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
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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 .
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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
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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
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Obstetric anal sphincter injury
includes both
third- and fourth-degree
perineal tears.
IntroductionIntroduction
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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
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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.
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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
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THIRD DEGREETHIRD DEGREE
PERINEAL TEARPERINEAL TEAR
FOURTHFOURTH--DEGREE DEGREE
PERINEAL TEARPERINEAL TEAR
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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
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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
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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
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Normal anal ultrasound
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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
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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)
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End-to-end(approximation) method Overlap technique
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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)
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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
(good practice point)
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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)
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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.
(good practice point)
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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
(good practice point)
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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
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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 .
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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.
Practice recommendationsPractice recommendations
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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 .
Practice recommendationsPractice recommendations
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All women, especially those with
risk factors for injury, should besurveyed for symptoms
of anal incontinenceat postpartum follow-up .
Practice recommendationsPractice recommendations
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