Methods of repair for obstetric anal sphincter injury
RHL practical aspects by Buppasiri P
FIRST CONTACT (PRIMARY CARE) LEVEL
- Selective (restricted) use of episiotomy should be encouraged to reduce the risk of third or fourth–degree perineal tears (1).
- In all cases of vaginal birth women should be examined carefully to identify and assess the extent of anal sphincter injuries.
- After controlling bleeding, women with anal sphincter injuries should be transferred to a secondary-level facility where expertise to repair the injury is available. If transfer to a secondary-level facility is not possible, then repair should be attempted ensuring the following: availability of good lighting; availability of adequate analgesia; availability of appropriate equipments - needle holder, toothed forceps, Allis clamps, suture materials; and conditions for conducting an aseptic operation.
- The overlap technique may be more difficult use if the person who is going to perform the operation is not experienced in the technique. In such a situation, the end-to-end technique should be used.
- Descriptions of both techniques can be found in textbooks of obstetrics and gynaecology (see for example reference 3).
- Prescribe stool softener for 5-10 days after repair (4).
- The efficacy of routine antibiotic prophylaxis fourth-degree perineal tear during vaginal birth remains inconclusive (5).
REFERRAL HOSPITAL (SECONDARY CARE) LEVEL
The following interventions should ideally take place in a hospital setting:
- Only experienced obstetricians with training in the repair of severe perineal injuries should attempt the repair (6-8).
- Currently, two techniques of repairing anal sphincter injuries are used: the end-to-end approximation technique and the overlap techniques (2, 9-12).
- Descriptions of the two techniques can be found in textbooks of obstetrics and gynaecology (see for example reference 3).
- After the operation, prescribe stool softener for 5-10 days.
- Follow-up of the woman at six weeks postpartum is recommended to evaluate anal incontinence symptoms.
- Endoanal ultrasound, anal manometry should be used for patients who present with anal incontinence, and secondary repair should be offered by a multidisciplinary team that includes well-trained obstetricians and colorectal surgeons (2, 13).
AT HOME OR IN THE COMMUNITY
I would like to thank Prof. Pisake Lumbiganon, Chairman of Thai Cochrane Network, and Ruth Martis, Clinical Educator at the SEA-ORCHID project, for their comment and suggestions.
- Carroli G, Belizan J. Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews 1997;Issue 2. Art. No.: CD000081; DOI: 10.1002/14651858.
- Fernando R, Sultan AH, Kettle C, Thakar R, Radley S. Methods of repair for obstetric anal sphincter injury. Cochrane Database of Systematic Reviews 2006;Issue 3. Art. No.: CD002866. DOI: 10.1002/14651858.CD002866.pub2.
- Cunningham FG, Leveno KJ, Bloom SL, Hauth JC, Gilstrap LC 3rd, Wenstrom KD. William obstetrics. 22nd edition. New York: McGraw-Hill; 2005:409-41.
- Eogan M, Daly L, Behan M, O'Connell PR, O'Herlihy C. Randomised clinical trial of a laxative alone versus a laxative and a bulking agent after primary repair of obstetric anal sphincter injury. BJOG 2007;114(6):736-40.
- Buppasiri P, Lumbiganon P, Thinkhamrop J, Thinkhamrop B. Antibiotic prophylaxis for fourth-degree perineal tear during vaginal birth. Cochrane Database of Systematic Reviews 2005;Issue 4. Art. No.: CD005125; DOI: 10.1002/14651858.CD005125.pub2.
- Sultan AH, Thakar R. Lower genital tract and anal sphincter trauma. Best Pract Res Clin Obstet Gynaecol 2002;16:99-115.
- Fernando RJ, Sultan AH, Radley S, Jones PW, Johanson RB. Management of obstetrics anal sphincter injury: a systematic review & national practice survey. BMC Health Service Research 2002;2:9. (Available at: http://www biomedcentral. com/1472-6963/2/9).
- Stepp KJ, Siddiqui NY, Emery SP, Barber MD. Textbook recommendations for preventing and treating perineal injury at vaginal delivery. Obstet Gynecol 2006;107:361-6.
- Fitzpatrick M, Behan M, O'Connell PR, O'Herlihy C. A randomized clinical trial comparing primary overlap with approximation repair of third-degree obstetric tears. Am J Obstet Gynecol 2000;183:1220-4.
- Garcia V, Rogers RG, Kim SS, Hall RJ, Kammerer-Doak DN. Primary repair of obstetric anal sphincter laceration: a randomized trial of two surgical techniques. Am J Obstet Gynecol 2005;192:1697-701.
- Williams A, Adams EJ, Tincello DG, Alfirevic Z, Walkinshaw SA, Richmond DH. How to repair an anal sphincter injury after vaginal delivery: results of a randomised controlled trial. BJOG 2006 Feb;113(2):201-7.
- Fernando RJ, Sultan AH, Kettle C, Radley S, Jones P, O’ Brien PMS. Repair techniques for obstetric anal sphincter injuries. Obstet Gynecol 2006;107:1261-8.
- Norderval S, Oian P, Revhaug A, Vonen B. Anal incontinence after obstetric sphincter tears: outcome of anatomic primary repairs. Dis Colon Rectum 2005;48(5):1055-61.
This document should be cited as: Buppasiri P. Methods of repair for obstetric anal sphincter injury: RHL practical aspects (last revised: 20 August 2007). The WHO Reproductive Health Library; Geneva: World Health Organization.