Sphincter Rupture Research Articles

Unplanned pregnancy and the association with maternal health and pregnancy outcomes: A Swedish cohort study.

Unplanned pregnancies are common and associated with late initiation and inadequate antenatal care attendance, which may pose health risks to mother and child. How pregnancy planning relates to maternal health and delivery in Sweden, a country with free antenatal care and free abortion, has not been studied previously. Our aims were to study whether pregnancy planning was associated with antenatal care utilization and pregnancy outcomes in a Swedish setting. Data for 2953 women, who answered a questionnaire when recruited at antenatal clinics in Sweden and later gave birth, was linked to the Swedish Medical Birth Register. The degree of pregnancy planning was estimated using the London Measure of Unplanned Pregnancy. Unplanned (comprising unplanned and ambivalent intention to pregnancy) was compared to planned pregnancy. Differences between women with unplanned and planned pregnancy intention and associated pregnancy outcomes were analyzed using Fisher's exact test and logistic regression. There were 31% unplanned (2% unplanned and 29% ambivalent) pregnancies, whereas most woman (69%) reported their pregnancy to be planned. Women with an unplanned pregnancy enrolled later to antenatal care, but there was no difference in number of visits compared with planned pregnancy. Women with an unplanned pregnancy had higher odds to have induced labor (17% versus 13%; aOR 1.33 95% CI 1.06-1.67) and a longer hospital stay (41% versus 37%; aOR 1.21 95% CI 1.02-1.44). No associations were found between pregnancy planning and pregnancy-induced hypertension, gestational diabetes mellitus, preeclampsia, epidural analgesia use, vacuum extraction delivery, Caesarean section or sphincter rupture. Unplanned pregnancy was associated with delayed initiation of antenatal care, higher odds for induction of labor and longer hospital stay, but not with any severe pregnancy outcomes. These findings suggest that women with an unplanned pregnancy cope well in a setting with free abortion and free health care.

Evaluation of Episiotomy Characteristics of EPISCISSORS-60 Scissors Compared with Mayo Scissors: A Single-Blind Randomized Clinical Trial.

It seems that angled scissors may be able to minimize the occurrence of obstetric anal sphincter injuries (OASIS) during vaginal delivery by correcting the angle of the episiotomy incision.For this purpose, this study aimed to evaluate the episiotomy characteristics of EPISCISSORS-60 scissors compared with Mayo scissors. In this single-blind clinical trial study, 64 pregnant women candidates for natural childbirth were included; 32 women underwent episiotomy with Mayo scissors and 32 underwent episiotomy with the EPISCISSORS-60 instrument. Then, post-suturing angle, incision length, episiotomy, postpartum pain, bleeding volume, and the incidence of OASIS and dyspareunia were assessed. The collected data were analyzed by independent sample t test, chi-square test, and the Fisher exact test. Episiotomy incision length in the EPISCISSORS-60 group with a mean of 4.75 ± 0.72 cm was significantly longer than the Mayo group with a mean of 3.91 ± 0.52cm (P < 0.001). In addition, the incidence of dyspareunia was not significantly different between the 2 groups (6.3% vs 15.6%; P = 0.426). Sphincter damage did not occur at all in the EPISCISSORS-60 group and only 2 cases of grade 3 sphincter rupture occurred in the Mayo group (P = 0.238). The mean of post suturing angle in the EPISCISSORS-60 group (59.09° ± 3.47°) was significantly higher than the Mayo group, with a mean of 31.06° ± 7.21° (P < 0.001). According to the results of the present study, the use of EPISCISSORS-60 can be associated with a higher post-suture episiotomy angle compared with Mayo scissors. As a result, both the incidence of OASIS and its long-term side effects, like dyspareunia, were decreased. However, in our study, the incidence of these complications was very rare and not different between the 2 groups.

Risk Factors for Anal Continence Impairment Following a Second Delivery after a First Traumatic Delivery: A Prospective Cohort Study

Postpartum anal incontinence is common. After a first delivery (D1) with perineal trauma, follow-up is advised to reduce the risk of anal incontinence. Endoanal sonography (EAS) may be considered to evaluate the sphincter and in case of sphincter lesions to discuss cesarean section for the second delivery (D2). Our objective was to study the risk factors for anal continence impairment following D2. Women with a history of traumatic D1 were followed before and 6 months after D2. Continence was measured using the Vaizey score. An increase ≥2 points after D2 defined a significant deterioration. A total of 312 women were followed and 67 (21%) had worse anal continence after D2. The main risk factors for this deterioration were the presence of urinary incontinence and the combined use of instruments and episiotomy during D2 (OR 5.12, 95% CI 1.22-21.5). After D1, 192 women (61.5%) had a sphincter rupture revealed by EAS, whereas it was diagnosed clinically in only 48 (15.7%). However, neither clinically undiagnosed ruptures nor severe ruptures were associated with an increased risk of continence deterioration after D2, and cesarean section did not protect against it. One woman out of five in this population had anal continence impairment after D2. The main risk factor was instrumental delivery. Caesarean section was not protective. Although EAS enabled the diagnosis of clinically-missed sphincter ruptures, these were not associated with continence impairment. Anal incontinence should be systematically screened in patients presenting urinary incontinence after D2 as they are frequently associated.

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

Fear of childbirth postpartum and its correlation with post-traumatic stress symptoms and quality of life among women with birth complications \u2014 a cross-sectional study

The primary aim of the study was to analyze differences in post-traumatic stress symptoms (PTSS) and quality of life (QoL) between women with and without severe fear of childbirth postpartum (PP FOC). The secondary aims were to analyze the correlation between PP FOC and PTSS, and PP FOC and QoL, in women undergoing complicated childbirth. This cross-sectional study was conducted in South-East Sweden. Women aged ≥ 18 years who had undergone complicated childbirth (i.e., acute or emergency cesarean section, vacuum extraction, child in need of neonatal care, manual placenta removal, sphincter rupture, shoulder dystocia, or hemorrhage ≥ 1000 ml) were invited. Seventy-six women answered demographic questions and three validated instruments measuring PP FOC, PTSS, and QoL. The study population was divided into two sub groups: severe PP FOC or no severe PP FOC. Statistical analyses were conducted using Mann–Whitney U-test, chi-square test or Fisher’s exact test, and Spearman’s rank-order correlation. Severe PP FOC was reported by 29% of the women, and 18% reported PTSS indicating post-traumatic stress disorder. Women with severe PP FOC reported significantly higher levels of PTSS, and significantly lower QoL in five dimensions: physical role functioning, emotional role functioning, energy/fatigue, emotional well-being, and social functioning. There was a positive significant correlation between level of PP FOC and PTSS. There were also significant negative correlations between level of PP FOC and most of the QoL dimensions. In conclusion, almost one-third of the women with complicated childbirth reported severe PP FOC, and almost one-fifth reported PTSS indicating post-traumatic stress disorder. PP FOC correlated with PTSS and deteriorated QoL.

Induction of labor in breech presentations - a retrospective cohort study.

There is limited evidence on the safety and outcome of induction of breech labor. In this study, we aimed to compare the outcomes of spontaneous and induced breech deliveries and to describe variations in induction rates. This was a retrospective cohort study comprising 1054 singleton live fetuses in breech presentation at Trondheim University Hospital from 2012 to 2019. The main outcome was intrapartum cesarean section, and secondary outcomes were postpartum hemorrhage, anal sphincter ruptures, Apgar scores, pH in the umbilical artery, and metabolic acidosis. All data were obtained from the hospital birth journal. Induction of labor was performed in 127/606 (21.0%) women with planned vaginal birth. The frequency of intrapartum cesarean section was 48.0% for induced labor vs 45.7% for spontaneous labor (P=.64). We found no differences in the frequency of postpartum hemorrhage or anal sphincter ruptures between induced and spontaneous births. The median pH in the umbilical artery was significantly lower in neonates with induced labor compared with neonates with spontaneous labor (7.22 vs 7.25; P=.02). The frequency of pH <7.05 was 7.0% for induced labor vs 2.9% (P=.05) for spontaneous labor, but the frequency of pH <7.0 was not significantly different: 2.6% vs 0.8% (P=.14), respectively. Three neonates with planned vaginal birth had metabolic acidosis: two with spontaneous labors and one with induced labor. Three fetuses with planned vaginal birth died during labor: two with spontaneous onset of labor and one with induced labor. All three were extremely preterm: two were delivered in week 23 and one in week 25. We did not observe any significant trend in induction rates in either parous or nulliparous women. The induction rates were stable during the study period. We did not observe any significant difference in intrapartum cesarean section rates, in the frequency of pH <7.0 in the umbilical artery, or in the frequency of metabolic acidosis when comparing induced and spontaneous breech deliveries.

Induction of labour in nulliparous women- quick or slow: a cohort study comparing slow-release vaginal insert with low-dose misoprostol oral tablets

BackgroundThis study was undertaken with the objective of comparing efficacy and safety for two different regimens using misoprostol for induction of labour.MethodsThe study was set in two different hospitals in the region of Zeeland, Denmark, and designed as a prospective cohort study. Nulliparous women with unripe cervix, eligible for vaginal delivery and medical induction of labour were included. Exclusion criteria were a previous uterine scar, suspicion of growth restriction of the fetus and prelabour rupture of membranes.One department used 25 mcg oral misoprostol tablets and the other department used 200 mcg slow-release misoprostol vaginal insert, for induction of labour.Primary outcomes were predefined as frequency of cesarean section, tachysystole and delivery within 24 h. Secondary outcomes were: time from induction to delivery, use of additional methods for induction, postpartum hemorrhage, anal sphincter rupture, epidural, pyrexia (rectal temperature > 38.5 °C), prolonged rupture of membranes, and use of tocolysis.ResultsNo significant differences in women achieving vaginal delivery was found. However, a significantly increased risk of tachysystole for the vaginal administration route was observed; 28.4% compared with 2.3%. There were no events of serious neonatal asphyxia. Half of the women induced with vaginal insert delivered within 24 h, compared with 16.8% of the women induced with oral misoprostol.ConclusionsInduction with vaginal slow-release misoprostol leads to quicker delivery with an increased risk of tachysystole but with similar perinatal outcomes and rates of cesarean sections. Low-dose oral misoprostol appears to be safe, however it leads to an increased use of secondary methods and a tendency of more intrapartum pyrexia.Trial registrationClinicaltrials.gov ID: NCT02693587 on February 262,016.EudraCT number 2020–000366-42 on 23 January 2020, retrospectively registered.

Anal/anogenital lesion revealing child sexual abuse: A case series of an unusual situation in a black African setting

IntroductionChild sexual abuse (CSA) remains a big taboo in black Africa with an underestimated prevalence. In our context, the majority of cases are known by revelations of the child at least one year after the facts. Presentation of casesWe report three cases of CSA revealed by an anal/anogenital lesion requiring surgery. All of these patients were female with ages ranging from 20 months to 8 years. The lesions encountered were: an anal abscess, a fissure-in-ano with permanent anal mucosal eversion and a complex perineal tear including partial anal sphincter rupture with partial section of the rectovaginal septum. The outcome was favorable in all cases after surgery. The abuser was subsequently able to be identified after the statements of two of these three children. DiscussionDetection of anogenital lesions during a pediatric consultation should make practitioners aware of the possibility of sexual abuse. Surgical repair of these lesions can be simple or complex, requiring major reconstructions. In such cases, it’s important to listening to the child’s voice. ConclusionAnogenital lesions discovered during pediatric consultation must evoke sexual abuse. The silence and the taboo surrounding these abuses in Africa must be break down.

Obstetric perineal ruptures—risk of anal incontinence among primiparous women 12 months postpartum: a prospective cohort study

Anal incontinence leads to impairment of the quality of life and lower self-esteem with implications for social, physical, and sexual health; anal incontinence after vaginal delivery is a major concern for many women. Only about half of the cases of postpartum anal incontinence can be related to anal sphincter injuries, and the remaining cases must thus be related to other factors. The aim of this study was to examine the association between maternal and obstetric characteristics, including the degree of perineal rupture and anal incontinence 12 months postpartum. Furthermore, the aim was to investigate the association between anal sphincter muscle defects, perineal length, and perineal strength and the risk of anal incontinence. We conducted a prospective cohort study at 4 Danish hospitals: Odense University Hospital, Aarhus University Hospital, Esbjerg Hospital, and Kolding Hospital. Baseline data were obtained 2 weeks postpartum in relation to an evaluation of perineal wound healing. Symptoms of anal incontinence were evaluated 12 months postpartum by a Web-based questionnaire (St. Mark's incontinence score questionnaire). In addition, defects in the anal sphincter muscles were examined using endoanal ultrasound, perineal length was measured, and perineal strength was examined using anal manometry. The main outcome measurement was anal incontinence defined as a St. Mark's score of >4. We performed multivariate analyses to investigate the risk factors for anal incontinence and to investigate the risk of anal incontinence according to endoanal ultrasound scanning and anal manometry findings. A total of 603 primiparous women (203 with no/labia/first-degree ruptures, 200 with second-degree ruptures, and 200 with third-/fourth-degree ruptures) were included between July 2015 and January 2018. At 12 months postpartum, 575 women (95%) answered the questionnaire; 193 with no/labia/first-degree ruptures, 193 with second-degree ruptures, and 189 with third-/fourth-degree ruptures. A total of 499 women underwent an endoanal ultrasound scanning and 482 women underwent anal manometry. Anal incontinence with a St. Mark's score of >4 was reported by 7% and 9% of women with no/labia/first-degree ruptures or second-degree ruptures, respectively, and by 14%, 15%, 35%, and 33% of women with ruptures of degree 3a, 3b, 3c, and 4, respectively. Compared to women with no or minor tears, women with anal sphincter ruptures had a higher risk of anal incontinence (adjusted relative risk, 2.46; 95% confidence interval, 1.28-4.71). Ruptures of degree 3c and 4 were associated with a substantial increase in risk of anal incontinence (adjusted relative risk, 4.74; 95% confidence interval, 1.98-11.3; and adjusted relative risk, 2.23; 95% confidence interval, 1.59-11.3, respectively), especially if a defect in the external or internal anal sphincter muscle was present (adjusted relative risk, 4.74; 95% confidence interval, 1.54-14.5; and adjusted relative risk, 6.58; 95% confidence interval, 3.35-12.9, respectively). The risk of anal incontinence increased by 8% per 1-unit increase in body mass index (adjusted relative risk, 1.08; 95% confidence interval, 1.03-1.14). Obesity with body mass index of >29.9 and a high-degree rupture (3c or 4), especially with a persistent defect in the internal or external anal sphincter muscle, increased the risk of anal incontinence.

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.

Severe perineal morbidity of instrumental deliveries using Thierry's spatulas and vacuum extraction: A prospective observational cohort study

To evaluate the risk of severe perineal tear following instrumental vaginal delivery (IVD) performed with spatulas and vacuum extraction. Secondary objectives were to estimate the impact of episiotomy on this risk. From December2008 to October2012, women who underwent spatulas or vacuum were prospectively included. Each spontaneous vaginal delivery (SVD) following each included IVD were included as control cases (1-1ratio). Careful perineal examination was systematically performed. Severe perineal tear was defined by the occurrence of anal sphincter rupture with or without anal mucosa tear. A total of 761patients were included in the current study: 248 (64%) spatulas, 137 (36%) vacuums and 381 (49%) SVDs. Severe perineal tear was diagnosed in 19 (2.5%) cases. Episiotomy had been performed in 276 (36.9%) patients. Only spatulas extraction was found to significantly increase the risk of severe perineal tear (AOR=7.66; 95% CI: 2.06-28; P=0.02). Although vacuum extraction seemed to increase this risk, it was not found to be significant (AOR=3.25; 95% CI: 0.65-16.24; P=0.15). No significant difference was observed between the risk of severe perineal tear following spatulas and vacuum (AOR=2.36; 95% CI: 0.63-8.82; P=0.202). Finally, neither foetal macrosomia, nor episiotomy, nor foetal extraction with the head in the deep pelvis, nor delivery at night had a significant impact on the probability of severe perineal tear. Spatulas extraction is an independent risk factor for severe perineal tear. The practice of episiotomy was not shown to have any significant impact on this risk.

State-of-the-art review.

State-of-the-art review.

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&#x0D; to evaluate risk factors of obstetric anal sphincter ruptures in Dr.&#x0D; Cipto Mangunkusumo Hospital.&#x0D; Method: We reviewed 2009 vaginal deliveries based on the analysis&#x0D; of obstetric data base and patient records of our department during&#x0D; 2012. Cases and control subjects were chosen randomly and patient’s&#x0D; records were reviewed for the following variable: maternal&#x0D; age, parity, gestational age, labor induction, duration of 2nd stage labor,&#x0D; use of forceps, use of vacuum, use of episiotomy, birth weight,&#x0D; and presentation of the baby.&#x0D; Result: There were 91 (4.53%) anal sphincter ruptures during period&#x0D; of study (91 of 2009 patients). An univariate analysis of these&#x0D; 91 case and 91 randomly selected control subjects show that primiparity&#x0D; (p = .000), gestational age (p = .016), duration of second-stage&#x0D; labor (p = .000), forceps delivery (p = .000), vacuum delivery (p =&#x0D; .001), episiotomy (p = .000), and birth weight (p = .000) increased&#x0D; the risk for anal sphincter ruptures. In multivariate re-gression models,&#x0D; only 5 of the 10 predictor variables were significantly related&#x0D; to the likelihood of having a severe perineal trauma greater than second&#x0D; degree. Primiparity (p = .023; OR 2.74, 95% [CI], 1.15-6.51),&#x0D; forceps delivery (p = .000; OR 18.18, 95% [CI] 3.84-86.07), vacuum&#x0D; delivery (p = .005; OR 6.83, 95% [CI] 1.77-26.42), episiotomy (p =&#x0D; .015; OR 2.86, 95% [CI] 1.23-6.65), and birth weight (p = .000; OR&#x0D; 0.99, 95% [CI] 0.997-0.999).&#x0D; Conclusion: Damage of the anal sphincter resulting in a third- or&#x0D; fourth- degree perineal tear is a relatively rare but severe complication&#x0D; of vaginal delivery. We found that factors as sociated with anal&#x0D; sphincter ruptures were primiparity, forceps, vacuum, episiotomy&#x0D; and birth weight.&#x0D; [Indones J Obstet Gynecol 2016; 1: 31-36]&#x0D; Keywords: anal sphincter ruptures, third- or fourth- degree perineal&#x0D; 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 …

A perineal protection device designed to protect the perineum during labor: a multicenter randomized controlled trial

ObjectiveThe objective of this study was to evaluate the protective effects of a new device for reducing perineal tears during vaginal childbirth. Study designA multicenter open randomized controlled trial (RCT) was performed in Helsingborg, Lund and Malmö, Sweden consisting of 1148 women. Women anticipating a vaginal delivery were either randomized to the intervention group (n=574 in which the perineal protection device was used, or a control group (n=574), in which the perineal protection device was not used. The main outcome measurements were incidence of vaginal and perineal tears (1st to 4th degree tears) and adverse effects on the parturient and newborn. ResultsThe incidences of first- and second-degree tears of the vagina (p=0.018) and perineum (p=0.005) were significantly reduced in the intervention group compared with the controls. In the intervention- and control group, 184 women (34.9%) and 142 (26.6%) showed no perineal tearing, respectively (p=0.034). Numbers needed to treat to avoid any perianal tearing was 12. The incidence of anal sphincter rupture (ASR) was the same in both groups (n=19; 3.4%). No negative effects on mother or child from using the device were observed. ConclusionsThe perineal protective device significantly reduced the incidence of first- and second-degree tears in the vagina and perineum during vaginal birth and also significantly increased the number of parturients with a fully intact posterior commissure. No significant reduction of ASR and no negative effects of the device were observed

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.

Surgical approaches to fecal incontinence in the adult

Surgical treatment of anal incontinence is indicated only for patients who have failed medical treatment. Sphincterorraphy is suitable in case of external sphincter rupture. In the last decade, sacral nerve stimulation has proven to be a scientifically validated solution when no sphincter lesion has been identified and more recently has also been proposed as an alternative in cases of limited sphincter defect. Anal reconstruction using artificial sphincters is still under evaluation in the literature, while indications for dynamic graciloplasty are decreasing due to its complexity and high morbidity. Less risky techniques involving intra-sphincteric injections are being developed, with encouraging preliminary results that need to be confirmed especially in the medium- and long-term. Antegrade colonic enemas instilled via cecostomy (Malone) can be an alternative to permanent stoma in patients who are well instructed in the techniques of colonic lavage. Stomal diversion is a solution of last resort.