Diagnosis and Repair2nd degree tears and episiotomy

Perineal trauma

Episiotomy Spontaneous tears

Tears not involving anal sphincter

Tears involving anal sphincter

SecondFirst FourthThird

Classification of Trauma Classification of Trauma Classification of Trauma Classification of Trauma

First degree involving skin only

Second degree involving Second degree involving the perineal muscles – the perineal muscles – bulbocavernosusbulbocavernosus transverse perineal transverse perineal if very deep may involve if very deep may involve

pubococcygeus pubococcygeus but not the sphincter complexbut not the sphincter complex

EpisiotomyEpisiotomyEpisiotomyEpisiotomy

RML RML episiotomyepisiotomy Midline Midline

episiotomyepisiotomy

“A surgical incision made intentionally to increase the diameter of the vulval outlet to facilitate delivery”

Episiotomy

When routine -v- restrictiveHow midline -v- mediolateral

Routine versus restrictiveCarroli & Belizan. Cochrane library, Issue 3, 2004.

Routine versus Restrictive (6 studies)Routine versus Restrictive (6 studies)

After restrictive use:Less posterior perineal traumaLess suturingFewer healing complicationsMore anterior perineal trauma

Indications for episiotomy

Minimise multiple & extensive tearsThick & inelastic perineumForceps deliveryMalpresentation & malposition

Expedite deliverySuspected fetal distressShoulder dystocia

Why do we repair perineal trauma?

To control bleedingTo control bleedingTo prevent infectionTo prevent infection If the wound is left unsutured it will heal If the wound is left unsutured it will heal

by secondary intention & healing occurs by secondary intention & healing occurs by the formation of granulation tissue by the formation of granulation tissue which eventually contracts to form scar which eventually contracts to form scar tissuetissue

Perineal haematoma

Before After

Evidence based practice

Which suture material?

Vicryl Rapide Vicryl Rapide vsvs Vicryl Suture Material Vicryl Suture MaterialGemynthe Gemynthe et al et al 1996; McElhinney 1996; McElhinney et al et al 2000; Kettle2000; Kettle et al 2002 et al 2002

3 RCT (n = 2003 women) 3 RCT (n = 2003 women) A more rapidly absorbed synthetic suture A more rapidly absorbed synthetic suture material (Vicryl Rapide™) material (Vicryl Rapide™) versusversus absorbable absorbable synthetic material (Vicryl™) synthetic material (Vicryl™) Significant reduction in pain when ‘walking’ (2 trials)Significant reduction in pain when ‘walking’ (2 trials)Reduction in the need for pain relief (1 trial)Reduction in the need for pain relief (1 trial)Significant reduction in suture removal (3 trials)Significant reduction in suture removal (3 trials)Reduction in superficial dyspareunia (1 trial)Reduction in superficial dyspareunia (1 trial)

Evidence based practice

Which technique?

Repair Techniques Repair Techniques Kettle C, Ismail K 2007Kettle C, Ismail K 2007

Cochrane systematic review - 7 RCT’s (n = 3822) Cochrane systematic review - 7 RCT’s (n = 3822) found that found that continuous subcuticularcontinuous subcuticular stitches stitches compared to compared to interruptedinterrupted is associated with : - is associated with : -

Less short term pain at 10 days Less short term pain at 10 days

Reduction in analgesia use Reduction in analgesia use

No significant difference in dyspareuniaNo significant difference in dyspareunia

Recommended material and technique Recommended material and technique 22ndnd degree tears or episiotomy degree tears or episiotomy

Level 1a evidenceLevel 1a evidence

Vicryl Rapide suture material Vicryl Rapide suture material &&

The continuous non-locking technique The continuous non-locking technique for perineal repair - all layersfor perineal repair - all layers

Prior to commencing the repair

Check extent of perineal trauma – perform per Check extent of perineal trauma – perform per vaginal and per rectal examinationvaginal and per rectal examination

Check equipment - suture pack, materials Check equipment - suture pack, materials If needed ensure that appropriate If needed ensure that appropriate

supervision/support is available prior to supervision/support is available prior to commencing the repaircommencing the repair

Adequate lightingAdequate lighting Ensure that the wound is adequately Ensure that the wound is adequately

anaesthetised (10-20mls Lignocaine 1%) - don’t anaesthetised (10-20mls Lignocaine 1%) - don’t inject local through the skininject local through the skin

Step 1 - suturing the vagina

Identify the apex of the vaginal Identify the apex of the vaginal woundwound

Close the vaginal trauma with Close the vaginal trauma with a loose continuous stitcha loose continuous stitch

Continue to suture the vagina Continue to suture the vagina until the hymenal remnants are until the hymenal remnants are reached and re-approximatedreached and re-approximated

At the fourchette insert the At the fourchette insert the needle through the skin to needle through the skin to emerge in the centre of the emerge in the centre of the perineal traumaperineal trauma

Step 2 - suturing the muscle layer

Check the depth of the Check the depth of the trauma - it may be trauma - it may be necessary to insert two necessary to insert two layers of sutureslayers of sutures

Continue to close the Continue to close the perineal muscle with a perineal muscle with a continuous non-locking continuous non-locking stitch - taking care not stitch - taking care not to leave any dead spaceto leave any dead space

Step 3 - suturing the perineal skin At the inferior end of the wound At the inferior end of the wound

bring the needle out under the bring the needle out under the skin surfaceskin surface

The stitches are placed below The stitches are placed below the skin surface in the the skin surface in the subcutaneous layer - thus subcutaneous layer - thus avoiding the profusion of nerve avoiding the profusion of nerve endingsendings

Continue taking bites of tissue Continue taking bites of tissue from each side of the wound from each side of the wound until the hymenal remnants are until the hymenal remnants are reachedreached

Secure the finished repair with Secure the finished repair with a loop knot tied in the vaginaa loop knot tied in the vagina

Finally

Check the finished repair is anatomically correctCheck the finished repair is anatomically correct No bleedingNo bleeding PV - insert two fingersPV - insert two fingers PRPR Check swabs & instrumentsCheck swabs & instruments Complete documentationComplete documentation

Rationale – continuous techniqueRationale – continuous technique

No knots – sutures accommodate themselves to No knots – sutures accommodate themselves to swelling as it occursswelling as it occurs

Tight sutures cause pain especially if the wound Tight sutures cause pain especially if the wound becomes oedematous - may cause tissue hypoxia becomes oedematous - may cause tissue hypoxia and delay healingand delay healing

Deep & superficial muscles closed in one layerDeep & superficial muscles closed in one layer Skin sutures inserted into subcutaneous layer thus Skin sutures inserted into subcutaneous layer thus

avoiding nerve endings in skin surface – less painavoiding nerve endings in skin surface – less pain Economical – single suture usedEconomical – single suture used

Risk factors for anal sphincter injuries

birth weight over 4 kg (up to 2%) ● persistent occipitoposterior position (up to 3%) ● nulliparity (up to 4%) ● induction of labour (up to 2%) ● epidural analgesia (up to 2%) ● second stage longer than 1 hour (up to 4%) ● shoulder dystocia (up to 4%) ● midline episiotomy (up to 3%) ● forceps delivery (up to 7%)

Guidelines

Clinicians need to be aware of the risk factors for obstetric anal sphincter injury but also recognise that known risk factors do not readily allow its prediction or prevention.

Where episiotomy is indicated, the mediolateral technique is recommended, with careful attention to the angle -60 degree- cut away from the midline.

Anal Sphincter Rupture - ClassificationSultan AH, Clinical Risk 1999;5:193-6

RCOG GreenTop Guidelines 2001; ICI 2002

1st degree = vaginal epithelium

2nd degree = perineal muscles

3rd degree = anal sphincter

3a = <50% external sphincter thickness

3b = > 50% external sphincter thickness

3c = internal sphincter torn

4th degree = anal epithelium torn

+

+

+

Anal Sphincter Rupture - ClassificationSultan AH, Clinical Risk 1999;5:193-6

RCOG GreenTop Guidelines 2001; ICI 2002

If there is any doubt about the grade of third-degree tear, it is advisable to classify it to the higherdegree rather than lower degree.

When repair of the EAS muscle is being performed, either monofilament sutures such as polydiaxanone (PDS) or modern braided sutures such as polyglactin (Vicryl®) can be used with equivalent outcome.

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.

Internal sphincter defectsMahony R et al 2007

500 consecutive OASIS Persistent internal sphincter defects

independently associated with an severe anal incontinence

OR 5.1 (95% CI = 1.5 – 22.9)

Diagnosis

History Examination Special Investigation

Obstetric Anal Sphincter InjurieSOASIS

History

Vaginal delivery

- undiagnosed

- suboptimal repair

Identification of EAS

End-to-end primary anal sphincter repair

Primary end-to-end sphincter repair

I

Faecal incontinence

0

20

40

60

80

100

6 weeks 3 months 6 months 12 months

Overlap

End to endp=0.01p=0.01

% Patients

Overlap vs end-to-end n = 64Overlap vs end-to-end n = 64

Fernando R et al 2006

Suture materials Sultan AH, Thakar R 2002

Anal Mucosa - interrupted 3-0 Vicryl with knot in anal canal

Internal Anal Sphincter - Mattress end-to-end 3-0 PDS/ Vicryl 2-0

External Anal Sphincter- Mattress/Overlap 3-0 PDS/ Vicryl 2-0

Principles of the overlap repair Sultan AH et al 1999

Operating theatre Lighting and equipment Regional or general anaesthesia Antibiotics Augmentin or ceph & met. Monofilament sutures PDS but can use Vicryl Foleys catheter Laxatives Lactulose

Recommended Practice Thakar R, Sultan AH 2003

Rectal examination after every delivery Adopt the new classification OASIS repair by experienced doctor in theatre Regional or GA External sphincter - end-to-end or overlap repair Repair torn internal sphincter - 3-0 PDS or Vicryl 2-0 Lactulose 15mls bd for 2 week Antibiotics Ensure bowels opened Follow-up @ hospital by a senior obstetrician

Post natal review

All women should be offered physiotherapy and pelvic-floor exercises for 6–12 weeks after obstetric anal sphincter repair.

All women who have had obstetric anal sphincter repair should be reviewed 6–12 weeks postpartum by a consultant obstetrician and gynaecologist.

When to refer?

If a woman is experiencing incontinence or pain at follow-up, referral to a specialist gynaecologist or colorectal surgeon for endoanal ultrasonography and anorectal manometry should be considered.

A small number of women may require referral to a colorectal surgeon for consideration of secondary sphincter repair.

Post delivery counseling

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

Counseling Post delivery

All women who sustained an obstetric anal sphincter injury in a previous pregnancy should be counselled about the risk of developing anal incontinence or worsening symptoms with subsequent vaginal delivery.

All women who sustained an obstetric anal sphincter injury in a previous pregnancy should be advised that there is no evidence to support the role of prophylactic episiotomy in subsequent pregnancies.

All women who have sustained an obstetric anal sphincter injury in a previous pregnancy and who are symptomatic or have abnormal endoanal ultrasonography and/or manometry

should have the option of elective caesarean birth.

Documentation and Information

When third- and fourth-degree repairs are performed, it is essential to ensure that the anatomical structures involved, method of repair and suture materials used are clearly documented and that instruments, sharps and swabs are accounted for.

The woman should be fully informed about the nature of her injury and the benefits to her of follow-up. This should include written information where possible.

Thank You

Episiotomy: midline -v- mediolateralCoats et al 1980

Randomised 407 primiparae

Incidence of OASIS

• midline = 12%

• mediolateral = 2%

Benefits of midline episiotomy blood loss Easier to recognise 3o tear Easier to repair Better anatomical result pain risk of infection dyspareunia

Disadvantage of midline episiotomy 30 and 40 tears

Vagina

Anal canal

Episiotomya

c

αb

Angle of episiotomyAndrews et al 2005

EpisiotomyAndrews et al BJOG 2004 Andrews et al Birth 2006

254 primipsNo midwife and only 13 (22%) doctors

performed a truly mediolateral episiotomy (between 40 to 60 degrees from the midline)

Episiotomies angled closer to the midline significantly associated with OASIS (26 vs 37 degrees)

EpisiotomyEogan et al BJOG 2006

Case-control study (54 versus 46 controls)Mean angle of episiotomy smaller (30%

versus 38% p<0.001)50% risk reduction for every 6°from

midlineThe relationship of episiotomy angle with

risk of OASIS was sig (p<0.001)

Training Sultan et al J Obstet Gynaecol 1995

Interviewed 75 doctors and 75 midwives

Less than 20% of doctors and 50% of midwives were satisfied that they had a good level of training at the time of repairing their first episiotomy unsupervised

ConclusionConclusion

It is imperative that women receive high quality It is imperative that women receive high quality evidenced based care wherever childbirth takes evidenced based care wherever childbirth takes placeplace

Practices that reduce the adverse effects of Practices that reduce the adverse effects of perineal trauma and make vaginal birth more perineal trauma and make vaginal birth more desirable are to be encourageddesirable are to be encouraged

Improved perineal care may decrease the Improved perineal care may decrease the escalating interest in caesarean section as an escalating interest in caesarean section as an alternative mode of deliveryalternative mode of delivery