Obstetric Anal Sphincter Rupture Research Articles

Surgery for female dyspareunia after perineal trauma

Perineal trauma during labor and vulvo-vaginal surgery is common and entails pain, dyspareunia, and other quality of life issues. Herein we describe common pitfalls, reconstruction problems and considerations illustrated by two cases. Diagnosis: A thorough conversation with the woman about her history concerning trauma and present symptoms including sex life before the trauma. Examination: Visual traces of the trauma and palpation for persisting trigger points in accordance with the history. CASE 1: Had previously had two operations for Bartholinitis and two operations for vulvo-vaginal fistulas. She had severe external dyspareunia and not been able to engage in intercourse for 1 ½ year when referred. CASE 2: Suffered a total obstetric anal sphincter rupture during first delivery. Primary suturing was performed in the delivery room. The patient suffered from severe dysparunia and soiling during intercourse three months after the delivery. A low perineum and a low rectocele were seen. By 3D ultrasound a very short external anal sphincter was seen. The transverse perineal and bulbocavernose muscle were still torn. Surgery: Removal of scar tissue. Identifying affected anatomical structures. Usually, the superficial and deep transverse perineal muscle, the bulbocavernosus muscle and the rectovaginal fascia are traumatized. Examples of anatomical correct reconstruction are presented. Postoperative: Weekly Low Level Laser therapy (LLLT) for three weeks was applied, and pain killers were used. Scar tissue massage after four weeks. Recommendation of no intercourse for six weeks. After a longer period with dyspareunia, sex is usually connected with an expectation of pain even when the trigger is removed. This is partially caused by strong pelvic muscle contractions. Supportive consultations about sexual issues are usually necessary to obtain a complete recovery with a healed body and mind. Anatomical correct reconstructive surgery after long term dyspareunia is best treated in a bio-psycho-social frame. No conflict of interest

Incidence and risk factors for obstetric anal sphincter ruptures, OASIS, following the introduction of preventive interventions. A retrospective cohort study from a Norwegian hospital 2012–2017

ObjectiveA decrease of obstetric anal sphincter injuries (OASIS) was observed after preventive interventions were implemented at a Norwegian university hospital. The aim was to investigate whether the improvement had sustained over the following years. Materials and methodsWe performed a retrospective cohort study of 18 258 singleton vaginal cephalic births, ≥37 + 0 weeks of gestation during 2012–2017, examining data from the hospital’s birth journals and separate registration forms. Interventions to prevent OASIS were implemented in 2011, and training in practical skills was repeated each year. Main outcome measuresThe main outcome was OASIS (n = 377). ResultsFrequency of OASIS overall decreased from 3.6% prior to 2011 to 2.1% after the intervention and sustained at that level throughout the study period. A trend of fewer OASIS among spontaneous deliveries, decreasing from 2.1% to 1.2% (p = 0.01) was observed, but no trend was seen for instrumental deliveries (p = 0.37), where the incidence fluctuated between 4.0% and 9.3% with an average of 6.5%. Primiparity, increased maternal age and increased fetal head circumference were associated with more OASIS in spontaneous deliveries. In instrumental deliveries, primiparity, occiput posterior position and increased fetal head circumference were associated with more OASIS, whilst episiotomy was associated with fewer OASIS. ConclusionThe incidence of obstetric anal sphincter injuries maintained at a similar level of around 2.1% during the six following years after introducing preventive interventions. Regularly repetition and practical training seemed to be effective.

Anal incontinence after two vaginal deliveries without obstetric anal sphincter rupture.

To evaluate prevalence and risk factors for long-term anal incontinence in women with two prior vaginal deliveries without obstetric anal sphincter injury (OASIS) and to assess the impact of anal incontinence-related symptoms on quality of life. This is a nation-wide cross-sectional survey study. One thousand women who had a first vaginal delivery and a subsequent delivery, both without OASIS, between 1997 and 2008 in Denmark were identified in the Danish Medical Birth Registry. Women with more than two deliveries in total till 2012 were excluded at this stage. Of the 1000 women randomly identified, 763 were eligible and received a questionnaire. Maternal and obstetric data were retrieved from the national registry. The response rate was 58.3%. In total, 394 women were included for analysis after reviewing responses according to previously defined exclusion criteria. Median follow-up time was 9.8years after the first delivery and 6.4years after the second. The prevalence of flatal incontinence, fecal incontinence and fecal urgency were 11.7, 4.1, and 12.3%, respectively. Overall, 20.1% had any degree of anal incontinence and/or fecal urgency. In 6.3% these symptoms affected their quality of life. No maternal or obstetric factors including episiotomy and vacuum extraction were consistently associated with altered risk of anal incontinence in the multivariable analyses. Anal incontinence and fecal urgency is reported by one fifth of women with two vaginal deliveries without OASIS at long-term follow-up. Episiotomy or vacuum extraction did not alter the risk of long-term anal incontinence.

A five year follow-up of women with obstetric anal sphincter rupture at their first delivery

ObjectivesObstetric anal sphincter rupture (OASR) is considered a risk factor for subsequent fecal incontinence and suspected to be a risk factor for urinary incontinence and sexual dysfunction. The aims of this study were to assess risk factors for the different grades of OASR and to evaluate the clinical outcome five years after birth using validated questionnaires. Study designA five year follow-up study was performed on 82 women with OASR during their first delivery in 2009. Case records were reviewed for known risk factors for OASR. Three questionnaires were mailed to the women: The St. Marks fecal incontinence score, The Danish anal sphincter rupture questionnaire (DASRQ) and a short supplemental questionnaire. The data were analyzed using Wilcoxon rank sum test, Fisher's exact test and Kruskal–Wallis test. ResultsFifty percent had an OASR 3a, 32% an OASR 3b, and 18% OASR 4. None of the investigated risk factors showed statistically significant difference according to the degree of rupture. Seventy-four percent of the women had some degree of fecal incontinence with a significantly higher frequency of fecal incontinence in rupture group 4 than in 3a. Forty-four percent had urinary incontinence and 50% had some sort of sexual dysfunction with no significant differences between the rupture groups. ConclusionNone of the investigated risk factors increased the incidence of more severe grades of rupture. Ninety-one percent of women with OASR at their first delivery had some degree of fecal or urinary incontinence or sexual dysfunction five years after. The symptoms of fecal incontinence showed a tendency to be more severe in women with more advanced sphincter rupture.

The Incidence of Anal Sphincter Ruptures and Risk Factors

Objective: To analyze the incidence of anal sphincter ruptures and
 to evaluate risk factors of obstetric anal sphincter ruptures in Dr.
 Cipto Mangunkusumo Hospital.
 Method: We reviewed 2009 vaginal deliveries based on the analysis
 of obstetric data base and patient records of our department during
 2012. Cases and control subjects were chosen randomly and patient’s
 records were reviewed for the following variable: maternal
 age, parity, gestational age, labor induction, duration of 2nd stage labor,
 use of forceps, use of vacuum, use of episiotomy, birth weight,
 and presentation of the baby.
 Result: There were 91 (4.53%) anal sphincter ruptures during period
 of study (91 of 2009 patients). An univariate analysis of these
 91 case and 91 randomly selected control subjects show that primiparity
 (p = .000), gestational age (p = .016), duration of second-stage
 labor (p = .000), forceps delivery (p = .000), vacuum delivery (p =
 .001), episiotomy (p = .000), and birth weight (p = .000) increased
 the risk for anal sphincter ruptures. In multivariate re-gression models,
 only 5 of the 10 predictor variables were significantly related
 to the likelihood of having a severe perineal trauma greater than second
 degree. Primiparity (p = .023; OR 2.74, 95% [CI], 1.15-6.51),
 forceps delivery (p = .000; OR 18.18, 95% [CI] 3.84-86.07), vacuum
 delivery (p = .005; OR 6.83, 95% [CI] 1.77-26.42), episiotomy (p =
 .015; OR 2.86, 95% [CI] 1.23-6.65), and birth weight (p = .000; OR
 0.99, 95% [CI] 0.997-0.999).
 Conclusion: Damage of the anal sphincter resulting in a third- or
 fourth- degree perineal tear is a relatively rare but severe complication
 of vaginal delivery. We found that factors as sociated with anal
 sphincter ruptures were primiparity, forceps, vacuum, episiotomy
 and birth weight.
 [Indones J Obstet Gynecol 2016; 1: 31-36]
 Keywords: anal sphincter ruptures, third- or fourth- degree perineal
 tear, vaginal delivery

Feeling old in a young body: Women’s experiences of living with severe consequences of an obstetric anal sphincter rupture: An interview study

Background: The incidence of obstetric anal sphincter rupture (OASR) is increasing. It may cause anal incontinence and dyspareunia,leading to reduced quality of life and wellbeing. Qualitative studies are lacking. The aim was to describe experiencesof living with ongoing severe consequences of an OASR 8 weeks after childbirth. Method: Twenty women with ongoing severe consequences of an OASR 8 weeks after delivery were interviewed usingqualitative content analysis. Results: The experience of complications of an OASR is described in the overall theme ”Feeling old in a young body” andfour categories: The body as injured; isolation; inability to function sexually, and anxiety for the future. Participants describedhow the consequences of OASR totally occupied their lives, making them feel old in a young body. They told of repercussionsfor their physical, psychological, sexual and social lives; how it affected their roles of mothers and partners, making them fearfuture childbirths. Diet, use of medicines, coal filters in incontinence pads, timing of toilet visits, use of the environment andmobile phones to conceal flatus and/or feces were strategies participants described. Conclusions: This study can contribute to increased understanding of how women can be affected by an OASR, and may enablehealthcare personnel and authorities to meet their needs and organize care so that adequate support is available. It would alsobe beneficial if the women’s physical strategies were integrated into the information provided by health caregivers involved infollow-up. However, more research in this area is warranted.

Is a low episiotomy rate associated with increased risk of obstetric anal sphincter rupture? An ecological study from 20 European countries in 2010

Background The incidence of obstetric anal sphincter ruptures (OASR) is considered a good indicator of the quality of obstetric care because of its impact on anal incontinence for women and its association with obstetric practices. OASR rates have increased in some countries. The dramatic decrease in episiotomies, after publication of a meta-analysis favouring restrictive use, might contribute to this trend. We compared OASR rates in European countries and investigated …

Anal incontinence in women with recurrent obstetric anal sphincter rupture: a case control study

Objectives: To determine the risk of recurrent anal sphincter rupture (ASR), and compare the risk of anal incontinence (AI) after recurrent ASR, with that seen in women with previous ASR who deliver by caesarean section or vaginally without sustaining a recurrent ASR.Methods: Women with recurrent ASR between January 2000 and June 2011 were identified at two delivery wards in Copenhagen. The women answered a questionnaire with a validated scoring system for AI (St. Mark`s score), and the results were compared with those obtained in two control groups: women with subsequent uncomplicated vaginal delivery or caesarean section.Results: There were 93 437 vaginal deliveries. ASR occurred in 5.5% (n = 2851) of the nulliparous and 1.5% (n = 608) of the multiparous women. Recurrent ASR occurred in 8% (n = 49) of whom 50% reported symptoms of AI. We found no difference in the occurrence of AI between women with recurrent ASR, and those who delivered vaginally without repeat ASR (p = 0.37; OR = 2.0) or by caesarean section (p = 0.77; OR = 1.3).Conclusion: Women with a past history of ASR have an 8% risk of recurrence. AI affects half of the women with recurrent ASR. Larger studies are required to confirm our findings.

From endometriosis to perineal trauma

From endometriosis to perineal trauma

Are obstetric anal sphincter ruptures preventable?– Large and consistent rupture rate variations between the Nordic countries and between delivery units in Norway

To study changes in the incidence of obstetric anal sphincter rupture (OASR) during recent years in Denmark, Finland, Sweden and Norway and hospital-based incidence in recent years in Norway. Retrospective birth register study. Unselected population of delivering women in four Nordic countries. All deliveries (574 175) registered in Denmark, Finland, Norway and Sweden, 2004-2010. Parity data, including maternal, obstetrical and fetal characteristics, were obtained. The incidence of OASR was calculated from vaginal deliveries. A chi-squared test was used to analyse differences between countries and time periods. Incidence of OASR. During the study period, the OASR incidence in Finland was notably lower (0.7-1.0%) than in the other three Nordic countries (4.2-2.3%). A significant and constant reduction in OASR incidence was observed in Norway only (from 4.1 to 2.3%, from 2004 to 2010, p < 0.001). This reduction occurred simultaneously with introduction of a national intervention program of improved delivery techniques that aimed to reduce the incidence of OASR. No major alterations in maternal or fetal risk factors for OASR or registration routines could explain this rapid reduction in the rate of OASR. Differences in the incidence of OASR between Norwegian delivery units were significant, with a threefold difference when comparing the units with lowest and highest incidences. Obstetric anal sphincter rupture seems to be preventable to a considerable extent, as indicated by the rapid and lasting reduction of OASR incidence after implementation of perineal protection programs in Norway. Improved delivery techniques should be implemented in all delivery units to prevent OASR as much as possible.

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.

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.

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.

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.

The incidence of obstetric anal sphincter rupture in primiparous women: a comparison between two European delivery settings

During the last years, the incidence of obstetric anal sphincter rupture (OASR) has increased markedly in Sweden, and significantly less frequently in Italy. Our objective was to explore if different delivery management may explain the variation in OASR incidences. In a retrospective study, data from 2,000 primiparous women in a Swedish and an Italian delivery unit were compared with respect to OASR, maternal age, gestational length, birth weight, labour induction, use of epidural analgesia (EDA) and oxytocin, vacuum extraction, episiotomy, and duration of the second stage of labour. Incidences of OASR were 9.2 and 0.4% in the Swedish and Italian centres, respectively. Other significant differences were noticed in maternal age, birth weight, gestational length, use of EDA, oxytocin, vacuum extraction, episiotomy, and frequency of induction. Further analysis of the Swedish population revealed a significant association between OASR and birth weight as well as vacuum extraction. The association with gestational age and duration of the second stage of labour approached significance level. However, no association could be found between OASR and maternal age, EDA, episiotomy or induction of labour. Women delivering in the Swedish setting had a 23 times higher risk of OASR. An association between OASR and birth weight, gestational age, instrumental vaginal deliveries and duration of second stage was found. These factors varied between the settings and could possibly explain the differences in OASR incidence. The importance of alternative management, such as constant midwife support and perineal protection during delivery, may be a subject for further studies.

Long‐term effects of anal sphincter rupture during vaginal delivery: faecal incontinence and sexual complaints

To determine the long-term effects of obstetric anal sphincter rupture on the frequency of faecal incontinence and sexual complaints. Retrospective case-control study. Department of Gynaecology and Obstetrics, Ikazia Hospital, The Netherlands. All 171 women operated for anal sphincter rupture between 1971 and 1990 and 171 controls matched for parity and date of delivery. Postal questionnaires regarding faecal incontinence were sent in 1996 and 2005 to all cases and controls with questions regarding sexual complaints added to the questionnaire in 2005. Anorectal complaints defined as any form of faecal incontinence including faecal urgency and faecal soiling. Sexual complaints defined as dyspareunia or faecal incontinence during intercourse. Sixty-one percent of the women responded to both questionnaires. Anorectal complaints were reported by 38% of case versus 16% of controls in 1996 (risk difference: 0.22, 95% CI 0.10-0.34) and by 61% of cases versus 22% of controls in 2005 (risk difference: 0.41, 95% CI 0.29-0.53). In contrast to the control group, the increase of anorectal complaints in the case group between 1996 and 2005 was highly significant (P < 0.0001). Postmenopausal state was not associated with an increased risk for faecal incontinence. Dyspareunia was reported by 29% of cases versus 13% of controls (P = 0.01). Faecal incontinence during intercourse was reported by 13% of cases versus 1% of controls (P = 0.005). Obstetric anal sphincter rupture is an important risk factor for sexual complaints and for faecal incontinence increasing with age irrespective of menopausal state.

Outcome of primary repair of obstetric anal sphincter rupture using the overlap technique

Grade III and IV anal sphincter ruptures after vaginal delivery are an increasing problem. We assessed the outcome of an overlap technique in primary repair. In this retrospective observational study, from 2002 to 2004, 61 consecutive women with grade III and IV obstetric tears were included. Of the 61 women, 42 had complete rupture of the external sphincter and underwent sphincter repair using standardised overlap technique. The outcome was assessed by clinical examination, Wexner questionnaire, and endoanal ultrasonography (EAUS), after a median follow-up of 9.4 months. Main outcome measure was continence following primary repair. At follow-up, 64% of the patients had no symptoms of anal incontinence. A total of 29% experienced occasional incontinence to flatus, 1 patient (2%) experienced occasional incontinence to liquid stools, and 1 patient to liquid or normal stools. EAUS revealed intact external sphincter in 29 of the 35 patients (83%). In 6 patients (17%), EAUS showed partial discontinuity of the sphincter muscle. The results show that the primary overlap technique in the repair of anal sphincter rupture following vaginal delivery is highly successful.

Obstetric anal sphincter rupture in older primiparous women: a case–control study

To determine if maternal age (35 years of age or older) in primiparous women is a risk factor for the development of obstetric anal sphincter rupture (OASR) and to identify obstetric factors associated with it. This is a retrospective case-control study. The study population was made up of the 5,345 primiparous women aged 24-45 years who delivered vaginally with singleton live-born neonates during 1990-99 at the Department of Obstetrics and Gynecology, Linköping University Hospital, Sweden. As cases the 327 primiparous women aged 35-45 years at delivery were selected. For each case two primiparous controls ten years younger were selected, matched for gestational age and year of delivery, in all 654 controls. Maternal, obstetrical, and neonatal data were obtained from the delivery records. Obstetric factors for the development of OASR were assessed with multivariate logistic regression analysis. No significant association was found between the primiparous age category and OASR. Vacuum extraction, forceps delivery, and the head circumference of the neonate were found to be independent risk factors for OASR, while the use of mediolateral episiotomy or epidural analgesia were independent protective factors for developing OASR. Primiparous women, 35 years of age or older, do not seem to have a greater risk of OASR than younger primiparous women. Risk factors for OASR are instrumental vaginal delivery and the size of the neonate. Mediolateral episiotomy and epidural analgesia seem to reduce the risk for OASR.