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Obst e t r ic Ana l sph inc t er in ju ry :r i sk fac t ors , p revent ion andmanagementVani Dandolu MD
Director, Division of Urogynecology,Temple University Hospital,
Philadelphia, PA
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Objec t ives
Examine the factors that predispose to analsphincter injury at vaginal delivery
Describe evidence based strategies to
prevent such injuryOptimal technique of repair and post-partummanagement
and
Identify the long term consequences of analsphincter lacerations
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Cat egor ies o f Perinea l andVaginal Lac erat ion
First degree:skin and mucosa onlySecond degree:Involves perineal muscles
Third degree:Involves the anal sphincter A. < 50% of external anal sphincter
B. > 50% of EAS
C. Internal anal sphincter also
Fourth degree:Involves the rectal mucosaand usually transects the anal sphincter
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I nc idence
Perineal lacerations are common, seenin upto 80% of deliveries
Clinical injury to anal sphincter in 0.6-9% of vaginal deliveries
Occult injury by endoanal ultrasound ina third of vaginal deliveries
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Anal-Sphincter Disruption DuringVaginal Delivery
Occult sphincter lacerations are common,Can occur with an intact perineum, and
Result in substantial morbidity
Sultan AH N Engl J Med 1993
Clinically evident sphincter tears in 3%
Occult sphincter lacerations on EAUS
35 percent of primiparous women
44 percent of multiparous women and
80% of women delivered by forceps
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Risk fac t ors for OASI
Nulliparity, BOccipito posterior position BFetal macrosomia B
Short perineal body BAsian race BInduction of labor BInstrumental vaginal delivery A Forceps vs vacuum
Episiotomy ? Midline vs mediolateral AB
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Epis io t om y and ana l
sph inc t e r lac era t ion
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Epis io tomy
Episiotomy is an incision into the perinealbody made during the second stage of laborto facilitate delivery
Purpose:
increase the diameter of the soft tissuepelvic outlet and facilitate delivery
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Prophy lac t ic versusind ica ted
Indicated in cases of arrested or protracted descent,
in association with an instrumental delivery, or
to expedite delivery in the setting of fetal heartrate abnormalities
Use of prophylactic episiotomy iswidely debated
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Reasons forp rophylac t i c epis iot om y
Substitution of a straight surgical incision for aragged spontaneous laceration
Ease of repair and improved wound healing
Reduction in the duration of the second stageReduction in third and fourth degree tears
Less neonatal trauma
premature infant (soft cranium) or
macrosomic infant (shoulder dystocia)
Pelvic floor protection
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Role of episiotomy
Subnsequently several reports haveimplicated routine episiotomy in the genesisof major perineal and anal sphincter tears
Myers-Helfgott M, Obstet Gynecol Clin North Am1999
Anthony S, Br J Obstet Gynaecol 1994
Henrikson T, Br J Obstet Gynaecol 1992
Sleep J, BMJ 1984 Buchave P, Eur J Obstet Gynecol 1999
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Coc hrane rev iew
Restrictive versus liberal use: less posterior perineal trauma RR 0.88,
less suturing RR 0.74, and
fewer healing complications RR 0.69
However, more anterior perineal trauma RR 1.79 No difference in the incidence of
severe lacerations,
dyspareunia,
urinary incontinence, and
several measures of pain.
Restrictive (27%) and liberal (72%)
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Medio la t e ra l --Du t c hdatabase
284,783 vaginal deliveries in 1994 and1995 from Dutch National ObstetricDatabase
OASI 1.94%
Mediolateral episiotomy strongly protective
OR: 0.21, 95% CI: 0.20-0.23 Midline OR (0.81 small numbers)
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Epis iot om y and OASI
Midline episiotomy increases the risk ofanal sphincter injury
Mediolateral episiotomy in indicated
cases may be protective
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Prevent ion s t ra t eg ies
EpisiotomyOperative vaginal delivery
Forceps delivery is associated with moreperineal trauma than vacuum
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Prevent ion s t ra t eg iescon td
Perineal massage Antepartum
Intrapartum
Birthing positionWhirlpool baths
Flexion of head
Perineal protection
Minimizing pushing to slow delivery of head
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Repair
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Repai r o f t h i rd or four t hdegree lac erat ion
Rectal mucosa with continuous 3-0 vicrylIAS or perirectal fascia
EAS
2-0 PDS incorporate the capsule
Usually one end retracted
Side to side versus overlapping technique 3-4 figure of eight sutures
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Fai lure of pr im ary repai r
Persistence anal incontinence in 30%, fecalurgency in 25% and persistent occult defectsin the sphincter in 80% by endoanalultrasound
Overlap versus side to side technique
Suture material
Incorporation of IAS
Residual defects
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Postpartum Defect of the External Anal Sphincter
by Anal Endosonography
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Postpartum Defect of the Internal Anal Sphincterby Anal Endosonography
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Rec ogni t ion o f obst e t r ic analsph inc t er in ju ry
All women having a vaginal delivery systematic examination of the perineum,
vagina and rectum to assess the severity ofdamage prior to suturing.
All women having instrumental deliveryor who have extensive perineal injury
examined by an experienced obstetrician,trained in the recognition and management ofperineal tears.
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Met hod o f repa irCurrently there is no reliableevidence to show that the overlapmethod is superior to the end-to-end
(approximation) method.
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Mode of repair of obstetricsphincter injury
Most primary repairs are performed by end-to-endapproximation of the torn anal sphincter ends
relative simplicity
Colorectal surgeons favor overlapping of thesphincter muscles secondary or delayedprocedure
No difference in outcome Fitzpatricket al Eur J Obstet Gynecol 2000
Overlap technique superior Sultan et al . Br J Obstet Gynaecol 1999
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A randomized clinical trial comparing primaryoverlap with approximation repair
55 women overlap procedure, and 57approximation
Outcome after primary repair was
similar
Fitzgerald M; Am J Obstet Gynecol2000;183:1220-4
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Met hod o f repa irRepair in an operating theatre, underregional or general anesthesia islikely to be associated with improved
outcome.
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Sut ure m at er ia lThe use of monofilament sutures suchas PDS compared to catgut or vicryl, isassociated with less infection and better
long-term function of the anal sphinctercomplex.
Catgut no longer available in UK
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Sk i l l o f t he operat orResidents in-training need specificinstruction about the repair of third-and fourth degree tears.
Surgical skills workshops needed withthe use of models and audiovisualmaterial.
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Episiot omy Sut ur ingSimulator
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Postopera t ivemanagementAntibiotics intra-op and postop are
associated with less post-operativeinfection and wound dehiscence.
The use of postoperative laxatives isassociated with less postoperativewound dehiscence.
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Fol low-upFollow-up at 612 months by agynaecologist with an interest in anorectal
dysfunction or a colorectal surgeon.
If symptomatic, they should be offeredendoanal ultrasonography and anorectal
manometry and consideration ofsecondary sphincter repair.
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Counsel ing aboutsubsequent de l iverySubsequent vaginal delivery may worsen anal incontinence
symptoms.
Counselled regarding the risk of developing analincontinence or worsening symptoms with subsequentvaginal delivery.
If symptomatic or with abnormal endoanal ultrasonographyor manometry, the option of elective caesarean sectionshould be discussed.
If asymptomatic, there is no clear evidence as to the bestmode of delivery.
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Medico lega limp l i ca t ions
Document clearly the anatomicalstructures involved, the method of repairand suture materials used.
Inform about the nature of the injury andimportance of subsequent follow-up.
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Anal inc ont inenc e and c h i ldbi r t h - m echanism o f i njury
External anal sphincter demonstrates evidence ofdenervation in 47-60% of women with recognized
third- or fourth-degree lacerations Snooks SJ et al BJOG 1985
Toglia, Delancey Obstet Gynecol 1994
Possible dual mechanism
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Rec om m endat ions formon i to r ing
Monitor the use of agreed definition ofseverity and degree of injury
The rate of third- and fourth-degree
tearsThe proportion repaired in theatre, typeof analgesia, suture material and
method of repairThe presence of attending
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Rec om m endat ions formon i to r ing
Adequate note-keeping and counsellingThe proportion seen for follow-uppostnatally (with symptom
questionnaire) and
The percentage continence rate
following primary repair
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Risk fac t ors fo r ana lsph inc t e r lac era t ions inPennsylvania and r isk ofrec ur renc e in subsequentpregnanc ies
Vani Dandolu MD
Assistant ProfessorDivision of Urogynecology and Pelvic Reconstructive
SurgeryTemple University Hospital, Philadelphia, PA
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Objec t ivesIdentify the incidence of anal sphincterlacerations
Risk of recurrence in subsequent
pregnancies, andAnalyze risk factors associated with this
condition
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MethodsObtained data from Pennsylvania stateinpatient database (PHC4) regarding allcases of third and fourth degree perineallacerations that occurred during a two-yearperiod from January 1990 to December 1991
All subsequent pregnancies over the next tenyears were identified and risk of recurrence oflaceration was analyzed
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Resul ts
There were a total of 168,337deliveriesin 1990 and 165,051 deliveries in 1991.
22.5% (n=74881) deliveries were by
cesarean section and were excludedfrom analysis.
Out of the remaining 258,507 deliveries,
incidence of third and fourth degreelacerations was 7.31% (n=18,888).
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Resul ts
Instrumental vaginal delivery particularly withuse of episiotomy increased the risk oflaceration significantly
forceps OR 3.84
forceps with episiotomy OR 3.89
vacuum OR 2.58
vacuum with episiotomy 2.93
Episiotomy in the absence of instrumentaldelivery had an odds of 0.9.
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Resul ts
In the next ten years there were 16152deliveries in the group with priorlacerations, out of which 1162 were
cesarean sections.Among 14990 subsequent vaginaldeliveries, 864 (5.76%) had a
recurrence of third or fourth degreelaceration.
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Resul ts
Rate of recurrent lacerations (5.76%) issignificantly lower than the 7.3% rate forinitial lacerations (OR 0.78 CI 0.72-
0.83).In the group with recurrent lacerations
also instrumental vaginal delivery was
associated with a greater than two foldincrease in the risk of sphincter tears.
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Conclus ions
This is the largest study so far looking at risk ofrecurrence of anal sphincter lacerations.Prior anal sphincter laceration does not appear to bea significant risk factor for recurrence of laceration.
Operative vaginal delivery particularly with episiotomyis associated with a two to four fold increase in therisk of anal sphincter tear.
Forceps delivery is associated with higher occurrence
of anal sphincter injury compared to vacuum delivery.There is no greater risk in women with prior analsphincter laceration.
C f O S
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Year C/s episiotom forceps vacuum OASI
1991 16.0% 22.2% 1.2% 3.4% 3.8%1992 16.9% 19.2% 1.4% 4.5% 4.4%
1993 15.8% 18.9% 1.0% 4.7% 4.4%
1994 12.2% 17.3% 2.4% 2.7% 3.8%
1995 18.4% 15.3% 2.9% 6.5% 3.5%
1996 20.2% 11.6% 1.2% 7.3% 2.0%
1997 17.1% 7.3% 2.7% 6.0% 2.5%
1998 15.7% 5.8% 2.3% 5.4% 2.0%1999 17.2% 6.0% 2.4% 3.6% 2.9%
2000 21.1% 7.0% 3.0% 3.2% 3.2%
2001 23.3% 8.1% 2.0% 1.9% 2.6%2002 25.5% 10.0% 2.0% 4.0% 2.6%
2003 24.0% 7.0% 2.7% 5.2% 3.5%
Mean 19.0% 11.3% 1.9% 4.1% 3.2%
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