Obstetric Anal Sphincter Injury-Fouda

Click here to load reader

  • date post

    07-Apr-2018
  • Category

    Documents

  • view

    218
  • download

    0

Embed Size (px)

Transcript of Obstetric Anal Sphincter Injury-Fouda

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    1/36

    THE MANAGEMENT OFTHE MANAGEMENT OF

    OBSTETRIC ANALOBSTETRIC ANAL

    SPHINCTER INJURYSPHINCTER INJURY

    (EVIDENCE BASED)(EVIDENCE BASED)

    Dr. Ashraf Fouda

    Ob./Gyn. ConsultantOb./Gyn. Consultant

    Damietta General HospitalDamietta General Hospital

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    2/36

    Sources of Guidelines

    The Cochrane Library. Medline and PubMed .

    UpToDateAugust 2006 .August 2006 .

    RCOGRCOG March 2007, THE MANAGEMENT OF THIRD- AND

    FOURTH-DEGREE PERINEAL TEARS .

    RCOGRCOG June 2004 , METHODS AND MATERIALS USED INPERINEAL REPAIR .

    American Family Physician October 2003 .

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    3/36

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    4/36

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    5/36

    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

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    6/36

    The internal anal

    sphincter (IAS) is a

    thickened continuation

    of the circular smoot

    h

    muscle of the bowel.

    It contributes about

    70% of the resting

    pressure and is under

    autonomic control.

    Applied anatomy

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    7/36

    Obstetric anal sphincter injury

    includes both

    third- and fourth-degree

    perineal tears.

    IntroductionIntroduction

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    8/36

    The overall risk of

    obstetric anal sphincter injury is

    1% of all vaginal deliveries.

    This condition may also present inThis condition may also present in

    women without obvious analwomen without obvious analsphincter tears during labour andsphincter tears during labour and

    deliverydelivery (occult injury).(occult injury).

    IntroductionIntroduction

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    9/36

    Importance

    Anal incontinence is defined as any

    involuntary loss of faeces, flatus or urge

    incontinence that is adversely affectinga womans quality of life.

    Up to

    Up to 4

    040%%

    of women with

    third orof women wit

    hthird or

    fourth degree perineal tears duringfourth degree perineal tears during

    childbirth suffer from anal incontinence.childbirth suffer from anal incontinence.

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    10/36

    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% ofEAS thickness torn.

    3b: More than 50% ofEAS thickness torn.

    3c: BothEAS and IAS torn.

    Fourth degree Injury to perineum involving the anal

    sphincter complex and anal epithelium.

    Classification and terminology of perineal tears

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    11/36

    THIRD DEGREETHIRD DEGREE

    PERINEAL TEARPERINEAL TEAR

    FOURTHFOURTH--DEGREEDEGREE

    PERINEALTEARPERINEALTEAR

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    12/36

    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 analRisk factors for obstetric anal

    sphincter injurysphincter injury

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    13/36

    When episiotomy is indicated,

    the mediolateral technique

    is recommended,

    with careful attention to the

    angle cut away from the midline.

    Prediction and prevention ofPrediction and prevention ofobstetric anal sphincter injuryobstetric anal sphincter injury

    Grade B

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    14/36

    With introduction ofendoanal 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 ofPrediction and prevention ofobstetric anal sphincter injuryobstetric anal sphincter injury

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    15/36

    Normal anal ultrasound

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    16/36

    How can the identification of obstetricHow can the identification of obstetric

    anal sphincter injuries be improved?anal sphincter injuries be improved?

    All women having a vaginal delivery

    with

    evidence ofgenital tract traumashould be

    examinedsystematically

    to assess the severity of damage

    prior to suturing.

    Grade B

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    17/36

    Surgical techniques

    F

    or repair of the external anal sp

    hincter, eit

    her

    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 shouldbe conducted in an operating theatre, under

    regional or general anaesthesia.

    (Grade A)

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    18/36

    End-to-end(approximation) method Overlap technique

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    19/36

    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)

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    20/36

    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

    with

    out any tension

    Surgical techniquesSurgical techniques

    (Grade C)

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    21/36

    The use of absorbable synthetic material

    polyglactin 910 (vicryl) when compared with

    catgut, is associated withless :

    Perineal pain,

    Analgesic use,

    Dehiscence and Resuturing,

    but increased suture removal.

    Choice of suture materials

    (Grade A)

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    22/36

    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 removalwhen compared with standardabsorbable 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)

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    23/36

    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)

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    24/36

    Method of repair

    Aloose, continuous non-locking suturing

    for (vaginal tissue, perineal muscle and skin)

    & the use of a continuous subcuticular

    technique for perineal skin closure is

    associated withless short term pain than

    techniques employing interrupted sutures.

    (Grade A)

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    25/36

    SurgicalSurgical competencecompetence

    Obstetric anal sphincter repairshould 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)

  • 8/6/2019 Obstetric Anal Sphincter Injury-Fouda

    26/36

    Postoperative managementPostoperative management

    The use ofbroad-spectrum antibioticsis recommended to reduce the incidence

    of postoperative infections and wound

    dehiscence.

    The use ofpostoperative laxatives

    is recommended to reduce the incidence

    of postoperative wound dehiscence.

    (good practice point)

    (