The role of episiotomy in prevention of genital lacerations during vaginal deliveries – results from two european centers

Pełen tekst

(1)Ginekol Pol. 2015, 86, 168-175.

(2)

(3) po ł o ż n i c t wo. The role of episiotomy in prevention of genital lacerations during vaginal deliveries – results from two european centers Rola nacięcia krocza w profilaktyce uszkodzeń podczas porodów pochwowych – wyniki z dwóch ośrodków europejskich Antonio Simone Laganà1, Milan Terzic2,3, Jelena Dotlic2,3, Emanuele Sturlese1, Vittorio Palmara1, Giovanni Retto1, Dusica Kocijancic2 1. Department of Pediatric, Gynecological, Microbiological and Biomedical Sciences, University of Messina, Messina, Italy Clinic of Obstetrics and Gynecology, Clinical Center of Serbia, Belgrade, Serbia 3 School of Medicine, University of Belgrade, Belgrade, Serbia 2. Abstract Objectives: There is an ongoing debate regarding the routine versus restrictive use of episiotomy. The study aim was to investigate if episiotomy during vaginal deliveries can reduce both, the number and severity of genital lacerations. Material and methods: The study included all women who gave vaginal birth at AOU. “G. Martino” Messina (n=382) and the Clinic for Ob/Gyn Clinical Center of Serbia, Belgrade (n=4221) during 2011. Lacerations during birth were recorded and divided according to location and severity. Women with lacerations were subdivided into two groups: with or without medio-lateral episiotomy. We assessed potential risk factors for laceration: maternal age, parity, use of labor stimulants and epidural analgesia, participation in antenatal classes, fetal presentation, neonatal birth weight, and duration of the second stage of labor. Results: Older women had higher grade perineum or combined lacerations. Children with higher birth weight in occipito-posterior presentation caused higher grade lacerations. Performance of episiotomy was connected with fewer perineum and labial lacerations. There were no differences in laceration grade between patients with and without episiotomy. Assessed parameters proved to be good discriminating factors between lacerations sites. According to logistic regression, laceration site was the most important risk factor for laceration grade. Combined lacerations had the highest grade. Conclusions: Episiotomy can significantly reduce the number of genital lacerations, but it does not influence laceration grade. Advanced maternal age, higher parity, occipito-posterior presentation and fetal macrosomia can cause lacerations during vaginal birth. Therefore, we suggest analysis of maternal and fetal factors to prevent widespread genital lacerations.. Key words: episiotomy / genital lacerations / vaginal delivery / laceration risk factors /. Corresponding author: Milan M. Terzic Clinic of Ob/Gyn, Clinical Centre of Serbia, Faculty of Medicine, University of Belgrade Serbia,11000 Belgrade, Dr Koste Todorovica 26 Tel: +381 11 361 5592; Fax: +381 11 361 5603 e-mail: terzicmilan@yahoo.co.uk. 168. © Polskie Towarzystwo Ginekologiczne. Otrzymano: 14.12.2013 Zaakceptowano do druku: 14.05.2014. Nr 3/2015.

(4) Ginekol Pol. 2015, 86, 168-175. P R A C E. O R Y G I N A L N E po ł o ż n i c t wo. Antonio Simone Laganà et al. The role of episiotomy in prevention of genital lacerations during vaginal deliveries – results from two european centers.. Streszczenie Cel: Trwa debata w prawie właściwego stosowania nacięcia krocza: regularne kontra ograniczone. Celem badania była ocena czy nacięcie krocza podczas porodu pochwowego może zredukować zarówno liczbę jak i ciężkość uszkodzeń krocza. Materiał i metoda: Do badania włączono wszystkie kobiety, które w 2011 roku urodziły drogą pochwową w ośrodku w AOU „G.Martino” Messina (n=382) i w Klinice Położniczo-Ginekologicznej w Serbii, w Belgradzie (n=4221). Uszkodzenia krocza podczas porodu zostały podzielone względem lokalizacji i ciężkości. Kobiety z uszkodzeniami podzielono na dwie podgrupy: z nacięciem i bez nacięcia pośrodkowo-bocznego krocza. Oceniono możliwe czynniki ryzyka uszkodzeń krocza: wiek matki, rodność, użycie stymulacji porodu, znieczulenie zewnątrzoponowe, uczestnictwo w szkole rodzenia, położenie płodu, masa urodzeniowa noworodka, czas trwania drugiej fazy porodu. Wyniki: Starsze kobiety miały wyższy stopień uszkodzenia krocza i bardziej złożone pęknięcia. Urodzenie dziecka z większą masą urodzeniową w ułożeniu potylicowym-tylnym powodowało wyższy stopień pęknięć krocza. Nacięcie krocza wiązało się z mniejszą ilością pęknięć krocza i warg sromowych. Nie zanotowano różnic w stopniu uszkodzenia krocza pomiędzy pacjentkami z i bez nacięcia krocza. Oceniane czynniki są przydatne w różnicowaniu miejsca uszkodzenia. Na podstawie regresji logistycznej, miejsce pęknięcia było najważniejszym czynnikiem ryzyka stopnia uszkodzenia krocza. Złożone uszkodzenia miały najwyższy stopień. Wnioski: Nacięcie krocza istotnie zmniejszało liczbę uszkodzeń krocza, lecz nie wpływało na ich stopień. Zaawansowany wiek matki, wyższa rodność, ułożenie potylicowe-tylne i makrosomia płodu mogą powodować pęknięcia krocza w trakcie porodu. Sugerujemy analizę matczynych i płodowych czynników ryzyka celem zapobiegania szerokim uszkodzeniom krocza w trakcie porodu.. Słowa kluczowe:

(5) /

(6) / poród pochwowy / /

(7)

(8)

(9) /. Introduction There are several techniques to prevent perineum trauma

(10)

(11)

(12)

(13)

(14)

(15)

(16)

(17)

(18)

(19)

(20)

(21)

(22)

(23)

(24) !

(25)

(26)

(27) "

(28)

(29)

(30)

(31)

(32)

(33)

(34)

(35)

(36)

(37) #

(38)

(39)

(40)

(41)

(42)

(43)

(44)

(45)

(46)

(47)

(48) $

(49)

(50)

(51)

(52)

(53)

(54)

(55) .

(56)

(57)

(58)

(59)

(60)

(61)

(62)

(63)

(64)

(65)

(66) %

(67)

(68) &

(69)

(70)

(71)

(72)

(73)

(74)

(75)

(76)

(77)

(78)

(79)

(80)

(81)

(82)

(83)

(84) '

(85)

(86)

(87) (

(88) )

(89)

(90)

(91)

(92)

(93)

(94) *#

(95)

(96)

(97)

(98)

(99)

(100)

(101)

(102)

(103)

(104)

(105) #

(106)

(107)

(108)

(109)

(110)

(111)

(112)

(113)

(114)

(115)

(116)

(117)

(118)

(119)

(120)

(121) . Material and methods #

(122)

(123)

(124)

(125) +-./04 5 4

(126) !

(127) 6 0

(128) -

(129) 6 6

(130)

(131) 7

(132) 8

(133)

(134) 7

(135)

(136)

(137) " #

(138)

(139)

(140)

(141) 9

(142)

(143)

(144)

(145)

(146)

(147)

(148) :*;'<

(149)

(150) )

(151) =

(152)

(153)

(154) &

(155)

(156)

(157) 9

(158)

(159)

(160)

(161)

(162) >

(163) :?<@"" =

(164)

(165)

(166)

(167) .

(168) :

(169) !!!'!B=

(170)

(171)

(172) C

(173)

(174)

(175)

(176)

(177)

(178)

(179)

(180)

(181)

(182)

(183) :

(184)

(185)

(186) =. Nr 3/2015.

(187)

(188) :

(189)

(190)

(191) '

(192) !!B=C

(193)

(194)

(195)

(196)

(197)

(198) 9

(199) +

(200)

(201)

(202)

(203)

(204) '

(205) <@F

(206)

(207)

(208)

(209)

(210) #

(211)

(212)

(213)

(214) <

(215) *

(216) 4

(217)

(218)

(219)

(220)

(221)

(222) (

(223)

(224)

(225) )

(226) 9

(227)

(228)

(229) .

(230)

(231)

(232)

(233)

(234)

(235)

(236)

(237)

(238)

(239)

(240)

(241) &

(242)

(243)

(244)

(245)

(246)

(247)

(248)

(249) -8'0H !

(250)

(251)

(252)

(253)

(254)

(255)

(256)

(257)

(258) .

(259)

(260)

(261) %

(262)

(263)

(264)

(265)

(266) I

(267)

(268)

(269)

(270) N

(271)

(272)

(273) O

(274)

(275)

(276)

(277) :7

(278) Q

(279) U2 test, Kruskal-Wallis test, logistic regression, discriminant. =. Results !

(280)

(281) "

(282)

(283)

(284)

(285) <

(286)

(287)

(288)

(289)

(290) 8

(291)

(292) -

(293)

(294)

(295)

(296) ;<@Y

(297)

(298)

(299)

(300) Z[;Y

(301)

(302) !

(303) !

(304)

(305)

(306)

(307) *Z

(308)

(309) -

(310)

(311)

(312)

(313) <Z\[Y

(314)

(315)

(316)

(317) <\\"Y

(318)

(319) ]

(320)

(321)

(322)

(323)

(324)

(325)

(326) <@"" ;

(327)

(328)

(329)

(330)

(331)

(332)

(333)

(334) 8

(335)

(336) ]

(337)

(338) O

(339) *[*

(340) :@ ^ ;Z=

(341) #

(342)

(343)

(344)

(345)

(346)

(347) ]

(348) . © Polskie Towarzystwo Ginekologiczne. 169.

(349) Ginekol Pol. 2015, 86, 168-175. P R A C E O R Y G I N A L N E poł ożn i ct wo. Antonio Simone Laganà et al. The role of episiotomy in prevention of genital lacerations during vaginal deliveries – results from two european centers.. Figure 1. Investigated population structure.. 4

(350)

(351)

(352) \<*C

(353)

(354)

(355)

(356) I

(357)

(358)

(359)

(360) :_CU2`*<b`"""=:#

(361) !=C

(362) .

(363)

(364)

(365)

(366)

(367)

(368) I

(369) C

(370)

(371)

(372)

(373)

(374)

(375)

(376)

(377)

(378)

(379) :#

(380) !!= #

(381)

(382)

(383)

(384)

(385) ;" <@"" C

(386)

(387)

(388)

(389)

(390)

(391)

(392)

(393)

(394) :_CU2`<;b `"""= $

(395)

(396)

(397)

(398)

(399) I

(400)

(401) :#

(402) !!= !

(403)

(404)

(405)

(406)

(407)

(408)

(409)

(410)

(411) *@

(412) ^>' #

(413)

(414)

(415)

(416) I

(417)

(418)

(419)

(420)

(421)

(422)

(423)

(424)

(425)

(426)

(427)

(428)

(429) :_CU2` "*;b `"*@=:#

(430) !=+ I

(431)

(432)

(433)

(434)

(435)

(436)

(437)

(438)

(439)

(440)

(441)

(442)

(443) :#

(444) !!= #

(445)

(446)

(447)

(448)

(449)

(450)

(451)

(452) <

(453) f

(454)

(455)

(456) :U2`*;Z<@b `"""= #

(457)

(458)

(459)

(460) I

(461)

(462)

(463) . I

(464)

(465)

(466)

(467)

(468) :`"""= &

(469)

(470) :#

(471) !!!= w

(472) !!

(473) :#

(474) !!=x

(475) "Y

(476)

(477)

(478)

(479)

(480) '

(481)

(482)

(483) :U2`@;Z;<b`"""=#

(484)

(485)

(486)

(487) I . 170.

(488)

(489)

(490)

(491)

(492)

(493)

(494)

(495)

(496)

(497)

(498)

(499) :#

(500) !!!=#

(501)

(502)

(503)

(504) I

(505)

(506) !!!

(507)

(508)

(509)

(510) I

(511)

(512)

(513)

(514)

(515)

(516)

(517)

(518)

(519)

(520) :#

(521) !!= +

(522)

(523)

(524)

(525)

(526) .

(527)

(528)

(529)

(530) I

(531)

(532)

(533) :U2`*[<;b`"""= !

(534)

(535)

(536)

(537)

(538)

(539)

(540)

(541) I

(542)

(543)

(544)

(545)

(546) I

(547)

(548)

(549)

(550)

(551) :U2`*[\[[*b`"""=#

(552)

(553)

(554)

(555) I

(556)

(557)

(558) !

(559)

(560) [

(561) !! @

(562) !!!

(563)

(564)

(565)

(566)

(567)

(568)

(569) :U2`<;*<;b `"""= 6

(570)

(571)

(572)

(573)

(574)

(575) :#

(576) !!= 7I

(577)

(578)

(579)

(580)

(581)

(582)

(583)

(584)

(585)

(586)

(587)

(588)

(589)

(590)

(591)

(592)

(593) #

(594)

(595)

(596)

(597) I

(598)

(599)

(600) .

(601)

(602)

(603) I

(604)

(605)

(606)

(607)

(608) #

(609)

(610)

(611)

(612) I

(613)

(614)

(615)

(616)

(617)

(618)

(619)

(620)

(621)

(622)

(623)

(624)

(625)

(626) :#

(627) !! !!!= + f

(628) :@!y - @"" @Y 0

(629) = :U2`";*;<;b `"""=

(630)

(631)

(632)

(633)

(634)

(635)

(636)

(637) I

(638)

(639)

(640)

(641)

(642)

(643)

(644)

(645)

(646)

(647) :#

(648) !!!=8

(649)

(650)

(651)

(652)

(653)

(654) I

(655)

(656)

(657)

(658) .

(659)

(660)

(661)

(662) :#

(663) !!=. © Polskie Towarzystwo Ginekologiczne. Nr 3/2015.

(664) Ginekol Pol. 2015, 86, 168-175. P R A C E. O R Y G I N A L N E po ł o ż n i c t wo. Antonio Simone Laganà et al. The role of episiotomy in prevention of genital lacerations during vaginal deliveries – results from two european centers.. Tab le I . Descriptive data of patient population. Episiotomy. All women. Parameters. Maternal age Baby weight gram II labor stage minute. With. Without. p. Mean. SD. Mean. SD. Mean. SD. 29.38. 5.17. 27.25. 5.15. 29.66. 5.14. 3389.82. 416.77. 3419.67. 433.87. 3321.99. 390.83. 0.001. 35. 12. 34.7. 8.3. 35.5. 14. 0.351. 0.001. Tab le I I . Differences between patients regarding laceration grade and site. Laceration grade. Parameters. 2. Laceration site 2. . p. . p. Age. 6.281. 0.043. 26.535. 0.001. Parity. 19.392. 0.001. 50.317. 0.001. Episiotomy presence. 0.630. 0.730. 243.658. 0.001. Laceration site. 19.920. 0.001. /. /. Baby weight. 14.058. 0.001. 3.479. 0.324. Laceration grade. /. /. 27.258. 0.001. Labor stimulation. 2.048. 0.359. 1.866. 0.601. Classes. 1.694. 0.328. 10.421. 0.015. Epidural use. 2.531. 0.282. 7.085. 0.069. II labor stage duration. 1.452. 0.473. 0.952. 0.846. Fetal presentation. 4.023. 0.001. 2.295. 0.326. Tab le I I I . Investigated parameters in groups of women with and without episiotomy. With episiotomy. Parameters vagina Laceration site. Laceration grade. Stimulation Neonatal classes Epidural use. Parity. Occipital presentation. Nr 3/2015. Without episiotomy. Frequency (No). Percent (%). Frequency (No). Percent (%). 178. 12.78. 146. 10.48. perineum. 63. 4.52. 544. 39.05. labia. 17. 1.22. 67. 4.81. combined. 68. 4.88. 310. 22.25. I. 315. 22.61. 1024. 73.51. II. 5. 0.36. 24. 1.72. III. 6. 0.43. 19. 1.36. yes. 884. 63.46. 259. 18.59. no. 56. 4.02. 18. 1.29. yes. 174. 12.49. 544. 39.05. no. 152. 10.91. 523. 37.45. yes. 204. 14.64. 643. 46.16. no. 122. 8.76. 424. 30.44. 1. 224. 16.08. 199. 14.29. 2. 72. 5.17. 680. 48.82. 3. 14. 1.01. 140. 10.05. 4. 16. 1.15. 48. 3.45. anterior. 640. 45.94. 610. 43.79. posterior. 69. 4.95. 64. 4.59. © Polskie Towarzystwo Ginekologiczne. 2. p. 101.662. 0.001. 0.276. 0.600. 0.584. 0.445. 0.571. 0.450. 0.561. 0.454. 208.769. 0.001. 1.732. 0.138. 171.

(665) Ginekol Pol. 2015, 86, 168-175. P R A C E O R Y G I N A L N E poł ożn i ct wo. Antonio Simone Laganà et al. The role of episiotomy in prevention of genital lacerations during vaginal deliveries – results from two european centers.. Tabl e I V. Correlations of the examined parameters.. Parameters Age. Birth number. Age. Birth No. Episiot. Lacerat site. Baby weight. Stimul. Classes. Epidur. . 1.000. 0.153. -0.103. 0.004. 0.068. 0.056. 0.032. -0.021. -0.011. p. .. 0.001. 0.001. 0.873. 0.011. 0.035. 0.228. 0.423. 0.678. . 0.153. 1.000. -0.387. 0.088. 0.196. -0.118. -0.014. 0.029. 0.027. p. 0.001. .. 0.001. 0.001. 0.001. 0.001. 0.593. 0.287. 0.318. . -0.103. -0.387. 1.000. -0.270. -0.109. -0.014. -0.020. -0.020. -0.020. p. 0.001. 0.000. .. 0.000. 0.000. 0.600. 0.445. 0.450. 0.454. Laceration site. . 0.004. 0.088. -0.270. 1.000. 0.026. 0.120. -0.004. -0.028. -0.038. p. 0.873. 0.001. 0.001. .. 0.338. 0.001. 0.877. 0.064. 0.158. Newborn weight. . 0.068. 0.196. -0.109. 0.026. 1.000. -0.100. -0.026. 0.020. -0.046. Episiotomy presence. p. 0.011. 0.001. 0.001. 0.338. .. 0.001. 0.336. 0.464. 0.089. Laceration grade. . 0.056. -0.118. -0.014. 0.120. -0.100. 1.000. -0.036. -0.026. 0.007. p. 0.035. 0.001. 0.600. 0.001. 0.001. .. 0.180. 0.064. 0.789. Labor stimulation. . 0.032. -0.014. -0.020. -0.004. -0.026. -0.036. 1.000. -0.061. -0.020. p. 0.228. 0.593. 0.445. 0.877. 0.336. 0.180. .. 0.022. 0.447. Neonatal classes Epidural use II stage duration Presenting part. . -0.021. 0.029. -0.020. -0.028. 0.020. -0.026. -0.060. 1.000. 0.013. p. 0.423. 0.287. 0.450. 0.064. 0.464. 0.064. 0.022. .. 0.627. . -0.011. 0.027. -0.020. -0.038. -0.046. 0.007. -0.020. 0.013. 1.000. p. 0.678. 0.318. 0.454. 0.158. 0.089. 0.789. 0.447. 0.627. .. . 0.032. 0.078. 0.014. -0.020. -0.081. 0.004. -0.014. 0.032. -0.021. p. 0.569. 0.035. 0.593. 0.450. 0.040. 0.873. 0.593. 0.228. 0.423. . 0.032. -0.014. 0.182. 0.016. -0.026. 0.158. 0.004. 0.007. 0.046. p. 0.228. 0.593. 0.001. 0.538. 0.336. 0.001. 0.873. 0.952. 0.089. #

(666)

(667)

(668)

(669) I

(670)

(671)

(672)

(673)

(674) :U2`\@"<"b `""""= $

(675)

(676)

(677)

(678)

(679)

(680) I

(681)

(682)

(683)

(684)

(685)

(686)

(687)

(688)

(689)

(690)

(691) :#

(692) !!!=4

(693)

(694)

(695)

(696)

(697)

(698) I

(699)

(700)

(701)

(702)

(703)

(704)

(705)

(706)

(707)

(708)

(709) :#

(710) !!= #

(711)

(712)

(713)

(714) I

(715)

(716)

(717)

(718)

(719)

(720)

(721)

(722)

(723)

(724)

(725) :U2`*;b `"<[= #

(726)

(727)

(728)

(729) I

(730)

(731)

(732)

(733)

(734)

(735)

(736)

(737)

(738)

(739)

(740) :#

(741) !!!= ]

(742)

(743)

(744)

(745)

(746)

(747) I

(748)

(749)

(750)

(751)

(752)

(753)

(754)

(755)

(756)

(757)

(758)

(759) $

(760)

(761)

(762)

(763)

(764)

(765)

(766)

(767)

(768)

(769)

(770)

(771)

(772)

(773) :#

(774) !!= & I

(775)

(776)

(777)

(778)

(779)

(780)

(781)

(782)

(783)

(784) #

(785)

(786)

(787)

(788)

(789)

(790)

(791)

(792)

(793)

(794)

(795)

(796)

(797) 4

(798)

(799)

(800)

(801) I

(802)

(803)

(804)

(805)

(806)

(807) +

(808)

(809)

(810) I

(811)

(812)

(813)

(814)

(815)

(816) I

(817)

(818)

(819)

(820)

(821) .

(822)

(823)

(824)

(825)

(826) #. 172. Lacerat grade.

(827)

(828)

(829)

(830)

(831)

(832)

(833)

(834)

(835)

(836) 6

(837)

(838)

(839)

(840)

(841)

(842) +

(843)

(844)

(845)

(846)

(847)

(848)

(849)

(850)

(851) -

(852)

(853)

(854)

(855)

(856) w I

(857)

(858)

(859)

(860)

(861)

(862)

(863)

(864)

(865)

(866)

(867)

(868)

(869)

(870) .

(871) N

(872)

(873)

(874) I

(875)

(876)

(877)

(878)

(879)

(880)

(881) 6

(882) %

(883)

(884)

(885)

(886)

(887)

(888) x

(889)

(890)

(891)

(892) I

(893)

(894)

(895)

(896)

(897)

(898)

(899)

(900)

(901)

(902)

(903)

(904) .

(905)

(906)

(907)

(908)

(909)

(910)

(911)

(912)

(913)

(914)

(915)

(916) #

(917)

(918)

(919)

(920) I

(921)

(922)

(923)

(924)

(925)

(926)

(927) x

(928)

(929)

(930)

(931)

(932)

(933)

(934)

(935) :#

(936) !B= #

(937)

(938)

(939)

(940)

(941)

(942)

(943)

(944)

(945)

(946)

(947)

(948) C

(949)

(950)

(951)

(952) I : 9

(953)

(954)

(955) `""b Y

(956) `Z<<b

(957) `"<<b C ) {`";ZZb U2`***\@b `"""b 9

(958)

(959)

(960) `""@b Y

(961) `[;b

(962) `"@;bC ){`"[\bU2`@\;b`""". *9

(963)

(964)

(965) `""\bY

(966) `\"b . © Polskie Towarzystwo Ginekologiczne. Nr 3/2015.

(967) Ginekol Pol. 2015, 86, 168-175. P R A C E. O R Y G I N A L N E po ł o ż n i c t wo. Antonio Simone Laganà et al. The role of episiotomy in prevention of genital lacerations during vaginal deliveries – results from two european centers.. Tab le V. Correlation coefficients between discriminating variables and standardized canonical discriminant function and group centroids of discriminant function. Function. Parameters. 1 episiotomy presence. Examined parameters. Functions at Group Centroids. 2. 3. 0.982(*). -0.021. 0.102. mothers age. -0.070. 0.646(*). 0.539. parity. -0.365. 0.494(*). 0.070. neonatal classes. 0.052. 0.381(*). -0.339. epidural use. -0.041. 0.357(*). -0.215. labor stimulation. -0.039. 0.187(*). 0.031. fetal presentation. -0.021. 0.154(*). 0.073. neonatal birth weight. -0.108. 0.137(*). 0.109. II labor stage duration. -0.103. 0.090(*). 0.256. laceration grade. -0.101. -0.278. 0.759(*). vagina. 0.838. 0.022. -0.039. perineum. -0.336. 0.014. -0.108. labia. -0.050. -0.612. 0.106. combination. -0.160. 0.094. 0.186. LEGEND: Function 1 – significant; Function 2 – significant; Function 3 – significant (*) – Largest absolute correlation between each variable and any discriminant function.

(968) `"<b C ) {`"[Z@b U2`@"b `"""= ]

(969)

(970)

(971) I

(972)

(973)

(974)

(975)

(976)

(977)

(978)

(979)

(980)

(981)

(982) .

(983)

(984)

(985)

(986)

(987)

(988)

(989)

(990)

(991)

(992)

(993) '

(994)

(995) :#

(996) B= 7 I

(997)

(998)

(999) %

(1000) &

(1001)

(1002)

(1003)

(1004)

(1005)

(1006)

(1007) .

(1008)

(1009)

(1010)

(1011)

(1012)

(1013)

(1014)

(1015)

(1016)

(1017)

(1018) :|`"[b f|2`""**b ]`"\\[b `""""= 8

(1019) 7

(1020)

(1021)

(1022)

(1023)

(1024) I

(1025)

(1026)

(1027)

(1028)

(1029)

(1030)

(1031)

(1032)

(1033)

(1034)

(1035)

(1036)

(1037) 9 LACERATION GRADE: 0.980 + 0.032 x LACERATION SITE LACERATION GRADE: 1.013 + 0.034 x LACERATION SITE – 0.040 x PARITY LACERATION GRADE: 0.879 + 0.034 x LACERATION SITE – 0.045 x PARITY + 0.005 x AGE LACERATION GRADE: 1.045 + 0.034 x LACERATION SITE – 0.045 x PARITY + 0.005 x AGE – 0.005 x NEONATAL BIRTH WEIGHT. Discussion w

(1038)

(1039)

(1040)

(1041)

(1042)

(1043)

(1044) '

(1045)

(1046)

(1047)

(1048) (!