Management of obstetric anal sphincter injuries (OASIS) in subsequent pregnancy

Abstract

Obstetric anal sphincter injuries (OASIS) are common and may greatly affect a patient's quality of life. There is very little information regarding optimum management in future pregnancies. Based upon anecdotal experience, this study describes the recommendations of a cohort of consultant obstetricians in the UK, in this clinical situation. There is limited adherence to the available national guidelines due to the absence of available equipment and expertise to perform endo-anal ultrasound and manometry. Elective episiotomy is still recommended by a small number of obstetricians but the majority of patients are routinely followed-up. Caesarean section is only advised for asymptomatic patients with a previous stage 4 tear, and for any symptomatic patient with a previous stage 3 or 4 tear, irrespective of subgrade. A request for elective caesarean section is likely to be granted, irrespective of OASIS grade. The use of postpartum endo-anal ultrasound would help identify those women in whom a further vaginal delivery is unlikely to exacerbate any symptoms of faecal incontinence.

Effect of subsequent vaginal delivery on bowel symptoms and anorectal function in women who sustained a previous obstetric anal sphincter injury

“…The use of this particular set of criteria, however, left a relatively large number of “equivocal” cases in which decision-making was once again, and by admission of the authors, left to a variety of assessment methods that are neither validated nor consistent. The uncertainty regarding management for this group of women was evident in a paper reporting the recommendations for mode of subsequent delivery from a large UK survey [ 19 ]. Although clinical judgement and patient-centred care are always imperative, one of the strengths of our study is that it is the largest study to date to report the outcomes of using a protocol to aid clinicians in recommending mode of subsequent delivery that leaves no “equivocal” group of women.…”

“…There is currently a huge variation in the advice given to pregnant women who have sustained a previous OASI and this is reflective of the weak evidence base [ 19 ]. A previous national survey showed a wide variation in clinical practice with regard to subsequent mode of delivery recommendations [ 20 ].…”

The impact of first birth obstetric anal sphincter injury on the subsequent birth: a population-based linkage study

“…The presence of ongoing symptoms following OASI are likely to have had an effect on decision-making as well. The results of a recent questionnaire completed by UK consultant obstetricians reported that they would be far more likely to advise women to have a caesarean section if they had ongoing symptoms (including incontinence of flatus or stool) following a first OASI than those without symptoms [ 43 ]. This is in agreement with the Royal College of Obstetricians and Gynaecologists Guideline [ 44 ].…”

The OASI care bundle quality improvement project: lessons learned and future direction

“…OASI can have long lasting consequences on women's continence, sexual function, and mental health, all of which significantly impact on quality of life [3]. More than half of women with OASI experience ongoing symptoms and approximately half report an impact on their future birth choices [3,4].…”