ob episiotomy and severe perineal lacerations

8/2/2019 Ob Episiotomy and Severe Perineal Lacerations

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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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ob episiotomy and severe perineal lacerations

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