Repair Of Obstetric Anal Sphincter Injuries Research Articles

Perineoplasty for anal incontinence after obstetric anal sphincter injury repair: a case report

BackgroundThe rectal and vaginal walls are typically sutured if severe perineal lacerations with rectal mucosal damage occur during vaginal delivery. In case of anal incontinence after the repair, re-suturing of the anal sphincter muscle is standard procedure. However, this procedure may not result in sufficient improvement of function.Case presentationA 41-year-old woman underwent suture repair of the vaginal and rectal walls for fourth-degree perineal laceration at delivery. She was referred to our department after complaining of flatus and fecal incontinence. Her Wexner score was 15 points. Examination revealed decreased anal tonus and weak contractions on the ventral side. We diagnosed anal incontinence due to sphincter dysfunction after repair of a perineal laceration at delivery. We subsequently performed sphincter re-suturing with perineoplasty to restructure the perineal body by suturing the fascia located lateral to the perineal body and running in a ventral–dorsal direction, which filled the space between the anus and vagina and increased anal tonus. One month after surgery, the symptoms of anal incontinence disappeared (the Wexner score lowered to 0 points), and the anorectal manometry values increased compared to the preoperative values. According to recent reports on the anatomy of the female perineal region, bulbospongiosus muscle in women does not move toward the midline to attach to the perineal body, as has been previously believed. Instead, it attaches to the ipsilateral surface of the external anal sphincter. We consider the fascia lateral to the perineal body to be the fascia of the bulbospongiosus muscle.ConclusionsIn a case of postpartum anal incontinence due to sphincter dysfunction after repair of severe perineal laceration, perineoplasty with re-suturing an anal sphincter muscle resulted in improvement in anal sphincter function. Compared to conventional simple suture repair of the rectal wall only, this surgical technique may improve sphincter function to a greater degree.

Obstetric Anal Sphincter Injury Management at a Tertiary Academic Birthing Center: A Quality Improvement Initiative [ID 2683441

INTRODUCTION: As a quality improvement project, we implemented an evidence-based management protocol to optimize outcomes after obstetric anal sphincter injuries (OASIS). The aim was to evaluate compliance with practice guidelines for antibiotic use, standardized surgical technique and documentation, utilization of a bowel regimen, and short-term outpatient follow-up after a resident educational OASIS program. METHODS: An OASIS practice guideline was implemented via a curriculum utilizing didactics and simulation with porcine sphincter models to demonstrate primary prevention, proper diagnosis, repair technique, documentation, and post-procedure OASIS management. Pre (August 2018 to July 2022) and post-intervention (August 2022 to July 2023) cohorts were compared for characteristics and provider adherence to guidelines. We used control charts, chi-squared, and Student's t-tests to estimate the effect of the intervention. RESULTS: Among 226 OASIS cases, 168 were pre-intervention and 58 were post-intervention. Proper documentation of OASIS repair increased from 13 (7.7%) pre-intervention to 24 (41.4%) post-intervention (risk ratio [RR] 7.57; 95% CI, 4.3–13.1); proper antibiotic use increased from 79 (47.0%) pre-intervention to 39 (67.2%) post-intervention (RR 1.42; CI, 1.12–1.18); and utilization of bowel regimen increased from 147 (87.5%) to 56 (96.6%) post-intervention (RR 1.1; CI, 1.02–1.18). There was no change in close follow-up appointment attendance (81.0% for both groups; P=.98). Control charts showed a process change in bowel regimen use and OASIS documentation, but no significant change in antibiotic use or close follow-up appointments. CONCLUSION: Implementation of an evidence-based management guideline was associated with increased compliance with evidence-based practices. Future improvement cycles are necessary to optimize outpatient follow-up after OASIS.

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

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). 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. 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. 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.

UK survey of colorectal surgeons on the management of acute obstetric anal sphincter injuries.

The role of colorectal surgeons in the management of acute obstetric anal sphincter injury (OASI) is an ongoing debate. Their expertise in operating in the anorectal region lends itself to assisting in OASI repair. The aim of this study was to establish the current involvement and recommended management of acute OASI by colorectal surgeons. An online survey of consultant colorectal surgeons was sent to members of the Pelvic Floor Society to assess current involvement in acute OASI management and repair. Forty completed surveys were collated and analysed. Sixty-five per cent of respondents had seen an acute OASI since being a consultant and 50% stated they were involved in the repair of OASI less than once per year. 37.5% felt that a de-functioning stoma was still necessary sometimes. Many agreed with current guidelines for OASI repair in terms of antibiotics, laxatives and follow-up. Colorectal surgeons have varied opinions on the management of OASI. We suggest that multidisciplinary training of obstetricians and colorectal surgeons could lead to more collaboration regarding the management of women with acute OASI.

Episiotomy: Are Indian Obstetricians Getting the Angle Right?

Abstract Background A mediolateral episiotomy is recommended when indicated at a 60° angle at crowning, to avoid obstetric anal sphincter injuries (OASIs) by episiotomies angled too close or distant to the anus. This study surveyed obstetricians in India regarding the recommended episiotomy angle and their ability to correctly draw the angle. Methods Workshops were conducted in India to share knowledge in the prevention and repair of OASIs. A questionnaire was distributed prior to the workshop. Participants were asked to describe the recommended episiotomy angle and to draw this on a paper replica of the perineum. The intra-class correlation coefficient (ICC) was calculated to assess the inter-rater reliability between the angle stated and drawn. A 2° difference was deemed acceptable. Standard errors of measurement (SEM) were calculated to measure the range of error of each measurement. Results One hundred and forty doctors participated. 47.9% described the angle of an episiotomy to be 60°. Only 2.2% drew an angle of 60°, but 8.7% (n = 12) drew between 58 and 62°. Only 5.8% (n = 6) of doctors correctly drew the episiotomy angle they described. There was poor agreement ICC = 0.18 (− 0.01 to 0.36) with a SEM of ± 12.2° Conclusions Knowledge surrounding the recommended episiotomy angle is lacking. Doctors are failing to estimate their desired episiotomy angle. This highlights the need for national guidelines, the creation and validation of structured training programmes to improve accuracy, or using fixed-angle devices such as the EPISCISSORS-60 or other proven measurement aids to minimise preventable harm due to human error.

Residents’ experience and training in obstetric anal sphincter injury repair in the United States

With the reduction in obstetric anal sphincter injuries (OASIS) cases, it is unknown if learning and exposure to their repair is compromised during obstetrics and gynecology (OBGYN) residency in the United States (US). The aim of this study was to evaluate the exposure and confidence level of the US OBGYN residents to OASIS repair. Residents’ education on OASIS repair was also assessed. This was a cross sectional online survey that collected residents’ demographics, characteristics of residency program, the number of deliveries and OASIS repairs performed, the site and technique of OASIS repair, post-repair care provided, residents’ confidence level in OASIS repair and their education on the repair. Descriptive analyses, Fisher’s Exact tests, Ordinal regression models and Spearman’s correlation were performed. Response from 160 residents (11% response rate) was obtained. Confidence was higher with increasing level of training (OR = 3.442, 95% CI, 2.473-4.791, p<0.004), a greater number of deliveries (OR=2.672, 95% CI, 1.511-4.723, p<0.001), third-degree repairs (OR=5.522, 95%CI, 3.67-8.308, p<0.001) and fourth-degree repairs (OR=4.364, 95% CI, 2.785-6.837, p<0.001) performed. Exposure to lecture or/and simulation improved confidence than no exposure to either (OR= 0.225, 95% CI, 0.092-0.545, p<0.001). Residents’ confidence level increased with a greater number of simulations attended (r=0.368, p< 0.001). Lectures and simulations enhance residents’ knowledge and skills in OASIS repair. Surgical skill curriculum is essential to maintain good quality training, prompt recognition, and meticulous perineal repair among OBGYN physicians despite the declining OASIS cases.

Follow up of women after obstetric anal sphincter injuries (OASI)-What is the role of anorectal testing?

To evaluate the benefit of performing anorectal studies on all women following primary obstetric anal sphincter injury (OASI) repair over performing them on symptomatic women only. Women who attended perineal clinic between 2007 and 2020 underwent symptom assessment and anorectal studies at 6 weeks and 6 months postpartum. Anorectal studies including endo anal ultrasound (EAUS) and anal manometry (AM) were performed. The anorectal studies of symptomatic women who were the case group, were compared with asymptomatic women who were the control group. A total of 1348 women were seen in the perineal clinic over 13 years. A total of 454 (33.7%) women were symptomatic. A total of 894 (66.3%) women were asymptomatic. A total of 313 (35%) asymptomatic women had two abnormal anorectal studies, 274 (31%) had abnormal AM alone, and 86 (9.6%) had abnormal EAUS alone. A total of 221 (24.7%) asymptomatic women had normal anorectal studies. Almost 70% of women were asymptomatic 6 months following primary OASI repair. Most had at least one abnormal anorectal study result. Selectively performing anorectal tests on symptomatic women would not identify asymptomatic women at risk of future faecal incontinence following further vaginal birth. Without anorectal study results, women would not receive accurate counseling about the risks of vaginal birth. Anorectal studies should be offered to all women following OASI where resources allow.

Development of a Departmental Resident Educational Program to Increase Knowledge and Confidence Related to Obstetric Anal Sphincter Injuries [ID: 1375536

INTRODUCTION: Obstetric anal sphincter injuries (OASIS) have been reported in up to 35% of vaginal deliveries; thus, understanding these injuries is a critical part of obstetrics and gynecology training. Formal educational programs with incorporated simulation training can have an advantageous effect, particularly when provided as part of residency education. This project seeks to evaluate the positive effect of departmental resident education related to OASIS, on confidence and knowledge of obstetrics and gynecology residents at Wake Forest University. METHODS: A structured OASIS curriculum was developed by the urogynecology program, including 2 hours of didactic lecture followed by stepwise simulation with swine models to demonstrate and practice anatomic repair techniques. Participants completed pre- and post-class surveys including skill confidence assessments via Likert scale (range 1–10), and standardized knowledge assessments adapted from ACOG Obstetric Laceration Repair Module, along with educational experience reports. These items were scored and analyzed. RESULTS: In August 2022, 16 residents (4 per residency year) participated. Prior to education, mean confidence level with techniques was 4.2 among all areas (range 1.6–7.4), with mean knowledge assessment score 64% (range 33–100%). Post-education, confidence improved across several domains including effectively applying perineal support (7.3–7.9), identifying lacerations and performing rectal examinations (6.1–8.0), and OASIS repair (1.9–5.4) (P<.05). Knowledge assessment scores remained similar, at 70% (P>.05). In qualitative analysis, all individuals reported beneficial aspects of the program. CONCLUSION: Introduction of an OASIS curriculum including repair simulation utilizing an animal model, increased resident skill confidence. Future research will investigate longitudinal data to improve outcomes.

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

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

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

Introduction and hypothesisMinorly 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.MethodsAn 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.ResultsSeventy-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].ConclusionsSurgeons 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.

Is there a role for transperineal ultrasound imaging of the anal sphincter immediately after primary repair of third degree tears?

ObjectiveWhen obstetric anal sphincter injuries are identified, it is crucial that the defects are repaired appropriately to achieve a better outcome. Although the presence of an intact anal sphincter is not the sole mechanism for maintaining continence, and not all women with an anal sphincter defect are symptomatic, there is an association between sphincter defects and anal incontinence. Our aim was to evaluate whether transperineal ultrasound (TPUS) is useful in assessing anal sphincter integrity immediately following primary repair of obstetric anal sphincter injuries (OASIs). Study DesignThis is a prospective observational study of women who sustained OASIs during their first vaginal delivery. Three dimensional (3D) TPUS was performed immediately after repair of OASIs to identify anal sphincter defects. A repeat TPUS was performed 12 weeks following repair. Results21 women sustained OASIs of whom 20 (95%) attended follow up. Eight (40%) had a grade 3a tear and 12 (60%) a 3b tear.8/20 (40%) women had residual external anal sphincter (EAS) defects identified by TPUS immediately after repair. Of these eight defects, six (75%) persisted at 12 weeks postpartum. No new defects were seen at follow up among the twelve women in whom no defect was seen immediately following the repair.Six residual EAS defects were found at 12 weeks postpartum. An EAS defect at 12 weeks postpartum was associated with anal incontinence (p = 0.04). Women with 3b tears were more likely to have anal incontinence (AI) and residual sonographic EAS defects when compared with 3a tears but this was not statistically significant. ConclusionsWomen who had no TPUS defect detected immediately following primary repair of OASIs, remained as such at 12 weeks postpartum. Of those in whom a defect was seen immediately after repair, it persisted in 75% of cases at 12 weeks. We believe that the value of TPUS immediately after repair appears to be limited and would need to be defined if it were to be considered for routine practice. Further research on its role immediately after repair of major tears (Grade 3C/4) is needed. In addition, performing ultrasound would require widespread training of obstetricians to develop expertise. This highlights the importance of adequate training of obstetricians in OASI repair.

Training in obstetric anal sphincter injuries in Australia and New Zealand: A survey of Royal Australian and New Zealand College of Obstetricians and Gynaecologists trainees.

Training in obstetric anal sphincter injuries (OASIS) in Australia and New Zealand relies upon consultant teaching and has not previously been assessed. The aims of this study are to establish if training in OASIS is consistent and optimal in Australia and New Zealand and to evaluate trainee perspectives on supervision and teaching, along with confidence in repairing OASIS. A descriptive cross-sectional study was performed. Royal Australian and New Zealand College of Obstetricians and Gynaecologists trainees were sent a 21-question survey. The survey was distributed to 725 trainees, and 132 trainees provided complete responses (18.2%). The main outcome measures were (i) comparison of confidence in performing a caesarean section versus OASIS repair and (ii) descriptive analysis of views towards training and suggestions for improvement. Trainees were significantly more confident in performing a caesarean section independently compared to OASIS repair (P<0.05). This was the case for all year groups. Confidence increased with each year of training. Only 62% reported credentialing at their site. Whereas 50% reported training at the time of first unsupervised repair as good or excellent, 22.7% felt it was suboptimal and 2.3% unsatisfactory; 75.8% had attended a workshop; 38.6% requested mandatory workshops. Requests included that workshops be yearly, include video training and be required at consultant level. Trainees asked for supervision despite credentialing and for separate credentialing for 3A/B- and 3C/4th-degree tears. Trainees have increasing confidence in their ability to independently perform OASIS repairs throughout training. They requested that improvements be made to training and that there be an increase in structured teaching.

Which factors are associated with anal incontinence after obstetric anal sphincter injury?

Obstetric anal sphincter injury (OASI) is an important factor in the etiology of anal incontinence. This study aimed to evaluate whether anal sphincter defects, levator avulsion or levator ballooning after OASI are associated with severity of anal incontinence. Furthermore, we evaluated whether factors such as constipation and altered stool consistency are associated with symptoms of incontinence after OASI. In this multicenter prospective observational cohort study, women with OASI were invited to participate at least 3 months after primary repair. All women completed validated questionnaires, including St Mark's incontinence score, Bristol stool scale (BSS) and Cleveland clinic constipation score (CCCS), and underwent four-dimensional (4D) transperineal ultrasound for assessment of the levator ani muscle and anal sphincter. In total, 220 women were included. Median follow-up was 4 months (range, 3-98 months). Univariate linear regression analysis showed an association of St Mark's incontinence score with a residual defect of the external anal sphincter (EAS) (β, 1.55 (95% CI, 0.04-3.07); P = 0.045), higher parity (β, 0.85 (95% CI, 0.02-1.67); P = 0.046), BSS (β, 1.28 (95% CI, 0.67-1.89); P < 0.001) and CCCS (β, 0.36 (95% CI, 0.18-0.54); P < 0.001). However, multivariate linear regression found an association of St Mark's incontinence score only with BSS (β, 1.50 (95% CI, 0.90-2.11); P < 0.001) and CCCS (β, 0.46 (95% CI, 0.29-0.63); P < 0.001). Residual defects of the EAS, detected on 4D transperineal ultrasound, are associated with severity of anal incontinence symptoms measured using St Mark's incontinence score 4 months after OASI repair. Furthermore, clinical factors such as constipation and altered stool consistency appear to influence this association and may therefore play a more important role in clinical management. © 2020 International Society of Ultrasound in Obstetrics and Gynecology.

Early secondary repair of obstetric anal sphincter injuries (OASIs): experience and a review of the literature.

Secondary anal sphincter repair for a dehisced obstetric anal sphincter injury (OASI) is required following 2.6% of primary repairs. There is growing evidence that instead of delaying repair for 3-6months, early secondary repair of the anal sphincter can be completed within 14days. Our aims were to review the literature and to describe experiences in our unit. This is a narrative review of all published cases reporting outcomes of early secondary repair of dehisced OASIs. In addition, we report a series from Croydon University Hospital (CUH) between 2010 and 2019. Ninety patients from five studies were identified on literature search. Six patients from CUH were included in the case series. Overall, the most common complications following secondary repair included skin dehiscence [10.3% (n= 10)], infection [5.2% (n= 5)] and fistula formation [8.2% (n= 8)]. In our case series, following secondary repair, normal manometric incremental squeeze pressure was found in five women (83%). Also, on endoanal ultrasound, internal anal sphincter (IAS) defects were found in 75% with a history of IAS injury (n= 4). There were no full-thickness external anal sphincter defects. Compared to those requiring primary repair alone, residual defects were significantly larger in thosewho also underwent secondary repair (Starck score 2.1 vs. 5.7, p= 0.01). Early secondary repair is a feasible surgical procedure for the reconstruction of dehisced OASIs. This case series and review of the literature can be used to support clinicians in the management of primary OASI repair dehiscence.

The impact of a nationwide hands-on workshop on the diagnostic rates and management of obstetrical anal sphincter Injuries in Israel.

The aim was to evaluate the influence of a half day, hands-on, workshop on the detection and repair of obstetric anal sphincter injuries (OASIs). Starting in February 2011, hands-on workshops for the diagnosis and repair of OASIs were delivered by trained urogynaecologists in departments of tertiary medical centres in Israel. The structure of the hands-on workshop resembles the workshop organized at the International Urogynecological Association annual conferences. Participants included medical staff, midwives and surgical residents from each medical centre. We collected data regarding the rate of OASIs, 1year before and 1year following the workshop, in 11 medical centres. The study population was composed of parturients with the following inclusion criteria: singleton pregnancy, vertex presentation and vaginal delivery. Pre-viable preterm gestations (<24weeks), birth weight <500g, stillborn, and those with major congenital anomalies, multifoetal pregnancies, breech presentations and caesarean deliveries were excluded from the analysis. In the reviewed centres, 70663 (49.3%) women delivered prior to the workshop (pre-workshop group) and 72616 (50.7%) women delivered following the workshop (post-workshop group). Third- or fourth-degree perineal tears occurred in 248 women (0.35%) before the workshop, and in 328 (0.45%) following the workshop, a significant increase of 28.7% (P=0.002). The increase in diagnosis was significant also in women with third-degree tears alone, 226 women (0.32%) before the workshop and 298 (0.41%) following the workshop, an increase of 28.3% (P=0.005). The detection rate of OASIs has significantly increased following the hands-on workshop. The implementation of such programmes is crucial for increasing awareness and detection rates of OASI following vaginal deliveries.

How comparable is clinical grading of obstetric anal sphincter injury with that determined by four‐dimensional translabial ultrasound?

To evaluate the agreement between grading of obstetric anal sphincter injuries (OASI) on translabial ultrasound (TLUS), using a newly developed algorithm, and grading on postpartum examination. A secondary aim was to assess the correlation between tear severity, as defined on ultrasound, and symptoms of anal incontinence and/or fecal urgency. This was a retrospective study of patients seen at a perineal clinic between 2012 and 2018, after recent primary repair of OASI. All patients underwent a standardized interview including the St Mark's anal incontinence test and four-dimensional TLUS. Post-processing of ultrasound volume data was performed blinded to all other data. Using tomographic ultrasound imaging, a set of eight slices was obtained, and the central six slices were evaluated for sphincter abnormalities. Slices with distortion, thinning or defects were rated as abnormal. The following algorithm was used to grade OASI: a Grade-3a tear was diagnosed if the external anal sphincter (EAS) was abnormal in < 4/6 slices; a Grade-3b tear was diagnosed if the EAS was abnormal in ≥ 4/6 slices; and a Grade-3c/4 tear was diagnosed if both the EAS and internal anal sphincter were abnormal in ≥ 4/6 slices. Clinical grading of OASI was determined according to the Royal College of Obstetricians and Gynaecologists guidelines. Agreement between clinical and TLUS diagnosis of OASI was evaluated using weighted κ. Of the 260 women seen during the study period, 45 (17%) were excluded owing to missing data or a repeat OASI, leaving 215 complete datasets for analysis. The average follow-up interval was 2.4 months (range, 1-11 months) after OASI and the mean age of the women was 29 years (range, 17-42 years). One hundred and seventy-five (81%) women were vaginally primiparous. OASI was graded clinically as Grade 3a in 87 women, Grade 3b in 80, Grade 3c in 29 and Grade 4 in 19. On imaging, full agreement between clinical and TLUS grading was noted in 107 (50%) women, with a weighted κ of 0.398. In 96 (45%) women, there was disagreement by one category, with a weighted κ of 0.74 and in 12 (6%) there was disagreement by two categories. Twenty-four (11%) women were found to have a normal anal sphincter on imaging. Overall, potential clinical over-diagnosis was noted in 72 (33%) women and potential under-diagnosis in 36 (17%). The seniority of the diagnosing obstetrician did not significantly alter agreement between clinical and sonographic OASI grading (κ 0.44, 0.43, and 0.34, for specialists and senior and junior residents, respectively). The association between symptoms of anal incontinence and/or fecal urgency and TLUS grading did not reach significance (P = 0.052). Clinical and TLUS-based grading of OASI showed fair agreement. Clinical over-diagnosis may be increasingly common in our population, although under-diagnosis may still occur in a significant minority. Copyright © 2020 ISUOG. Published by John Wiley & Sons Ltd.

Patient's characteristics and incidence of fecal incontinence after primary repair of Obstetric Anal Sphincter Injuries (OASIS) at three Indonesian tertiary hospitals in 2014-2016.

IntroductionObstetric Anal Sphincter Injuries (OASIS) is a common complication of vaginal delivery. The incidence was 4.53 % of total vaginal deliveries. OASIS is associated with an increased risk of fecal incontinence (FI), which affects one’s quality of life. The incidence of OASIS and FI varied from study to study. In this study, we described the characteristics of patients with OASIS at three Indonesian tertiary hospitals in 2014−2016 and FI outcome among those patients.MethodologyThis is a descriptive study on the characteristics of OASIS patients after primary repair in three tertiary hospitals: dr. Cipto Mangunkusumo National General Hospital, Persahabatan General Hospital and Fatmawati General Hospital from 2014 to 2016. From a total of 234 patients, only 58 patients could be contacted and interviewed using Revised Fecal Incontinence Score (RFIS) questionnaires. Out of the 58 patients, only 16 patients came for transperineal ultrasound. Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 20.ResultsFrom a total of 234 patients, the mean age was 26.6 years old with a mean Body Mass Index (BMI) of 24.8 kg/m2. Most of the patients were nulliparous (67.5 %) and the median duration of second stage of labor was 45 min. Episiotomy was not performed on most patients (59.4 %) and most of them underwent spontaneous vaginal delivery (65.4 %) with mean baby’s birthweight of 3217 g. From 58 interviewed patients, three patients complained of FI (5.2 %). Sixteen patients came for transperineal ultrasound examination, and only one of them had FI. Anal sphincter defects were identified in five patients, comprising three external anal sphincter (EAS) and two internal anal sphincter (IAS) defects. All five patients did not experience FI. One patient who had FI had no anal sphincter defect.DiscussionThis is a pilot study for the incidence of FI among the OASIS population in Jakarta, Indonesia. The incidence of FI observed in this study was relatively low (3 out of 58 patients) compared to other studies. This could be due to differences in study population. The fact that the patient with FI had intact anal sphincter suggests that other factors may contribute to the development of FI in addition to the integrity of the anal sphincter. These factors may include pelvic floor muscle and innervation of the surrounding tissues.ConclusionThe outcomes of primary repair of OASIS varied between studies. Patients’ characteristics might play an important role in the development of OASIS as well as the outcome after repair. Further studies with larger sample size are needed.

Comparison of 3D endoanal ultrasound and external phased array magnetic resonance imaging in the diagnosis of obstetric anal sphincter injuries

ObjectivesThe gold standard of postpartum anal sphincter imaging has been the 3D endoanal ultrasound (EAUS). Development of magnetic resonance imaging (MRI) has allowed anal sphincter evaluation without the use of endoanal coils. The aim of this study is to compare these two modalities in diagnosing residual sphincter lesions post obstetric anal sphincter injury (OASI).MethodsForty women were followed up after primary repair of OASI with both 3D EAUS and external phased array MRI. Details of the anal sphincter injury and sphincter musculature were gathered and analysed.ResultsThere was a moderate interrater reliability (κ = 0.510) between the two imaging modalities in detecting sphincter lesions, with more lesions detected by MRI. There was a moderate intraclass correlation (ICC) between the circumference of the tear (κ = 0.506) and a fair ICC between the external anal sphincter thickness measurements at locations 3 and 9 on the proctologic clock face (κ = 0.320) and (κ = 0.336).ConclusionsThe results of our study indicate that the use of external phased array MRI is feasible for detecting obstetric anal sphincter lesions postpartum. This allows for imaging of the sphincter defects in centres where EAUS imaging is not available.Key Points• A two centre prospective study that showed external phased array MRI to be a valid imaging modality for diagnosing obstetric anal sphincter injuries.

Prevention and Management of Severe Obstetric Anal Sphincter Injuries (OASIs): a National Survey of Nurse- Midwives.

There are no data on midwives' knowledge and management of obstetric anal sphincter injuries (OASIs) in the USA. We performed a cross-sectional national survey characterizing OASI practice by certified nurse midwives (CNMs), hypothesizing that few midwives personally repair OASIs and that there are gaps in CNM OASI training/education. We emailed a REDCap internet-based survey to 6909 American College of Nurse Midwives members (ACNM). We analyzed responses from active clinicians performing at least one delivery per month, asking about OASI risks, prevention, repair, and management. We summarized descriptive data then evaluated OASI knowledge by patient and provider characteristics. We received 1070 (15.5%) completed surveys, and 832 (77.8%) met the inclusion/exclusion criteria. Participants were similar to ACNM membership. Respondents most frequently identified prior OASI (87%) and nutrition (71%) as antepartum OASI risk factors and, less frequently, nulliparity (36%) and race (22%). Identified intrapartum risks included forceps delivery (94%) and midline episiotomy (88%). When obstetric laceration is suspected, 13.6% of respondents perform a rectal examination routinely. Only 15% of participants personally perform OASI repair. Overall, participants matched 64% of evidence-based answers. OASI education/training courses were attended by 30% of respondents, and 44% knew of OASI protocols within their group/institution. Of all factors evaluated, the percent of evidence-based responses was only different for respondent education/CME and protocols. Quality initiatives regarding OASI prevention and management may improve care. Our data suggest OASI training for midwives may improve delivery care in the US. Further studies of other obstetric providers are needed.

Improving Documentation of Obstetric Anal Sphincter Injuries (OASIS) Using a Standardized Electronic Template at Two University-Affiliated Institutions.

Adequate repair is vital to reduce the long-term sequelae of obstetric anal sphincter injuries (OASIS). Sufficient documentation is necessary to reflect the quality of care provided, to guide future management, and to reduce medicolegal liability. With the advent of electronic health records, proper methods of documentation can be more easily disseminated and applied for general use. The objectives of our study were to assess whether documentation of OASIS management is improved by introducing a standardized electronic operative report, determining rates of readmission due to complications, and measuring adherence to practice guidelines. A pre- and postintervention study was conducted by auditing electronic charts of patients affected by OASIS at two university-affiliated delivery units throughout the 2016 calendar year. Unit A is a safety-net hospital and unit B is private. A standardized electronic template was created in the electronic health records of both units. The primary outcome was the quality of repair documentation, which was quantified using a scale that included all relevant aspects of the repair. Analyzing both units separately, baseline characteristics including operator training level, episiotomy rate, and operative delivery were similar pre- and postintervention. The quality of documentation measured by the scale score improved significantly postintervention. Proper use of antibiotics and bowel regimen significantly increased after the intervention at both units. The use of a standardized electronic template for reporting the diagnosis and repair of OASIS improves the thoroughness of documentation and appears to promote the implementation of best practice guidelines.