Third and fourth degree perineal tears after restrictive use of episiotomy

Ciljevi: Primarni cilj je bio ustvrditi ukupan broj i učestalost razdora međice III. i IV. stupnja (OASIS: engl. obstetric anal spincter injuries) u uvjetima restriktivne uporabe epiziotomije. Sekundarni ciljevi su bili ustvrditi učestalost OASIS-a u odnosu na paritet, način dovršenja porođaja, trajanje porođaja, epiduralnu analgeziju, iskustvo porodničkog tima, porođajnu težinu i opseg glave novorođenčeta. Također je analizirana učestalost u odnosu na rizične čimbenike za nastanak OASIS-a kao što su rotacijske i defleksijske anomalije, distocija fetalnih ramena, OASIS u prethodnom porođaju i nesuradnja rodilje. Materijali i metode: U istraživanje je uključena 51 rodilja kojima je specijalističkim pregledom postavljena dijagnoza OASIS i koje su rodile na Klinici za ginekologiju i porodništvo KB-a „ Sveti Duh „ u razdoblju od 1. siječnja 2010. godine do 31. prosinca 2014. Kriteriji za uključivanje žena u istraživanje temelje se na Sultanovoj klasifikaciji opstetričkih razdora međice III. i IV. stupnja. Podaci su prikupljeni retrospektivno, pretraživanjem povijesti bolesti i rađaoničkog protokola. Rezultati: Od ukupno 12858 vaginalnih porođaja u istraživanom razdoblju, 77% (n=9887) žena nije imalo epiziotomiju, dok je 23% (n=2971) imalo epiziotomiju. Ukupna učestalost OASIS-a u promatranom razdoblju iznosila je 0,4% (n=51). Nađena je statistički značajna razlika u udjelu OASIS-a kod porođenih žena s mediolateralnom epiziotomijom (0,7%; n=22) u odnosu na porođene žene bez epiziotomije (0,3%; n=29) (p<0,05). Udio prvorodilja s OASIS-om statistički je bio viši (68,7%; n=35) u odnosu na višerodilje (31,3%; n=16). Također u podskupini žena s mediolateralnom epiziotomijom nađena je statistički značajna razlika u broju OASIS-a između prvorodilja (57,1%; n=20) i višerodilja (12,5%; n=2) (p<0,05). Nađena je veća učestalost OASIS-a u skupini žena čiji je porođaj trajao dulje od deset sati uz epiziotomiju (61,1%; n=11), u odnosu na žene koje su također rađale dulje od deset sati, ali bez epiziotomije (38,9%; n=7) (p<0,05). Ukupno je bilo 33% (n=17) žena sa rizičnim čimbenicima za nastanak OASIS-a (stražnji zatiljačni, tjemeni i duboki poprečni stav glavom, distocija fetalnih ramena, OASIS u prethodnom porođaju i nesuradnja rodilje). Od toga je 65% (n=11) porođaja vodio najiskusniji tim na klinici. Nije nađena statistički značajna razlika u odnosu na porođajnu težinu novorođenčeta ispod 4000 g (78,4%; n=40) i iznad 4000 g (21,6%; n=11), opseg glave novorođenčeta ispod 34 cm (20,8%; n=10) i iznad 34 cm (79,2%; n=38). Nadalje, nije nađena statistički značajna razlika u učestalosti OASIS-a u odnosu na trajanje drugog porođajnog doba duže od jedan sat (43,6%; n=17) i kraće od jedan sat (56,4%; n=22). Vakuumskom ekstrakcijom dovršeno je 21,6% (n=11) porođaja s OASIS-om, a spontano 78,4% (n=40) porođaja. Od 11 porođaja dovršenih vakuumskom ekstrakcijom, 63,6%; (n=7) bilo je s epiziotomijom i 36,4% (n=4) bez epiziotomije. Epiduralnu analgeziju imalo je 43,1% (n=22) žena s OASIS-om, dok 56,9% (n=29) nije. U podskupini s epiduralnom analgezijom 50% (n=11) OASIS-a bilo je uz epiziotomiju i 50% (n=11) bez epiziotomije. Zaključak: Ukupna učestalost OASIS od 0,4% na našoj Klinici u promatranom razdoblju je dobra budući se u literaturi učestalost OASIS-a kreće od 0,9% do 4,2%. Autori navode učestalost OASIS-a od 0,25% do 7% uz mediolateralnu epiziotomiju. U našem istraživanju učestalost OASIS-a kod žena koje su imale mediolateralnu epiziotomiju iznosi 0,7%. Budući da smo u našem istraživanju dobili statistički značajnu razliku u broju OASIS-a sa i bez epiziotomije, možemo zaključiti da epiziotomija ne sprječava nastanak OASIS-a. Kao rizični čimbenici za nastanak OASIS-a pokazali su se prvorodnost i duljina trajanja porođaja više od deset sati unatoč korištenju epiziotomije. U trećini slučajeva s OASIS-om bili su prisutni rizični čimbenici za nastanak OASIS-a. Rizični čimbenici za nastanak OASIS-a prepoznati su prije faze izgona, budući da je u više od polovine slučajeva na porođaju bio nazočan najiskusniji tim. Na učestalost OASIS-a nisu utjecali porođajna težina i opseg glave novorođenčeta, trajanje drugog porođajnog doba preko jedan sat, instrumentalno dovršenje porođaja vakuumskom ekstrakcijom i epiduralna analgezija.Goals: The primary goal of this research was to determin the total amount of the third and fourth degree perineal tears (OASIS, English abbr. obstetric anal sphincter injuries) in the restrictive use of episiotomy. The secondary goal was to determin the frequency of OASIS in comparison to parity, the way a labour was carried out till the end, duration of labour, risk factors for occurence of OASIS, obstetrics teams' experience, birth weight and infant's head circumference within the group of examinees. Factors that have been taken into consideration when analyzing all the information were: rotational and deflection anomalies, shoulder dystocia, registered OASIS in previous labour and non-cooperation of the parturient woman. Materials and methods: Fifty one parturient women were included in this research. They have all given birth in period between January the first 2010 and December the thirty first 2014 at the department of gynecology and obstetrics in clinical centre „ Sveti Duh“. OASIS was diagnosed to them by a specialist examination. Criteria for diagnosis of OASIS were based on Sultan’s classification of obstetrics perineal tears. The data were collected retrospectively going through medical history and labour room protocols. Results: At the time of the research seventy seven percent of women (77%; n=9887) from the total of 12858 vaginal labours did not have an episiotomy while twenty three percent (23%; n=2971) had the aforementioned procedure. The total frequency of OASIS in the research period was 0,4% (n=51). A statistically significant difference was found in the number of OASIS for women who had vaginal labours and a mediolateral episiotomy (0,74%; n=22) when compared to those who gave birth vaginally but without an episiotomy (0,29%; n=29) (p<0,05). The number of parturient women who have had their first child and who were diagnosed with OASIS was 68,7% (n=35) and it was higher than for women who gave birth several times. Within the sub group of women with a mediolateral episiotomy a statistically significant difference was found for number of OASIS among parturient women who gave birth for the first time (57,1%; n=20) and those who gave birth for several times (12,5%;n=2) (p<0,05). A higher frequency of OASIS was found within the group of women who were giving birth for longer than 10 hours and who had an episiotomy (61,1%; n=11) in comparison to women who were also giving birth for longer than ten hours but who did not have an episiotomy (38,9%; n=7) (p<0,05). Thirty three percent of women (33%; n=17) diagnosed with OASIS had risk factors for occurence of OASIS such as (occipito-posterior position, parietal position, deep transverse arrest, shoulder dystocia, previously diagnosed OASIS and non-cooperation of parturient woman). In the mentioned group of 33% of women (n=17), 65% of them (n=11) had their births carried out by the most experienced obstetrics team at the clinic. A statistically significant difference was not found when the infant's birth weight was under 4000g (78,4%; n=40) and above 4000 g (21,6%; n=11) and when the infant's head circumference was less than 34cm (20,8%; n=10) and more than 34cm (79,2%; n=38). Also, a statistically significant difference has not been found when taking into account duration of the second stage of labour for more than 1 hour (43,6%; n=17) or less than 1 hour (56,4%; n=22). Twenty-one point six percent of women had a vacuum extraction (21,6%; n=11) and were diagnosed with OASIS and 78,4% (n=40) spontaneously. Eleven women who have had vacuum extraction 63,6%; (n=7) also had an episiotomy and 36,4% (n=4) did not have one. Forty-three point one percent (43,1%; n=22) of women diagnosed with OASIS had an epidural anaesthesia while 56,9% (n=29) did not have one. Within the group of women who have had epidural anaesthesia 50% (n= 11) were diagnosed with OASIS and had an episiotomy and 50% (n= 11) did not. Conclusion: Frequency of OASIS of 0,4% (n=51) at the department of gynecology and obstetrics in clinical centre „Sveti Duh“ is acceptable because registered frequency of OASIS in literature variess between 0,9% to 4,2%. Frequency of OASIS after mediolateral episiotomy varies from 0,25% to 7% and is registered in literature. Our research records 0,7% frequency of OASIS for women who have had mediolateral episiotomy. Since our research has shown a statistically significant difference in the number of women diagnosed with OASIS with and without episiotomy use, we can conclude that episiotomy use does not prevent genesis of OASIS. Some risk factors such as parity and duration of labour for periods longer than ten hours were singled out as risk factors for occurence of OASIS despite use of episiotomy. One third of the women who were diagnosed with OASIS had risk factors responsible for OASIS. Risk factors for occurence of OASIS were recognised by the obstetrics team before the third or expulsion stage of labour because for more than half of the of the cases the most experienced obstetrics team at the clinic was present at the labour. Infant's birth weight and head circumference, extended duration of second stage of labour for periods of time longer than one hour, surgical intervention in form of vacuum extraction and epidural anaesthesia did not affect the frequency of OASIS

Šezdeset godina primjene modificirane manualne perinealne zaštite po Ritgenu

The aim is to present the 60-year experience in modified Ritgen maneuver according to perineal injuries. This retrospective clinical observational study (1950-2010) analyzed the impact of modified Ritgen maneuver delivery technique (controlled fetal head deflexion with left hand and synchronous reduction of perineal strain with extended right hand thumb along the right side of the vulva and perineum without pushing) on peripartum perineal tears at the Maternity Ward, Bjelovar General Hospital in Bjelovar, Croatia, divided into five-year intervals. The rate of perineal tear in general was less than 5% until 2000. The rate of perineal tear grade I was very low until 1995, then increased to 8.6% in 2010, yet never exceeding 10%. The rate of perineal tear grade II never exceeded 2%, whereas perineal tear grade III was a sporadic event never exceeding 0.4% of the study material with a single case of grade IV tear. The rate of intact perineum in vaginal deliveries without episiotomy ranged from 96.2% to 100% in the 1950-1960 period, with a decrease to 46% in 2010. The study revealed the modification of Ritgen maneuver described to have resulted in significant reduction of all grades of perineal tear over decades.Cilj istraživanja bio je prikazati 60-godišnje iskustvo u modificiranoj manualnoj perinealnoj zaštiti po Ritgenu u odnosu na razdore međice. Retrospektivna opservacijska klinička studija (1950.-2010.) analizirala je petogodišnje intervale učinka modificirane Ritgenove tehnike perinealne zaštite (kontrolirana fetalna defleksija lijevom rukom uz sinkronu redukciju napetosti međice desnom rukom koja je ispružena s desne strane međice i vulve, bez tiskanja rodilje) na peripartalne razdore međice u rodilištu Opće bolnice u Bjelovaru, Hrvatska. Ukupna stopa razdora međice bila je manja od 5% do 2000. godine. Stopa razdora I. stupnja bila je vrlo niska do godine 1995., zatim se povećala na 8,6% u 2010. godini, ali nikada iznad 10%. Razdori međice II. stupnja nisu prelazili stopu od 2%, dok su razdori međice III. stupnja bili sporadični i nisu prelazili 0,4% u ispitivanom materijalu, uz jedan slučaj razdora IV. stupnja. Netaknuta međica bez epiziotomije bila je u rasponu od 96,2% do 100% u razdoblju od 1950. do 1960. godine, sa smanjenjem od 46% u 2010. godini. Ovo istraživanje dokazalo je značajno smanjenje razdora međice svih stupnjeva uporabom modificirane manualne zaštite po Ritgenu

THIRD- AND FOURTH-DEGREE PERINEAL TEARS AND RESTRICTIVE USE OF EPISIOTOMY

Cilj: Utvrditi ukupan broj i učestalost razdora međice III. i IV. stupnja u uporabi restriktivne epiziotomije te učestalost opstetričkih ozljeda analnog sfi nktera (OASIS) u odnosu na paritet, način dovršenja porođaja, trajanje porođaja, epiduralnu analgeziju, iskustvo porodničkog tima, porođajnu težinu i opseg glave novorođenčeta. Ispitanice i metode: U retrospektivno kliničko istraživanje uključena je 51 rodilja koje su rodile na Klinici za ginekologiju i porodništvo KB-a Sveti Duh u razdoblju od 1. siječnja 2010 do 31. prosinca 2014. s dijagnozom OASIS. Rezultati: Od ukupno 12858 vaginalnih porođaja, 77 % (n=9887) žena nije imalo epiziotomiju, dok je 23% (n=2971) imalo epiziotomiju. Ukupna učestalost OASIS-a u promatranom razdoblju iznosila je 0,4%, s mediolateralnom epiziotomijom (0,7%) u odnosu na žene bez epiziotomije (0,3 %; p0,05). Zaključak: Kao rizični čimbenici za nastanak OASIS-a pokazali su se prvorodnost, duljina trajanja porođaja više od deset sati te primjena epiziotomije. U trećini slučajeva s OASIS-om bili su prisutni ostali opstetrički rizični čimbenici za nastanak OASIS-a. Restriktivna uporaba epiziotomije i manualna perinealna protekcija smanjuju incidenciju razdora III. i IV. stupnja.Aim: To determine the number and prevalence of third- and fourth-grade perineal tears with restrictive use of episiotomy, and the prevalence of obstetric anal sphincter injuries (OASIS) according to parity, mode of labor termination, delivery duration, epidural analgesia, obstetric team experience, and neonatal birth weight and head circumference. Subjects and Methods: This retrospective clinical study included 51 women diagnosed with OASIS, having delivered their newborns at Department of Gynecology and Obstetrics, Sveti Duh University Hospital from January 1, 2010 until December 31, 2014. Results: Out of 12858 vaginal deliveries, episiotomy was not used in 77% (n=9887), whereas it was used in 23% (n=2971) of women. The overall prevalence of OASIS during the study period was 0.4%, with 0.7% for mediolateral episiotomy versus 0.3% in women without episiotomy (p10 hours (p4000 g (21.6%), maternal body mass index, and second stage of labor >1 hour (43.6%) versus 0.05 both). Conclusion: Primiparity, delivery duration >10 hours, and use of episiotomy were identifi ed as risk factors for OASIS. Other obstetric risk factors for OASIS were present in one-third of OASIS cases. The prevalence of third- and fourth-degree perineal tears can be reduced with restrictive use of episiotomy and manual perineal protection

Third and fourth degree perineal tears after restrictive use of episiotomy

Ciljevi: Primarni cilj je bio ustvrditi ukupan broj i učestalost razdora međice III. i IV. stupnja (OASIS: engl. obstetric anal spincter injuries) u uvjetima restriktivne uporabe epiziotomije. Sekundarni ciljevi su bili ustvrditi učestalost OASIS-a u odnosu na paritet, način dovršenja porođaja, trajanje porođaja, epiduralnu analgeziju, iskustvo porodničkog tima, porođajnu težinu i opseg glave novorođenčeta. Također je analizirana učestalost u odnosu na rizične čimbenike za nastanak OASIS-a kao što su rotacijske i defleksijske anomalije, distocija fetalnih ramena, OASIS u prethodnom porođaju i nesuradnja rodilje. Materijali i metode: U istraživanje je uključena 51 rodilja kojima je specijalističkim pregledom postavljena dijagnoza OASIS i koje su rodile na Klinici za ginekologiju i porodništvo KB-a „ Sveti Duh „ u razdoblju od 1. siječnja 2010. godine do 31. prosinca 2014. Kriteriji za uključivanje žena u istraživanje temelje se na Sultanovoj klasifikaciji opstetričkih razdora međice III. i IV. stupnja. Podaci su prikupljeni retrospektivno, pretraživanjem povijesti bolesti i rađaoničkog protokola. Rezultati: Od ukupno 12858 vaginalnih porođaja u istraživanom razdoblju, 77% (n=9887) žena nije imalo epiziotomiju, dok je 23% (n=2971) imalo epiziotomiju. Ukupna učestalost OASIS-a u promatranom razdoblju iznosila je 0,4% (n=51). Nađena je statistički značajna razlika u udjelu OASIS-a kod porođenih žena s mediolateralnom epiziotomijom (0,7%; n=22) u odnosu na porođene žene bez epiziotomije (0,3%; n=29) (p<0,05). Udio prvorodilja s OASIS-om statistički je bio viši (68,7%; n=35) u odnosu na višerodilje (31,3%; n=16). Također u podskupini žena s mediolateralnom epiziotomijom nađena je statistički značajna razlika u broju OASIS-a između prvorodilja (57,1%; n=20) i višerodilja (12,5%; n=2) (p<0,05). Nađena je veća učestalost OASIS-a u skupini žena čiji je porođaj trajao dulje od deset sati uz epiziotomiju (61,1%; n=11), u odnosu na žene koje su također rađale dulje od deset sati, ali bez epiziotomije (38,9%; n=7) (p<0,05). Ukupno je bilo 33% (n=17) žena sa rizičnim čimbenicima za nastanak OASIS-a (stražnji zatiljačni, tjemeni i duboki poprečni stav glavom, distocija fetalnih ramena, OASIS u prethodnom porođaju i nesuradnja rodilje). Od toga je 65% (n=11) porođaja vodio najiskusniji tim na klinici. Nije nađena statistički značajna razlika u odnosu na porođajnu težinu novorođenčeta ispod 4000 g (78,4%; n=40) i iznad 4000 g (21,6%; n=11), opseg glave novorođenčeta ispod 34 cm (20,8%; n=10) i iznad 34 cm (79,2%; n=38). Nadalje, nije nađena statistički značajna razlika u učestalosti OASIS-a u odnosu na trajanje drugog porođajnog doba duže od jedan sat (43,6%; n=17) i kraće od jedan sat (56,4%; n=22). Vakuumskom ekstrakcijom dovršeno je 21,6% (n=11) porođaja s OASIS-om, a spontano 78,4% (n=40) porođaja. Od 11 porođaja dovršenih vakuumskom ekstrakcijom, 63,6%; (n=7) bilo je s epiziotomijom i 36,4% (n=4) bez epiziotomije. Epiduralnu analgeziju imalo je 43,1% (n=22) žena s OASIS-om, dok 56,9% (n=29) nije. U podskupini s epiduralnom analgezijom 50% (n=11) OASIS-a bilo je uz epiziotomiju i 50% (n=11) bez epiziotomije. Zaključak: Ukupna učestalost OASIS od 0,4% na našoj Klinici u promatranom razdoblju je dobra budući se u literaturi učestalost OASIS-a kreće od 0,9% do 4,2%. Autori navode učestalost OASIS-a od 0,25% do 7% uz mediolateralnu epiziotomiju. U našem istraživanju učestalost OASIS-a kod žena koje su imale mediolateralnu epiziotomiju iznosi 0,7%. Budući da smo u našem istraživanju dobili statistički značajnu razliku u broju OASIS-a sa i bez epiziotomije, možemo zaključiti da epiziotomija ne sprječava nastanak OASIS-a. Kao rizični čimbenici za nastanak OASIS-a pokazali su se prvorodnost i duljina trajanja porođaja više od deset sati unatoč korištenju epiziotomije. U trećini slučajeva s OASIS-om bili su prisutni rizični čimbenici za nastanak OASIS-a. Rizični čimbenici za nastanak OASIS-a prepoznati su prije faze izgona, budući da je u više od polovine slučajeva na porođaju bio nazočan najiskusniji tim. Na učestalost OASIS-a nisu utjecali porođajna težina i opseg glave novorođenčeta, trajanje drugog porođajnog doba preko jedan sat, instrumentalno dovršenje porođaja vakuumskom ekstrakcijom i epiduralna analgezija.Goals: The primary goal of this research was to determin the total amount of the third and fourth degree perineal tears (OASIS, English abbr. obstetric anal sphincter injuries) in the restrictive use of episiotomy. The secondary goal was to determin the frequency of OASIS in comparison to parity, the way a labour was carried out till the end, duration of labour, risk factors for occurence of OASIS, obstetrics teams' experience, birth weight and infant's head circumference within the group of examinees. Factors that have been taken into consideration when analyzing all the information were: rotational and deflection anomalies, shoulder dystocia, registered OASIS in previous labour and non-cooperation of the parturient woman. Materials and methods: Fifty one parturient women were included in this research. They have all given birth in period between January the first 2010 and December the thirty first 2014 at the department of gynecology and obstetrics in clinical centre „ Sveti Duh“. OASIS was diagnosed to them by a specialist examination. Criteria for diagnosis of OASIS were based on Sultan’s classification of obstetrics perineal tears. The data were collected retrospectively going through medical history and labour room protocols. Results: At the time of the research seventy seven percent of women (77%; n=9887) from the total of 12858 vaginal labours did not have an episiotomy while twenty three percent (23%; n=2971) had the aforementioned procedure. The total frequency of OASIS in the research period was 0,4% (n=51). A statistically significant difference was found in the number of OASIS for women who had vaginal labours and a mediolateral episiotomy (0,74%; n=22) when compared to those who gave birth vaginally but without an episiotomy (0,29%; n=29) (p<0,05). The number of parturient women who have had their first child and who were diagnosed with OASIS was 68,7% (n=35) and it was higher than for women who gave birth several times. Within the sub group of women with a mediolateral episiotomy a statistically significant difference was found for number of OASIS among parturient women who gave birth for the first time (57,1%; n=20) and those who gave birth for several times (12,5%;n=2) (p<0,05). A higher frequency of OASIS was found within the group of women who were giving birth for longer than 10 hours and who had an episiotomy (61,1%; n=11) in comparison to women who were also giving birth for longer than ten hours but who did not have an episiotomy (38,9%; n=7) (p<0,05). Thirty three percent of women (33%; n=17) diagnosed with OASIS had risk factors for occurence of OASIS such as (occipito-posterior position, parietal position, deep transverse arrest, shoulder dystocia, previously diagnosed OASIS and non-cooperation of parturient woman). In the mentioned group of 33% of women (n=17), 65% of them (n=11) had their births carried out by the most experienced obstetrics team at the clinic. A statistically significant difference was not found when the infant's birth weight was under 4000g (78,4%; n=40) and above 4000 g (21,6%; n=11) and when the infant's head circumference was less than 34cm (20,8%; n=10) and more than 34cm (79,2%; n=38). Also, a statistically significant difference has not been found when taking into account duration of the second stage of labour for more than 1 hour (43,6%; n=17) or less than 1 hour (56,4%; n=22). Twenty-one point six percent of women had a vacuum extraction (21,6%; n=11) and were diagnosed with OASIS and 78,4% (n=40) spontaneously. Eleven women who have had vacuum extraction 63,6%; (n=7) also had an episiotomy and 36,4% (n=4) did not have one. Forty-three point one percent (43,1%; n=22) of women diagnosed with OASIS had an epidural anaesthesia while 56,9% (n=29) did not have one. Within the group of women who have had epidural anaesthesia 50% (n= 11) were diagnosed with OASIS and had an episiotomy and 50% (n= 11) did not. Conclusion: Frequency of OASIS of 0,4% (n=51) at the department of gynecology and obstetrics in clinical centre „Sveti Duh“ is acceptable because registered frequency of OASIS in literature variess between 0,9% to 4,2%. Frequency of OASIS after mediolateral episiotomy varies from 0,25% to 7% and is registered in literature. Our research records 0,7% frequency of OASIS for women who have had mediolateral episiotomy. Since our research has shown a statistically significant difference in the number of women diagnosed with OASIS with and without episiotomy use, we can conclude that episiotomy use does not prevent genesis of OASIS. Some risk factors such as parity and duration of labour for periods longer than ten hours were singled out as risk factors for occurence of OASIS despite use of episiotomy. One third of the women who were diagnosed with OASIS had risk factors responsible for OASIS. Risk factors for occurence of OASIS were recognised by the obstetrics team before the third or expulsion stage of labour because for more than half of the of the cases the most experienced obstetrics team at the clinic was present at the labour. Infant's birth weight and head circumference, extended duration of second stage of labour for periods of time longer than one hour, surgical intervention in form of vacuum extraction and epidural anaesthesia did not affect the frequency of OASIS

Školovanje primalja u Republici Hrvatskoj i stjecanje kompetencija u primaljstvu

U dalekoj prošlosti primaljstvom su se bavile uglavnom nepismene žene koje su svoj zanat učile od drugih iskusnih žena, a njihova praksa temeljila se na iskustvu. Dolaskom I. K. Lalanguea 1776. godine na područje današnje Republike Hrvatske postavljeni su temelji sustavnog obrazovanja primalja. Do 1959. g. primaljska skrb se sastojala u kontroli trudnice neposredno prije poroda, te u vođenju poroda, u pravilu kod kuće žene, nakon čega porodničari preuzimaju cjelokupan nadzor nad rodiljama. Zakon o primaljstvu koji stupa na snagu 2008.g. slijedi odredbe Direktive 2005/36EZ te kao temeljno obrazovanje navodi završetak preddiplomskog studija primaljstva, kao i djelokrug rada primalje odnosno prvostupnice primaljstva koji se između ostalog odnosi na vođenje fiziološke trudnoće i poroda te p.p. urezivanje i šivanje epiziotomije. Ista Direktiva propisuje potrebno obrazovanje u trajanju od tri godine, 180 ECTS bodova i 4600 sati teoretske nastave i praktičnog osposobljavanja. Preddiplomski program kao takav trenutno se izvodi na Fakultetu zdravstvenih studija Sveučilišta u Rijeci, a u postupku je pokretanje diplomskog studija primaljstva. Isti Zakon navodi i drugi kadar, sa završenim srednješkolskim obrazovanjem i nazivom primaljska – asistentica čiji se djelokrug rada svodi na postupke pripreme za izvođenje primaljske skrbi. Međutim, u sustavu zdravstva prvostupnice primaljstva nisu prepoznate i trenutno obavljaju istu djelatnost kao i primaljske – asistentice, a Zakon je samo pravni akt za što je potrebno donijeti i provedbene propise, što do sada nije učinjeno

Školovanje primalja u Republici Hrvatskoj i stjecanje kompetencija u primaljstvu

U dalekoj prošlosti primaljstvom su se bavile uglavnom nepismene žene koje su svoj zanat učile od drugih iskusnih žena, a njihova praksa temeljila se na iskustvu. Dolaskom I. K. Lalanguea 1776. godine na područje današnje Republike Hrvatske postavljeni su temelji sustavnog obrazovanja primalja. Do 1959. g. primaljska skrb se sastojala u kontroli trudnice neposredno prije poroda, te u vođenju poroda, u pravilu kod kuće žene, nakon čega porodničari preuzimaju cjelokupan nadzor nad rodiljama. Zakon o primaljstvu koji stupa na snagu 2008.g. slijedi odredbe Direktive 2005/36EZ te kao temeljno obrazovanje navodi završetak preddiplomskog studija primaljstva, kao i djelokrug rada primalje odnosno prvostupnice primaljstva koji se između ostalog odnosi na vođenje fiziološke trudnoće i poroda te p.p. urezivanje i šivanje epiziotomije. Ista Direktiva propisuje potrebno obrazovanje u trajanju od tri godine, 180 ECTS bodova i 4600 sati teoretske nastave i praktičnog osposobljavanja. Preddiplomski program kao takav trenutno se izvodi na Fakultetu zdravstvenih studija Sveučilišta u Rijeci, a u postupku je pokretanje diplomskog studija primaljstva. Isti Zakon navodi i drugi kadar, sa završenim srednješkolskim obrazovanjem i nazivom primaljska – asistentica čiji se djelokrug rada svodi na postupke pripreme za izvođenje primaljske skrbi. Međutim, u sustavu zdravstva prvostupnice primaljstva nisu prepoznate i trenutno obavljaju istu djelatnost kao i primaljske – asistentice, a Zakon je samo pravni akt za što je potrebno donijeti i provedbene propise, što do sada nije učinjeno

THIRD- AND FOURTH-DEGREE PERINEAL TEARS AND RESTRICTIVE USE OF EPISIOTOMY

Aim: To determine the number and prevalence of third- and fourth-grade perineal tears with restrictive use of episiotomy, and the prevalence of obstetric anal sphincter injuries (OASIS) according to parity, mode of labor termination, delivery duration, epidural analgesia, obstetric team experience, and neonatal birth weight and head circumference. Subjects and Methods: This retrospective clinical study included 51 women diagnosed with OASIS, having delivered their newborns at Department of Gynecology and Obstetrics, Sveti Duh University Hospital from January 1, 2010 until December 31, 2014. Results: Out of 12858 vaginal deliveries, episiotomy was not used in 77% (n=9887), whereas it was used in 23% (n=2971) of women. The overall prevalence of OASIS during the study period was 0.4%, with 0.7% for mediolateral episiotomy versus 0.3% in women without episiotomy (p10 hours (p<0.05). Risk factors for OASIS were present in 33% of women and included fetal head malrotation, shoulder dystocia, and OASIS in previous delivery. There was no statistically signifi cant difference in the prevalence of OASIS according to birth weight 4000 g (21.6%), maternal body mass index, and second stage of labor >1 hour (43.6%) versus 0.05 both). Conclusion: Primiparity, delivery duration >10 hours, and use of episiotomy were identifi ed as risk factors for OASIS. Other obstetric risk factors for OASIS were present in one-third of OASIS cases. The prevalence of third- and fourth-degree perineal tears can be reduced with restrictive use of episiotomy and manual perineal protection