Wound Complications After Obstetric Anal Sphincter Injuries

Abstract

The rate of obstetric anal sphincter injuries at the time of vaginal delivery varies from 0.0% to 23.9%; the highest and lowest rates represent studies with smaller sample sizes.The incidence of perineal wound breakdown is much less common; reported rates vary from 0.1% to 4.6%. Risk factors for obstetric anal sphincter injuries have been identified in previous studies, but few groups have assessed the factors associated with obstetric anal sphincter injury wound complications. The few studies available were retrospective and reported an incidence of approximately 5% to 13%. Infection is 1 of the most common sequelae of perineal wound complications and often leads to hospital readmission. No standard guidelines exist for follow-up of patients who sustain a severe perineal laceration, and many women are not routinely seen until their sixth postpartum week.The aim of this prospective cohort study was to estimate the incidence of and risk factors for wound complications in women who sustain obstetric anal sphincter injuries.All women included in the study group sustained these injuries during delivery of a full-term neonate between September 2011 and August 2014 at an academic, tertiary care obstetric center in Chicago and were seen for perineal wound assessment in the urogynecology clinic within 1 week of delivery and at 2, 6, and 12 weeks postpartum. At each visit, a visual analog scale for pain was administered.Among 615 women who sustained obstetric anal sphincter injuries, 502 met inclusion criteria, and 268 were enrolled. Most women (87%) were nulliparous and had a third-degree laceration (81%). The majority (n = 194) had undergone an operative vaginal delivery: 66.0% forceps and 6.0% vacuum. At the initial evaluation, the overall risk for wound infection was 19.8% (95% confidence interval [CI], 15.2%-25.1%; n = 53), and the overall risk for wound breakdown was 24.6% (95% CI, 19.6%-30.2%; n = 66). Operative vaginal delivery was a significant risk factor for wound complications (infection, breakdown, or both; the adjusted odds ratio was 2.54, with a 95% confidence interval of 1.32-4.87; P = 0.008). Women given intrapartum antibiotic therapy for obstetric indications had a decreased risk of wound complications (adjusted odds ratio, 0.50; 95% confidence interval, 0.27-0.94; P = 0.03).Significantly higher pain was reported by women with a perineal wound complication than those with a normally healing perineum within 1 week of delivery (visual analog scale: 40.1 ± 25.6 vs 31.0 ± 23.6; P = 0.002), and the difference persisted at 12 weeks (6.6 ± 7.5 vs 3.4 ± 7.1; P = 0.005).Wound complications after obstetric anal sphincter injuries are much more common than previously described, with approximately 1 in 4 women developing a wound breakdown, and 1 in 5 a wound infection. These findings support the need for early follow-up of such patients in the postpartum period. EDITORIAL COMMENT(The findings of this study convincingly argue for a change from routine postpartum practice for women with third-and fourth-degree lacerat...

Birth Trauma: Sphincter Injuries

“…15 Infection rates following anal sphincter repair due to vaginal birth injury is as high as 20%, whereas, wound healing problems reach up to 25%. 16 Surgical site infection was not observed in any of our patients. We administer a combination of third generation cephalosporin and metronidazole prophylaxis, and we continue treatment for 3 days.…”

Non-surgical acute traumatic perianal injuries

“…Randomized controlled studies have demonstrated that prophylaxis with sec-ond generation cephalosporin significantly reduces the rate of infection (15). While infection rates following anal sphincter repair done because of vaginal birth injury go as high as 20%, wound healing problems reach up to 25% (16). Surgical site infection was not seen in any of our patients.…”

Obstetric anal sphincter injury: Prevention and repair

“…The prolonged process required for early secondary repair may be best undertaken by a subspecialty practice. 24 The surgical repair and postpartum care of OASIS continues to evolve. In your practice you should consider: • performing a mediolateral episiotomy at a 60-degree angle to Do you use intrapartum warm compresses to the perineum or perineal massage in your practice?…”