Obstetrical Anal Sphincter Injuries (OASIS): Prevention, Recognition, and Repair

A Postpartum Perineal Clinic in Nova Scotia: Characteristics Associated With Attendance and Its Association With Recurrent Obstetrical Anal Sphincter Tears

OBJECTIVES

The Healthy Recovery after Childbirth Clinic (HRCC) in Nova Scotia provides postpartum care to patients who experience obstetric anal sphincter injuries (OASIS). The purpose of this study was to describe characteristics associated with HRCC attendance, characteristics associated with a trial of labour in a subsequent delivery, and OASIS recurrence by HRCC attendance status.

METHODS

A retrospective cohort study using the Atlee Perinatal Database and clinical record review included primiparous individuals who sustained an OASIS at IWK Health in Halifax between 2013 and 2020. The χ2 and Fisher exact tests were performed to compare groups.

RESULTS

Of the 1041 individuals included, 67% attended HRCC. Attendance increased from 58% in 2013-2015 to 77% in 2019-2020. Younger age (<25 years) and smoking were associated with lower HRCC attendance (P = 0.07 and <0.01, respectively). Other characteristics, including area-level income and driving distance to HRCC, were not associated with attendance (P > 0.05). Of the 439 individuals who had a subsequent delivery, 92% had a trial of labour. Individuals with fourth-degree injury were less likely to attempt a trial of labour than those with third-degree injury (73% vs. 94%, P < 0.01). Of those who delivered vaginally, OASIS recurrence was similar in those who did and did not attend the HRCC (7.5% vs. 6.5%, P = 0.84).

CONCLUSIONS

HRCC attendance was high, but the disparity by age and smoking status suggests some barriers to access that should be explored. Although we found no difference in OASIS recurrence by HRCC attendance, more research with larger samples with adjustment for confounders is needed.

Incidence of obstetric anal sphincter injuries according to the type of forceps used in the Mexican population

OBJECTIVE

This study describes the frequency of obstetric anal sphincter injuries (OASIS) in patients after instrumental delivery according to the type of forceps used.

METHODS

A retrospective comparative cohort study was conducted on patients who underwent instrumental delivery from January 2017 to April 2022. The primary outcome was the presence of OASIS following delivery. Patients were categorized into Cohort A if only rotation forceps were used, Cohort B for only traction forceps, and Cohort C if both types were used sequentially. Statistical analysis was performed with SPSS (IBM, New York, NY) with χ2, Fisher's exact, and analysis of variance testing. A P-value <0.05 was considered significant.

RESULTS

OASIS occurred in 45 of 328 instrumental deliveries. OASIS after rotation forceps occurred in 12.9% (n = 8) of cases, after traction forceps in 13.2% (n = 34), and after sequential use of rotation and traction forceps in 37.5% (n = 3) of cases (p = 0.141). An odds ratio (OR) of 0.91 (95% confidence interval [CI] 0.40-2.08) for OASIS was obtained with the use of rotation forceps, 0.81 (95% CI 0.38-1.70) for traction forceps, and 3.97 (95% CI 0.91-17.2) for the sequential use of rotation and traction forceps.

CONCLUSION

There were no significant differences in the presence of OASIS comparing traction and rotation forceps. A non-significant trend of higher OASIS following the sequential use of traction and rotation forceps was observed.

Perineal injuries during vaginal birth in low-resource countries

Birth related perineal trauma (BRPT) and obstetric anal sphincter injuries (OASIS) are leading causes of anal incontinence in women, which negatively impacts on their quality of life, resulting in low self-esteem and abandonment. In low resource countries (LRC), the true incidence is not known and since most births are unattended or occur in community-based health care systems, one can anticipate that it is a significant problem. Dissemination of information to women, education of traditional birth attendants, improvement of resources and transport, and training of health professionals on the detection and appropriate surgical management of these injuries will reduce morbidity and improve outcome. Intrapartum measures such as controlled head descent and perineal support, correct episiotomy techniques and selective use of instruments to assist vaginal births is pivotal in avoiding these injuries. Policy makers should prioritize maternity care in LRC, and research is urgently needed to address all aspects of BRPT.

Variation in Episiotomy Use Among Nulliparous Individuals by Maternity Care Provider and Associated Rates of Obstetric Anal Sphincter Injury

OBJECTIVES

To quantify variation in the association between episiotomy and obstetric anal sphincter injury (OASI) by maternity care provider in spontaneous and operative vaginal deliveries (SVDs and OVDs).

METHODS

Population-based retrospective cohort study of vaginal, term deliveries among nullipara in Canada (2004-2015). Adjusted rate ratios (ARRs) and 95% CIs were estimated using log-binomial regression to quantify the associations between episiotomy and OASI, stratified by care provider (obstetrician [OB], family physician [FP], or registered midwife [RM]) while adjusting for potential confounders.

RESULTS

The study included 631 642 deliveries. Episiotomy use varied by provider: among SVDs, the episiotomy rate was 19.6%, 14.4%, and 8.4% in the OB, FP, and RM groups, respectively. The rate of OASI was higher among SVDs with versus without episiotomy (5.8% vs 4.6%). Conversely, OASI occurred less frequently in operative vaginal deliveries with episiotomy (15.3%) compared with those without (16.7%). In all provider groups, the ARR for OASI was increased with episiotomy in SVD and decreased with episiotomy with forceps delivery. No differences in these associations were observed by provider except among vacuum delivery (ARR with episiotomy vs. without, OB: 0.88, 95% CI 0.84-0.92; FP: 0.89, 95% CI 0.83-0.96, RM: 1.22, 95% CI 1.02-1.48).

CONCLUSIONS

In nullipara, irrespective of maternity care provider, there is a positive association between episiotomy and OASI among SVDs and an inverse association between episiotomy and deliveries with forceps. The relationship between episiotomy and OASI is modified by maternity care providers among vacuum deliveries.

Irritable bowel syndrome worsens faecal incontinence after primary repair of major obstetric anal sphincter injuries

AIM

Obstetric anal sphincter injuries (OASIS) occur in approximately 3%-6% of vaginal deliveries and are the leading risk factor for late-onset faecal incontinence, which is an underdiagnosed pathology. The aim of this work was to use a validated scoring system to quantify the effect of irritable bowel syndrome (IBS) on the severity of faecal incontinence symptoms after primary repair of major OASIS (Grade IIIb-IV).

METHOD

A prospective cohort study was performed on all women who underwent primary repair of major OASIS over a 6-year period. They were assessed with ultrasonography within 12 weeks. Two control groups (who did not have OASIS) were women who underwent elective caesarean section and primigravid women. Questionnaires were sent at least 12 months after delivery, or at first consultation for primigravids, which generated the main outcome measures: Cleveland Clinic faecal incontinence severity scores and the presence of IBS based on Rome III criteria.

RESULTS

There was a total of 211 patients included in the three groups and the mean follow-up time was 26 months after sphincter repair. Ultrasonographic sphincter defects were detected in 37% but did not affect the faecal incontinence score (p = 0.47), except in patients with IBS. Within each group, patients with IBS had significantly worse faecal incontinence than those without. Women with both OASIS and IBS had the most severe faecal incontinence scores.

CONCLUSION

OASIS has a limited negative effect on faecal incontinence, independent of whether residual ultrasonographic sphincter defects are present. However, the presence of IBS has a significant compounding effect on faecal incontinence in OASIS patients. The effect of IBS on faecal incontinence is also notable in caesarean section patients and primigravids, suggesting that IBS is an independent risk-factor that should have its place in predelivery assessment and counselling.

Repair of episiotomy and obstetrical perineal lacerations (first-fourth)

Perineal injury after vaginal delivery is common, affecting up to 90% of women. Perineal trauma is associated with both short- and long-term morbidity, including persistent pain, dyspareunia, pelvic floor disorders, and depression, and may negatively affect a new mother's ability to care for her newborn. The morbidity experienced after perineal injury is dependent on the type of laceration incurred, the technique and materials used for repair, and the skill and knowledge of the birth attendant. After all vaginal deliveries, a systematic evaluation including visual inspection and vaginal, perineal, and rectal exams is recommended to accurately diagnose perineal lacerations. Optimal management of perineal trauma after vaginal birth includes accurate diagnosis, appropriate technique and materials used for repair, providers experienced in perineal laceration repair, and close follow-up. In this article, we review the prevalence, classification, diagnosis, and evidence supporting different closure methods for first- through fourth-degree perineal lacerations and episiotomies. Recommended surgical techniques and materials for different perineal laceration repairs are provided. Finally, best practices for perioperative and postoperative care after advanced perineal trauma are reviewed.

Comparison of etiological and physiological characteristics of fecal incontinence in men and women

Fecal incontinence (FI) is often underreported and underestimated in men. Our aims were to clarify the causes and the physiological characteristics of FI in men and to underline the differences between etiological and physiological factors in men and women diagnosed with FI. The study cohort encompassed 200 men and 200 women who underwent anatomical and physiological evaluation for FI in a tertiary referral center specializing in pelvic floor disorders. All patients underwent endoanal ultrasound and anorectal manometry. Evacuation proctography was performed in some patients. Demographic, medical, anatomical, and physiological parameters were compared between the two study groups. Urge incontinence was the most frequent type of FI in both genders. In men, anal fistula, history of anal surgeries, rectal tumors, and pelvic radiotherapy were common etiologic factors, whereas history of pelvic surgeries was more common in women. Associated urinary incontinence was reported more frequently by women. External anal sphincter defects, usually anterior, were more common in women (M: 1.5%, F: 24%, P < 0.0001), whereas internal anal sphincter defect prevalence was similar in men and women (M: 6%, F: 12%, P = 0.19). Decreased resting and squeeze pressures were less common in men (M: 29%, F: 46%, P < 0.0001: M: 44%, F: 66%, P < 0.0001). The incidence of rectal hyposensitivity was higher in men (M: 11.1%, F: 2.8%, P < 0.0001), whereas rectal hypersensitivity was higher in women (M: 5.8%, F: 10.8%, P < 0.0001). Anorectal dyssynergia was more common in men (M: 66%, F: 37%, P < 0.0001). Significantly different etiological factors and physiological characteristics for FI were found in men. Acknowledging these differences is significant and may yield better treatment options.NEW & NOTEWORTHY Fecal incontinence (FI) in men has different etiological factors when compared with women. The prevalence of internal anal sphincter defect among men with FI was similar to women. Different manometric measurements were found among men with FI: decreased anal pressures were less common among men, whereas rectal hyposensitivity and anorectal dyssynergia were more common among men.

Anal incontinence after obstetrical anal sphincter injury significantly impacts quality of life for women: a cohort study

PURPOSE

To assess the prevalence of anal incontinence (AI) after obstetrical anal sphincter injuries (OASIS) and its severity, as well as the risk factors for AI and AI episodes ≥ 6 months.

METHODS

This prospective and observational monocentric cohort study included all the women who had an OASIS between 1 January 2005 and 31 December 2019. Information was collected by using a letter informing for the fecal incontinence quality of life (FIQL) questionnaire and by a phone interview. The main outcome measure was "1 passed or ongoing episode of AI".

RESULTS

Among the 227 patients included, 19.8% had ongoing AI, and 35.2% had AI passed or ongoing episodes. A total of 46.7% of women with AI reported a change in their quality of life in all fields of the FIQL. Excluding a history of inflammatory bowel disease, no factor was associated with the incidence of an AI episode. Post-obstetrical AI ≥ 6 months (POAI ≥ 6) represented 63.7% of AI cases. This incontinence began with significant incidence in the immediate postpartum period but increased over time, unlike AI < 6 months, which appeared primarily in the immediate postpartum period. Instrumental birth was a protective factor for POAI ≥ 6 (OR = 0.24; CI 95% [0.08-0.78]; p = 0.016), while an increase in parity and BMI were risk factors for POAI ≥ 6 (OR = 4.21; CI 95% [1.01-17.71]; p = 0.05 and OR = 1.15; CI 95% [1.03-1.30]; p = 0.016, respectively).

CONCLUSION

The prevalence of AI after OASIS is not underestimated. Despite the fact that women do not seek care, the impact of AI on the quality of life is significant. A case of AI that lasts for 6 months after giving birth risks becoming chronic. Therefore, specialist advice should be recommended in this case.

CLINICAL TRIAL REGISTRY

NCT04940494.

Asian-White disparities in obstetric anal sphincter injury: a systematic review and meta-analysis

OBJECTIVE

Obstetrical anal sphincter injury describes a severe injury to the perineum and perianal muscles after birth. Obstetrical anal sphincter injury occurs in approximately 4.4% of vaginal births in the United States; however, racial and ethnic inequities in the incidence of obstetrical anal sphincter injury have been shown in several high-income countries. Specifically, an increased risk of obstetrical anal sphincter injury in individuals who identify as Asian vs those who identify as White has been documented among residents of the United States, Australia, Canada, Western Europe, and the Scandinavian countries. The high rates of obstetrical anal sphincter injury among the Asian diaspora in these countries are higher than obstetrical anal sphincter injury rates reported among Asian populations residing in Asia. A systematic review and meta-analysis of studies in high-income, non-Asian countries was conducted to further evaluate this relationship.

DATA SOURCES

MEDLINE, Ovid, Embase, EmCare, and the Cochrane databases were searched from inception to March 2023 for original research studies.

STUDY ELIGIBILITY CRITERIA

Observational studies using keywords and controlled vocabulary terms related to race, ethnicity and obstetrical anal sphincter injury. All observational studies, including cross-sectional, case-control, and cohort were included. 2 reviewers followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and the Meta-analysis of Observational Studies in Epidemiology recommendations.

METHODS

Meta-analysis was performed using RevMan (version 5.4; Cochrane Collaboration, London, United Kingdom) for dichotomous data using the random effects model and the odds ratios as effect measures with 95% confidence intervals. Subgroup analysis was performed among Asian subgroups. The risk of bias was assessed using the Joanna Briggs Institute Critical Appraisal tools. Meta-regression was used to determine sources of between-study heterogeneity.

Results

A total of 27 studies conducted in 7 countries met the inclusion criteria encompassing 2,337,803 individuals. The pooled incidence of obstetrical anal sphincter injury was higher among Asian individuals than White individuals (pooled odds ratio, 1.64; 95% confidence interval, 1.48-1.80). Subgroup analyses showed that obstetrical anal sphincter injury rates were highest among South Asians and among population-based vs hospital-based studies. Meta-regression showed that moderate heterogeneity remained even after accounting for differences in studies by types of Asian subgroups included, study year, mode of delivery included, and study setting.

Conclusion

Obstetrical anal sphincter injury is more frequent among Asian versus white birthing individuals in multiple high-income, non-Asian countries. Qualitative and quantitative research to elucidate underlying causal mechanisms responsible for this relationship are warranted.

Asian-white disparities in obstetric anal sphincter injury: Protocol for a systematic review and meta-analysis

BACKGROUND

Obstetric anal sphincter injury (OASI) describes severe injury to the perineum and perineum and perianal muscles following birth and occurs in 4.4% to 6.0% of vaginal births in Canada. Studies from high-income countries have identified an increased risk of OASI in individuals who identify as Asian race versus those who identify as white. This protocol outlines a systematic review and meta-analysis which aims to determine the incidence of OASI in individuals living in high-income countries who identify as Asian versus those of white race/ethnicity. We hypothesize that the pooled incidence of OASI will be higher in Asian versus white birthing individuals.

METHODS

We will search MEDLINE, OVID, Embase, Emcare and Cochrane databases from inception to 2022 for observational studies using keywords and controlled vocabulary terms related to race, ethnicity and OASI. Two reviewers will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines and Meta-analysis of Observational Studies (MOOSE) recommendations. Meta-analysis will be performed using RevMan for dichotomous data using the random effects model and the odds ratio (OR) as effect measure with a 95% confidence interval (CI). Subgroup analysis will be performed based on Asian subgroups (e.g., South Asian, Filipino, Chinese, Japanese individuals). Study quality assessment will be performed using The Joanna Briggs Institute Critical Appraisal tools.

DISCUSSION

The systematic review and meta-analysis that this protocol outlines will synthesize the extant literature to better estimate the rates of OASI in Asian and white populations in non-Asian, high-income settings and the relative risk of OASI between these two groups. This systematic summary of the evidence will inform the discrepancy in health outcomes experienced by Asian and white birthing individuals. If these findings suggest a disproportionate burden among Asians, they will be used to advocate for future studies to explore the causal mechanisms underlying this relationship, such as differential care provision, barriers to accessing care, and social and institutional racism. Ultimately, the findings of this review can be used to frame obstetric care guidelines and inform healthcare practices to ensure care that is equitable and accessible to diverse populations.

Correlation of anorectal symptoms and endoanal ultrasound findings after obstetric anal sphincter injuries (OASIS)

INTRODUCTION

Obstetric anal sphincter injuries (OASIS) predispose to development of anorectal symptoms that affect women's quality of life.

METHODS

A retrospective cohort study was conducted for all women with singleton vaginal deliveries who had a primary OASIS repair and attended the Postpartum Perineal Clinic between July 1st 2017 and December 31st 2020. This study was approved by the Research Ethics Board. The purpose of this study was (1) to determine correlation between endoanal ultrasound (EAUS) findings and anorectal symptoms quantified by the St. Mark's Incontinence Score (SMIS), (2) to determine the incidence of residual anal sphincter defects, and (3) to determine the rate of clinical overdiagnosis of OASIS. Pearson correlation coefficient was used to assess correlation between anorectal symptoms and EAUS findings.

RESULTS

A total of 247 participants with clinical diagnosis of OASIS met the inclusion criteria. A 3rd-degree tear was identified in 126 (51.0%) and 4th-degree tear was identified in 30 (12.1%) participants. In participants with sonographic evidence of OASIS, there was a statistically significant weak positive correlation between the size of residual defect and SMIS for both external anal sphincter (EAS) (r = .3723, p < .0001) and internal anal sphincter (IAS) (r = .3122, p = .0180). Residual defect in the anorectal sphincter of greater than 1 hour (> 30°) in width was present in 64.3% participants with 3rd-degree tear and 86.7% participants with 4th-degree tear. The rate of overdiagnosis was 36.8%.

CONCLUSION

The size of residual defect of EAS and IAS has a weak positive correlation with anorectal symptoms, emphasizing the importance of EAUS for counselling regarding mode of subsequent delivery.

Are we using best practice to guide laxative use in post-partum patients with obstetric anal sphincter injuries - A retrospective review

OBJECTIVE

Obstetric anal sphincter injury (OASI) is the leading cause of anal incontinence (AI) in young women. Laxatives are recommended to enhance recovery, however there are no consistent guidelines to guide best practice on the type, frequency, and dose of laxative should be used. This study aimed to evaluate the current use of laxatives following repair of OASIs, and to determine any association with AI. Study design A retrospective cohort study of 356 women who sustained OASIs between January 2016 and June 2020, at a single tertiary centre in Adelaide. Data regarding the type, dose and frequency of laxatives prescribed was extracted from each patient. The degree of OASIs was determined by clinical examination and endoanal ultrasound, and AI was measured by the St Marks incontinence score.

RESULTS

Multiple combinations and classes of laxatives were prescribed including bulking agent (Metamucil and Fybogel), emollients (Coloxyl), and osmotic laxatives (lactulose and Movicol). Bulking agents were prescribed for 245 women (68.8%), which is contrary to the current recommendations based on two previous randomised controlled trials. AI reported by 51 (14.3%) women. There were no statistical differences between AI and laxative type, dose, or frequency.

CONCLUSION

Considerable variation existed in laxatives prescription. Bulking agents was not associated with higher rates of AI. Further research is required to improve post-partum care in women following repair of OASIs.

Delayed surgical management of rectovaginal fistula: a case report highlighting challenges and lessons learned

Background

Rectovaginal fistulas following an obstetric anal sphincter injury's repair are rare in developed country and their management could be challenging, particularly in cases of delayed repair. This study emphasizes the importance of accurately diagnosing and promptly repairing such fistulas for optimal patient well-being.

Case

A 30-year-old patient presented with gas incontinence and a greenish discharge from the vagina, 6 months after delivering her baby. Examination revealed a small pinhole lesion on the posterior vaginal wall, and an endoanal ultrasound confirmed the presence of a rectovaginal fistula. Surgical repair was delayed for 9 months due to the patient's breastfeeding. The fistula was eventually repaired through a transrectal approach, with excision of the fistulous tract and closure of both the rectum and vagina. A laparoscopic protective ileostomy was also performed due to the delayed repair. However, a recurrence of the fistula was detected 8 months later, requiring a second repair. The patient underwent physiotherapy for the anal sphincter and achieved optimal sphincter function. After 6 months, the ileostomy was successfully closed, and the patient remained continent.

Conclusions

This case highlights the importance of early recognition and prompt repair of rectovaginal fistulas following obstetric anal sphincter injury. Delayed repairs pose greater challenges and increase the risk of recurrence. Individualized surgical approaches, skilled pelvic floor repair, and a multidisciplinary approach are crucial for successful outcomes. This case underscores the need for careful planning and consideration of patient characteristics in the management of rectovaginal fistulas, aiming to achieve optimal outcomes and patient well-being.

Neonatal head circumference as a risk factor for obstetric anal sphincter injuries: a systematic review and meta-analysis

OBJECTIVE

Between 53% and 79% of women will sustain some degree of perineal laceration during vaginal delivery. Third- and fourth-degree perineal lacerations are known as obstetric anal sphincter injuries. Timely diagnosis and prompt treatment of obstetric anal sphincter injuries can help to prevent the development of severe consequences like fecal incontinence, urinary incontinence, and rectovaginal fistula. Neonatal head circumference is routinely measured postpartum but is often not mentioned as a risk factor for obstetric anal sphincter injuries in clinical guidelines. Thus far, no review article on the risk factors for obstetric anal sphincter injuries has discussed the role of neonatal head circumference. This study aimed to review and analyze the relationship between head circumference and the occurrence of obstetric anal sphincter injuries among previous studies to conclude whether head circumference should be recognized as an important risk factor.

DATA SOURCES

Through study screening on Google Scholar, PubMed, Scopus, and Science Direct for articles published between 2013 to 2023, followed by assessment of eligibility, this study ended up reviewing 25 studies, 17 of which were included in the meta-analysis.

STUDY ELIGIBILITY CRITERIA

Only studies that reported both the neonatal head circumference and the occurrence of obstetric anal sphincter injuries were included in this review.

METHODS

The included studies were appraised using the Dartmouth Library risk of bias assessment checklist. Qualitative synthesis was based on the study population, findings, adjusted confounding factors, and suggested causative links in each study. Quantitative synthesis was conducted using calculation and pooling of odds ratios and inverse variance using Review Manager 5.4.1.

RESULTS

A statistically significant association between head circumference and obstetric anal sphincter injuries was reported in 21 of 25 studies; 4 studies reported that head circumference was a true independent risk factor. A meta-analysis of the studies that reported neonatal head circumference as a dichotomous categorical variable with a cutoff point of 35±1 cm yielded statistically significant pooled results (odds ratio, 1.92; 95% confidence interval, 1.80-2.04).

CONCLUSION

The risk for obstetric anal sphincter injuries increased as the neonatal head circumference increased-this should be considered in decision-making during labor and postpartum management to attain the best outcome.

Relationship between urethral motion profile and parity assessed by translabial ultrasound imaging

PURPOSE

This study aims to describe the differences in the urethral motion profile (UMP) of primiparous and multiparous women immediately postpartum.

METHODS

This prospective study recruited 65 women (29 primiparous, 36 multiparous) one-seven days postpartum. The patients underwent a standardised interview and two-dimensional translabial ultrasound (TLUS). To evaluate the UMP, the urethra was manually traced and divided into five segments with six equidistant points. The mobility vector (MV) for each point was calculated as [Formula: see text]. A Shapiro-Wilk test was conducted to test normality. An independent t-test and a Mann-Whitney test were conducted to express differences between the groups. The Pearson correlation coefficient was used to determine the relationships among MVs, parity and confounders. Finally, a univariate generalised linear regression analysis was performed.

RESULTS

MV1-MV4 were found to be normally distributed. A significant difference for all MVs, except for MV5, was demonstrated between parity groups (MV1: t = 3.88 (p < .001), MV2: t = 3.82 (p < .001), MV3: t = 2.65 (p = .012), MV4: t = 2.54 (p = .015), MV6: U = 150.00 (exact sig. two tailed = .012)). A strong-to-very strong mutual correlation was observed between MV1 to MV4. The univariate generalised linear regression showed that parity can predict up to 26% of urethral mobility.

CONCLUSION

This study shows that multiparous women have significantly higher urethral mobility compared to primiparous women in the first week postpartum, with the most significant effect observed in the proximal urethra.

Implementation of Episcissors-60 for Prevention of Obstetric Anal Sphincter Injuries (OASIS) in a Centre with Low Episiotomy Rates

OBJECTIVE

The purpose of this study was to determine whether introduction of Episcissors-60 into a labour and birth unit would decrease the incidence of Obstetric Anal Sphincter Injuries (OASIS).

METHODS

A before-and-after quality improvement study was conducted between April 1, 2020 and March 31, 2021. All patients who had a vaginal delivery were included in this study. All healthcare providers who perform vaginal deliveries were offered an educational session. Episcissors-60 were then introduced into a labour and birth unit. The primary outcome measure was the change in incidence of OASIS before and after introduction of Episcissors-60. Secondary outcome measures were episiotomy rates before and after introduction of Episcissors-60, device-related adverse events, and provider satisfaction and feedback. Data was analyzed using chi-square tests, independent t-tests, and Mann-Whitney tests.

RESULTS

A total of 1383 vaginal deliveries occurred prior and 1254 vaginal deliveries after introduction of Episcissors-60. There was a decrease in the total OASIS rate from 7.37% of all vaginal deliveries prior to 5.37% after introduction of Episcissors-60 (P = .037). The episiotomy rate was 11.42% prior to and 9.97% after introduction of Episcissors-60 (P = .228). OASIS rate in women who had an episiotomy was 12.02% before and 13.60% after introduction of Episcissors-60 (P = .421).

CONCLUSION

Although introduction of Episcissors-60 was associated with a statistically significant decrease in total OASIS rate, there was no difference in OASIS rates within the subgroup that received an episiotomy. Therefore, reduction in the total OASIS rate in this study cannot be attributed to the use of Episcissors-60.

Post-repair laxative management in obstetric anal sphincter injury guidelines: A narrative review

BACKGROUND

Childbirth is a common factor which increases the risk of obstetric anal sphincter injuries (OASIS). Damage to the anal sphincters increases the risk of anal incontinence, which has a debilitating impact on the quality of life. Post-repair laxatives are prescribed in this group of women. However, there is no consensus regarding the type or frequency with which they are used, and available guidelines lack consistency and evidence to support the recommendations.

AIM

The aim was to review and compare the international, national and local Australian management guidelines for recommendations regarding laxative use in women after OASIS.

METHOD

An online literature search of medical and nursing databases such as PubMed, Embase, MEDLINE, CINAHL, Web of Science, Scopus and Cochrane was performed between January 2000 and October 2020. Full-text articles with MeSH headings and Text Words [TW] identified guidelines in the prevention, management and care of OASIS. The search terms included 'obstetric anal sphincter injury', 'OASIS', 'perineal tear', 'postpartum continence', 'bowel injury', 'aperient', 'laxative use' and 'bulking agents'.

RESULTS

Thirteen guidelines were included. Laxatives were recommended in most guidelines; however, there was a lack of consistency regarding the type of laxative used, frequency, dose and duration of use. Guidelines were based on historical evidence, with paucity of recently acquired data identified.

CONCLUSIONS

There is no consensus regarding an optimal laxative regime for women who sustain an anal sphincter injury after childbirth. Further research is required to develop evidence-based robust clinical guidelines regarding laxative use in women who sustain OASIS.

More than time: travel time to the delivery ward and maternal outcomes - onset of labour, postpartum haemorrhage and obstetric anal sphincter injury

BACKGROUND

Closing delivery units increases travel time for some women. Whether increased travel time is associated with maternal outcomes is important for understanding the consequences of such closures. Previous studies are limited in measuring travel time and restricted to the outcome of caesarean section.

METHODS

Our population-based cohort includes data from the Swedish Pregnancy Register for women giving birth between 2014 and 2017 (N = 364,630). We estimated travel time from home to the delivery ward using coordinate pairs of actual addresses. The association between travel time and onset of labour was modelled using multinomial logistic regression, and logistic regression was used for the outcomes postpartum haemorrhage (PPH) and obstetric anal sphincter injury (OASIS).

FINDINGS

Over three-quarters of women had ≤30 min travel time (median 13.9 min). Women who travelled ≥60 min arrived to care sooner and laboured there longer. Women with further to travel had increased adjusted odds ratio (aOR) of having an elective caesarean section (31-59 min aOR 1.11; 95% confidence interval [CI] 1.07-1.16; ≥60 min aOR 1.25; 95% CI 1.16-1.36) than spontaneous onset of labour. Women (at full term with spontaneous onset) living ≥60 min away had reduced odds of having a PPH (aOR 0.84; 95% CI 0.76-0.94) or OASIS (aOR 0.79; 95% CI 0.66-0.94).

INTERPRETATION

Longer travel time increased the odds of elective caesarean section. Women with furthest to travel arrived sooner and spent more time in care; although they had a lower risk of PPH or OASIS, they also tended to be younger, have a higher body mass index and were Nordic born.

Universal Urogynecologic Consultation and Screening for Fecal Incontinence in Pregnant Women With a History of Obstetric Anal Sphincter Injury: A Cost-Effectiveness Analysis

IMPORTANCE

Obstetric anal sphincter injuries (OASIS) predispose for the development of fecal incontinence (FI), but management of subsequent pregnancy after OASIS is controversial.

OBJECTIVE

We aimed to determine if universal urogynecologic consultation (UUC) for pregnant women with prior OASIS is cost-effective.

STUDY DESIGN

We performed a cost-effectiveness analysis of pregnant women with a history of OASIS modeling UUC compared with no referral (usual care). We modeled the route of delivery, peripartum complications, and subsequent treatment options for FI. Probabilities and utilities were obtained from published literature. Costs using a third-party payer perspective were gathered from the Medicare physician fee schedule reimbursement data or published literature converted to 2019 U.S. dollars. Cost-effectiveness was determined using incremental cost-effectiveness ratios).

RESULTS

Our model demonstrated that UUC for pregnant patients with prior OASIS was cost-effective. Compared with usual care, the incremental cost-effectiveness ratio for this strategy was $19,858.32 per quality-adjusted life-year, below the willingness to pay a threshold of $50,000/quality-adjusted life-year. Universal urogynecologic consultation reduced the ultimate rate of FI from 25.33% to 22.67% and reduced patients living with untreated FI from 17.36% to 1.49%. Universal urogynecologic consultation increased the use of physical therapy by 14.14%, whereas rates of sacral neuromodulation and sphincteroplasty increased by only 2.48% and 0.58%, respectively. Universal urogynecologic consultation reduced the rate of vaginal delivery from 97.26% to 72.42%, which in turn led to a 1.15% increase in peripartum maternal complications.

CONCLUSIONS

Universal urogynecologic consultation in women with a history of OASIS is a cost-effective strategy that decreases the overall incidence of FI, increases treatment utilization for FI, and only marginally increases the risk of maternal morbidity.

Reconstructing the anal sphincters to reverse iatrogenic overstretching following a pull-through for Hirschsprung disease. One-year outcomes

BACKGROUND

In patients with Hirschsprung disease (HSCR), soiling may be related to anal sphincter damage following the initial pull-through. No optimal treatment has been developed for such patients, although enemas (rectal or antegrade) have been applied with some success. We present the one-year outcomes of a new technique for anal sphincter reconstruction.

METHODS

All patients with HSCR referred from other institutions for post pull-through soiling were studied. Seven patients with patulous sphincters underwent sphincter reconstruction. Six had a full preoperative evaluation and were included in the study. Their 12-month outcomes were assessed.

RESULTS

All six patients had soiling without voluntary bowel movements (VBMs). One patient was clean on Malone flushes when referred. Three underwent pre- and post-reconstruction non-sedated three-dimensional anorectal manometry, and objectively were able to close their sphincters following the reconstruction. All patients without Down syndrome (4 of 6) showed improvement in the abbreviated Baylor Continence Scale (4.5 vs. 0.75). One patient has achieved total bowel control without antegrade flushes, three now have VBMs which they did not have before but have occasional accidents and use antegrade flushes intermittently. They reported higher productivity, the ability to participate in sports and be away from home with confidence in their regimen. Two of 6 patients have Down syndrome and required a redo pull-through for other indications and underwent empiric sphincter reconstruction. For these two patients we do not have an outcomes assessment.

CONCLUSIONS

A new technique for sphincter reconstruction shows promising results in improvement of bowel control at one year.

LEVEL OF EVIDENCE

IV.

Obstetric rectal buttonhole tear and a successful three-layer repair: A case report

An obstetric rectal buttonhole tear (ORBT) is a rare obstetric complication with only 21 cases reported in the literature. The choice of two- or three-layer repair of ORBT is controversial. In this case, the author describes (with high-quality images) an ORBT repaired in three layers in order to provide clinical lessons to healthcare professionals involved in obstetrical care. The patient was a 26-year-old pregnant woman with a previous vertex delivery and 4 previous first-trimester miscarriages. In the index pregnancy, she had a spontaneous vertex vaginal birth of a 3095 g male baby at 39 weeks of gestation. During childbirth, she sustained an ORBT and a third-degree perineal tear involving <50% of the external anal sphincter. The ORBT was repaired in three layers using continuous 2-0 Vicryl to the rectal mucosa, and interrupted polydioxanone (PDS) 3-0 to the adjoining vagino-rectal fascia. Subsequently, the external anal sphincter was repaired end-to-end with interrupted PDS 3-0. Thereafter, the vagina was repaired with continuous Vicryl 2-0. The wound healed with no complications over the 12 weeks of postnatal clinic visits. A three-layer repair is arguably preferable given that closure of the fascia between the rectal and vaginal mucosae (vagino-rectal fascia) may improve the tensile strength at the injury site. However, a two-layer repair may be undertaken in rare cases where the vagino-rectal fascia is not identifiable.

Effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women: A systematic review and meta-analysis

BACKGROUND

Perineal massage during childbirth has been recommended as an effective measure to prevent perineal injury. However, the overall effects of perineal massage during childbirth on maternal and neonatal outcomes in primiparous women remain inconclusive. Particularly, the effects of perineal massage begun during different stages of labor need to be further investigated.

OBJECTIVES

To comprehensively review the effects of perineal massage during childbirth on primiparous health outcomes, including perineal-related outcomes, duration of labor, hemorrhage and postpartum perineal pain, and neonatal outcomes, including Apgar scores and neonatal complications, and to further explore the effects of perineal massage begun during different stages of labor.

DESIGN

A systematic review and meta-analysis following the Cochrane Handbook guidelines and PRISMA2020.

METHODS

A systematic search strategy was developed following the three-phase search approach, and the literature search was conducted in electronic databases and clinical trial registers from inception to 7th January 2022. Study selection and data extraction were completed independently by two researchers. The updated Cochrane risk of bias 2.0 tool for randomized trials was chosen to evaluate the quality of included studies. Data analyses were conducted using the Revman5.4 software, and subgroup analyses were performed based on the different start times of perineal massage. Furthermore, the certainty of body of evidence for each outcome was assessed utilizing the GRADEpro online tool.

RESULTS

Seventeen randomized controlled trials involving 3248 primiparous women were included in the review. The pooled results of meta-analyses indicated that perineal massage begun during the second stage of labor significantly increased the occurrence of intact perineum (RR = 2.78, 95 % CI: [1.52, 5.05], P < 0.001), reduced the rate of second- and third-degree perineal lacerations (P < 0.05), and decreased the incidence of episiotomy (RR = 0.63, 95 % CI: [0.50, 0.79], P < 0.001), while perineal massage during the first stage of labor effectively shortened the duration of the first and second stages of labor (P < 0.05). The available evidence also suggests the potential role of perineal massage on hemorrhage and long-term postpartum perineal pain (P < 0.05). However, the aggregated results failed to demonstrate the beneficial effects of perineal massage on neonatal outcomes (P > 0.05).

CONCLUSIONS

Perineal massage begun during the second stage of labor effectively improves the perineal-related outcomes in primiparous women, while perineal massage during the first stage of labor significantly shortens the duration of labor. High-quality studies exploring the standardized procedure for perineal massage and the short- and long-term effects of perineal massage are warranted.

REGISTRATION NUMBER

CRD42022302336 (PROSPERO).

Pelvic floor healing milestones after obstetric anal sphincter injury: a prospective case control feasibility study

INTRODUCTION AND HYPOTHESIS

Severe perineal tears can predict bothersome pelvic floor disorders later in life. We have a poor understanding of pelvic floor changes during the third trimester and the first few postpartum months. We aimed to compare women with severe perineal trauma during childbirth with women who experienced minimal trauma, for condition-specific quality of life, sexual function, mental health and overall quality of life in the first 6 months postpartum.

METHODS

We recruited primiparous women with third- or fourth-degree tears (obstetric anal sphincter injuries, OASIS) and age-matched controls with no tears or first-degree tears in the immediate postpartum period. Participants completed validated questionnaires at baseline, 2, 4 and 6 months postpartum. Mixed effects linear regression or quantile regression adjusted for baseline score were used to compare the groups as appropriate.

RESULTS

A total of 74 women completed at least one questionnaire (35 OASIS, 39 controls). Both groups had similar demographics. Women with OASIS tended to have worse Pelvic Floor Distress Index-40 scores at month 2; median scores were similar in the two groups by month 6. They also had significantly lower Female Sexual Function Index scores (mean difference: -6.1; 95% CI: -11.9, -0.2, p=0.043) at month 2. There were no mental health group differences and quality of life improved over time, mainly in the OASIS group. Six-month participant attrition rate was 52%.

CONCLUSIONS

Women with OASIS encounter specific pelvic floor challenges during the first 6 months postpartum. Although our recruitment rate was high, the attrition rate was also high, demonstrating challenges with retention of postpartum women into longitudinal research.

Antibiotic administration and wound complications after obstetric anal sphincter injuries

BACKGROUND

Obstetric anal sphincter injuries are associated with both short-term and long-term maternal morbidity. Antibiotic administration has been shown to decrease wound complications after obstetric anal sphincter injuries. However, the rate of antibiotic administration in a contemporary obstetrical population is not known.

OBJECTIVE

This study aimed to describe the rate of antibiotic administration for obstetric anal sphincter injuries, to characterize factors associated with antibiotic administration on the day of delivery among women with obstetric anal sphincter injuries, and to determine if there was an association between antibiotic administration and reduced wound complications.

STUDY DESIGN

This was a retrospective cohort study of women with a singleton vaginal birth complicated by obstetric anal sphincter injuries between 2016 and 2021 in a single healthcare system. Information about any antibiotic administration on the day of delivery was collected. Information on wound complications (determined by International Classification of Disease, 10th Revision, codes) that occurred within the first 6 months postpartum were available for patients who delivered at tertiary-care centers. Multivariable logistic regression analysis was used to identify factors associated with antibiotic administration and the association between antibiotics and wound complications.

RESULTS

During the study period, 1550 women met the inclusion criteria of whom 855 (55.2%) received antibiotics. Antibiotic administration was higher at tertiary-care hospitals than at community-based hospitals (68.7 vs 26.8%; P<.001). In the adjusted analysis, antibiotic administration was higher among women with a fourth-degree laceration (adjusted odds ratio, 2.72; 95% confidence interval, 1.69-4.37) and lower among women of Asian or Pacific Islander heritage (adjusted odds ratio, 0.88; 95% confidence interval, 0.80-0.97). At tertiary-care hospitals, 43 women (4.1%) had a wound complication, and more than 80% of those presented within the first 2 weeks postpartum. Antibiotic use was associated with reduced rates of wound complications (adjusted odds ratio, 0.34; 95% confidence interval, 0.13-0.91). All patients received a regimen with gram-positive bacterial coverage; there was no association between type of antibiotic regimen administered and wound complications.

CONCLUSION

Any antibiotic administration on the day of delivery was associated with a decreased rate of wound complications after obstetric anal sphincter injuries. However, only about half of the women with obstetric anal sphincter injuries received antibiotics. Optimizing antibiotic administration may help to reduce the risk of complications in this population.

Incidence and risk factors for secondary failure after acute obstetric sphincter injury repair - an audit of 239 women

AIM

The rate of secondary failure after obstetric sphincter injury repair is unknown, with the literature reporting rates ranging from 0.1% to 53%. We aimed to perform an audit to identify the rate and risk factors for failure of sphincter repair in a cohort of postpartum women using endoanal ultrasound (EAUS) and manometry, assessing the risk factors and impact of these events.

METHOD

Prospective data were collected within a 2 year period from patients who attended the perineal clinic at Eastern Health. Variables of primary repair and presence of postpartum complications were recorded and subsequently analysed.

RESULTS

Of 239 patients with obstetric anal sphincter injury (OASI) included, 100 (41.8%) had EUAS evidence of sphincter defects. Only 20% with secondary repair failure were symptomatic with faecal or flatal incontinence at a mean follow-up of 23.4 months postpartum. Patients with secondary repair failure had lower anal resting (p = 0.006) and maximum squeeze pressures compared with patients with intact repairs (p < 0.001). In terms of variables that were investigated, namely location, operator hierarchy, type of repair and material used, none had a statistically significant correlation with secondary repair failure of OASI. Postpartum complications had an overall incidence of 12.7%, and those with any complication were found to have an increased rate of secondary failure of repair (p = 0.157).

CONCLUSION

Using EAUS to confirm secondary failure of repair, incidence was 41.4% in this cohort. There were no identifiable modifiable variables that reduced the risk of secondary failure of repair. Further prospective research with increased sample size and longer follow-up periods is required to assess the validity of the findings.

[Couder's maneuver. Knowledge and practices in a French university maternity hospital]

BACKGROUND

During childbirth, the performance of a systematic Couder's maneuver could be linked to a reduction in the risk of perineal tear.

OBJECTIVE

To know the practices and knowledge of childbirth professionals regarding the Couder's maneuver. To measure the effect of a training program for juniors.

MATERIALS AND METHODS

Single-center questionnaire survey of senior and junior obstetricians and midwives. Before-and-after study in juniors to evaluate maneuver training.

RESULTS

One hundred and twenty-five caregivers responded to the questionnaire: (19 physicians and 46 senior midwives; 21 residents and 39 midwifery students). Only one third of the respondents said they practiced the Couder's maneuver "always or almost always" (41/125, 32.8%) and less than one third felt "very comfortable" with the maneuver (34/125, 27.2%), with large differences according to profession and senior vs junior status. Being a doctor (vs midwife) was significantly related to systematic or frequent practice of the maneuver (70.0 vs 15.3%, ORMH=42.7 [9.4; 192.3]) as was being a senior (vs junior) (46.2 vs 18.3%, ORMH=15.9 [3.5; 72.9]). Less than half of the seniors surveyed had received education in maneuvering. Of those who did not practice the maneuver, the majority did not consider its systematic practice to be useful (19/26, 73.1%), and one third considered it potentially harmful (8/26, 30.8%). Theoretical and practical training of the juniors significantly improved their knowledge.

CONCLUSION

There are great differences in the practice of the Couder's maneuver. It deserves to be better known, practiced and evaluated.

Use of antibiotics in women undergoing correction of an obstetric anal sphincter injury: Results from a national Israeli survey

OBJECTIVE

Obstetric anal sphincter injures (OASIS) have long-term implications on women's health. Administration of antibiotic prophylaxis and treatment following OASIS repair is controversial. We conducted a national survey to provide data about practice routines regarding antibiotic prophylaxis and treatment following OASIS repair in Israeli labor and delivery units.

METHODS

A national survey was performed among obstetricians and gynecologists from 24 university-affiliated delivery centers within the jurisdiction of the Israeli Ministry of Health during 2020. Representatives from each center completed the "Google form" electronic survey. For each questionnaire item, the most common answer was chosen to represent the center's answer.

RESULTS

The number of physicians who responded per center varied from 1 to 14 (median, 3.5). Preoperative and postoperative antibiotic treatment was given in 75% and 92% of the centers, respectively. While most centers (58.3%) recommend pelvic floor physical therapy on release, recommendations about functional radiologic tests vary. In all centers, there is a designated clinic for postpartum follow-up of OASIS. Most centers (83%) allow trial of vaginal delivery in the subsequent pregnancy, on an individual basis.

CONCLUSION

Heterogeneity exists in managing OASIS in Israel, particularly regarding administration of antibiotics. Further studies are needed to examine the consequences of different management protocols.

When does oasis cause de novo pelvic floor dysfunction? role of the surgeon's skills

INTRODUCTION AND HYPOTHESIS

Minorly skilled gynecologists are less likely to repair obstetric anal sphincter injuries (OASIS), and this can lead to higher rate of de novo onset of pelvic floor dysfunction (PFD). The aim of this study was to understand the impact of surgeon skills in OASIS repair on de novo incidence of PFDs.

METHODS

An observational prospective cohort study performed between January 2019 and December 2020. We included 116 women with OASIS. At 6-weeks from delivery, women were divided into two groups in relation to the onset of PFDs. Characteristics were compared; categorical and continuous variables were assessed with chi-squared test and the Mann-Whitney rank-sum test respectively. Factors involved in PFDs development were analysed with explorative univariate analysis; significant (p<0.05) or approaching significance (p≤0.10) variables were included in multivariable analysis.

RESULTS

Seventy-six women (76/116; 65.5%) reported at least one PFD symptom and anal incontinence was the most prevalent (44.73%; 34/76). OASIS management by a skilled gynaecologist resulted protective for PFDs [aOR 0.33 (0.13-0.61)]. Skilled surgeon reported fewer PFDs than less skilled surgeon (4% vs 82.4%; p<0.0001). Operative delivery was more performed (32.5% vs 15.8%; p= 0.03) and severe OASIS resulted more prevalent (60% vs 17.1%; p<0.0001) among women without PDFs, even if these didn't affect the incidence of de novo PFDs [aOR 1.03 (0.23-1.45) and 0.83 (0.13-1.45), respectively].

CONCLUSIONS

Surgeons skilled in OASIS repair resulted the only protective factor for incidence of de novo PFDs in women with OASIS at 6 weeks of follow up. Improvement of training in OASIS repair is necessary.

Obstetric anal sphincter injuries (OASIS): using transperineal ultrasound (TPUS) for detecting, visualizing and monitoring the healing process

Purpose

The aim of this study was to examine whether OASIS, and its extent, can be confirmed or excluded using transperineal ultrasound (TPUS). A further objective of this study was to monitor the healing process over a period of 6 months and to establish a connection between the sonographic appearance of obstetric anal sphincter injury (OASIS) and anal incontinence.

Materials and methods

In this retrospective clinical study, women with OASIS who gave birth between March 2014 and August 2019 were enrolled. All the patients underwent TPUS 3 days and 6 months after delivery. A GE E8 Voluson ultrasound system with a 3.5–5 MHz ultrasound probe was used. The ultrasound images showed a third-degree injury, with the measurement of the width of the tear and its extent (superficial, partial, complete, EAS and IAS involvement). A positive contraction effect, a sign of sufficient contraction, was documented. Six months after delivery, a sonographic assessment of the healing (healed, scar or still fully present) was performed. A Wexner score was obtained from each patient. The patients’ medical histories, including age, parity, episiotomy and child’s weight, were added.

Results

Thirty-one of the 55 recruited patients were included in the statistical evaluation. Three patients were excluded from the statistical evaluation because OASIS was excluded on TPUS 3 days after delivery. One patient underwent revision surgery for anal incontinence and an inadequately repaired anal sphincter injury, as shown sonographic assessment, 9 days after delivery. Twenty patients were excluded for other reasons. The results suggest that a tear that appears smaller (in mm) after 3 days implies better healing after 6 months. This effect was statistically significant, with a significance level of alpha = 5% (p = 0.0328). Regarding anal incontinence, women who received an episiotomy had fewer anal incontinence symptoms after 6 months. The effect of episiotomy was statistically significant, with a significance level of alpha = 5% (p = 0.0367).

Conclusion

TPUS is an accessible, non-invasive method for detecting, quantifying, following-up and monitoring OASIS in patients with third-degree perineal tears. The width, as obtained by sonography, is important with regard to the healing of OASIS. A mediolateral episiotomy seems to prevent anal incontinence after 6 months.

Bilateral Inferiorly Based Labia Majora Flaps: A Simple Technique for Post Episiotomy Dehiscence Coverage

Episiotomy dehiscence because of infection is a cause of major physical, psychological and social problems. Management depends on the degree of injury. The loco-regional flap can be considered in recurrent dehiscence with loss of tissue. We report a case of a 26-year-old female who presented with a post episiotomy wound in the perineal region extending from the posterior fourchette to the anal opening. She gave the history of resuturing of dehiscence twice but the result was the same. On examination, there was a loss of skin and subcutaneous tissue between vaginal and anal opening with pouting of the anal and vaginal mucosa. Per rectal examination, the anal tone was normal. Her wound was covered with bilateral inferiorly based labia majora flaps with a good outcome. So, an inferiorly based labia majora flap can be a useful option in coverage of recurrent perineal dehiscence.

Comparison of the outcomes of overlapping and direct apposition sphincteroplasty techniques in anal sphincter repair

OBJECTIVES

Sphincteroplasty is of great importance in the repair of anal sphincter damage. In the present study, we compared the results of overlapping sphincteroplasty and direct apposition techniques used in anal sphincter repair.

MATERIAL AND METHODS

Between 2011 and 2021, 36 patients underwent sphincteroplasty for anal sphincter injury and were analysed retrospectively. Sex, age, etiologic factors, repair technique, degree of laceration, postoperative complications, length of hospital stay, time between injury and repair, follow-up time and postoperative Cleveland Clinic Incontinence Score (CCIS) were recorded for analysis, and the two techniques were compared statistically using SPSS statistics, Version 17.0.

RESULTS

Of the sample, 31 were females and five were males, with a mean age of 31.50 ± 6.7 years. The etiologic factors were obstetric trauma in 25 patients, perianal interventions in seven patients and other traumas in four patients. The overlapping technique was applied to 14 patients and the direct apposition technique was applied to 22 patients. Mean postoperative CCIS of all cases was 5.53 ± 2.59, and was significantly lower in those who underwent overlapping sphincteroplasty technique than those who underwent apposition repair (p= 0.006). It was observed that postoperative CCIS decreased as the time between sphincter injury and repair decreased (p <0.001; r= 0.625).

CONCLUSION

It is vital to repair anal sphincter damage as early as possible. The overlapping sphincteroplasty and direct apposition methods can both be considered safe for anal sphincter repair although in terms of faecal incontinence, the outcomes of overlapping sphincteroplasty are better than those of the direct apposition technique.

Short and long term results of anatomical reconstruction of perineal body and sphincter complex in obstetric anal sphincter injuries

OBJECTIVES

The effective way to reduce the risk of fecal incontinence (FI) in primary repaired obstetric anal sphincter injuries (OASIS) patients is to accurately detect the injury and provide complete anatomical reconstruction. The aim of the study was to evaluate the short-term and long-term results of OASIS cases that were diagnosed by an experienced surgical team and whose perineal body and anal sphincters were reconstructed separately.

MATERIAL AND METHODS

Sixteen patients that required consultations due to anal sphincter damage during vaginal delivery and underwent anatomical reconstruction due to Grade 3c and Grade 4 sphincter damage between 2007 and 2019 were included in the study. These cases were divided into three groups [Group 1 (≤12 months), Group 2 (12-60 months), Group 3 (≥60 months)] according to the time elapsed until anal manometry, and incontinence questionnaires were conducted in the postoperative period. Recto-anal inhibitory reflex (RAIR), mean resting (IB) and squeezing (SB) pressures were measured by anal manometry. Anal incontinence (AI) and FI rates were determined by questionnaires. Anal sphincter damage repair techniques (overlapping, end-to-end) were determined. These parameters were compared between the three groups.

RESULTS

Mean age of the patients was 27.5 (16-35) years. Six (37.5%) patients had Grade 3c, while 10 (62.5%) had Grade 4 injury. The overall mean RP and SP were 35 (26-56) mmHg and 67 (31-100) mmHg, respectively. Mean RP and SP were 46/67 mmHg, 33.5/75.5 mmHg, and 37.5/70.5 mmHg in Groups 1, 2, and 3 respectively. There was no difference between the three groups in terms of mean RP and SP (p= 0.691, p= 0.673). The rate of AI and FI in all patients were 18.75% and 12.5%, respectively while the rate of severe AI incontinence was 6%. Severe AI was observed in 1 (16.7%) case in Group 1, mild AI was observed in 1 (25%) case in group 2, and in 1 (16.7%) case in Group 3. RAIR was positive in all patients. In Group 1, 5 (83.3%) patients underwent overlapping repair, and in Group 3, 6 (100%) patients underwent end-to-end repair. This difference was statistically significant (p= 0.011).

CONCLUSION

In vaginal births, evaluation of anal sphincter damage, determination of perineal body structures and anal sphincters separately and performing anatomical reconstruction when needed significantly reduce the rate of FI in the short and long term.

[Postpartum fecal incontinence. State of the problem]

A review of the current national and foreign literature is devoted to epidemiology, risk factors, causes, diagnosis and modern treatment approaches for fecal incontinence (FI). Incidence of FI in early and delayed period after childbirth is 30% or more. At the same time, up to 87% of postpartum injuries of anal sphincter remain undiagnosed. Importantly, routine caesarean section does not reduce the risk of incontinence. In addition to typical complaints of spontaneous gas and stool, diagnosis of FI after childbirth includes transrectal ultrasound, MRI, anorectal manometry and pudendal nerve terminal motor latency testing. Survey of proctologists from different regions of Russia revealed a high demand from medical community for educational programs devoted to diagnosis, treatment and rehabilitation of patients with postpartum perineal injuries.

Is age at menarche a predictor of maternal birth trauma?

OBJECTIVE

Age at menarche and the interval between menarche and age at first vaginal birth have been shown to be associated with reproductive performance; however, their association with maternal birth trauma has not been studied. We aimed to determine whether age at menarche, age at first vaginal birth and their interval are associated independently with levator ani muscle (LAM) avulsion and external anal sphincter (EAS) defect.

METHODS

This was a retrospective analysis of the ultrasound volume datasets of 466 vaginally parous patients attending one of two tertiary urogynecological units in Australia. All patients had undergone a standardized interview and clinical examination using the pelvic organ prolapse quantification staging system, followed by four-dimensional translabial ultrasound. Tomographic ultrasound imaging was used to evaluate the LAM for avulsion and the EAS for significant defect.

RESULTS

Of the 466 women analyzed, LAM avulsion was diagnosed in 121 (26.0%) and significant EAS defect in 55 (11.8%). Logistic regression analysis showed no association between age at menarche and LAM avulsion (P = 0.67). Weak but significant associations were noted between LAM avulsion and age at first vaginal birth (odds ratio (OR), 1.070 (95% CI, 1.03-1.11); P = 0.0007) and between LAM avulsion and menarche-to-first-vaginal-birth interval (OR, 1.064 (95% CI, 1.02-1.11); P = 0.0018). No significant associations were noted between significant EAS defect and any of the evaluated variables (all P ≥ 0.49).

CONCLUSIONS

Age at menarche is not predictive of maternal birth trauma i.e. LAM avulsion and EAS residual defect. There was a statistically significant association between LAM avulsion and menarche-to-first-vaginal-birth interval; however, this was not stronger than the previously established association between LAM avulsion and age at first vaginal birth, arguing against any distinct effect of prolonged prepregnancy hormonal stimulation on the biomechanical properties of the pelvic floor. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Aspects of Pelvic Floor Protection in Spontaneous Delivery - a Review

The necessity of increasingly addressing aspects of pelvic floor protection, i.e., prevention of the most frequent female pelvic floor disorders, such as urinary incontinence, faecal incontinence and pelvic organ prolapse, is the result of the steadily improving understanding of the association of pregnancy and delivery with the prevalence of these disorders. About a quarter of all women experience one or more such symptoms during their life. Apart from age and weight, pregnancies and births play an important part. While initial discussion of pelvic floor protection often focused very rapidly on the mode of delivery and elective caesarean section as a possible protective intervention, it has become apparent in the last few decades how varied and wide-ranging the options are that can be used to protect against pelvic floor disorders. The mode of delivery as such is "only" one element among numerous other considerations and has diminished markedly in importance. Interprofessionality and interdisciplinarity undoubtedly represent an important development as resulting recommendations must always be incorporated in an overall context that considers mother and child at the same time. Considering the pelvic floor only certainly does not make sense. This review article will analyze in greater detail important pre-, intra- and postpartum aspects that in their entirety can provide insight into the various aspects of pelvic floor protection. The authors regard the following article as an additional basis for discussion on achieving a sustained reduction in the incidence and prevalence of female pelvic floor disorders.

Modifiable and non-modifiable risk factors for obstetric anal sphincter injury in a Norwegian Region: a case-control study

Background

Obstetric anal sphincter injury (OASI) is a common and severe complication of vaginal delivery and may have short- and long-term consequences, including anal incontinence, sexual dysfunction and reduced quality of life. The rate of OASI varies substantially between studies and national birth statistics, and a recent meta-analysis concluded that there is a need to identify unrecognized risk factors. Our aim was therefore to explore both potential modifiable and non-modifiable risk factors for OASI.

Methods

We performed a case–control study in a single center maternity clinic in South-Eastern Norway. Data were extracted retrospectively from an institutional birth registry. The main outcome measure was the occurrence of the woman’s first-time 3^rd or 4^th degree perineal lesion (OASI) following singleton vaginal birth after 30 weeks’ gestation. For each woman with OASI the first subsequent vaginal singleton delivery matched for parity was elected as control. The study population included 421 women with OASI and 421 matched controls who gave birth during 1990–2002. Potential risk factors for OASI were assessed by conditional logistic regression analyses.

Results

The mean incidence of OASI was 3.4% of vaginal deliveries, but it increased from 1.9% to 5.8% during the study period. In the final multivariate regression model, higher maternal age and birthweight for primiparous women, and higher birthweight for the multiparous women, were the only non-modifiable variables associated with OASI. Amniotomy was the strongest modifiable risk factor for OASI in both primi- (odds ratio [OR] 4.84; 95% confidence interval [CI] 2.60–9.02) and multiparous (OR 3.76; 95% CI 1.45–9.76) women, followed by augmentation with oxytocin (primiparous: OR 1.63; 95% CI 1.08–2.46, multiparous: OR 3.70; 95% CI 1.79–7.67). Vacuum extraction and forceps delivery were only significant risk factors in primiparous women (vacuum: OR 1.91; 95% CI 1.03–3.57, forceps: OR 2.37; 95% CI 1.14–4.92), and episiotomy in multiparous women (OR 2.64; 95% CI 1.36–5.14).

Conclusions

Amniotomy may be an unrecognized independent modifiable risk factor for OASI and should be further investigated for its potential role in preventive strategies.

Are Perineal Massage and Instrument-Assisted Perineal Stretching With Short Protocol Effective for Increasing Pelvic Floor Muscle Extensibility? A Randomized Controlled Trial

OBJECTIVE

The purpose of this study was to compare (1) the effects of the instrument-assisted perineal stretching technique with different application protocols in combination with perineal massage and (2) the effects of the isolated techniques on the extensibility and strength of the pelvic floor muscles (PFMs).

METHODS

A randomized controlled clinical trial with parallel randomization, assessor blinding, and concealed allocation was conducted in the Campus Physical Education at the Federal University of Uberlândia in Brazil. Ninety-six pregnant women (18-40 years of age) were allocated into 4 groups: perineal massage (PnM) group (PnM protocol for 10 minutes); instrument-assisted perineal stretching with a long static protocol for 15 minutes [IStrLS group]); PnM + IStrLS group (both techniques applied in the 2 previous groups); and PnM + IStrSR group (the same techniques as used in the PnM + IStrLS group but with a short repeated protocol; 4 sets lasting 30 seconds each). Eight interventions were performed in all 4 groups twice weekly (beginning at the 34th gestational week). The primary outcome was PFM extensibility, assessed using vaginal dilator circumference, and the secondary outcome was PFM strength, assessed using vaginal manometry.

RESULTS

For the PFM extensibility variable, a significant main effect of time (F2,88 = 87.951) and group (F3,88 = 7.193) was found. Tukey post hoc test results showed that the PnM + IStrSR group presented greater extensibility than the PnM and IStrLS groups. The PnM group showed increased PFM strength after 8 sessions compared with the other groups.

CONCLUSIONS

Women who were pregnant and received the combination of perineal massage and instrument-assisted perineal stretching with short repeated application had a greater increase in PFM extensibility than perineal massage and instrument-assisted perineal stretching alone.

IMPACT

The combination of perineal massage and instrument-assisted perineal stretching techniques with a short, repeated protocol led to better PFM extensibility results than the application of the techniques alone in women who were pregnant.

LAY SUMMARY

Pregnant women can benefit from intervention using the combination of perineal massage and instrument-assisted perineal stretching techniques with a short, repeated protocol.

Maternal and neonatal morbidity after forceps or spatulas-assisted delivery in preterm birth

OBJECTIVE

The aim of this study was to assess perinatal morbidity associated with spatulas or forceps assisted delivery in preterm birth.

STUDY DESIGN

This is a retrospective cohort study including all women with assisted deliveries on singleton pregnancy in cephalic presentation, before 37 weeks of gestation, in two tertiary care centers. We compared forceps-assisted deliveries with spatula-assisted deliveries. The main outcome was the rate of neonatal birth trauma. Secondary outcomes included other neonatal parameters, maternal outcomes and obstetric anal sphincter injuries.

RESULTS

Out of 37 002 deliveries, 59 (0.2 %) preterm assisted deliveries with forceps and 111 (0.3%) preterm spatulas deliveries were included. The rate of neonatal birth trauma was low for both devices, without significant difference (3.4% in Forceps group vs 0.9% in Spatulas group, p = 0.28). The rate of episiotomy was 79.7% after forceps-assisted delivery and 48.6% for spatulas (p < 0.001). The rate of obstetric anal sphincter injuries was 1.7% and 2.7% respectively (p = 0,9).

CONCLUSION

The rate of birth trauma was low in both forceps-assisted deliveries and spatula-assisted deliveries and was not significantly different between the two groups.

Obstetrical anal sphincter injury and unnecessary episiotomy are both associated with anal incontinence 8 years after childbirth: A nationwide database analysis

OBJECTIVE

to assess the relationship between anal incontinence (AI) 8 years after childbirth and the occurrence of Obstetrical Anal Sphincter Injury (OASI) and/or performance of an episiotomy during childbirth.

METHODS

This is a nationwide database analysis performed on two national medico-administrative databases, including all the women aged ≥18 years who delivered infants in France in 2012. The main outcome measure was AI in the 8-years after delivery.

RESULTS

Of the 163,443 perineal tears reported, 0.47% were grade-3 and 0.08% were grade-4; 8,938 women experienced AI (1.33%) and 261 women experienced severe AI (0.04%). Episiotomies performed in the absence of risk factors for OASI were significantly associated with an increased risk of AI (Odds Ratio (OR)=1.59; 95% Confidence Interval (CI):1.49-1.69;p<0.001). Grade 3 and 4 OASI also significantly increased the risk of AI and severe AI. Mediolateral episiotomy was preventative of OASI when performed in subjects at risk (OR=0.26; 95% CI:0.23-0.30; p<0.001) but contributed to OASI in the absence of risk (OR=2.18; 95% CI:1.98-2.40; p<0.001).

CONCLUSIONS

OASI is a risk factor for AI. Episiotomies could reduce the occurrence of OASI, but they could also have a increase the risk of long-term AI in the absence of risk factors for OASI.

Association between second stage of labour length and risk of obstetrical anal sphincter injury in nulliparous women: a population-based retrospective cohort study

INTRODUCTION AND HYPOTHESIS

Obstetrical anal sphincter injury (OASIS) is a common consequence of vaginal delivery in nulliparas and carries the risk of short- and long-term morbidity. The objective of this study was to estimate the association between the duration of the second stage of labour and OASIS risk.

METHODS

A population-based, retrospective cohort of nulliparas delivering singleton, vertex, non-anomalous fetuses at term in Nova Scotia, Canada, from 2005 to 2019, were identified using the Nova Scotia Atlee Perinatal Database. Poisson regression models were used to estimate risk ratios (RR) with robust 95% confidence intervals (CI) adjusting for confounding variables to investigate the association between the length of the second stage and OASIS in the entire cohort and in operative vaginal deliveries.

RESULTS

Of 36,662 participants, 7.6% sustained an OASIS (6.8% third-degree, 0.8% fourth-degree tear). The proportion of participants who sustained an OASIS increased over the study period. For each 30-min increase in the length of second stage, the OASIS risk increased by 11% (RR 1.11, 95% CI 1.10-1.12). When stratified by mode of delivery, second stage length ≥ 90 min was associated with an increased OASIS risk in spontaneous (RR 1.35, 95% CI 1.15-1.58) and vacuum-assisted vaginal deliveries (RR 1.42, 95% CI 1.11-1.81). In forceps-assisted vaginal deliveries, OASIS risk was increased, with shorter and longer durations of the second stage.

CONCLUSION

Increasing length of the second stage of labour was associated with increasing risk of OASIS overall, but the association was heterogeneous between modes of delivery. Length of the second stage should be considered in counseling about OASIS risk.

Maternal and neonatal trauma following operative vaginal delivery

Background:

Operative vaginal delivery (OVD) is considered safe if carried out by trained personnel. However, opportunities for training in OVD have declined and, given these shifts in practice, the safety of OVD is unknown. We estimated incidence rates of trauma following OVD in Canada, and quantified variation in trauma rates by instrument, region, level of obstetric care and institutional OVD volume.

Methods:

We conducted a cohort study of all singleton, term deliveries in Canada between April 2013 and March 2019, excluding Quebec. Our main outcome measures were maternal trauma (e.g., obstetric anal sphincter injury, high vaginal lacerations) and neonatal trauma (e.g., subgaleal hemorrhage, brachial plexus injury). We calculated adjusted and stabilized rates of trauma using mixed-effects logistic regression.

Results:

Of 1 326 191 deliveries, 38 500 (2.9%) were attempted forceps deliveries and 110 987 (8.4%) were attempted vacuum deliveries. The maternal trauma rate following forceps delivery was 25.3% (95% confidence interval [CI] 24.8%–25.7%) and the neonatal trauma rate was 9.6 (95% CI 8.6–10.6) per 1000 live births. Maternal and neonatal trauma rates following vacuum delivery were 13.2% (95% CI 13.0%–13.4%) and 9.6 (95% CI 9.0–10.2) per 1000 live births, respectively. Maternal trauma rates remained higher with forceps than with vacuum after adjustment for confounders (adjusted rate ratio 1.70, 95% CI 1.65–1.75) and varied by region, but not by level of obstetric care.

Interpretation:

In Canada, rates of trauma following OVD are higher than previously reported, irrespective of region, level of obstetric care and volume of OVD among hospitals. These results support a reassessment of OVD safety in Canada.