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Obstetric Anal Sphincter Injuries

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Principles and Practice of Urogynaecology
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Abstract

Care during vaginal birth has vastly improved over the last two decades. However, more than 85 % of women sustain various degrees of perineal trauma during vaginal delivery in the UK. The incidence of severe perineal trauma varies between 0.5 and 3 % in Europe and 6–9 % in the USA. Recent years have witnessed a gradual increase in the incidence with a recent survey in the UK revealing rates as high as 8 %. Though the prevalence of perineal trauma in India is not really known and is impacted by variations in obstetric practice, including episiotomy rates, it is unlikely that the numbers in India are any different. Even more worrying is the fact that sphincter injuries are most often missed clinically at the time of delivery. The aim of this chapter is to provide a comprehensive review of this very important topic including discussion of the risk factors, diagnosis, and evidence in the management of obstetric anal sphincter injuries (OASIS).

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References

  1. McCandlish R, Bowler U, van Asten H, et al. A randomized controlled trial of care of the perineum during second stage of normal labour. Br J Obstet Gynaecol. 1998;105:1262–72.

    Article  CAS  PubMed  Google Scholar 

  2. Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal sphincter disruption during vaginal delivery. N Engl J Med. 1993;329(26):1905–11.

    Article  CAS  PubMed  Google Scholar 

  3. Handa VL, Danielsen BH, Gilbert WM. Obstetric anal sphincter lacerations. Obstet Gynecol. 2001;98:225–30.

    Article  CAS  PubMed  Google Scholar 

  4. Naidu M, Sultan AH, Thakar R. Reducing obstetric anal sphincter injuries using perineal support: a preliminary experience. Int Urogynecol J. 2014;25(9 Suppl 1):S19.

    Google Scholar 

  5. Fowler GE. Obstetric anal sphincter injury. J Assoc Chartered Physiother Womens Health. 2009;104:12–9.

    Google Scholar 

  6. MacArthur C, Bick DE, Keighley MRB. Fecal incontinence after childbirth. Br J Obstet Gynaecol. 1997;104(1):46–50.

    Article  CAS  PubMed  Google Scholar 

  7. Chaliha C, Sultan AH, Bland JM, Monga AK, Stanton SL. Anal function: effect of pregnancy and delivery. Am J Obstet Gynecol. 2001;185(2):427–32.

    Article  CAS  PubMed  Google Scholar 

  8. Fernando RJ, Sultan AH, Radley S, Jones PW, Johanson RB. Management of obstetric anal sphincter injury: a systematic review & national practice survey. BMC Health Serv Res. 2, No. 1, 2002: 9.

    Google Scholar 

  9. Donnelly VS, Fynes M, Campbell DM, et al. Obstetric events leading to anal sphincter damage. Obstet Gynecol. 1998;92:955–61.

    Article  CAS  PubMed  Google Scholar 

  10. Institute of Obstetricians and Gynaecologists and Directorate of Clinical Strategy and Programmes, Health Service Executive. Royal College of Physicians of Ireland. Clinical Practice Guideline. Management of obstetric anal sphincter injury. Version 1. Guideline No. 8. Date of publication: Apr 2012. Revised April 2014.

    Google Scholar 

  11. Haadem K, Ohrlander S, Lingman G. Long-term ailments due to anal sphincter rupture caused by delivery – a hidden problem. Eur J Obstet Gynecol Reprod Biol. 1998;27(1):27–32.

    Article  Google Scholar 

  12. Crawford LA, Quint EH, Pearl ML, DeLancey JO. Incontinence following rupture of the anal sphincter during delivery. Obstet Gynecol. 1993;82(4, Pt 1):527–31.

    CAS  PubMed  Google Scholar 

  13. Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. Br Med J. 1994;308(6933):887–91.

    Article  CAS  Google Scholar 

  14. Walsh CJ, Mooney EF, Upton GJ, Motson RW. Incidence of third-degree perineal tears in labour and outcome after primary repair. Br J Surg. 1996;83(2):218–21.

    Article  CAS  PubMed  Google Scholar 

  15. Fernando RJ, Sultan AH, Radley S, Jones PW, Johanson RB. Management of obstetric anal sphincter injury: a systematic review and national practice survey. BMC Health Serv Res. 2002;2(1):9.

    Article  PubMed Central  PubMed  Google Scholar 

  16. Sultan AH, Thakar R. Lower genital tract and anal sphincter trauma. Best Pract Res Clin Obstet Gynaecol. 2002;16:99–116.

    Article  PubMed  Google Scholar 

  17. Royal College of Obstetricians and Gynaecologists (RCOG). Management of third- and fourth- degree perineal tears following vaginal delivery, RCOG guideline, vol. 29. London: RCOG Press; 2001.

    Google Scholar 

  18. Norton C, Christiansen J, Butler U, et al. Anal incontinence. In: Abrams P, Cardozo L, Khoury S, Wein A, editors. Incontinence: 2nd international consultation on incontinence. 2nd ed. Plymouth: Health Books; 2002. p. 985–1043.

    Google Scholar 

  19. Varma A, Gunn J, Gardiner A, et al. Obstetric anal sphincter injury: prospective evaluation of incidence. [Invited editorial]. Dis Colon Rectum. 1999;42(12):1537–43.

    Article  CAS  PubMed  Google Scholar 

  20. Faltin DL, Boulvain M, Irion O, et al. Diagnosis of anal sphincter tears by postpartum endosonography to predict fecal incontinence. Obstet Gynecol. 2000;95(5):643–7.

    Article  CAS  PubMed  Google Scholar 

  21. Andrews V, Sultan AH, Thakar R, Jones PW. Occult anal sphincter injuries – myth or reality? BJOG. 2006;113(2):195–200.

    Article  PubMed  Google Scholar 

  22. Adams EJ, Bricker L, Richmond DH, Neilson JP. Systematic review of third degree tears: risk factors. Int Urogynecol J Pelvic Floor Dysfunct. 2001;12 Suppl 3:12.

    Google Scholar 

  23. Coats PM, Chan KK, Wilkins M, Beard RJ. A comparison between midline and mediolateral episiotomies. Br J Obstet Gynaecol. 1980;87(5):408–12.

    Article  CAS  PubMed  Google Scholar 

  24. Signorello LB, Harlow BL, Chekos AK, Repke JT. Midline episiotomy and anal incontinence: retrospective cohort study. Br Med J. 2000;320(7227):86–90.

    Article  CAS  Google Scholar 

  25. Bavel JV, De Vries L, Vogel JD, Hukkelhoven CW, Gietelink DA, Mol BW, De Leeuw JW, Papatsonis DN. Does medio-lateral episiotomy during operative vaginal delivery decrease the risk of obstetric anal sphincter injuries? – A ten year analysis of a national registry. Int Urogynecol J. 2014;25 Suppl 1:S20.

    Google Scholar 

  26. Williams A, Tincello DG, White S, et al. Risk scoring system for prediction of obstetric anal sphincter injury. BJOG. 2005;112(8):1066–9.

    Article  PubMed  Google Scholar 

  27. Laine K, Gissler M, Pirhonen J. Changing incidence of anal sphincter tears in four Nordic countries through the last decades. Eur J Obstet Gynecol Reprod Biol. 2009;146:71–5.

    Article  PubMed  Google Scholar 

  28. Hals E, Pirhonene T, Gissler M, Hjelle S, Nilsen EB, et al. A multicenter interventional program to reduce the incidence of anal sphincter tears. Obstet Gynecol. 2010;116(4):901–8.

    Article  PubMed  Google Scholar 

  29. Stedenfeldt M, Oian P, Gissler M, Blix E, Pirhonene J. Risk factors for obstetric anal sphincter injury after a successful multicenter interventional programme. BJOG. 2014;121(1):83–91.

    Article  CAS  PubMed  Google Scholar 

  30. Royal College of Obstetricians and Gynaecologists (RCOG). The management of third- and fourth- degree perineal tears, RCOG guideline, vol. 29 (revised). London: RCOG Press; 2007.

    Google Scholar 

  31. Fernando RJ, Sultan AH, Kettle C, Thakar R, Radley S. Methods of repair for obstetric anal sphincter injury. Cochrane Database Syst Rev. 2006; Issue 3. Art. No.: CD002866. doi:10.1002/14651858.CD002866.pub2.

  32. Sultan AH, Monga AK, Kumar D, Stanton SL. Primary repair of obstetric anal sphincter rupture using the overlap technique. Br J Obstet Gynaecol. 1999;106(4):318–23.

    Article  CAS  PubMed  Google Scholar 

  33. Fitzpatrick M, Behan M, O’Connell PR, O’Herlihy C. A randomized clinical trial comparing primary overlap with approximation repair of third-degree obstetric tears. Am J Obstet Gynecol. 2000;183(5):1220–4.

    Article  CAS  PubMed  Google Scholar 

  34. Williams A, Adams EJ, Tincello DG, et al. How to repair an anal sphincter injury after vaginal delivery: results of a randomised controlled trial. BJOG. 2006;113(2):201–7.

    Article  PubMed  Google Scholar 

  35. Garcia V, Rodgers RG, Kim SS, Hall RJ, Kammerer-Doak DN. Primary repair of obstetric anal sphincter laceration: a randomized trial of two surgical techniques. Am J Obstet Gynecol. 2005;192(5):1697–701.

    Article  PubMed  Google Scholar 

  36. Fernando RJ, Sultan AH, Kettle C, et al. Repair techniques for obstetric anal sphincter injuries: a randomized controlled trial. Obstet Gynecol. 2006;107(6):1261–8.

    Article  PubMed  Google Scholar 

  37. Thakar R, Sultan AH. Management of obstetric anal sphincter injury. Obstet Gynecol. 2003;5:72–8.

    Article  Google Scholar 

  38. Thakar R, Sultan AH, Fernando R, Monga A, Saton S. Can workshops on obstetric anal sphincter rupture change practice? Int Urogynecol J Pelvic Floor Dysfunct. 2001;12 Suppl 1:S5.

    Google Scholar 

  39. Dodd JM, Hedayati H, Pearce E. Rectal analgesia for the relief of perineal pain after childbirth: a randomised controlled trial of diclofenac suppositories. Br J Obstet Gynaecol. 2004;111:1059–64.

    Article  CAS  Google Scholar 

  40. Fynes M, Donnelly VS, Behan M, O’Connell PR, O’ Hcrlihy C. Effect of second vaginal delivery and anorectal physiology and faecal incontinence: a prospective study. Lancet. 1999;354:983–6.

    Article  CAS  PubMed  Google Scholar 

  41. Sultan AH, Abulafi MA. Anal incontinence – the role of the obstetrician and gynaecologist. In: Sturdee D, Olah K, Keane D, editors. The yearbook of obstetrics and gynecology, vol. 9. London: RCOG Press; 2001. p. 170–87.

    Google Scholar 

  42. Bugg GJ, Kiff ES, Hosker G. A new condition-specific health-related quality of life questionnaire for the assessment of women with anal incontinence. BJOG. 2001;108:1057–67.

    Google Scholar 

  43. Harkin R, Fitzpatrick M, O’Connell PR, O’Herlihy C. Anal sphincter disruption at vaginal delivery: is recurrence predictable? Eur J Obstet Gynecol Reprod Biol. 2003;109:149–52.

    Article  PubMed  Google Scholar 

  44. Elfaghi I, Johansson–Ernste B, Rydhstroem H. Rupture of the sphincter ani: the recurrence rate in second delivery. BJOG. 2004;111:1361–4.

    Article  PubMed  Google Scholar 

  45. Spydslaug A, Trogstad LI, Skrondal A, Eskild A. Recurrent risk of anal sphincter laceration among women with vaginal deliveries. Obstet Gynecol. 2005;105:307–13.

    Article  PubMed  Google Scholar 

  46. Bek KM, Laurberg S. Intervention during labour: risk factors associated with complete tear of the anal sphincter. Acta Obstet Gynecol Scand. 1992;71(7):520–4.

    Article  Google Scholar 

  47. Fynes M, Donnelly VS, O’Connell PR, O’Herlihy C. Cesarean delivery and anal sphincter injury. Obstet Gynecol. 1998;92(4, Pt 1):496–500.

    Article  CAS  PubMed  Google Scholar 

  48. Poen AC, Felt-Bersma RJF, Strijers RLM, et al. Third-degree obstetric perineal tear: long-term clinical and functional results after primary repair. Br J Surg. 1998;85(10):1433–8.

    Article  CAS  PubMed  Google Scholar 

  49. Tetzschner T, Sørensen M, Lose G, Christiansen J. Anal and urinary incontinence in women with obstetric anal sphincter rupture. Br J Obstet Gynaecol. 1996;103(10):1034–40.

    Article  CAS  PubMed  Google Scholar 

  50. Edozien LC, Gurol-Urganci I, Cromwell DA, Adams EJ, Richmond DH, Mahmood TA, van der Meulen JH. Impact of third- and fourth-degree perineal tears at first birth on subsequent pregnancy outcomes: a cohort study. BJOG. 2014. doi:10.1111/1471-0528.12886.

    Google Scholar 

  51. Mant J, Painter R, Vessey M. Epidemiology of genital prolapse: observations from the Oxford Family Planning Association Study. Br J Obstet Gynaecol. 1997;104:579–85.

    Article  CAS  PubMed  Google Scholar 

  52. Rortveit G, Hannestad YS, Daltveit AK, Hunskaar S. Age- and type-dependent effects of parity on urinary incontinence: the Norwegian EPINCONT study. Obstet Gynecol. 2001;98:1004–10.

    Article  CAS  PubMed  Google Scholar 

  53. Dietz HP, Lanzarone V. Levator trauma after vaginal delivery. Obstet Gynecol. 2005;106(4):707–12.

    Article  PubMed  Google Scholar 

  54. Otcenasek M, Krofta L, Baca V, Grill R, Kucera E, Herman H, et al. Bilateral avulsion of the puborectal muscle: magnetic resonance imaging- based three-dimensional reconstruction and comparison with a model of a healthy nulliparous woman. Ultrasound Obstet Gynecol. 2007;29:692–6.

    Article  CAS  PubMed  Google Scholar 

  55. DeLancey J, Morgan D, Fenner D, Kearney R, Guire K, Miller JM, et al. Comparison of levator ani muscle defects and function in women with and without pelvic organ prolapse. Obstet Gynecol. 2007;109:295–302.

    Article  PubMed  Google Scholar 

  56. Dietz HP, Steensma AB. The prevalence of major abnormalities of the levator ani in urogynaecological patients. BJOG. 2006;113:225–30.

    Article  CAS  PubMed  Google Scholar 

  57. Rostaminia G, White D, Hegde A, Quiroz L, Davila GW, Shobeiri A. Levator ani deficiency and pelvic organ prolapse severity. Obstet Gynecol. 2013;121(5):1017–24.

    Article  PubMed  Google Scholar 

  58. Adekanmi OA, Freeman RM, Jackson SA, Puckett M, Bombieri L, Waterfield MR. Do the anatomical defects associated with cystocele affect the outcome of the anterior repair? A clinical and radiological study. Int Urogynecol J Pelvic Floor Dysfunct. 2009;20(11):1369–77.

    Article  PubMed  Google Scholar 

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Correspondence to Aparna Hegde .

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Hegde, A. (2015). Obstetric Anal Sphincter Injuries. In: Tamilselvi, A., Rane, A. (eds) Principles and Practice of Urogynaecology. Springer, New Delhi. https://doi.org/10.1007/978-81-322-1692-6_17

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  • DOI: https://doi.org/10.1007/978-81-322-1692-6_17

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