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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

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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 .

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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 smoot

h

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 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

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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.

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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% 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

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THIRD DEGREETHIRD DEGREE

PERINEAL TEARPERINEAL TEAR

FOURTHFOURTH--DEGREEDEGREE

PERINEALTEARPERINEALTEAR

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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 analRisk 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 ofPrediction and prevention ofobstetric anal sphincter injuryobstetric anal sphincter injury

Grade B

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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

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Normal anal ultrasound

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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

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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)

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End-to-end(approximation) method Overlap 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

with

out 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 withless :

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 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)

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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

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)

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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)

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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)

(