THE MANAGEMENT OF OBSTETRIC ANAL SPHINCTER INJURY (EVIDENCE BASED) Dr. Ashraf Fouda Ob./Gyn....
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Transcript of THE MANAGEMENT OF OBSTETRIC ANAL SPHINCTER INJURY (EVIDENCE BASED) Dr. Ashraf Fouda Ob./Gyn....
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THE MANAGEMENT OF THE MANAGEMENT OF
OBSTETRIC ANAL OBSTETRIC ANAL
SPHINCTER INJURYSPHINCTER 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 MANAGEMENT OF THIRD-
AND FOURTH-DEGREE PERINEAL TEARS .
RCOGRCOG June 2004 , METHODS AND MATERIALS
USED IN PERINEAL REPAIR .
American Family Physician October
2003 .
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Muscles of perineal body
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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 smooth
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 in This condition may also present in
women without obvious anal sphincter women without obvious anal sphincter
tears during labour and delivery tears during labour and delivery
(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 affecting
a woman’s quality of life.
Up to 40%Up to 40% of women with third or fourth of women with third or fourth
degree perineal tears during childbirth degree perineal tears during childbirth
suffer from anal incontinence. 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 DEGREE THIRD DEGREE PERINEAL TEARPERINEAL TEAR
FOURTH-DEGREE FOURTH-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 anal Risk 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 obstetric How can the identification of obstetric
anal sphincter injuries be improvedanal sphincter injuries be improved??
All women having a vaginal delivery
with evidence of genital tract
trauma should be
examined systematically
to assess the severity of
damage prior to suturing.Grade
B
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Surgical techniques For repair of the external anal sphincter, either
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 should
be conducted in an operating theatre, under
regional or general anaesthesia.
(Grade A)
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End-to-end (approximation)
methodOverlap 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
without 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 :
Perineal 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 standard
absorbable 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 competence competence Obstetric anal sphincter repair
should 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 antibiotics
is 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 anal sphincter repair should be :
Offered physiotherapy and pelvic-floor exercises for 6–12 weeks after 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 sphincter
injury in a previous pregnancy should be :
Counselled about the risk of developing
anal incontinence or worsening symptoms
with subsequent vaginal delivery.
Advised 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 litigation
related 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 be
surveyed for symptoms of
anal incontinence
at postpartum follow-up .
Practice Practice recommendationsrecommendations
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