How to repair an anal sphincter injury after vaginal delivery: results of a randomised controlled trial

Williams, A. O.; Adams, Elisabeth J; Tincello, Douglas G.; Alfirević, Z̄arko; Walkinshaw, Stephen; Richmond, D. H.

doi:10.1111/j.1471-0528.2006.00806.x

Cited by 95 publications

(57 citation statements)

References 29 publications

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“…The experience of physicians performing primary repairs varies, and some may feel inadequately trained to perform an optimal repair. 12,28,29 In cases when the responsible physician feels uncomfortable performing the procedure, our study suggests that delaying the operation until the adequate expertise is in place or up to 12 hours is safe and does not adversely affect anal continence status 1 year after delivery. However, our results do not suggest a benefit in delaying primary repair per se.…”

Section: Discussionmentioning

confidence: 98%

“…10 A partial sphincter tear is, however, not compatible with an overlap repair, and several trials have concluded equivalence between the methods. 9,11,12 Child deliveries are evenly distributed over the hours and it is plausible that awaiting surgical expertise following detection of an obstetric anal sphincter injury may optimise the subjective outcome. However, it is also possible that the consequential time delay between the injury and the repair will affect the outcome of the repair.…”

Section: Introductionmentioning

confidence: 99%

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Immediate or delayed repair of obstetric anal sphincter tears—a randomised controlled trial*

Nordenstam

Mellgren

Altman

et al. 2008

BJOG

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Objective To investigate if an 8-to 12-hour time delay of primary repair affects anal incontinence at 1-year follow up.Design Randomised controlled trial.Setting University hospital in Sweden.Population A total of 165 women diagnosed with a third-to fourth-degree perineal tear.Methods The participants were randomised to immediate or delayed (8-to 12-hour delay) end-to-end repair; 78 were allocated to immediate operation and 87 to a delayed repair. An incontinence and pelvic floor symptom questionnaire was completed by the participants at baseline and at 6-and 12-month follow up.Main outcome measures Anal incontinence measured by the validated Pescatori incontinence score.Results A total of 161 (98%) and 155 (94%) women completed the two follow-up questionnaires. There was no significant difference in anal incontinence between the groups. There were no significant differences in pelvic floor symptoms between the groups. A multivariate proportional odds model revealed that increasing maternal age was significantly associated with both increased symptoms of faecal urgency and inability to discriminate flatus from faeces.Conclusion Delayed repair provided the same functional outcome at 1-year follow up. Delaying the repair should thus not be recommended routinely, but can be an alternative under special circumstances when appropriate surgical expertise is not readily available.Keywords Anal incontinence, obstetric anal sphincter tear, primary repair, randomised controlled trial.

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Section: Discussionmentioning

confidence: 98%

Section: Introductionmentioning

confidence: 99%

Immediate or delayed repair of obstetric anal sphincter tears—a randomised controlled trial*

Nordenstam

Mellgren

Altman

et al. 2008

BJOG

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“…Another consideration is improvement in OASIS recognition and repair. Structured training, use of recommended suture materials and repair techniques are associated with good clinical outcomes [36,43,44]. Attention to the above was driven by the RCOG Green-top guideline first published in 2001 [3].…”

Section: Discussionmentioning

confidence: 99%

Impact of subsequent birth and delivery mode for women with previous OASIS: systematic review and meta-analysis

et al. 2016

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Introduction and hypothesis Obstetric anal sphincter injuries (OASIS) are serious complications of vaginal birth. In a pregnancy following OASIS women may be keen to avoid an elective caesarean section, yet cautious about pursuing another vaginal birth that may result in further damage to the pelvic floor and possible long-term anal incontinence. This review aimed to evaluate the impact of subsequent birth and its mode on anal incontinence (AI) and/or quality of life (QoL), for women with previous OASIS. Methods Searches of MEDLINE, EMBASE, CINAHL, and AMED from inception to February 2016 were undertaken with selection criteria of any study evaluating the effect of a subsequent birth on AI and/or QoL in women with previous OASIS. Where possible, data were extracted to populate 2 × 2 tables and allow meta-analysis relating to the impact of subsequent birth on AI and/or QoL. Results Twenty-seven non-randomised studies were included. Meta-analysis of 14 studies (977 women) did not demonstrate any significant associations between AI in women with previous OASIS and subsequent birth or its mode. Impact on QoL was reported in 12 studies (912 women); however, difference in outcome reporting precluded data meta-analysis. Conclusions Comparisons of outcomes and effective synthesis were limited by sample size, quality and heterogeneity of the studies included. Consequently, the optimal mode of delivery for women with previous OASIS is still not known and better data are needed.

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“…If not recognised and repaired, this type of tear may lead to a rectovaginal fistula. 25 An increasing incidence of third-or fourth-degree perineal tears does not necessarily indicate poor quality care. But it may rather indicate an improved quality of care through better detection and reporting.…”

mentioning

confidence: 99%

“…Regional or general anaesthesia will facilitate identification of the full extent of the injury and enable retrieval of the retracted ends of the torn anal sphincter. 25 A randomized trial by Williams et al, compared OASIS repairs with polyglactin (Vicryl) and polydioxanone (PDS). They found no significant difference in suturerelated morbidity at 6 weeks.…”

mentioning

confidence: 99%

OASIS: clinical audit in a tertiary care centre

Soman¹,

Nair²,

Janani³

et al. 2018

Int J Reprod Contracept Obstet Gynecol

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Background: Obstetric anal sphincter injury involves injury to the anal sphincter and rectal mucosa sustained at time of vaginal delivery and can result in significant long-term morbidity. These injuries have been defined as 3rd and 4th degree lacerations that involve disruption of the anal sphincter and rectal mucosa respectively. Objectives of this study were to find out the incidence of obstetrical anal sphincter injuries, to identify the risk factors for of OASIS and the outcome of primary repair in terms of anal incontinence and its associated complications.Methods: We did a descriptive study of OASIS by retrospective analysis of the labour case records. The study period was 1 year between August 2016 to July 2017. Inclusion criteria were singleton pregnancy, vertex presentation, instrumental and normal vaginal delivery. Exclusion criteria were multiple pregnancy, non-vertex presentation and caesarean section. Proforma was developed to capture the age, parity, gestational age in weeks, induction of labour, epidural analgesia, delivery duration, type of episiotomy, instrumentation, shoulder dystocia, occipito posterior position,manual support, weight of the baby, suturing method. Postnatal evaluation after 6 weeks and 6 months for perineal discomfort, pain, incontinence, wound infection, breakdown, fistula were noted. Results: The incidence of OASIS was 1.4%. 81.8% women had 3rd degree perineal and 18.1% had 4th degree perineal tear. The mean age of the patients were 27.9 years, gestational age of 39.45 weeks, 72.7% were primiparous. Induction of labour with prostaglandins was done in 36.36% and Pitocin augmentation for 81.81%. The duration of second 36.36% had 60-89 min and 27.27% had duration more than 90 min. 54.54% had epidural analgesia, 36.36% had shoulder dystocia, 36.36% had instrumental delivery. 72.72% babies had birth weight between 3-3.5 kg, 9% between 3.5-4 kg. Ano vaginal fistula developed in 9%.Conclusions: Appropriate training, anticipating and identifying major degrees of perineal tear helps in reducing the complications. Anovaginal fistula is distressing and disabling the patient and to her near ones.

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How to repair an anal sphincter injury after vaginal delivery: results of a randomised controlled trial

Cited by 95 publications

References 29 publications

Immediate or delayed repair of obstetric anal sphincter tears—a randomised controlled trial*

Immediate or delayed repair of obstetric anal sphincter tears—a randomised controlled trial*

Impact of subsequent birth and delivery mode for women with previous OASIS: systematic review and meta-analysis

OASIS: clinical audit in a tertiary care centre

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