by evidence of different risk profiles for women who have planned caesareans compared with planned vaginal births.

Assessment, diagnosis and treatment of urinary incontinence in women

Abstract: This article gives an overview of female urinary incontinence including the symptoms, diagnosis and treatment of stress urinary incontinence and overactive bladder syndrome. It summarises recent guidelines, the role of the nurse in conservative management and when a referral for specialist care is required. It aims to encourage nurses to use all opportunities to identify women who have urinary incontinence then to assess and treat urinary incontinence effectively. All patients should receive a full continence assessment. National Institute for Health and Care Excellence guidelines recommend conservative treatments including lifestyle advice, pelvic floor exercises and bladder retraining. Nurses may need to access training from their local specialist continence nurse service to enable them to provide evidence-based care. This article concludes that equitable, integrated continence services are essential to improve the quality of care for people with continence problems.

Evidence-based intrapartum practice and its associated factors at a tertiary teaching hospital in the Philippines, a descriptive mixed-methods study.

Abstract: Evidenced-based practice is a key component of quality care. However, studies in the Philippines have identified gaps between evidence and actual maternity practices. This study aims to describe the practice of evidence-based intrapartum care and its associated factors, as well as exploring the perceptions of healthcare providers in a tertiary hospital in the Philippines. A mixed-methods study was conducted, which consisted of direct observation of intrapartum practices during the second and third stages, as well as semi-structured interviews and focus group discussions with care providers to determine their perceptions and reasoning behind decisions to perform episiotomy or fundal pressure. Univariate and multivariate logistic regression were used to analyse the relationship between observed practices and maternal, neonatal, and environmental factors. Qualitative data were parsed and categorised to identify themes related to the decision-making process. A total of 170 deliveries were included. Recommended care, such as prophylactic use of oxytocin and controlled cord traction in the third stage, were applied in almost all the cases. However, harmful practices were also observed, such as intramuscular or intravenous oxytocin use in the second stage (14%) and lack of foetal heart rate monitoring (57%). Of primiparae, 92% received episiotomy and 31% of all deliveries received fundal pressure. Factors associated with the implementation of episiotomy included primipara (adjusted Odds Ratio [aOR] 62.3), duration of the second stage of more than 30 min (aOR 4.6), and assisted vaginal delivery (aOR 15.0). Factors associated with fundal pressure were primipara (aOR 3.0), augmentation with oxytocin (aOR 3.3), and assisted delivery (aOR 4.8). Healthcare providers believe that these practices can prevent laceration. The rate of obstetric anal sphincter injuries (OASIS) was 17%. Associated with OASIS were assisted delivery (aOR 6.0), baby weights of more than 3.5 kg (aOR 7.8), episiotomy (aOR 26.4), and fundal pressure (aOR 6.2). Our study found that potentially harmful practices are still conducted that contribute to the occurrence of OASIS. The perception of these practices is divergent with current evidence, and empirical knowledge has more influence. To improve practices the scientific evidence and its underlying basis should be understood among providers.

Impact d’un atelier de formation au diagnostic et à la réparation des lésions obstétricales du sphincter anal et de la muqueuse rectale sur les compétences des internes et chefs de clinique

Abstract: Resume But Evaluer l’impact d’un atelier de formation a la reparation des lesions obstetricales du sphincter anal et de la muqueuse rectale sur les competences des internes et chefs de clinique-assistants (CCA). Materiel Un questionnaire evaluant les connaissances pratiques et theoriques des internes et chefs de clinique a ete envoye en utilisant la mailing list de l’association des gynecologues-obstetriciens en formation (AGOF). Ce questionnaire a choix multiple portait sur l’epidemiologie, les facteurs de risques et les types de sutures. Les scores obtenus ont ete compares entre fonction de la participation ou non a l’atelier. Resultats Les effectifs etaient : 106 internes ou CCA (48,4 %) dans le groupe atelier et 113 (51,6 %) dans le groupe controle. Les scores etaient significativement plus eleves dans le groupe atelier que dans le groupe controle pour les connaissances theoriques (4,1 vs 3,7), les connaissances pratiques (17,6 vs 15,9) et les scores globaux (21,7 vs 19,7). Il n’existait pas de difference de score en fonction de la participation a l’atelier avant ou apres le troisieme semestre d’internat. Les scores globaux des internes etaient statistiquement superieurs dans le groupe atelier par rapport au groupe controle (21,8 vs 19,5) mais il n’y pas de differences significatives entre les CCA des deux groupes. Dans le groupe atelier les participants s’estimaient statistiquement plus performant que dans le groupe controle, en ce qui concerne la reparation des lesions du sphincter anal et de la muqueuse rectale. Conclusion Un atelier de formation semble ameliorer significativement les connaissances theoriques et pratiques. Niveau de preuve 4.