Episiotomy and severe perineal lacerations Forceps Delivery

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					Obstetric Anal sphincter injury:
risk factors, prevention and

           Vani Dandolu MD
 Director, Division of Urogynecology,
     Temple University Hospital,
           Philadelphia, PA
Examine the factors that predispose to anal
sphincter injury at vaginal delivery
Describe evidence based strategies to
prevent such injury
Optimal technique of repair and post-partum
Identify the long term consequences of anal
sphincter lacerations
Categories of Perineal and
   Vaginal Laceration
First degree: skin and mucosa only
Second 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 mucosa
and usually transects the anal sphincter
Perineal lacerations are common, seen
in upto 80% of deliveries
 Clinical injury to anal sphincter in 0.6-
9% of vaginal deliveries

Occult injury by endoanal ultrasound in
a third of vaginal deliveries
Anal-Sphincter Disruption During
       Vaginal 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
 Risk factors for OASI
Nulliparity,                    B
Occipito posterior position     B
Fetal macrosomia                B
Short perineal body             B
Asian race                      B
Induction of labor              B
Instrumental vaginal delivery   A
  Forceps vs vacuum
Episiotomy ? Midline vs mediolateral AB
Episiotomy and anal
sphincter laceration
Episiotomy is an incision into the perineal
body made during the second stage of labor
to facilitate delivery

   increase the diameter of the soft tissue
  pelvic outlet and facilitate delivery
  Prophylactic versus
     in cases of arrested or protracted descent,
    in association with an instrumental delivery, or
     to expedite delivery in the setting of fetal heart
    rate abnormalities

Use of prophylactic episiotomy is
widely debated
     Reasons for
prophylactic episiotomy
Substitution of a straight surgical incision for a
ragged spontaneous laceration
   Ease of repair and improved wound healing
Reduction in the duration of the second stage
Reduction in third and fourth degree tears
Less neonatal trauma
   premature infant (soft cranium) or
   macrosomic infant (shoulder dystocia)
Pelvic floor protection
       Role of episiotomy
Subnsequently several reports have
implicated routine episiotomy in the genesis
of major perineal and anal sphincter tears
        Myers-Helfgott M, Obstet Gynecol Clin North Am
        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
      Cochrane review
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,
      urinary incontinence, and
      several measures of pain.
   Restrictive (27%) and liberal (72%)
 Mediolateral --Dutch
284,783 vaginal deliveries in 1994 and
1995 from Dutch National Obstetric
OASI 1.94%

  Mediolateral episiotomy strongly protective
  OR: 0.21, 95% CI: 0.20-0.23
  Midline OR (0.81 small numbers)
 Episiotomy and OASI
Midline episiotomy increases the risk of
anal sphincter injury
Mediolateral episiotomy in indicated
cases may be protective
Prevention strategies
Operative vaginal delivery
  Forceps delivery is associated with more
  perineal trauma than vacuum
 Prevention strategies
Perineal massage
Birthing position
Whirlpool baths
Flexion of head
Perineal protection
Minimizing pushing to slow delivery of head
Repair of third or fourth
  degree laceration
Rectal mucosa with continuous 3-0 vicryl
IAS or perirectal fascia
  2-0 PDS
  incorporate the capsule
  Usually one end retracted
  Side to side versus overlapping technique
  3-4 figure of eight sutures
Failure of primary repair
Persistence anal incontinence in 30%, fecal
urgency in 25% and persistent occult defects
in the sphincter in 80% by endoanal

Overlap versus side to side technique
Suture material
Incorporation of IAS
Residual defects
Postpartum Defect of the External Anal Sphincter
by Anal Endosonography
Postpartum Defect of the Internal Anal Sphincter
by Anal Endosonography
Recognition of obstetric anal
     sphincter injury
All women having a vaginal delivery
     systematic examination of the perineum,
    vagina and rectum to assess the severity of
    damage prior to suturing.
All women having instrumental delivery
or who have extensive perineal injury
    examined by an experienced obstetrician,
    trained in the recognition and management of
    perineal tears.
    Method of repair
Currently there is no reliable
evidence to show that the overlap
method is superior to the end-to-end
(approximation) method.
   Mode of repair of obstetric
       sphincter injury
Most primary repairs are performed by end-to-end
approximation of the torn anal sphincter ends
  relative simplicity
Colorectal surgeons favor overlapping of the
sphincter muscles – secondary or delayed
No difference in outcome
     Fitzpatrick et al Eur J Obstet Gynecol 2000
Overlap technique superior
     Sultan et al . Br J Obstet Gynaecol 1999
A randomized clinical trial comparing primary
     overlap with approximation repair

55 women overlap procedure, and 57
Outcome after primary repair was

Fitzgerald M; Am J Obstet Gynecol
    Method of repair
Repair in an operating theatre, under
regional or general anesthesia is
likely to be associated with improved
      Suture material
The use of monofilament sutures such
as PDS compared to catgut or vicryl, is
associated with less infection and better
long-term function of the anal sphincter

Catgut no longer available in UK
  Skill of the operator
Residents in-training need specific
instruction about the repair of third-
and fourth degree tears.
Surgical skills workshops needed with
the use of models and audiovisual
Episiotomy Suturing
Antibiotics intra-op and postop are
 associated with less post-operative
 infection and wound dehiscence.
 The use of postoperative laxatives is
 associated with less postoperative
 wound dehiscence.
Follow-up at 6–12 months by a
  gynaecologist with an interest in anorectal
  dysfunction or a colorectal surgeon.

If symptomatic, they should be offered
  endoanal ultrasonography and anorectal
  manometry and consideration of
  secondary sphincter repair.
    Counseling about
   subsequent delivery
Subsequent vaginal delivery may worsen anal incontinence

Counselled regarding the risk of developing anal
incontinence or worsening symptoms with subsequent
vaginal delivery.

If symptomatic or with abnormal endoanal ultrasonography
or manometry, the option of elective caesarean section
should be discussed.

If asymptomatic, there is no clear evidence as to the best
mode of delivery.
Document clearly the anatomical
structures involved, the method of repair
and suture materials used.
Inform about the nature of the injury and
importance of subsequent follow-up.
Anal incontinence and child
 birth- mechanism of injury
External anal sphincter demonstrates evidence of
denervation 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
Recommendations for
Monitor the use of agreed definition of
severity and degree of injury
The rate of third- and fourth-degree
The proportion repaired in theatre, type
of analgesia, suture material and
method of repair
The presence of attending
Recommendations for
Adequate note-keeping and counselling
The proportion seen for follow-up
postnatally (with symptom
questionnaire) and
The percentage continence rate
following primary repair
Risk factors for anal
sphincter lacerations in
Pennsylvania and risk of
recurrence in subsequent

                  Vani Dandolu MD
                 Assistant Professor
Division of Urogynecology and Pelvic Reconstructive
    Temple University Hospital, Philadelphia, PA
Identify the incidence of anal sphincter
Risk of recurrence in subsequent
pregnancies, and
Analyze risk factors associated with this
Obtained data from Pennsylvania state
inpatient database (PHC4) regarding all
cases of third and fourth degree perineal
lacerations that occurred during a two-year
period from January 1990 to December 1991
All subsequent pregnancies over the next ten
years were identified and risk of recurrence of
laceration was analyzed
There were a total of 168,337deliveries
in 1990 and 165,051 deliveries in 1991.
22.5% (n=74881) deliveries were by
cesarean section and were excluded
from analysis.
Out of the remaining 258,507 deliveries,
incidence of third and fourth degree
lacerations was 7.31% (n=18,888).
Instrumental vaginal delivery particularly with
use of episiotomy increased the risk of
laceration 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 instrumental
delivery had an odds of 0.9.
In the next ten years there were 16152
deliveries in the group with prior
lacerations, out of which 1162 were
cesarean sections.
Among 14990 subsequent vaginal
deliveries, 864 (5.76%) had a
recurrence of third or fourth degree
Rate of recurrent lacerations (5.76%) is
significantly lower than the 7.3% rate for
initial lacerations (OR 0.78 CI 0.72-
 In the group with recurrent lacerations
also instrumental vaginal delivery was
associated with a greater than two fold
increase in the risk of sphincter tears.
This is the largest study so far looking at risk of
recurrence of anal sphincter lacerations.
Prior anal sphincter laceration does not appear to be
a significant risk factor for recurrence of laceration.
Operative vaginal delivery particularly with episiotomy
is associated with a two to four fold increase in the
risk 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 anal
sphincter laceration.
Year     C/s       episiotomyforceps 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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