Hypothesis: Obstetric perineal trauma can be of variable severity. Its most severe form, obstetric anal sphincter injuries (OASIS) can have a significant impact on quality of life.  Optimal clinical management is therefore essential and a number of international and national guidelines have been published to inform clinical practice. However, the clinical value of these guidelines depends on their quality and robustness and the methodology of their development as well as their properties require rigorous evaluation.

Aim of study: The aim of this study was to systematically evaluate the quality of the currently available clinical guidelines on obstetric perineal trauma.

Study design: Systematic Review

Materials and methods: Literature searches were performed using Medline, PubMed, Web of Science databases from inception to December 2018. National and international associations and societies were searched manually for published clinical practice guidelines. National and international guidelines on perineal care, as well as OASIS management, were considered for inclusion. Five appraisers independently scored each guideline using the AGREE II Reporting checklist (1).

Results: In total, twelve guidelines were included and appraised. 
(Table 1)
All guidelines are in English except from the Mexican guidelines that are in Spanish language. SIx of the included guidelines provided specific guidance on the management of major perineal trauma (OASIS) (Mexican 2013, ACOG 2016, AUB 2012, AWMF 2014, RCOG 2015, SOGC 2015) and 6 on the care of obstetric perineal trauma in general (NICE 2017, South Australian 2014, Queensland 2018, RCOM 2012, Spanish 2011, WHO 2018). Seven out of the twelve guidelines were developed and published by specialist societies (ACOG 2016, AUB 2012, AWMF 2014, RCOG 2015, SOGC 2015 and RCOM 2012) and the rest were developed by national or international institutions or organizations. The mean overall quality rating of the twelve guidelines was between 3.0 and 6.2 and 8 of 12 (ACOG 2016, AUB 2012, AWMF 2014, RCOG 2015, SOGC 2015, Queensland 2018, Spanish 2011, WHO 2018) A score over 4.5 suggests a high quality of the guidelines. Spanish 2011 received the overall highest scores (Overall Quality Score 82,38%) and RCOM 2012 the lowest scores (Overall Quality Score 36,81%). Overall, highest scores were noted in the domains related to ‘ ‘Rigour of Development’ and Clarity of Presentation’ with a mean 67,76 and 65,88 respectively The lowest ratings were on ‘Stakeholder Involvement’ with mean 54,79 and following Editorial Independence’ with 56,34.

Interpretation of the results: This study was the first systematic review on the quality of the guidelines of the management of OASIS and perineal care using the AGREE II validation tool. Significant agreement in overall ratings among appraisers was achieved, which implies higher reliability on the findings of this study. Spanish 2011 guidelines (2) received the highest scores, a fact that indicates that it has been developed with significant high quality of methodology. Nevertheless, RCOG 2015 was rated with the highest recommendation score at overall assessment among the appraisers according to AGREE II tool. The NICE and WHO guidelines are better complying with the AGREE II criteria but deal with many topics and are of considerable size, which makes them difficult to consult in everyday practice. Conversely, those that received the highest recommendation scores are focused exclusively on the management of severe perineal tears and may be more useful in clinical practice.

Concluding message: The quality of the OASIS and Perineal Care clinical practice guidelines on the diagnosis, management, and treatment in this study was found to be highly variable.  Tools as AGREE II can be considered as guidance for developing national and international guidelines. Harmonization of guidelines may also be considered by institutions and societies based on the highest quality available evidence and such tools may assist in this direction.

Brouwers MC, Kho ME, Browman GP, Burgers J, Cluzeau F, Feder G, Fervers B, Graham, ID, Grimshaw J, Hanna S, Littlejohns P, Makarski J, Zitzelsberger L on behalf of the AGREE Next Steps Consortium. AGREE II: Advancing guideline development, reporting and evaluation in healthcare.  Preventive Medicine, 2010;51(5):421-424.
Clinical Practice Guideline on Care in Normal Childbirth. Clinical Practice Guideline on Care in Normal Childbirth.  Quality Plan for the Spanish National Healthcare System of the Spanish Ministry for Health and Social Policy. Health Technology Assessment Agency of the Basque Country (OSTEBA). Health Technology Assessment Agency of Galicia (avalia-t). 2010. Clinical Practice Guidelines in the Spanish National Healthcare System: OSTEBA No. 2009/01