Results of endosonographic imaging of the anal sphincter 2-7 days after primary repair of third- or fourth-degree obstetric sphincter tears

Background. Obstetric anal sphincter injuries (OASIS) arise from perineal trauma during vaginal delivery and are associated with poor maternal health outcomes. Most OASIS occur in unattended deliveries in resource-limited settings. However, even in facilities where deliveries are attended by skilled personnel, a number of women still get OASIS. Objectives. To determine the incidence and risk factors for obstetric anal sphincter injuries among women delivering at Mbarara Regional Referral Hospital (MRRH). Methods. We conducted an unmatched hospital-based case control study, with the ratio of cases to controls of 1 : 2 (80 cases and 160 controls). We defined a case as a mother who got a third- or fourth-degree perineal tear after vaginal delivery while the controls recruited were the next two mothers who delivered vaginally without a third- or fourth-degree perineal tear. A questionnaire and participants’ medical records review were used to obtain sociodemographic and clinical data. We estimated the incidence of OASIS and performed univariable and multivariable logistic regression to identify the associated risk factors. Results. The cumulative incidence for OASIS during the study period was 6.6%. The risk factors for OASIS were 2nd stage of labour ≥1 hour (aOR 6.07, 95%CI 1.86–19.82, p=0.003), having episiotomy performed during labour (aOR 2.57, 95%CI 1.07–6.17, p=0.035), perineum support during delivery (aOR 0.03, 95%CI 0.01–0.12, p<0.001), and monthly income of >50,000 shillings (aOR 0.09, 95%CI 0.03–0.28, p<0.001). Conclusions and Recommendations. The risk factors for obstetric anal sphincter injury were prolonged second stage of labour and performing episiotomies during deliveries while higher monthly income and perineum support during delivery were protective. We recommend routine support to the perineum during delivery. Care should be taken in mothers with episiotomies, as they can extend and cause OASIS.

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Does a missed obstetric anal sphincter injury at time of delivery affect short-term functional outcome?

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2017.0140 ◽

2018 ◽

Vol 100 (1) ◽

pp. 26-32 ◽

Cited By ~ 6

Author(s):

L Ramage ◽

C Yen ◽

S Qiu ◽

C Simillis ◽

C Kontovounisios ◽

...

Keyword(s):

Quality Of Life ◽

Anal Sphincter ◽

Short Form ◽

Primary Repair ◽

Obstetric Anal Sphincter Injury ◽

Short Term ◽

Sphincter Injury ◽

Anal Sphincter Injury

Introduction This study aimed to ascertain whether missed obstetric anal sphincter injury at delivery had worse functional and quality of life outcomes than primary repair immediately following delivery. Materials and methods Two to one propensity matching was undertaken of patients presenting to a tertiary pelvic floor unit with ultrasound evidence of missed obstetric anal sphincter injury within 24 months of delivery with patients who underwent primary repair at the time of delivery by parity, grade of injury and time to assessment. Outcomes compared included Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ), Wexner Incontinence Score, Short Form-36, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire and anorectal physiology results. Results Thirty-two missed anal sphincter injuries were matched two to one with sixty-two patients who underwent primary repair of an anal sphincter defect. Mean time to follow-up was 9.31 ± 6.79 months. Patients with a missed anal sphincter injury had suffered more incontinence, as seen in higher the Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ; 30.56% ± 14.41% vs. 19.75% ± 15.65%, P = 0.002) and Wexner scores (6.00 ± 3.76 vs. 3.67 ± 4.06, P = 0.009). They also had a worse BBUSQ urinary domain score (28.25% ± 14.9% vs. 17.01 ± 13.87%, P = 0.001) and worse physical functioning as measured by the Short Form-36 questionnaire (P = 0.045). There were no differences in other outcomes compared, including anorectal physiology and sexual function. Discussion In the short-term, patients with a missed obstetric anal sphincter injury had significantly worse faecal incontinence and urinary function scores, however quality of life and sexual function were largely comparable between groups. Conclusions Longer-term follow-up is needed to assess the effects of missed obstetric anal sphincter injury over time.

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A Simple, Reproducible and Low-cost Simulator for Teaching Surgical Techniques to Repair Obstetric Anal Sphincter Injuries

Revista Brasileira de Ginecologia e Obstetrícia / RBGO Gynecology and Obstetrics ◽

10.1055/s-0038-1668527 ◽

2018 ◽

Vol 40 (08) ◽

pp. 465-470 ◽

Cited By ~ 3

Author(s):

Roxana Knobel ◽

Lia Volpato ◽

Liliam Gervasi ◽

Raquel Viergutz ◽

Alberto Trapani

Keyword(s):

Anal Sphincter ◽

Low Cost ◽

Internal Sphincter ◽

Surgical Techniques ◽

External Sphincter ◽

Rectal Mucosa ◽

Obstetric Anal Sphincter Injuries ◽

Fourth Degree ◽

Anatomy And Physiology ◽

Application Techniques

Objective To describe and evaluate the use of a simple, low-cost, and reproducible simulator for teaching the repair of obstetric anal sphincter injuries (OASIS). Methods Twenty resident doctors in obstetrics and gynecology and four obstetricians participated in the simulation. A fourth-degree tear model was created using low-cost materials (condom simulating the rectal mucosa, cotton tissue simulating the internal anal sphincter, and bovine meat simulating the external anal sphincter). The simulator was initially assembled with the aid of anatomical photos to study the anatomy and meaning of each component of the model. The laceration was created and repaired, using end-to-end or overlapping application techniques. Results The model cost less than R$ 10.00 and was assembled without difficulty, which improved the knowledge of the participants of anatomy and physiology. The sutures of the layers (rectal mucosa, internal sphincter, and external sphincter) were performed in keeping with the surgical technique. All participants were satisfied with the simulation and felt it improved their knowledge and skills. Between 3 and 6 months after the training, 7 participants witnessed severe lacerations in their practice and reported that the simulation was useful for surgical correction. Conclusion The use of a simulator for repair training in OASIS is affordable (low-cost and easy to perform). The simulation seems to improve the knowledge and surgical skills necessary to repair severe lacerations. Further systematized studies should be performed for evaluation.

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Third and Fourth Degree Perineal Tear in Four-Year Period at Sestre Milosrdnice University Hospital Center, Zagreb, Croatia

Open Access Macedonian Journal of Medical Sciences ◽

10.3889/oamjms.2018.253 ◽

2018 ◽

Vol 6 (6) ◽

pp. 1067-1071 ◽

Cited By ~ 1

Author(s):

Ivka Djaković ◽

Emina Ejubović ◽

Ivan Bolanča ◽

Marina Markuš Sandrić ◽

Dino Bečić ◽

...

Keyword(s):

Anal Sphincter ◽

Gestational Age ◽

Obstetric Anal Sphincter Injury ◽

Large For Gestational Age ◽

Vacuum Extraction ◽

Sphincter Injury ◽

Fourth Degree ◽

Anal Sphincter Injury ◽

Perineal Injury ◽

Vaginal Deliveries

OBJECTIVES: Obstetric anal sphincter injury (OASIS) includes the third and fourth degree of perineal injury. The risk for OASIS is about 1% of all vaginal deliveries. If not recognised and treated properly, obstetric anal sphincter injury can have serious consequences for reproductive age woman.MATERIAL AND METHODS: We have retrospectively gathered and analysed data on obstetric anal sphincter injury in a four-year period at our department. The control group in this study included vaginal deliveries in 2012.RESULTS: We recorded 0.34% third and fourth degree of perineal injury in all vaginal deliveries, and 87.9% of those patients were primiparae. Episiotomy was performed in 57.6% of all women with obstetric anal sphincter injury. In 30.3% of cases, newborns were large for gestational age. Gestational diabetes was found in 9.1% of OASIS cases, occipitoposterior position was found in 9.1% of cases. Induced labour took place in 39.4%, and oxytocin infusion was applied in 60.6% of OASIS cases. Vacuum extraction was performed in 12.1% of deliveries with OASIS. The average BMI in 3a and 3b injuries was 29.9. In 3c degree it was 28.0, and in the fourth degree, it was 32.1. In 27.0% of OASIS cases due to the extent of the injury surgeon engagement was necessary. When compared with vaginal deliveries in 2012 we found a significant increase in OASIS in primiparas, large for gestational age, occipitoposterior position, induced labour, vacuum extraction and hypertension (P < 0.01). There is also increased incidence of OASIS in episiotomy and oxytocin use group (P < 0.05).CONCLUSION: Low incidence of OASIS in our department is a result of active management of delivery, manual perineal protection and timely episiotomy.

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Evaluation of Suzor forceps training by studying obstetric anal sphincter injuries: a retrospective study

BMC Pregnancy and Childbirth ◽

10.1186/s12884-020-03358-0 ◽

2020 ◽

Vol 20 (1) ◽

Author(s):

Perrine COSTE MAZEAU ◽

Nedjma BOUKEFFA ◽

Nathalie TICAUD BOILEAU ◽

Samantha HUET ◽

Maud TRAVERSE ◽

...

Keyword(s):

Risk Factors ◽

Body Mass Index ◽

Retrospective Study ◽

Observational Study ◽

Anal Sphincter ◽

University Hospital ◽

Obstetric Anal Sphincter Injuries ◽

Fourth Degree ◽

Perineal Tears ◽

Vacuum Extractor

Abstract Background Instrumental deliveries are an unavoidable part of obstetric practice. Dedicated training is needed for each instrument. To identify when a trainee resident can be entrusted with instrumental deliveries by Suzor forceps by studying obstetric anal sphincter injuries. Methods A French retrospective observational study of obstetric anal sphincter injuries due to Suzor forceps deliveries performed by trainee residents was conducted from November 2008 to November 2016 at Limoges University Hospital. Perineal lesion risk factors were studied. Sequential use of a vacuum extractor and then forceps was also analyzed. Results Twenty-one residents performed 1530 instrumental deliveries, which included 1164 (76.1%) using forceps and 89 (5.8%) with sequential use of a vacuum extractor and then forceps. Third and fourth degree perineal tears were diagnosed in 82 patients (6.5%). Residents caused fewer obstetric anal sphincter injuries after 23.82 (+/− 0.8) deliveries by forceps (p = 0.0041), or after 2.36 (+/− 0.7) semesters of obstetrical experience (p = 0.0007). No obese patient (body mass index> 30) presented obstetric anal sphincter injuries (p = 0.0013). There were significantly fewer obstetric anal sphincter injuries after performance of episiotomy (p < 0.0001), and more lesions in the case of the occipito-sacral position (p = 0.028). Analysis of sequential instrumentation did not find any additional associated risk. Conclusion Training in the use of Suzor forceps requires extended mentoring in order to reduce obstetric anal sphincter injuries. A stable level of competence was found after the execution of at least 24 forceps deliveries or after 3 semesters (18 months) of obstetrical experience.

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