Repair Of Obstetric Anal Sphincter Injuries Research Articles

Antibiotics for the Prevention and Treatment of Postsurgical Obstetric Infections.

Importance Infectious complications contribute significantly to maternal morbidity and mortality. Antibiotics are a cornerstone of prevention and management of postsurgical infections in obstetrics. However, antibiotic resistance from inappropriate use of antibiotics is an emerging global health threat. Objective The aim of this study was to review the evidence and provide recommendations for antibiotic selection for prevention and treatment of postsurgical infections in obstetrics. Evidence Acquisition Published literature was retrieved through a search of PubMed. Relevant original research articles, systematic reviews, review articles, and practice guidelines were identified and included. Results Available evidence supports the use of a first-generation cephalosporin for an unlabored cesarean delivery, with the addition of adjunctive azithromycin for women undergoing labored cesarean delivery. Limited data also support the use of a second-generation cephalosporin at the time of obstetric anal sphincter injury repair. Limited retrospective studies suggest against the use of prophylactic antibiotics for manual removal of the placenta. Data are insufficient to recommend prophylactic antibiotics for postpartum dilation and curettage. Evidence from a systematic review supports clindamycin and gentamicin as the optimal regimen for the treatment of postpartum endometritis. Original obstetric research for the treatment of other postsurgical obstetric infections is limited, and recommendations provided are based on expert opinion. Conclusions and Relevance Obstetric providers should be familiar with available evidence and guidelines regarding antibiotic selection for the prevention and treatment of obstetric infections. Widespread selection of the narrowest effective antibiotic regimen has the potential to combat the rising threat of antibiotic resistance while ensuring appropriate prevention and treatment of postsurgical infections in obstetrics. Target Audience Obstetricians and gynecologists, family physicians. Learning Objectives After completing this activity, the learner should be better able to (1) categorize the most common bacterial isolates responsible for obstetric postsurgical infections; (2) determine which obstetric operative interventions warrant antibiotic prophylaxis based on evidence-based guidelines; and (3) select appropriate, effective, and targeted antibiotics for the treatment of postsurgical infections in obstetrics patients.

Republication de : Incontinence anale et lésions obstétricales du sphincter anal, épidémiologie et prévention

Our main objectives were to identify risk factors, methods for early diagnosis, and prevention of obstetric anal sphincter injuries (OASIs), using a literature review. The main risk factors for OASIs are nulliparity, instrumental delivery, posterior presentation, median episiotomy, prolonged second phase of labor and fetal macrosomia. Asian origin, short ano-vulvar distance, ligamentous hyperlaxity, lack of expulsion control, non-visualization of the perineum or maneuvers for shoulder dystocia also appear to be risk factors. There is a risk of under-diagnosis of OASIs in the labor ward. Experience of the accoucheur is a protective factor. Secondary prevention is based on the training of birth professionals in recognition and repair of OASIs. Primary prevention of OASIs is based on training in the maneuvers of the second phase of labor; if possible, instrumental extractions should be avoided. Mediolateral episiotomy may have a preventive role in high-risk OASIs deliveries. A robust predictive model is still lacking to allow a selective use of episiotomy.

Incontinence anale et lésions obstétricales du sphincter anal, épidémiologie et prévention

Our main objectives were to identify risk factors, methods for early diagnosis, and prevention of obstetric anal sphincter injuries (OASIs), using a literature review. The main risk factors for OASIs are nulliparity, instrumental delivery, posterior presentation, median episiotomy, prolonged second phase of labor and fetal macrosomia. Asian origin, short ano-vulvar distance, ligamentous hyperlaxity, lack of expulsion control, non-visualization of the perineum or maneuvers for shoulder dystocia also appear to be risk factors. There is a risk of under-diagnosis of OASIs in the labor ward. Experience of the accoucheur is a protective factor. Secondary prevention is based on the training of birth professionals in recognition and repair of OASIs. Primary prevention of OASIs is based on training in the maneuvers of the second phase of labor; if possible, instrumental extractions should be avoided. Mediolateral episiotomy may have a preventive role in high-risk OASIs deliveries. A robust predictive model is still lacking to allow a selective use of episiotomy.

Prevention and Management of Severe Obstetric Lacerations: A National Survey of Nurse Midwives [21L

INTRODUCTION: There is no detailed information on US obstetric providers' understanding of risks and management of severe obstetric anal sphincter injuries (OASIS). We performed a cross-sectional national survey study to identify OASIS education gaps among certified nurse midwives (CNMs) that could improve obstetric quality. METHODS: We invited American College of Nurse Midwives members (ACNM; n=6909) via email, and included active ACNM members performing at least one delivery within the past year. We assessed their understanding of OASIS risks, prevention, repair, and management based on a RedCap survey instrument that was previously created and piloted within a university OB-GYN department. RESULTS: We received 1069 (15.5%) completed surveys; 889 (83.2%) met our inclusion criteria. Participant age, race, and gender were statistically representative of ACNM membership. Poor nutrition, nulliparity, forceps and vacuum use, and midline episiotomy were reported as the top OASIS risk factors. CNM prevention techniques included perineal support, guided delivery, avoiding episiotomies, and maternal positioning. 15.1% of respondents reported repairing OASIS personally, 78.8% referred out. Over 85% of respondent reported they did not routinely perform a rectal exam if lacerations were suspected. At discharge, CNMs recommend stool softeners, sitz baths, NSAIDS, lidocaine ointment or spray, and fiber supplements. 30% of respondents reported receiving formal education on OASIS, and 37.5% reported that their delivery sites have protocols or guidelines regarding OASIS management. CONCLUSION: CNMs report standard care for OASIS that is similar to the American College of Obstetricians and Gynecologists’ recent practice bulletin recommendations, though additional formal training on OASIS prevention and management appears warranted.

Obstetric Anal Sphincter Injuries (OASIs) in Israel: A Review of the Incidence and Risk Factors.

Obstetric anal sphincter injuries (OASIs) following vaginal deliveries are the main reason for subsequent development of anal incontinence in women. The diagnosis of such tears is crucial for treating and preventing such a grave sequela. The reported rate of OASIs in Israel was between 0.1% and 0.6%, out of all vaginal births, which is 10-fold lower than that reported in Europe and the United States. Structured hands-on training in repair of OASIs in seven medical centers in Israel significantly increased the detection rate of third-degree perineal tears. The implementation of such programs is crucial for increasing awareness and detection rates of OASIs following vaginal deliveries.

Feasibility and benefits of the ewe as a model for vaginal surgery training.

The objective was to evaluate the ewe as an animal model for teaching and training in vaginal surgery. Twenty-nine postgraduate surgeons attended a training course on vaginal prolapse surgery. After a review of human and sheep anatomy, the participants performed transvaginal meshes, vaginal hysterectomy, SSLF (Richter), and OAS repair in ewes and human cadavers. Participants completed questionnaires on the whole course. Questionnaires showed the significant superiority of ewes over human cadavers for all items evaluated regarding surgical dissections. Only identification of the sacrospinous ligament and the spine were judged to be similar in ewes and human cadavers. Participants noticed that ewe model is appropriate for vaginal prolapse surgery training for resident and for postgraduate surgeons. Two vaginal hysterectomies were also performed. Operating time, surgery, and anatomy were nearly identical to that of humans. The same conclusions were made while performing sacrospinous ligament fixation (Richter) and obstetric anal sphincter injury repair. This series indicates that the ewe is a useful animal model for teaching vaginal surgery.

Can Anal Sphincter Defects Be Identified by Palpation?

The aim of this study was to correlate clinical findings of anal sphincter defects and function with a sonographic diagnosis of significant sphincter defects. This is an observational cross-sectional study on women seen 6 to 10 weeks after primary repair of obstetric anal sphincter injuries (OASIs). All patients underwent a standardized interview including the St Mark incontinence score, a digital rectal examination, and 3-/4-dimensional transperineal ultrasound imaging. Two hundred forty-five patients were seen after primary repair of OASIs. Mean age was 29 (17-43) years. They were assessed at a median of 58 (15-278) days postpartum. One hundred fifty-seven (64%) delivered normal vaginally, 72 (29%) delivered by vacuum, and 16 (7%) delivered by forceps. A comparison of external anal sphincter (EAS) and internal anal sphincter ultrasound volume data and palpation was possible in 220 and 212 cases, respectively. Sphincter defects at rest and on contraction were both detected clinically in 17 patients. Significant abnormalities of the EAS were diagnosed on tomographic ultrasound imaging in 99 cases (45%), and significant abnormalities of the internal anal sphincter were diagnosed in 113 cases (53%). Agreement between digital and sonographic findings of sphincter defect was poor (k = 0.03-0.08). Women with significant EAS defects on ultrasound were found to have a lower resistance to digital insertion (P = 0.018) and maximum anal squeeze (P = 0.009) on a 6-point scale. The difference was however small. Digital rectal examination does not seem to be sufficiently sensitive to diagnose residual sphincter defects after primary repair of OASIs. Imaging is required for the evaluation of sphincter anatomy after repair.

Residual defects after repair of obstetric anal sphincter injuries and pelvic floor muscle strength are related to anal incontinence symptoms.

The aim was to analyze the correlation between residual anal sphincter (AS) defects and pelvic floor muscle (PFM) strength on anal incontinence (AI) in patients with a history of obstetric AS injuries (OASIS). From September 2012 to February 2015, an observational study was conducted on a cohort of females who underwent repair of OASIS intrapartum. The degree of OASIS was scored intrapartum according to Sultan's classification. Participants were assessed at 6months postpartum. Incontinence symptoms were evaluated using Wexner's score and PFM strength using the Modified Oxford Scale (MOS). 3D-endoanal ultrasound was performed to classify AS defects according to Starck's system. Correlation between Sultan's and Starck's classifications was calculated using Cohen's kappa and Spearman's rho (Rs) test. The impact of residual AS defects and PFM strength on AI was analyzed using a multiple regression model. A total of 95 women were included in the study. Good correlation (κ= 0.72) was found between Sultan's and Starck's classifications. Significant positive correlation was observed between Wexner's score and both Sultan's (p = 0.023, Rs =0.212) and Starck's (p < 0.001, Rs =0.777) scores. The extent of the residual AS defect was the most relevant factor correlating with AI symptoms. In patients with severe AS injuries, higher MOS values were associated with lower Wexner's score. The degree of AS tear measured intrapartum was the most important factor related to AI after primary repair of OASIS. PFM strength was associated with lower incontinence symptoms in the postpartum period.

Factors predicting a failed primary repair of obstetric anal sphincter injury.

The success of the primary repair of obstetric anal sphincter injury (OASI) is paramount in maintaining adequate fecal continence after childbirth. The factors determining the success or failure of primary repair are unclear. The aim of this study is to investigate modifiable factors determining the success or failure of the primary sphincter repair after OASI. Sixty women with OASI were investigated by endoanal ultrasound or magnetic resonance imaging, and with the Wexner incontinence questionnaire. Based on the findings, the women were divided in two groups; successful primary repair group (n = 41) and failed primary repair group (n = 19). The primary repair failed in 31.7% of the tears. These included more tears repaired by less experienced personnel (p < 0.001) and more repairs performed during on-call hours (p = 0.039) than in the successful primary repair group. Significantly more pain medication was used in the failed group (p = 0.003), and the use of antibiotics and laxatives after the repair was more common in the successful group (p < 0.001). Sphincter injuries were repaired using the overlapping suture technique in 95.1% of the repairs in the successful group compared with 47.4% in the failed group (p = 0.03). The mean (SD) Wexner score was significantly higher in the failed group [5.92 (4.1) vs. 1.88 (4.2), p < 0.001], in agreement with the findings on endoanal ultrasound. Postpartum perineal tears should be evaluated by personnel familiar with the diagnosis and repair of OASI. Delaying the primary repair until next morning is recommended if experienced personnel are unavailable during on-call hours.

The management of obstetric anal sphincter injuries (OASIS): A national postal questionnaire survey in hospitals in the UK

Obstetric anal sphincter injuries (OASIS) represent a serious morbidity that can cause short- and long-term consequences. It has attracted attention leading to the development of a national guideline by the Royal College of Obstetricians and Gynaecologists (RCOG). The aim of this study was to establish the current management of these injuries in hospitals across the UK. An anonymous self-construct questionnaire was posted to clinical directors/lead obstetricians in all hospitals in the UK and a total of 104 out of 233 (44.6%) questionnaires were returned. Over 90% of respondents’ hospitals had protocols that required repair in theatre, as well as the prescription of laxatives and antibiotics and included these injuries in the risk management list. More than half of the respondents’ hospitals did not have a dedicated perineal trauma clinic or used symptoms and quality of life questionnaires, endoanal scans or anal manometry routinely at follow-up. Over a third of respondents indicated that their units did not provide any training on repair of OASIS and did not have a multidisciplinary meeting involving colorectal surgeons. More effort is needed to improve all these aspects of care.

Confidence in repair of obstetric anal sphincter injuries and objective assessment in obstetricians

Objective: To describe attending obstetricians’ self-reported confidence to recognize and repair Obstetric Anal Sphincter Injuries (OASIS), assess knowledge of anatomy and risk factors for OASIS and evaluate the need for a protocol. Study design: A questionnaire was distributed to attending obstetricians at seven major medical centers. The survey was divided into categories including demographics, self-reported confidence at recognition of OASIS, self–reported competence at OASIS repair, questions on anatomy and risk factors for OASIS and need for a protocol for OASIS repair. Results: We collected 82 questionnaires for a response rate of 40.2 percent. Twenty-two (26.8%) and 59 (72%) survey respondents were respectively mostly confident or very confident and only one (1.2%) was somewhat confident at OASIS recognition. Thirty-two (39%) participants felt mostly competent, and 47 (57.3%) felt very competent at OASIS repairs. Percentage of correct answers to the objective questions on anatomy and risk factors ranged from 45.1 to 58.5. Overall performance in objective questions did not differ by self-reported competence in repair of higher order lacerations (p=0.09). Conclusions: Our study shows that self-reported confidence in detecting OASIS and competence in repair of OASIS does not correlate with knowledge of anatomy and risk factors of OASIS.

Outcome of repair of obstetric anal sphincter injuries after three years

ObjectiveTo prospectively assess change in bowel symptoms and quality of life (QoL) approximately 3years after primary repair of obstetric anal sphincter injuries (OASIS). MethodsBetween July 2002 and December 2007 women who attended the perineal clinic at Croydon University Hospital, UK, 9weeks following primary repair of OASIS were asked to complete the Manchester Health Questionnaire and a questionnaire to obtain a St Mark incontinence score. All women had endoanal scans at this visit. In June 2008 all women were asked to complete the questionnaires again. ResultsOf 344 patients who responded to the questionnaires and were included in the analysis, long-term symptoms of fecal urgency, flatus incontinence, and fecal incontinence occurred in 62 (18.0%), 52 (15.1%), and 36 (10.5%), respectively. Overall, there was a significant improvement in fecal urgency (P<0.001) and flatus incontinence (P<0.001) from 9weeks to 3years. Of 31 women with fecal incontinence symptoms at early follow-up, 28 were asymptomatic at 3years. However, 33 women developed de novo symptoms. The only predictors of fecal incontinence at 3years were fecal urgency at 9weeks (OR 4.65; 95% CI, 1.38–15.70) and a higher St Mark score (OR 1.40; 95% CI, 1.09–1.80). ConclusionFollowing primary repair of OASIS, the majority of symptoms and QoL significantly improve, unless there is a persistent anal sphincter defect. This highlights the importance of adequate repair.

Long-term outcome of obstetric anal sphincter injury repaired by experienced obstetricians

ObjectiveTo examine the long-term outcomes of women with obstetric anal sphincter injury (OASI) repaired by obstetricians without the involvement of colorectal surgeons. MethodsA retrospective cohort study was undertaken of women who had been admitted for delivery between 2004 and 2012. All OASIs had been repaired by experienced obstetricians using the end-to-end technique. An unexposed group (no OASI) was matched at a ratio of 1:1. Fecal incontinence was graded using a modified Wexner questionnaire. ResultsOverall, 113 OASIs were recorded. Sixty-seven (59.3%) and 71 (62.8%) women from the exposed and unexposed groups, respectively, agreed to participate in the study (P=0.9). Continence to both stool and gas was reported by 48 (71.6%) and 64 (90.1%) women in the exposed and unexposed groups, respectively (P=0.03). The incidence of urgency, dyspareunia, and use of a pad or constipating agents was the same in both groups. ConclusionThe long-term outcome of OASI repair performed by experienced obstetricians is comparable to that reported in the literature. Some women who did not sustain an OASI reported fecal incontinence, which suggests that only a proportion of fecal incontinence can be attributed to OASI.

Outcome of obstetric anal sphincter injuries in terms of persisting endoanal ultrasonographic defects and defecatory symptoms

ObjectiveTo determine the prevalence of persisting endoanal ultrasonographic defects among women with obstetric anal sphincter injuries (OASIS), and the incidence of defecatory symptoms. MethodsIn a prospective study in Enschede, Netherlands, women with OASIS were enrolled between 2007 and 2012. Three months after surgical repair, all women had an endoanal ultrasound, and data were collected on gas and fecal incontinence, soiling, and fecal urgency. ResultsOverall, 99 women were included. At follow-up, 35 (35.4%) women had a persisting defect of the external anal sphincter on ultrasound, and 5 women (5.1%) also had a persisting defect of the internal anal sphincter. Overall, 35 (35.4%) women had one or more defecatory complaints—predominantly involuntary loss of gas and fecal urgency. Overall, 22 of 35 (63.0%) women with and 13 of 64 (20.3%) women without a persisting defect on ultrasound had defecatory complaints. The number of defecatory symptoms showed a positive correlation with severity of injury. Women with a persisting defect had a threefold higher risk of defecatory complaints as compared with women who had a successful repair (odds ratio, 6.6; 95% confidence interval, 2.6–16.6). ConclusionThe results emphasize the importance of adequate repair of OASIS and demonstrate that repair can be difficult or underestimated.

Methods of repair for obstetric anal sphincter injury

Anal sphincter injury during childbirth - obstetric anal sphincter injuries (OASIS) - are associated with significant maternal morbidity including perineal pain, dyspareunia (painful sexual intercourse) and anal incontinence, which can lead to psychological and physical sequelae. Many women do not seek medical attention because of embarrassment. The two recognised methods for the repair of damaged external anal sphincter (EAS) are end-to-end (approximation) repair and overlap repair. To compare the effectiveness of overlap repair versus end-to-end repair following OASIS in reducing subsequent anal incontinence, perineal pain, dyspareunia and improving quality of life. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 September 2013) and reference lists of retrieved studies. Randomised controlled trials comparing different techniques of immediate primary repair of EAS following OASIS. Trial quality was assessed independently by all authors. Six eligible trials, of variable quality, involving 588 women, were included. There was considerable heterogeneity in the outcome measures, time points and reported results. Meta-analyses showed that there was no statistically significant difference in perineal pain (risk ratio (RR) 0.08, 95% confidence interval (CI) 0.00 to 1.45, one trial, 52 women), dyspareunia (average RR 0.77, 95% CI 0.48 to 1.24, two trials, 151 women), flatus incontinence (average RR 1.14, 95% CI 0.58 to 2.23, three trials, 256 women) between the two repair techniques at 12 months. However, it showed a statistically significant lower incidence of faecal urgency (RR 0.12, 95% CI 0.02 to 0.86, one trial, 52 women), and lower anal incontinence score (standardised mean difference (SMD) -0.70, 95% CI -1.26 to -0.14, one trial, 52 women) in the overlap group. The overlap technique was also associated with a statistically significant lower risk of deterioration of anal incontinence symptoms over 12 months (RR 0.26, 95% CI 0.09 to 0.79, one trial, 41 women). There was no significant difference in quality of life. At 36 months follow-up, there was no difference in flatus incontinence (average RR 1.12, 95% CI 0.63 to 1.99, one trial, 68 women) or faecal incontinence (average RR 1.01, 95% CI 0.34 to 2.98, one trial, 68 women). The data available show that at one-year follow-up, immediate primary overlap repair of the external anal sphincter compared with immediate primary end-to-end repair appears to be associated with lower risks of developing faecal urgency and anal incontinence symptoms. At the end of 36 months there appears to be no difference in flatus or faecal incontinence between the two techniques. However, since this evidence is based on only two small trials, more research evidence is needed in order to confirm or refute these findings.

Élaboration et évaluation d’un outil d’enseignement de la réparation des déchirures périnéales du troisième et quatrième degré

To evaluate the educational interest of a workshop on diagnosis and repair of obstetric anal sphincter injuries (OASIS). To evaluate the theoretical and anatomical knowledge of OASIS repair by French residents in obstetrics and gynecology. The workshop was composed of slides, video of repair and training using cadaveric sow's anal sphincters. All subjects were tested with a questionnaire before and after the course. Thirty residents participated. Classification of OASIS was known by 13.3% of the residents before the training versus 93.3% after the workshop (P<0.001). Initially, only 6.7% correctly classified operative procedures of OASIS versus 86.7% after the workshop (P<0.001). Per pre-test, 90% of residents did not know how to identify the internal anal sphincter (IAS) versus 3% at post-test (P<0.001). Seventy percent of trainees correctly identified the external anal sphincter (EAS) at the beginning of training. Before the course, no resident knew the repair of the IAS and only one third knew the technical repair of the EAS. After the workshop, the theoretical knowledge of EAS and IAS repair were acquired by all (P<0.001). Structured hands-on training improves significantly the knowledge of OASIS diagnosis and repair.

Obstetric Anal Sphincter Injuries: A Survey of Clinical Practice Among Canadian Obstetricians

ObjectiveTo describe the current practice, experience, and confidence of Canadian obstetricians in the management of obstetric anal sphincter injuries (OASIS) and to explore the need for national practice guidelines on this topic. MethodsWe conducted a cross-sectional, Internet-based survey between December 2010 and March 2011. The survey was initially tested among a sample population and then distributed electronically to 665 Canadian obstetricians. Data were analyzed descriptively. The main outcome measures were the self-reported confidence and experience of Canadian obstetricians in OASIS management and the frequency of performing specific OASIS management steps. ResultsThe survey response rate was 28.7%. The majority of the respondents (95%) reported confidence in performing OASIS repairs. In the event of a perineal laceration, 47.9% of respondents routinely performed a rectal examination. Most OASIS repairs were performed in the delivery room (89.4%) under local anaesthesia (60.6%) when regional anaesthesia was not already present. If lacerated, the internal anal sphincter was repaired separately by 63.4% of respondents, and intraoperative antibiotics were ordered by 51.1% of respondents. Most (92%) reported the absence of a local protocol to guide OASIS repair. ConclusionThe confidence of Canadian obstetricians who participated in this survey in performing OASIS repairs was high. However, their experience in performing repairs and their use of management steps varied. The need for national guidelines and an increase in awareness is suggested.

Anal and urinary incontinence 4 years after a vaginal delivery

Our purpose was to establish the incidence of anal and urinary incontinence 4 years following vaginal delivery in women with and without obstetric anal sphincter injuries (OASIS). This was a prospective study of 241 having their first vaginal delivery who had independent verification and repair of OASIS by trained obstetricians. All obstetricians performing OASIS repairs had undergone structured hands-on training and were then directly supervised while repairing OASIS until they were deemed competent to repair independently. Patients were followed up for 4 years with validated bowel and urinary questionnaires. In order to minimise nonresponders, contact details were verified and obtained from their general practitioners, the local primary care trust and electoral roll. Two hundred and fifty-four women were invited, and 241 (95 %) participated. Fifty-nine (25 %) women sustained OASIS. One hundred and forty-nine were contactable 4 years later, and 86 (58 %) agreed to participate in the study at 4 years. No woman had faecal incontinence, and there was no difference in rates of flatus incontinence prior to delivery up to 4 years postpartum, regardless of whether OASIS occurred or not. Urinary incontinence was more than four times more common after vaginal birth, and this was not affected by whether OASIS occurred and resulted in a significant deterioration in quality of life. The previously reported higher rates of anal incontinence following OASIS can be minimised up to 4 years after delivery if repaired by trained doctors. There is a significant increase in urinary incontinence following vaginal delivery, and the mechanism for this is not linked to anal sphincter disruption.

Outcome of obstetric anal sphincter injuries (OASIS)—role of structured management

Prospective studies up to 1 year after repair of obstetric anal sphincter injuries (OASIS) report anal incontinence in 33% of women and up to 92% have a sonographic sphincter defect. The aim of this study is to determine the outcome of repair by doctors who have undergone structured training using a standardized protocol. Doctors repaired OASIS after attending a training workshop. The external anal sphincter was repaired by the end-to-end technique when partially divided and the overlap method when completely divided. Endoanal ultrasound was performed prior to suturing and 7 weeks later. A validated bowel symptom questionnaire was completed prior to delivery, at 7 weeks postpartum, and at 1 year postpartum. Fifty-nine women sustained OASIS. At 7 weeks, six (10%) had a defect on ultrasound. There was no significant deterioration in symptoms of fecal urgency, incontinence, or quality of life at 1 year after delivery. The 1-year outcome after repair of OASIS appears to be good when repaired by doctors after structured training.

Management of obstetric anal sphincter injury: a systematic review & national practice survey.

BackgroundWe aim to establish the evidence base for the recognition and management of obstetric anal sphincter injury (OASI) and to compare this with current practice amongst UK obstetricians and coloproctologists.MethodsA systematic review of the literature and a postal questionnaire survey of consultant obstetricians, trainee obstetricians and consultant coloproctologists was carried out.ResultsWe found a wide variation in experience of repairing acute anal sphincter injury. The group with largest experience were consultant obstetricians (46.5% undertaking ≥ 5 repairs/year), whilst only 10% of responding colorectal surgeons had similar levels of experience (p < 0.001). There was extensive misunderstanding in terms of the definition of obstetric anal sphincter injuries. Overall, trainees had a greater knowledge of the correct classification (p < 0.01). Observational studies suggest that a new 'overlap' repair using PDS sutures with antibiotic cover gives better functional results. However, our literature search found only one randomised controlled trial (RCT) on the technique of repair of OASI, which showed no difference in incidence of anal incontinence at three months. Despite this, there was a wide variation in practice, with 337(50%) consultants, 82 (55%) trainees and 80 (89%) coloproctologists already using the 'overlap' method for repair of a torn EAS (p < 0.001). Although over 50% of colorectal surgeons would undertake long-term follow-up of their patients, this was the practice of less than 10% of obstetricians (p < 0.001). Whilst over 70% of coloproctologists would recommend an elective caesarean section in a subsequent pregnancy, only 22% of obstetric consultants and 14% of trainees (p < 0.001).ConclusionAn agreed classification of OASI, development of national guidelines, formalised training, multidisciplinary management and further definitive research is strongly recommended.