Anal Sphincter Rupture Research Articles

Symptoms after obstetric sphincter injuries have little effect on quality of life

To compare the prevalence of anal incontinence and dyspareunia in women with or without obstetric sphincter injury after standardizing the suture technique. Retrospective case-control study. Regional hospital, Sweden. 305 women with an obstetric sphincter injury and 297 women with spontaneous vaginal delivery. In order to standardize and improve the repairing skills of sphincter injuries, collaboration between obstetricians and colorectal surgeons was begun in 2000. Inner and external sphincters were repaired in two layers with continuous monofilament polidioxane sutures. The participating women received a questionnaire with validated questions on anal incontinence, dyspareunia and quality of life. The follow-up time was 15 months to 8 years. Anal incontinence, dyspareunia and quality of life. Of the sphincter group, 72% returned the questionnaire, as did 67% in the control group. Significantly more women in the sphincter group suffered from incontinence of flatus and loose stool compared to controls (p < 0.05). There was no significant difference of incontinence of solid stool, soiling, or fecal urgency between the groups. The quality of life questions showed no significant difference between the groups. In the sphincter group, there was significantly more superficial coital pain compared to controls (p= 0.02). Significantly more women with complete sphincter injury reported anal incontinence than women with a partial sphincter injury. In spite of increased rate of anal incontinence and dyspareunia after anal sphincter rupture, there was no statistically significant reduction in the women's quality of life.

Risk factors of recurrent anal sphincter ruptures: a population‐based cohort study

To determine the incidence and risk factors of recurrent anal sphincter rupture (ASR). Population-based retrospective cohort study. Data were taken from the National Medical Birth Registry, Denmark. Patients with a first and a second vaginal delivery in the time period 1997-2010. Univariate analysis and multivariate logistic regression were used to determine risk factors of recurrent ASR. The incidence of recurrent ASR and odds ratios for possible risk factors of recurrent ASR: age, body mass index, grade of ASR, birthweight, head circumference, gestational age, presentation, induction of labour, oxytocin augmentation, epidural, episiotomy, vacuum extraction, forceps, shoulder dystocia, delivery interval and year of second delivery. Out of 159 446 women, 7336 (4.6%) experienced an ASR at first delivery, and 521 (7.1%) had a recurrent ASR (OR 5.91). The risk factors of recurrent ASR in the multivariate analysis were: birthweight (adjusted OR, aOR, 2.94 per increasing kg, 95% CI 2.31-3.75); vacuum extraction (aOR 2.96, 95% CI 2.03-4.31); shoulder dystocia (aOR 1.98, 95% CI 1.11-3.54); delivery interval (aOR 1.08 by year, 95% CI 1.02-1.15); year of second delivery (aOR 1.06, 95% CI 1.03-1.09); and prior fourth-degree ASR (aOR 1.72, 95% CI 1.28-2.29). Head circumference was a protective factor (aOR 0.91 per increasing cm, 95% CI 0.85-0.98). The incidence of recurrent ASR was 7.1%. Risk factors of recurrent ASR were excessive birthweight, vacuum extraction, shoulder dystocia, delivery interval, year of second delivery and prior fourth-degree ASR. A larger head circumference reduced the risk of recurrent ASR.

Glove Port Technique for Transanal Endoscopic Microsurgery

Introduction. Despite initial enthusiasm, the use of transanal endoscopic microsurgery (TEM) is still quite limited at present because of the expense of highly specialized equipment and the complexity of the learning curve. Furthermore, some authors report a relevant, although temporary, effect on anorectal function because of the considerable anal dilatation which can even produce a rupture of the internal anal sphincter. The “glove TEM” proposes itself as an alternative to traditional TEM that could settle these problems. Materials and Methods. The technique is accurately described together with the necessary equipment to perform it. Between 2011 and 2012, we operated eight patients with this technique for rectal adenomas or early carcinomas achieving R0 resection in all cases and reporting no early or late complications during the first five months of followup. Discussion. This technique offers multiple advantages compared to the original TEM. (i) It allows the use of all available laparoscopic instruments. (ii) It gives a great manoeuvrability of the instruments in contrast to rigid rectoscope systems. (iii) Given the limited length of the device, it permits to operate on tumors closer to the dentate line. (iv) It is less traumatic to the anal sphincter. It is definitively much cheaper. Conclusions. We believe that this new technique is easy to perform, cost-effective, and less traumatic to the anal sphincter compared to traditional TEM.

Experiences of expert midwives in a training program aimed at decreasing perineal tears

This descriptive study explored the roles and responsibilities of expert midwives involved in teaching staff from midwifery students to senior consultants/physicians. We have earlier conducted an intervention project, aimed at decreasing the number of anal sphincter tears. During this intervention a local core team of expert midwives was established. These experts continued the training of colleagues after the midwife instructor had fulfilled the active training period. Eighteen expert midwives from the four Norwegian hospitals which took part in this training program were recruited. To explore the views and experiences of these expert midwives, a questionnaire was completed, and the results were analyzed qualitatively. Before starting the program 24% of the midwives, working at the delivery ward were negative towards the supervision and project, while 46% were positive. One year after the program’s start 92% were positive.Negative feedback at the beginning of the intervention came mostly from the media and professional midwifery organizations. The expert midwives felt that doctors were the most challenging to teach. The response from pregnant women was ultimately positive.Eighteen well motivated midwives became highly appreciated experts after an intensive training program and deemed themselves better and more successful professionals than before. Key words: Delivery, anal sphincter rupture, prevention, qualitative research, interdisciplinary education.

Morbidité périnéale des extractions instrumentales par spatules et ventouses : qu’en est-il réellement ?

To evaluate the perineal morbidity of operative vaginal delivery using spatulas and vacuum. From December 2008 to May 2010, 419 single pregnancies after 37 weeks of gestation in cephalic position were prospectively included: 226 spontaneous vaginal deliveries and 193 operative vaginal deliveries (126 spatulas and 67 vacuum). Each patient had rigorous clinical examination of the perineum. Perineal tears were classified in four different degrees depending on their severity: injury to skin only or episiotomy, injury to the perineum involving perineal muscles, anal sphincter rupture without and with anal epithelium tear, respectively. The rate of second degree or more perineal tear among patients who had spontaneous vaginal delivery, operative vaginal delivery using spatulas and vacuum was: 5.9%, 27% and 28.6%, respectively (p<0.001). If no significant difference was observed between the rate of perineal damages after spatulas and vacuum, compared to spontaneous vaginal delivery, only spatulas were significantly associated to the risk of third degree or more perineal damage: 2 (0.9%) vs. 6 (5.2%), respectively (p=0.022). Only operative vaginal delivery was identified as an independent risk factor for second degree or more perineal tear (AOR: 4.589; 95%CI: 2.012-10.467; p<0.001). Episiotomy had no independent significant impact on that risk (AOR: 0.690; 95%CI: 0.350-1.359; p=0.283). Operative vaginal delivery using spatulas and vacuum does significantly increase perineal morbidity. This risk appears to be independent of the practice of episiotomy.

High episiotomy rate protects from obstetric anal sphincter ruptures: A birth register-study on delivery intervention policies in Finland

To assess the impact of hospital episiotomy policy on obstetric and anal sphincter rupture (OASR, n = 2448) rates and risks among singleton vaginal deliveries in Finland between 1997 and 2007. An observational, retrospective, population-based register study. All 424,297 women in hospitals with more than 1000 deliveries annually, were divided into three groups based on the episiotomy rate quartiles for 11 years and separated on the basis of whether the women were primiparous or multiparous. The lowest and the highest quartiles were compared against the hospitals with intermediate episiotomy rates, comprising the two quartiles around the median. Stepwise logistic regression analysis was used to adjust significant risk factors. The annual range of episiotomy varied from 11 to 94% in primiparous women, and from 1 to 46% in multiparous women. After adjustment the risk of OASR appears to be 39% lower (OR 0.61, 95% CI 0.52-0.90) in primiparous and 45% lower (OR 0.55, 95% CI 0.42-0.72) in multiparous women delivered in the highest quartile hospitals. At an individual level, episiotomy was a protective factor (OR 0.82, 95% CI 0.75-0.91) in primiparous women, but increased the risk by 2.36-fold in multiparous women (OR 2.36, 95% CI 1.86-2.84). The results suggest that high episiotomy rate provided protection from OASR among both groups of women. Among the multiparous women, the 2.4-fold risk of OASR related to episiotomy at an individual level might be explained by confounding by indication, since episiotomy was performed more often to women at a high risk of OASR.

Prevalence and risk factors for anal incontinence after obstetric anal sphincter rupture

To study prevalence and risk factors for anal incontinence (AI) after obstetric anal sphincter rupture. This was a retrospective clinical observational study. Among 14 959 vaginal deliveries, 591 women were diagnosed with obstetric anal sphincter ruptures (3.9%) at one Norwegian University Hospital in 2003-2005. Patients were examined and interviewed approximately 10 months after delivery. Anal continence was classified with St. Mark's incontinence score (0, complete anal continence; ≥3, anal incontinence), and defects in anal sphincter muscles were diagnosed by endoanal ultrasound. Prevalence of anal incontinence was assessed in relation to obstetrical and maternal characteristics as well as the correlation between anal incontinence and ultrasound-detectable defects of sphincter muscle. Anal incontinence with a St. Mark's score of ≥3 was reported by 21% of women with obstetric anal sphincter rupture, with inability to control gas as the most prevalent symptom. Women with AI were more likely to report urinary incontinence compared with women having no AI. In a multiple regression analysis of maternal and obstetrical risk factors, fourth degree sphincter tear was the only significant risk factor for AI. Anal incontinence was more frequent in patients diagnosed with than without ultrasound-identified anal sphincter muscle defects at 10 months postpartum follow-up. Anal as well as urinary incontinence after delivery with obstetric anal sphincter rupture is common, and prenatal obstetric and maternal variables could not predict anal incontinence. Fourth degree perineal tear and a persistent ultrasound-detected defect in the anal sphincter muscles are associated with AI.

Improvement of Recto-anal Function after Successful Two-tage Surgery for External Injury-related Anal Sphincter Rupture: A Case Report

症例は24歳女性でジェットスキーから転落し，外傷性ショックの状態で他院救急搬送となった．直腸膀胱腟壁損傷と診断され，損傷部の可及的な縫合閉鎖，ドレナージおよびS状結腸人工肛門造設術が施行された．膀胱機能は改善したものの括約筋断裂によって肛門機能は廃絶状態となり，受傷から3カ月後に当院紹介となった．排便造影で安静時に粘性造影剤の直腸内保持は不可能で完全便失禁であった．しかし恥骨直腸筋のわずかな動きと筋電図で断裂した括約筋の一部に収縮波を認めたため括約筋訓練を行った．2カ月後に最大随意圧の上昇を確認，また造影剤の直腸内保持が短時間ではあるが可能であり，恥骨直腸筋の収縮と超音波で断裂部の瘢痕組織への置換が確認された．受傷から6カ月後に瘢痕組織を用いた括約筋前方形成術，9カ月後に括約筋後方形成術と括約筋人工靭帯形成術を実施した．受傷から17カ月後に人工肛門を閉鎖し，便失禁もみられず経過は順調である．

Complete rupture of anal sphincter in primiparas: long‐term effects and subsequent delivery

To study long-term effects with respect to anal incontinence, pain, attitude to and mode of second delivery following complete rupture of the anal sphincter. Case-control study. Settings. Södersjukhuset, a university hospital in Stockholm. A case group of 136 primiparas who had experienced a complete rupture of the anal sphincter. Two matched control groups of primiparas, one of whom had cesarean section and the other a normal vaginal delivery. The case women were examined and asked for symptoms of anal incontinence 3-6 months after delivery; 3-8 years later they and two matched control groups answered a postal questionnaire. Response rate was 89%. Symptoms of pelvic floor dysfunction and, as secondary end-point, the attitude to and mode of second delivery. Anal incontinence after delivery was reported by 31% in the case group, and at long-term follow-up by 54% in the case group, 21% in the cesarean section and 23% in the normal delivery group (p < 0.0001). A wish to postpone or abandon further childbirth was significantly more common in the case women (33 and 18%) than in the other groups, but about 60% delivered again in all groups. In the case group, the next delivery was by cesarean section in 49%. At long-term follow-up after a complete rupture of the anal sphincter, anal incontinence was common and many women wished to postpone or avoid further delivery.

The overlap technique versus end‐to‐end approximation technique for primary repair of obstetric anal sphincter rupture: a randomized controlled study

To compare the outcome of end-to-end approximation versus the overlap technique for primary repair of obstetric anal sphincter rupture (OASR) at 12 month follow-up. Prospective, randomized controlled study. University hospital. Sample. One hundred and twenty-eight patients with grade 3b, 3c or 4 OASR were randomized; 119 (end-to-end 60, overlap 59) received the allocated treatment. We obtained information concerning fecal incontinence from 101 (85%) patients. The obstetric team on call performed the repairs. Wexner score, endoanal ultrasound (EAUS), and manometry were used to evaluate anal sphincter function at 12 months post-surgery. Primary outcome was incidence of solid stool leakage at least once a week. Secondary outcomes were flatus incontinence, Wexner score, external anal muscle defect examined by EAUS, and anal manometry results. One patient in the end-to-end group and none in the overlap group reported leakage of solid stool once a week or more. Fourteen patients in the end-to-end group and 10 in the overlap group reported flatus incontinence (p = 0.48). Mean Wexner score was similar in both groups, 2.4 versus 2.2. One patient in the end-to-end group and none in the overlap group had a Wexner score >10 (severe anal incontinence) (NS). External sphincter defect was found in 2/46 in the end-to-end group compared to 0/41 in the overlap group (NS). Anal manometry findings were similar in both groups. The overlap repair was not superior to the approximation technique with regard to fecal incontinence at 12 months.

Anorectal Functional Results After Transanal Endoscopic Microsurgery in Benign and Early Malignant Tumors

Transanal endoscopic microsurgery (TEM) has been suggested as a minimally invasive procedure of low morbidity for rectal villous adenomas and early anorectal adenocarcinomas. It has been used clinically in many areas outside of China for more than 20 years, but it began in mainland China only about 2 years ago. Some articles have reported excellent results with regard to morbidity and relapse rate with TEM, but there are no studies addressing its functional results in China until now. The aim of the present study was to analyze the effect of TEM on the manometric results. Thirty-seven patients (16 females, 21 males) underwent TEM and were followed for more than 6 months. Anorectal manometry and an incontinence questionnaire were administered 1 week preoperatively, 2 weeks postoperatively, 3 and 6 months postoperatively. Of the 37 patients, 24 had villous adenomas and 13 had adenocarcinomas (11 uT1 and 2 uT2). Anorectal manometric values showed the mean anal resting pressure (ARP) decrease from 45 +/- 6 mmHg to 29 +/- 4 mmHg (p < 0.05) and the maximum tolerable volume (MTV) decrease from 175 +/- 21 ml to 90 +/- 15 ml (p < 0.05) at the third month after TEM. Maximal squeeze pressure (MSP) decreased from 181 +/- 20 mmHg to 92 +/- 14 mmHg (p < 0.05) at second week after operation and returned to normal value by the third postoperative month. The ARP and MTV were 45 +/- 5 mmHg and 177 +/- 21 ml, respectively, at 6 months after TEM, near the normal value (p > 0.05). Rectoanal inhibitory reflex (RAIR) was absent preoperatively in two patients; it was also absent in 10 patients 3 months postoperatively and in three patients 6 months postoperatively. Endosonography demonstrated internal anal sphincter (IAS) rupture in five patients, and full integrity of the external anal sphincter (EAS) in all patients. Of the five patients with IAS rupture, four had temporary incontinence to flatus normalized up to three postoperative months. Most patients had more times of stools per day and relative higher Wexner scores in a short period after TEM. All these patients were followed for 6-20 months with no incidence of relapse. Anorectal function was preserved well after TEM, although some anorectal manometric parameters changed over time. Thus TEM is safe, in terms of anorectal function, for the cure of benign and early malignant tumors of the rectum.

What harm does a second delivery to the pelvic floor?

ObjectiveTo compare the pelvic floor function of primiparous women to women after a second delivery regarding symptoms of urinary and anal incontinence, anal sphincter ruptures and bladder-neck mobility.MethodsA questionnaire evaluating symptoms of urinary and anal incontinence was used in nulliparous women before and 27 months after childbirth. Furthermore these symptoms were correlated with functional changes of the pelvic floor based on a careful gynecologic examination as well as perineal and endoanal ultrasound.Results112 nulliparous women were included, 49 women returned for follow-up on average 27 months (SD 4.4 months) after the first delivery. 39 women (group A) had just one delivery, 10 women (group B - 10/49) had had a second delivery. Apart from levator ani muscle strength, no significant difference between pelvic floor function of group A vs group B was demonstrable. Furthermore, we could show no significant difference for symptoms of urinary (11 (28.2%) vs. 5 (50.0%)) and anal incontinence (14 (35.9%) vs. 4 (40.0%)) between both groups. However, we found a lasting increase of stress urinary and anal incontinence as well as overactive bladder symptoms after one or more deliveries. The position of the bladder neck at rest was lower in both groups compared to the position before the first delivery and bladder neck mobility increased after one or more deliveries.DiscussionOur study shows several statistically significant changes of the pelvic floor function even on average 27 months after delivery, but a subsequent delivery did not compromise the pelvic floor any further.

The role of nocturnal delivery and delivery during the holiday period in Finland on obstetric anal sphincter rupture rates- a population based observational study

BackgroundObstetric anal sphincter rupture (OASR) is a serious complication of delivery, which frequently results in faecal incontinence despite primary repair and has serious implications for women's health. The objective of this study was to assess whether human factors, workload and staffing at night, at weekends and during holidays has an effect on the increasing OASR rates among all singleton vaginal deliveries (n = 514,741) having occurred between 1997 and 2007 in Finland. Women (n = 2,849) with OASR were compared in terms of possible risk factors to women without OASR using stepwise logistic regression analysis.FindingsIn Finland, the increase in OASR rate is striking, from 0.2% in 1997 to 0.9% in 2007. OASR rates varied from 0.49% to 0.58% (≤ 0.001) according to the time of day, and were lowest at night. After adjustment for patient-mix and the use of interventions, the risk of OASR was 11% lower (95% CI 3-18%) at night and 15% lower (95% CI 3-26%) in July - the main holiday month. Only 14% of the increased OASR risk during the day time (8-23.59) was attributable to vacuum assistance and birth weight, whereas the holiday period had no effect.ConclusionsDecreased OASR rates at night and in July suggest that human factors such as decreased alertness due to fatigue or hospitals' administrative factors such as workload and staffing did not increase the rates of OASR.

Defects on endoanal ultrasound and anal incontinence after primary repair of fourth‐degree anal sphincter rupture: a study of the anal sphincter complex and puborectal muscle

To perform three-dimensional endoanal ultrasound (EAUS) after primary repair of fourth-degree anal sphincter rupture (ASR) and correlate the sonographic defects with anal incontinence (AI); to measure the axial and sagittal thickness and angle of the puborectal muscle (PRM) as well as the length of the anal canal, and then correlate these measures with AI; and to assess the interobserver measurement agreement between an inexperienced and an experienced sonologist. EAUS was offered to 84 consecutive women, who were asked to answer a validated questionnaire after fourth-degree ASR. AI was graded according to the Wexner score and EAUS defects were graded according to the Starck score. Sixty-one women (73%) answered the questionnaire. The median (range) follow-up time was 5.1 (1.3-8.7) years. Thirty-three (54%) of these women underwent EAUS and were included in the study. There was no difference in the incontinence scores between women who underwent EAUS and those who did not. Eleven of the women who underwent EAUS (33%) were continent, 22 women (67%) had flatus incontinence at least once a month, of whom 12 also had incontinence for liquid stool and two had incontinence for solid stool. The median Wexner score was 2 (range, 0-12). Five of the patients (15%) had no ultrasound defects. All of the patients with Wexner scores > or = 4 had a Starck score of > or = 10. No association between ultrasound defects and AI was demonstrated, however, the angle of the PRM and parity were associated with Starck score. No clear association between the measurements of the PRM and AI was shown. The experienced observer detected more of the small defects than did the inexperienced observer. In a 1-9-year follow-up period after primary suture of fourth-degree ASR, the frequency of AI was high, at 67%. No clear association was seen between AI and sphincter defects detected on ultrasonography. There was an association between the angle of the PRM and the extent of ultrasound defects.

Lateral episiotomy protects primiparous but not multiparous women from obstetric anal sphincter rupture

To identify the risk factors for obstetric anal sphincter rupture (OASR). Retrospective population-based register study. A total of 514,741 women with singleton pregnancy and vaginal delivery between 1997 and 2007 in Finland. Primiparous (n = 2,315) and multiparous women (n = 534) with OASR were compared with primiparous and multiparous women without OASR by using stepwise logistic regression analysis. The OASR risk. Episiotomy decreased the likelihood of OASR for the primiparous [odds ratio (OR) 0.83, 95% CI (confidence interval) 0.75-0.92], but not the multiparous women (OR 2.01, 95% CI 1.67-2.44). The strongest risk factors for OASR among the primiparous women were forceps delivery (OR 10.20, 95% CI 3.60-28.90), birth weight over 4,000 g (OR 4.66, 95% CI 3.86-5.63), vacuum assisted delivery (OR 3.88, 95% CI 3.25-4.63), occiput posterior presentation (OR 3.17, 95% CI 1.64-6.15), and prolonged active second stage of birth (OR 2.06, 95% CI 1.65-2.58). Episiotomy was associated with decreased risks for OASR in vacuum assisted deliveries (OR 0.70, 95% CI 0.57-0.85). Risk factors for OASR among the multiparous women included forceps delivery (OR 10.13, 95% CI 2.46-41.81), prolonged active second stage of the birth (OR 7.18, 95% CI 4.32-11.91), birth weight over 4,000 g (OR 5.84, 95% CI 3.40-10.02), and vacuum assisted delivery (OR 4.17, 95% CI 3.17-5.48). The results support the restrictive use of episiotomy, since 909 episiotomies appear to be needed to prevent one OASR among primiparous women. Equivalent estimate in vacuum assisted deliveries among primiparous women was 66, favoring routine use of episiotomy in such cases.

The increased incidence of obstetric anal sphincter rupture — An emerging trend in Finland

Objective To describe recent trends in the prevalence and risk factors of obstetric anal sphincter ruptures during between 1997 and 2007 in Finland. Method We analyzed a population-based register of 514,741 women with singleton vaginal deliveries recorded in the Finnish Medical Birth Register. Primiparous ( n = 2315) and multiparous women ( n = 534) with anal rupture compared in terms of possible risk factors to primiparous ( n = 215,463) and multiparous ( n = 296,429) women without anal rupture, respectively, using stepwise logistic regression analysis. Results The occurrence of anal rupture increased from 0.5% in 1997–1999 to 1.8% in 2006–2007 among primiparous women, and from 0.1% in 1997–2001 to 0.3% in 2006–2007 among multiparous women. Over the study period, the likelihood of women having anal rupture in these groups increased by a factor of 3.28 (95% CI 2.86–3.76) and 2.83 (95% CI 2.19–3.67), respectively, after adjustments for strong associations with many known risks. Changes in population characteristics and in the use of interventions were small, and these did not cause the increased anal rupture rate. The only exception was vacuum-assisted deliveries, which explained about 9% of the rising anal rupture risk. Conclusions The current obstetric practice is not optimal for protecting the perineum and reflects the need to standardise obstetric care.

Changing incidence of anal sphincter tears in four Nordic countries through the last decades

Objectives Anal sphincter rupture is a serious complication of a vaginal delivery. A considerable number of women suffer permanent anal incontinence after this type of injury. The incidence of sphincter tears is believed to have increased over several decades in Denmark, Norway, Sweden and Finland, but there seem to be significant differences in the incidence rates among these countries. The aim of this study is to compare frequency of anal sphincter tears among the four Nordic countries, and to discuss the possible reasons for the development. Study design Ecological register study. Anal sphincter ruptures are registered as third and fourth degree perineal tears in the national birth and hospital registries in the Nordic countries. Data from these registries were sampled from Denmark, Finland, Norway and Sweden. The incidences of anal sphincter ruptures were calculated as percentages of all vaginal deliveries and caesarean sections were excluded. The test of relative proportions, Chi-square and linear regression modelling were used to study the difference between countries and time trends. Results The frequency of anal sphincter rupture was significantly higher in three countries, Denmark 3.6%, Norway 4.1% and Sweden 4.2%, compared to Finland 0.6%. The trend was clearly increasing from the early 1970s in all countries. Conclusions There is a significant difference in the Nordic countries in the incidence of anal sphincter tears and a significant increment in the incidence over three decades. Our hypothesis is that change in the routines during labour may be one reason for this increment. Higher episiotomy frequency in Finland may be one contributing reason. We assume that there has been a change in the conduct of labour during the last decades, and protecting the perineum may have lost its importance in the three Nordic countries, while the classic method of protecting perineum is still in use in Finland.

The Danish anal sphincter rupture questionnaire: Validity and reliability

To revise, validate and test for reliability an anal sphincter rupture questionnaire in relation to construct, content and face validity. SETTING AND BACKGROUND: Since 1996 women with anal sphincter rupture (ASR) at one of the public university hospitals in Copenhagen, Denmark have been offered pelvic floor muscle examination and instruction by a specialist physiotherapist. In relation to that, a non-validated questionnaire about anal and urinary incontinence was to be answered six months after childbirth. The original questionnaire was revised and a pilot test was performed among health care personnel, followed by an expert panel discussion. Ten women were interviewed about their understanding and attitude toward answering the questionnaire and it was pre-tested on 52 women with ASR. The questionnaire was revised five times during the validation process. The final version was test-retested among 20 women with ASR. The questionnaire revealed typical problems after ASR. The length, use of language, and the way the questionnaire was constructed, was deemed appropriate. The reliability test showed good to very good correlation (Kappa values from 0.733 to 0.923) in all main questions but one. Two questions needed further explanation. Seven women made minor errors. The validated Danish questionnaire has a good construct, content and face validity. It is a well accepted, reliable, simple and clinically relevant screening tool. It reveals physical problems including sexual problems, impact on quality of life and need for treatment among women 6-8 months after ASR.

Episiotomy: What's the angle?

In part four of his treatise, The Law, Hippocrates states: “There are in fact two things, science and opinion; the first begets knowledge, the second ignorance.” In this issue of the Journal, Kalis and colleagues [1] provide scientific data concerning an important issue that has been debated for many years: whether the angle of mediolateral incision when the fetal head is distending the perineum is different from the angle of the wound after the neonate has been delivered. Although at first this may seem to be a semantic argument, it has great importance. When an episiotomy is needed, some clinicians choose a mediolateral rather than a midline episiotomy, primarily to reduce the chance of anal sphincter rupture since it is well established that midline episiotomy carries a higher risk of sphincter laceration. This is a highly relevant issue because sphincter lacerations increase the chance that a woman may suffer fecal incontinence. The angle at which an episiotomy can be made is a continuous variable. If we consider midline to be 0 degrees and a lateral episiotomy (never used today) to be 90 degrees, then it is theoretically possible to choose any angle from 0 to 90 degrees. Which angle should we choose? If a mediolateral episiotomy is performed to reduce anal sphincter injury, then this angle must be great enough that the incision and any potential subsequent tearing are far enough away from the anal sphincters that they are not injured. Statements quoted in Kalis et al. [1] suggest specific angles to be used when employing the mediolateral technique.

Decreasing the Incidence of Anal Sphincter Tears During Delivery

To estimate if an interventional program causes a decrease in the frequency of anal sphincter ruptures. A total of 12,369 vaginal deliveries between 2002 and March 2007 were enrolled in the interventional cohort study. Slowing the delivery of the infant's head and instructing the mother not to push while the head is delivered was the intervention. Data were analyzed in relation to occurrence of anal sphincter tears. The proportion of parturients with anal sphincter tears decreased significantly during the study period from 4.03% (285 of 7,069) to 1.17% (42 of 3,577) (P<.001). A similar decrease was observed for instrumental deliveries (from 16.26% to 4.90%; P<.001) and noninstrumental deliveries (from 2.70% to 0.72%; P<.001). Although the number of patients with fourth-degree anal sphincter ruptures from 2002 through 2004 was 10, 13, and 11 per year, respectively, there was just one fourth-degree anal sphincter rupture during the whole study period of 18 months (P<.001). The number of episiotomies increased from 13.9% (980 of 7,069) in the years 2002-2004, to 23.1% during the first 9 months of the intervention (416 of 1,776; P<.001), but decreased to 21.1% (381 of 1,801) during the last 9 months of the intervention. As a result of this intervention the number of anal sphincter ruptures was reduced from 4.03% to 1.17%. II.