Obstetric Anal Sphincter Laceration Research Articles

Antibiotics in Labor and Delivery

Infections are common in obstetric care and often require specific antibiotics, depending on the infection site and prevailing organisms. Summaries of antibiotic recommendations and treatment algorithms are provided for the following conditions: routine labor, group B streptococcus prophylaxis, preterm prelabor rupture of membranes, operative vaginal delivery, cesarean delivery, obstetric anal sphincter lacerations, chorioamnionitis, postpartum endometritis, infections of the urinary tract, and bacterial endocarditis prophylaxis.

Pregnancy in Women With Prior Treatments for Pelvic Floor Disorders.

Although the peak incidence of surgery for pelvic floor disorders does not occur until after menopause, an increasing number of younger women are seeking treatment for these problems. Whereas most surgeons would recommend delaying surgery until the completion of childbearing, published cases and case series address outcomes after subsequent pregnancies in women who have been treated for urinary incontinence and pelvic organ prolapse. This document synthesizes the available evidence on the impact of pregnancy on women with prior treatment for pelvic floor disorders and on the impact of these prior treatments on subsequent pregnancy. Pregnancy after the repair of obstetrical anal sphincter laceration is also discussed. Consensus recommendations are presented based on available literature review and expert involvement.

Impact of Selective vs Routine Midline Episiotomy and Lacerations of the Anal Sphincter

Introduction: Obstetric anal sphincter tear (OAST) is associated with anal incontinence. Episiotomy was proposed as a form of protection of the anal sphincter at delivery; however, several studies have shown that routine use of episiotomy does not reduce the risk of OAST. Objective: This study aims to analyse whether the reduction in the rate of episiotomy in a school hospital in Brazil was associated with an increase in the incidence of obstetric lacerations of the anal sphincter, in addition to associated factors. Methods: Observational, cross-sectional and retrospective study. We included all vaginal deliveries of single pregnancies, cephalic presentation, from 34 weeks of gestational age, performed in 2011-2012 (liberal episiotomy) and 2015-2016 (restricted episiotomy), and compared in relation to the rate of mediolateral episiotomy and OAST. Results: 4268 births were analysed (2043 in 2011-2012 and 2225 in 2015-2016). The episiotomy rate decreased from 59.4% to 44.2% (p ≤ 0.0001). In 2011-2012, there were 10 obstetric anal sphincter lacerations in 2043 births (0.48%), while in the period 2015-2016 there were 31 lacerations in 2225 births (1.39%). There was interaction when comparing the two periods in relation to the episiotomy and the occurrence of OAST (p ≤ 0.0001). Factors associated with OAST were labor induction and shoulder dystocia. Conclusion: There was an increase in the rate of lacerations of the anal sphincter with use of restrictive episiotomy. However, this increase occurred both in deliveries with and in deliveries without episiotomy.

Pregnancy and parturition negatively impact vaginal angle and alter expression of vaginal MMP-9.

Parity is the greatest risk factor for the development of pelvic organ prolapse. The normally supported vagina is pulled up and back over the levator ani. Loss of vaginal angulation has been associated with prolapse and may represent injury to the vaginal supportive tissues. We proposed and examined the following hypotheses: (1)pregnancy and delivery impact vaginal support, leading to loss of vaginal angle; (2) vaginal angulation is restored postpartum; and (3) uncomplicated vaginal delivery (VD) is associated with accelerated remodeling of the vaginal fibrillar matrix. We prospectively enrolled a cohort of nulliparas in the first trimester of pregnancy, and abstracted demographic and delivery data. Metalloproteinase 9 (MMP-9) activity in the vagina was determined in the first and third trimesters and 1 year postpartum using a substrate activity assay. Uncomplicated VD was defined as none of the following: cesarean delivery, forceps or vacuum use, shoulder dystocia, obstetric anal sphincter laceration, or prolonged second-stage labor. Women were grouped dichotomously for comparison based on this definition. A subset of participants underwent transperineal ultrasound. We enrolled 173 women with mean age of 25 ± 6 years and a body mass index of 20 ± 7 kg/m2. Of the women, 67% identified as white/Caucasian, 27% black/African American, or 6% Hispanic/Latina. The mean delivery age was 39 ± 3 weeks, with 59% of participants experiencing uncomplicated VD. The MMP-9 median activity (ng/mg protein) was 242.0 (IQR, 18.7, 896.8; n= 157) in the first trimester, 130.8 (IQR, 14.6, 883.8; n= 148) in the third trimester, and 463.5 (IQR, 92.2, 900.0; n= 94) postpartum. The MMP-9 activity increased between the third trimester and 1 year postpartum (P= .006), with no significant difference between MMP-9 values in the first and third trimesters (P=.674). The vaginal angle became less acute from the first to the third trimester, and this change persisted postpartum. The vaginal angulation over the levator plate became more acute between the third trimester and postpartum in women who experienced uncomplicated VD compared tothose who did not (-6.4 ± 22.1 degrees vs 17.5 ± 14.8 degrees; P=.017). Higher MMP-9 activity postpartum was associated with uncomplicated VD, with 67% of women in the third tertile achieving uncomplicated VD versus 39% in the first tertile (P= .029). Loss of vaginal angulation occurs between trimesters, and women do not recover their baseline resting angle postpartum. MMP-9 activity increases postpartum. Women experiencing uncomplicated VD demonstrate higher postpartum MMP-9 activity and are more likely to have recovered their vaginal angle.

Pelvic floor changes: consequences of pregnancy and delivery.

Reimers et al. describe changes in pelvic organ support during pregnancy and at 1 year postpartum in a cohort of 300 nulliparous women. The findings are reassuring, with an overall low prevalence of prolapse (<10%) and demonstrable changes that largely recover by 1 year. Significant findings from this longitudinal study are the cranial shift of the middle compartment from mid- to late pregnancy and the shortening of the perineal body and genital hiatus from 6 weeks to 6 months postpartum. The shift of the cervix during pregnancy (cranial) and postpartum (caudal) represents the largest change in pelvic support regardless of mode of delivery. This study emphasises the mechanical forces taking place within the pelvic floor, and hypothesises how these dynamics may increase a woman's risk for the development of subsequent pelvic floor disorders. Stress urinary incontinence and pelvic organ prolapse are often associated with parity and, more specifically, vaginal childbirth; however, the mechanism of injury has not been completely elucidated and likely involves direct injury to pelvic floor muscles, connective tissue and neurovascular structures. Many healthcare providers focus on the immediate complications of childbirth and mode of delivery, such as maternal mortality, infection, anaesthetic complications, thromboembolic diseases, haemorrhage, hysterectomy and depression, but perhaps more attention should be paid to delayed maternal complications, such as subsequent uterine rupture and placental implantation abnormalities, which have significant neonatal implications; as well as urinary and fecal incontinence, pelvic organ prolapse, sexual dysfunction, and pelvic pain. The latter pelvic floor conditions may take decades to develop as other lifestyle factors such as increasing body mass index and smoking further contribute to the development of these disorders. Very few studies have evaluated long-term effects of pregnancy on pelvic floor disorders. The Norwegian EPINCONT study found that parity was associated with stress and mixed urinary incontinence, and that first delivery had the most significant impact (Rortveit G et al. Obstet Gynecol 2001;98: 1004–10). Similarly, Evers et al. reported a significant association between obstetric anal sphincter lacerations and anal incontinence, and its negative impact on quality of life 5–10 years after childbirth, compared with women who either delivered vaginally without anal sphincter laceration or delivered via caesarean section (Evers EC et al. Am J Obstet Gynecol 2012;207:425.e1–425 46). Robust longitudinal studies such as these two often cited publications provide valuable information on consequences of parity, sphincter laceration and mode of delivery. Reimers et al. are encouraged to continue the longitudinal evaluation on objective changes in pelvic support in this cohort of women and should incorporate subjective measures such as bother and impact on quality of life using validated tools. Long-term data on outcomes that matter to patients will provide the most valuable information for future practice and guideline development. None declared. Completed disclosure of interests form available to view online as supporting information.

Risk of obstetric anal sphincter lacerations among obese women

To assess the risk for obstetric anal sphincter lacerations in relation to maternal obesity among primiparous women in Sweden. A population-based study. Sweden. All women with vaginal delivery and singleton pregnancy in Sweden in the years 2003-2008 (n = 210,678). The Medical Birth Registry, the National Board of Health and Welfare, was used to identify cases of rupture and body mass index (BMI) classes. The population was categorised into four classes with BMI of <25, 25 to <30, 30 to <35 and >35 kg/m². Odds ratios were estimated with 95% confidence intervals. In order to estimate the effect of BMI on obstetric anal sphincter lacerations, with possible confounders accounted for, uni- and multivariate logistic regressions were performed. In total, 8958 (4.25%) cases of anal sphincter lacerations (grade III-IV) occurred; increasing BMI showed a significant near-dose-response type of protective effect against grade III-IV lacerations when compared with women with BMI <25 kg/m²: BMI 25 to <30 kg/m², 0.89; BMI 30 to <35 kg/m², 0.84; BMI > 35 kg/m², 0.70. Overweight and obesity were associated with a decreased risk for obstetric anal sphincter lacerations.

Obstetric Sphincter Injury Interacts With Diarrhea and Urgency to Increase the Risk of Fecal Incontinence in Women With Irritable Bowel Syndrome

This study aimed to confirm that fecal urgency and diarrhea are independent risk factors for fecal incontinence (FI), to identify obstetrical risk factors associated with FI in women with irritable bowel syndrome, and to determine whether obstetric anal sphincter injuries interact with diarrhea or urgency to explain the occurrence of FI. The study is a supplement to a diary study of bowel symptoms in 164 female patients with irritable bowel syndrome. Subjects completed daily bowel symptom diaries for 90 consecutive days and rated each bowel movement for stool consistency and presence of urgency, pain, and FI. All female participants from the parent study were invited to complete a telephone-administered 33-item bowel symptom and obstetric history questionnaire, which included the fecal incontinence severity index. Of the 164 women in the parent study, 115 (70.1%) completed the interview. Seventy-four (45.1%) reported FI on their diary including 34 (29.6%) who reported at least 1 episode per month, 112 (97.4%) reported episodes of urgency, and 106 (92.2%) reported episodes of diarrhea. The mean fecal incontinence severity index score was 13.9 (9.7). On multivariable analysis, FI was significantly associated with parity (P = 0.007), operative abdominal delivery (P = 0.049), obstetrical sphincter lacerations (P = 0.007), fecal urgency (P = 0.005), diarrhea (P = 0.008), and hysterectomy (P = 0.004), but was not associated with episiotomy, pelvic organ prolapse, or urinary incontinence. The synergistic interactions of obstetric anal sphincter laceration with urgency (P = 0.002) and diarrhea (P = 0.004) were significant risk factors for FI. Fecal urgency and diarrhea are independent risk factors for FI, and they interact with obstetric anal sphincter laceration to amplify the risk of FI.

Overlapping Compared With End-to-End Repair of Complete Third-Degree or Fourth-Degree Obstetric Tears

Traditional obstetric practice for repair of third-degree or fourth-degree tears of the external anal sphincter has been using an end-to-end technique. Studies reporting that end-to-end repair was associated with higher rates of external anal sphincter defects and associated anal incontinence symptoms led to increased preference by clinicians for performing overlapping repair of obstetric anal sphincter lacerations. This study reports the results of a 3-year follow-up of a randomized controlled trial conducted in women who underwent primary repair of a complete third-degree or fourth-degree obstetric tear with either the overlapping technique or the end-to-end procedure. Participants were primiparous women enrolled at a single tertiary-care academic center between 2001 and 2007. Eligible women were randomized to receive either end-to-end (n = 86) or overlapping (n = 88) external anal sphincter repair. At a follow-up of 1, 2, and 3 years, questionnaires were mailed to participants to determine rates of flatal and fecal incontinence. At 1 year, rates of flatal and fecal incontinence were lower in women who underwent an end-to-end repair than in those who had an overlapping repair. The flatal incontinence rate was 31% for end-to-end repair and 56% for overlapping repair (difference: 25%, with a 95% confidence interval of 6%–43%; P = 0.012). The fecal incontinence rate for end-to-end repair was 7% and for overlapping repair was 16% (difference: 9%, with a 95% confidence interval of −4% to 21%; P = 0.17). By the end of year 2, the difference between the 2 methods of surgical repair had largely disappeared. These findings indicate that at 1-year follow-up, end-to-end repair of complete third-degree or fourth-degree obstetric anal sphincter tears is less likely than overlapping repair to result in anal incontinence. The lower rate of anal incontinence with end-to-end repair is not sustained at 2 years, suggesting no long-term benefit of either technique over the other.

W299 RISK OF OBSTETRIC ANAL SPHINCTER LACERATIONS AMONG OBESE WOMEN

International Journal of Gynecology & ObstetricsVolume 119, Issue S3 p. S802-S802 Poster presentations W299 RISK OF OBSTETRIC ANAL SPHINCTER LACERATIONS AMONG OBESE WOMEN E.S. Lindholm, E.S. LindholmSearch for more papers by this authorD. Altman, D. AltmanSearch for more papers by this author E.S. Lindholm, E.S. LindholmSearch for more papers by this authorD. Altman, D. AltmanSearch for more papers by this author First published: 22 October 2012 https://doi.org/10.1016/S0020-7292(12)62022-0AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume119, IssueS3Abstracts of XX FIGO World Congress of Gynecology and ObstetricsOctober 2012Pages S802-S802 RelatedInformation

Obstetrical anal sphincter laceration and anal incontinence 5-10 years after childbirth

The purpose of this study was to investigate the long-term impact of anal sphincter laceration on anal incontinence. Five to 10 years after first delivery, anal incontinence and other bowel symptoms were measured with the Epidemiology of Prolapse and Incontinence Questionnaire and the short form of the Colorectal-Anal Impact Questionnaire. Obstetric exposures were assessed with review of hospital records. Symptoms and quality-of-life impact were compared among 90 women with at least 1 anal sphincter laceration, 320 women who delivered vaginally without sphincter laceration, and 527 women who delivered by cesarean delivery. Women who sustained an anal sphincter laceration were most likely to report anal incontinence (odds ratio, 2.32; 95% confidence interval, 1.27-4.26) and reported the greatest negative impact on quality of life. Anal incontinence and quality-of-life scores were similar between women who delivered by cesarean section and those who delivered vaginally without sphincter laceration. Anal sphincter laceration is associated with anal incontinence 5-10 years after delivery.

Resident Competency in Obstetric Anal Sphincter Laceration Repair

To estimate objectively the proficiency of obstetrican-gynecologist (ob-gyn) residents in third-degree perineal tear repair. A total of 40 ob-gyn residents from 13 residency programs demonstrated their technique of perineal laceration repair on a modified beef tongue model. Two faculty members with expertise in repairing obstetric anal sphincter injury evaluated the residents using a checklist. The checklist identified three key steps of the procedure, including 1) repair of the internal anal sphincter; 2) selection of proper suture material; and 3) repair of the external anal sphincter, further evaluated using three subcomponents. The overall pass rate was 42.5% (17/40). Many residents missed critical steps of the repair. Year of training (P=.763), parent residency program (P=.5), and prior experience (P=.48) had no significant effect on the pass rate. There was greater than 90% concordance between the evaluators (r=0.9, P<.001). Satisfaction with the modified beef tongue model was higher than with current training methods in their program (7.81 compared with 6.92 on a scale of 1-10, P=.001). Ob-gyn residents demonstrated substandard skill in repairing anal sphincter laceration. The low pass rate of 42.5% suggests lack of adequate training in repair. The model had a high resident satisfaction, and high interobserver correlation was noted using the checklist. Thus, identification and evaluation of key steps using a standardized checklist may lead to standardization of repair and ensures consistency and quality. III.

Defining an at-risk population for obstetric anal sphincter laceration

The purpose of this study was to calculate the number of cesarean deliveries needed to prevent 1 case of obstetric anal sphincter laceration associated with operative vaginal delivery in an at-risk cohort. An institutional, computerized database was used to analyze women with obstructed labor who could have been managed by either operative vaginal or cesarean delivery from September 2006 to March 2008. Women with 1 or more of the following diagnoses comprised the cohort: cephalopelvic disproportion (CPD), arrest of descent, maternal exhaustion, and fetal distress. Fifty (23.9%) out of a total of 209 women managed by operative vaginal delivery experienced an anal sphincter laceration compared to none of 254 women in the cesarean delivery group (P < .0001). The ARR therefore was 23.9% (95% confidence interval, 18.1-29.7) and the NNT was 4.2 (95% confidence interval, 3.4-5.5). Five cesarean deliveries are needed to prevent 1 anal sphincter laceration associated with operative vaginal delivery in this cohort.

Anal sphincter defects and anal incontinence symptoms after repair of obstetric anal sphincter lacerations in primiparous women

A study was carried out to identify (1) incidence of anal incontinence symptoms, (2) incidence and size of both external anal sphincter (EAS) and internal anal sphincter (IAS) defects, and (3) relationship between anal incontinence symptoms and IAS or EAS defect size after repair of an obstetric anal sphincter laceration. Forty-seven vaginally primiparous women underwent obstetric anal sphincter laceration repair. At 8-12 weeks postpartum, anal incontinence symptoms were assessed, and endoanal ultrasound was performed. At 1-2 years postpartum, symptoms were reassesseds. The incidence of anal incontinence symptoms at 8-12 weeks was 43%. The incidence of IAS and EAS defects were 32% and 77%, respectively. IAS defects > or = 45 degrees were predictive of symptoms (p = 0.02). After 18 months mean follow-up, 11% reported chronic symptoms. After anal sphincter laceration repair, anal incontinence symptoms occur in 43% of women and remain chronic in 11%. Anal incontinence symptoms are associated with increasing IAS defect size.

Decreased rate of obstetrical anal sphincter laceration is associated with change in obstetric practice

A study was conducted to describe the rate of obstetrical anal sphincter laceration in a large cohort of women and to identify the characteristics associated with this complication. Data from all vaginal deliveries occurring between January 1996 and December 2004 at one institution were used to compare women with and without anal sphincter lacerations. Among 16,667 vaginal deliveries, 1,703 (10.2%) anal sphincter lacerations occurred. Regression models suggested that episiotomy (OR 1.36; 95% CI 1.16, 1.58), vacuum delivery (OR 3.19; 95% CI 2.69, 3.79), and forceps delivery (OR 2.79; 95% CI 1.94, 4.02) were each associated with the increased risk of anal sphincter laceration. Year of delivery was associated with a decreased risk of anal sphincter laceration (OR 0.94; 95% CI 0.92, 0.96) with the rate of laceration decreasing from 11.2% to 7.9% during the study period. Episiotomy and operative vaginal delivery are significant, modifiable risk factors. Changes in obstetric practice may have contributed to the dramatic reduction in anal sphincter laceration during the study period.

Is Severe Perineal Damage Increased in Women With Prior Anal Sphincter Injury?

Edwards, Heather MD; Grotegut, Chad MD; Harmanli, Ozgur H. MD; Rapkin, David MD; Dandolu, Vani MD Author Information

ORAL POSTER 3: Decreased Rate of Obstetrical Anal Sphincter Laceration Reflects Change in Obstetric Practice

ORAL POSTER 3: Decreased Rate of Obstetrical Anal Sphincter Laceration Reflects Change in Obstetric Practice

Is severe perineal damage increased in women with prior anal sphincter injury?

Objective. There is conflicting data in the literature regarding the risk of obstetric anal sphincter laceration in patients with a prior laceration. This retrospective chart review seeks to examine the risk of recurrence of obstetric anal sphincter lacerations.Methods. Patients who sustained anal sphincter laceration at delivery during a 13-year time period from January 1991 to December 2003 were identified from the medical records database at Temple University Hospital. All subsequent deliveries in this group of patients were extracted from the database. Chart review was performed on all subsequent deliveries with specific attention to demographic factors such as age, race, parity, etc., maternal weight, fetal weight, presence of maternal diabetes, and labor characteristics such as induction or augmentation of labor, instrumentation at delivery (vacuum or forceps), use of episiotomy, and degree of perineal laceration.Results. There were 23 451 vaginal deliveries at Temple University Hospital between January 1, 1991 and December 31, 2003. Anal sphincter laceration was noted in 778 subjects. Subsequent deliveries among the group of patients with prior sphincter tears numbered 271. Six (2.4%) patients had recurrence of anal sphincter lacerations, and five of them were third degree lacerations. The rate of recurrent lacerations was not significantly different from the rate of initial lacerations (2.4% vs. 3.3%; odds ratio 0.72, 95% confidence interval 0.33–1.59; p = 0.4). Women who sustained recurrent lacerations were older, more obese (mean weight 92 kg vs. 82 kg), had larger babies (3506 g vs. 3227 g), and were more likely to have episiotomies (66.7% vs. 7%) or instrumental deliveries (33.3 vs. 6.5%).Conclusion. Prior anal sphincter laceration does not result in an increased rate of recurrence. Operative vaginal delivery particularly with episiotomy is a risk factor for both initial and recurrent laceration.

Primary repair of obstetric anal sphincter laceration: A randomized trial of two surgical techniques

This study was undertaken to compare surgical techniques for the primary repair of obstetric anal sphincter lacerations. Patients with complete third- or fourth-degree lacerations were recruited and randomly assigned to either an end-to-end or overlapping repair. Data collection included demographic data, obstetric history, and intrapartum events. Postpartum, women completed incontinence questionnaires and underwent physical and ultrasound examinations. To detect a 36% difference between groups with an alpha = .05 and beta = .20, 30 patients were required. Data were analyzed with Student t test and chi2 analysis. Forty-one women were randomly assigned; 23 to an end-to-end and 18 to an overlapping repair. Twenty-seven percent of women underwent episiotomy and 61% operative vaginal delivery. Follow-up was limited to 26 of 41 patients. On physical examination, 3 patients had a separated anal sphincter. On ultrasound, overall 85% of patients had intact sphincters, with no difference between groups (all P > .05). Forty-two percent of women complained of anorectal symptoms with no differences between groups (all P > .28). We found no difference in anal incontinence symptoms, physical examination, or translabial ultrasonography findings between the 2 groups. Incontinence symptoms were common in both groups.

Poster 19: Trends in the Occurrence of Obstetric Anal Sphincter Lacerations Over the Past 3 Decades in the State of Maryland

OBJECTIVE: The objective of this study was to identify change in the use of obstetric procedures since 1979 and possible correlation among episiotomy, instrumental vaginal delivery, and obstetric anal sphincter laceration in the state of Maryland. METHODS: Data was obtained from the State of Maryland database regarding all vaginal deliveries that occurred during 6 different time periods at 5-year intervals since 1979. Rate of anal sphincter laceration was calculated in women who had spontaneous vaginal delivery and compared with those who had an episiotomy and/or instrumentation during delivery. Logistic regression was used to adjust for confounders. RESULTS: There were a total of 22,267 (8%) anal sphincter lacerations during the years studied. The rate was highest when instrumental vaginal delivery was performed with episiotomy (21.57% or one in 5), and lowest when neither episiotomy nor instrumentation was used at delivery (3.92% or approximately one in 25). SIGNIFICANT TRENDS: The rate of anal sphincter lacerations was 8.55% in the year 1979 and then decreased gradually to 4.94% in 2003. There was a tremendous drop in the rate of forceps delivery from 31.71% in 1979 to 1.44% in 2003. Although almost all instrumental vaginal deliveries in the earlier years were performed with episiotomy, in 2003, in 46% cases, instrumentation was used without episiotomy. The rate of episiotomy overall also decreased from 73.67% to 23.94% from 1979 to 2003. CONCLUSION: There was a gradual decrease in the rate of third-and fourth-degree lacerations over the past 24 years. This corresponds to a decrease in the use of episiotomy, decreased rate of operative delivery, and decreased forceps use.

Oral Poster 16: Primary Repair of Obstetrical Anal Sphincter Laceration: A Prospective Randomized Trial of Two Surgical Techniques

Oral Poster Presentations: AUGS-SGS Abstracts: 2004 Joint Scientific Meeting The American Urogynecologic Society and The Society of Gynecologic Surgeons