Anal incontinence and unrecognized anal sphincter injuries after vaginal delivery- a cross-sectional study in Norway

The influence of the fundal pressure manoeuvre at delivery on the anal sphincter injury diagnosed with endoanal ultrasonography

OBJECTIVES

The fundal pressure manoeuvre (FPM) is a procedure where the fundus of the uterus is pushed through the abdominal wall by the midwifes and doctors to shorten the terminal phase of the second stage vaginal delivery. Nowadays its use is controversial and associated with many adverse effects. The aim of the study was to evaluate benefits and adverse maternal outcomes after FPM. The correlation of the FPM with episiotomy was evaluated. The role of the FPM on pelvic floor dysfunction such as anal incontinence due to anal sphincter injury was assessed.

STUDY DESIGN

The retrospective study was conducted between 2017 and 2021. The women who came to the postpartum examination to Gynaecology department for various reasons and gave vaginal birth to a singleton were included in the study. The women who had instrumental delivery were excluded. Minimal sample size was calculated with calculator.net and set on 45. Two groups were formed one with fundal pressure and one without, 96 and 90 patients respectively. The maternal, fetal, and obstetric factors that could be associated with the application of FPM were examined. The endoanal ultrasound examination was performed on all women included in the study.

RESULTS

The study did not show that FPM would lead to a more frequent occurrence of anal sphincter injury (p = 0.73), effect its location (p = 0.77) and depth (p = 0.97), however the test group tended to have longer ruptures compared to control group (p = 0.1). No statistically significant differences in episiotomies between control and test group (p = 0.075) were shown. Endoanal ultrasound showed discrepancy between clinically stated and ultrasonographical diagnoses of anal sphincter injuries. In 61,3% of patients with anal sphincter injury after FPM, reported one of the anal incontinence problems of varying degrees six months after delivery.

CONCLUSION

Given that the study proved that FPM is not correlated to the anal sphincter injury it can be used safely. The FPM should be performed carefully and only if necessary to safely finish the labour or in combination with instrumental delivery.

Detailed classification of second-degree perineal tears in the delivery ward: an inter-rater agreement study

INTRODUCTION

Second-degree perineal tears can vary widely as to the extent of trauma, which may be relevant for women's pelvic floor health postpartum. However, the short- and long-term consequences of second-degree perineal tears are poorly understood, likely due to the lack of a detailed classification system. Such a classification system for second-degree tears has been suggested but the inter-rater agreement has not yet been assessed. The aim of this study was to assess the inter-rater agreement of the already established classification system for perineal tears recommended by the Royal College of Obstetricians and Gynaecologists (RCOG classification) among midwives. Further, we aimed to assess the inter-rater agreement of a classification system that provides three sub-categories for second-degree perineal tears.

MATERIAL AND METHODS

This was an inter-rater agreement study, conducted at Akershus University Hospital in Norway from 31 August to 29 November 2020. All midwives working in the delivery ward participated in the study. Midwives classified the integrity of the perineum of all women delivering vaginally within the study period. During the first month of the study, tears were classified by two midwives who were blinded to each other's findings, and the agreement of the RCOG classification was assessed. The following month, the detailed classification system was introduced to the midwifery staff. The last month, perineal tears were classified by two midwives using the detailed classification system, and the agreement was assessed. Inter-rater agreement was measured using Fleiss multirater kappa (k) and Kendall's coefficient of concordance (KCC_w ).

RESULTS

The inter-rater agreement for the RCOG classification was good to very good, with k = 0.705 (95% confidence interval [CI] 0.62-0.79, P < 0.001), KCC_w  = 0.928 (P < 0.001). The inter-rater agreement for the detailed classification system was good to very good, with k = 0.748 (95% CI 0.67-0.83, P < 0.001), KCC_w  = 0.956 (P < 0.001).

CONCLUSIONS

The inter-rater agreement among midwives using both the RCOG classification and the detailed classification system among midwives was good to very good. The detailed classification system provides additional information about the extent of tissue trauma in second-degree tears, warranted for future research on women's pelvic floor health postpartum.

Under-classified obstetric anal sphincter injuries

INTRODUCTION AND HYPOSTHESIS

Obstetric anal sphincter injuries (OASIs) that are missed at delivery can have long-term consequences. OASIs that are under-classified at delivery are likely to be inadequately repaired, resulting in a persistent anal sphincter defect. We aimed to identify women who have persistent defects on endoanal ultrasound, inconsistent with the original diagnosis, and compare the effect on St Mark's incontinence scores (SMIS). We also aimed to look for changes in numbers of under-classification over time.

METHODS

Records of women attending a perineal clinic who had endoanal ultrasound from 2012 to 2020 were reviewed. Women who had a modified Starck score implying a defect greater than the classification [indicated by the depth of external anal sphincter or internal anal sphincter (IAS) defect] at delivery were identified.

RESULTS

A total of 1056 women with a diagnosis of 3a or 3b tears were included. Of these, 120 (11.36%) were found to have a defect greater than the original diagnosis and therefore were incorrectly classified at delivery. Women who had a 3b tear diagnosed at delivery, but had an IAS defect, had a significantly higher SMIS (p < 0.01). When comparing two 4-year periods, there was a significant improvement in the diagnosis of IAS tears.

CONCLUSION

Some women with OASIs that have under-classified OASIs are associated with worse anorectal symptoms. This is likely because of an incomplete repair. Some improvement in diagnosis of IAS tears has been noted. We propose improved training in OASIs can help reduce the number of incorrectly classified tears and improve repair.