obstetric anal sphincter injury-fouda

8/6/2019 Obstetric Anal Sphincter Injury-Fouda

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THE MANAGEMENT OF THE MANAGEMENT OF

OBSTETRIC ANALOBSTETRIC ANAL

SPHINCTER INJURY SPHINCTER INJURY

(EVIDENCE BASED)(EVIDENCE BASED)

Dr. Ashraf Fouda

Ob./Gyn. ConsultantOb./Gyn. Consultant

Damietta General HospitalDamietta General Hospital



Sources of Guidelines

The Cochrane Library. Medline and PubMed .

UpToDate ® August 2006 . August 2006 .

RCOGRCOG March 2007, THE M ANAGEMENT OF THIRD- AND

FOURTH-DEGREE PERINEAL TEARS .

RCOGRCOG June 2004 , METHODS AND M ATERIALS USED IN

PERINEAL REPAIR .

American Family Physician October 2003 .



Applied anatomy The anal canal measures

about 3.5 cm in length.

The external anal

sphincter (EAS) is

striated muscle and is

subdivided into

subcutaneous, superficial

and deep regions and is

responsible for voluntary

squeeze and reflex

contraction pressure

It is innervated by the

pudendal nerve



The internal anal

sphincter (IAS) is a

thickened continuation

of the circular smoot

h

muscle of the bowel.

It contributes about

70% of the resting

pressure and is under

autonomic control.

Applied anatomy



Obstetric anal sphincter injury

includes both

third- and fourth-degree

perineal tears.

IntroductionIntroduction



The overall risk of

obstetric anal sphincter injury is

1% of all vaginal deliveries.

This condition may also present inThis condition may also present in

women without obvious analwomen without obvious analsphincter tears during labour andsphincter tears during labour and

deliverydelivery (occult injury).(occult injury).

IntroductionIntroduction



Importance

Anal incontinence is defined as any

involuntary loss of faeces, flatus or urge

incontinence that is adversely affectinga woman¶s quality of life.

Up to

Up to 4

040%%

of women with

third orof women wit

hthird or

fourth degree perineal tears duringfourth degree perineal tears during

childbirth suffer from anal incontinence.childbirth suffer from anal incontinence.



by International Consultation on Incontinence and

the RCOG.

First degree Injury to perineal skin only.

Second degree Injury to perineum involving

perineal muscles but not involving the anal sphincter.Third degree Injury to perineum involving the

anal sphincter complex (EAS and IAS) :

3a: Less than 50% of EAS thickness torn.

3b: More than 50% of EAS thickness torn.

3c: Both EAS and IAS torn.

Fourth degree Injury to perineum involving the anal

sphincter complex and anal epithelium.

Classification and terminology of perineal tears



THIRD DEGREETHIRD DEGREE

PERINEAL TEARPERINEAL TEAR

FOURTHFOURTH--DEGREE DEGREE

PERINEAL TEARPERINEAL TEAR



Birth weight over 4 kg

Persistent occipitoposterior position

Nulliparity

Induction of labour

Epidural analgesia

Second stage longer than 1 hour

Shoulder dystocia

Midline episiotomy

Forceps delivery

Risk factors for obstetric analRisk factors for obstetric anal

sphincter injurysphincter injury



When episiotomy is indicated,

the mediolateral technique

is recommended,

with careful attention to the

angle cut away from the midline.

Prediction and prevention of Prediction and prevention of obstetric anal sphincter injuryobstetric anal sphincter injury

Grade B



With introduction of endoanal ultrasound,

sonographic abnormalities of the anal sphincter

anatomy has been identified in up to 36% of

women after vaginal delivery, in prospective

studies.

A lower risk of third-degree tear is

associated with a larger angle of episiotomy.

Prediction and prevention of Prediction and prevention of obstetric anal sphincter injuryobstetric anal sphincter injury



Normal anal ultrasound



How can the identification of obstetricHow can the identification of obstetric

anal sphincter injuries be improved?anal sphincter injuries be improved?

All women having a vaginal delivery

with

evidence of genital tract traumashould be

examined syst emat icall y

to assess the severity of damage

prior to suturing.

Grade B



Surgical techniques

F

or repair of the external anal sp

hincter, eit

her

an overlapping or end-to-end

(approximation) method can be used,

with equivalent outcome.

Where the IAS can be identified, it is advisable

to repair separately with interrupted sutures.

Repair of third- and fourth-degree tears shouldbe conducted in an operating theatre, under

regional or general anaesthesia.

(Grade A)



End-to-end(approximation) method Overlap technique



A systematic review on the method of repair

showed that

no significant difference in:

perineal pain ,dyspareunia ,flatus incontinence

and faecal incontinence & quality of life

between the two repair techniques

at 12 months

But showed a significantly lower incidence

in faecal urgency in the overlap group.

Surgical techniquesSurgical techniques

(Grade A)



Repair in an operating theatre will allow the

repair to be performed under aseptic conditions

with appropriate instruments, adequate light

and an assistant .

Regional or general anaesthesia will allow

the anal sphincter to relax, which is essential to

retrieve the retracted torn ends of the sphincter

with

out any tension

Surgical techniquesSurgical techniques

(Grade C)



The use of absorbable synthetic material

polyglactin 910 (vicryl) when compared with

catgut, is associated with less :

P erineal pain,

Analgesic use,

Dehiscence and Resuturing ,

but increased suture removal.

Choice of suture materials

(Grade A)



The use of a more rapidly absorbed form of

polyglactin 910 (Vicryl®) is associated with a

significant reduction in pain and a reduction in

suture removal when compared with standardabsorbable synthetic material.

In the light of current evidence,

rapid-absorption polyglactin 910 (Vicryl®)

is the most appropriate suture material

for perineal repair.

Choice of suture materialsChoice of suture materials

(Grade A)



When repair of the IAS muscle is being

performed, fine suture size such as 3-0 PDS

and 2-0 Vicryl may cause less irritation and

discomfort.

Burying of surgical knots beneath the

superficial perineal muscles is recommended to

prevent knot migration to the skin.

Choice of suture materialsChoice of suture materials

(Grade C)

(Good practice point)



Method of repair

A loose, continuous non-locking suturing

for (vaginal tissue, perineal muscle and skin)

& the use of a continuous subcuticular

technique for perineal skin closure is

associated with less short term pain than

techniques employing interrupted sutures.

(Grade A)



SurgicalSurgical competencecompetence

Obstetric anal sphincter repairshould be performed by appropriately

trained practitioners.

Formal training in anal sphincter repair

techniques, is recommended as an

essential component of obstetric training.

(Good practice point)



Postoperative managementPostoperative management

The use of broad-spectrum antibioticsis recommended to reduce the incidence

of postoperative infections and wound

dehiscence.

The use of postoperative laxatives

is recommended to reduce the incidence

of postoperative wound dehiscence.

(good practice point)

(Grade C)



All women who have had obstetric analsphincter repair should be :

Offered physiotherapy and

pelvic-floor exercises for 6±12 weeksafter repair.

Reviewed 6±12 weeks postpartum

by a consultant obstetrician and

gynaecologist.

Postoperative managementPostoperative management




PrognosisPrognosis

Women should be advised that the

prognosis following EAS repair is good,

with 60±80% asymptomatic at

12 months.

Most women who remain symptomatic

describe incontinence of flatus or

faecal urgency.(Grade A)



Future deliveriesFuture deliveries

All women with an obstetric anal sphincterinjury in a previous pregnancy should be :

Coun selled about the risk of developing

anal incontinence or worsening symptoms

with subsequent vaginal delivery.

Advi sed that there is no evidence to

support the role of prophylactic episiotomy

in subsequent pregnancies.




All women with an obstetric anal

sphincter injury in a previous pregnancy

and who are symptomatic or have

abnormal endoanal ultrasonography

should have the option

of elective caesarean birth.

Future deliveriesFuture deliveries




There is a steady increase in litigationrelated to obstetric anal sphincter injury.

Litigation is related to failure to identify

the injury after delivery, leading to

subsequent anal incontinence and

rectovaginal fistulae. Poor technique, poor materials or poor

healing may cause a repair to fail.

Risk managementRisk management



Practice recommendationsPractice recommendations

Avoiding obstetrical injury to the

anal sphincter is the single biggest

factor in preventing anal incontinence . Any form of instrumental delivery has

been noted to increase the risk of

obstetric anal sphincter injury and altered

fecal continence , by between 2-7 fold .



Routine episiotomy is not recommended. Episiotomy use should be restricted to

situations where it directly facilitates an urgent

delivery .

A mediolateral incision, instead of a

midline, should be considered for persons at

high risk of obstetric anal sphincter injury

,with careful attention to the angle cut away

from the midline.




The internal anal sphincter needs

to be separately repaired, if torn .

Women with injuries to the internal

anal sphincter or rectal mucosa

have a worse prognosis for

future continence problems .




All women, especially those with

risk factors for injury, should besurveyed for symptoms

of anal incontinenceat postpartum follow-up .


obstetric anal sphincter injury-fouda

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