Max Brinsmead PhD FRANZCOG March 2013

 Definitions  Some anatomy  Repair of 2 nd degree obstetric injury  Risk factors for 3 rd & 4 th degree tears  The identification of 3 0 & 4 0 tears  Management of 3 0 & 4 0 tears  Avoiding obstetric injury  Pregnancy after previous 3 0 & 4 0 tears

 Cochrane database  Pubmed  RCOG Guidelines (March 2007)  NICE Guidelines for Intrapartum Care (September 2007)  Google  Personal experience

 1 st degree perineal injury Involves skin only  2 nd degree injury Involves perineal muscles (or perineal body) but not the anal sphincter  3 rd degree tear Involves the anal sphincter complex but not the mucosa of the anal canal or rectum 3a = Less than 50% of the external AS 3b = More than 50% of the external AS but the internal anal sphincter is intact 3c = Both external & internal AS torn  4 th degree tear Both external & internal AS is torn and the epithelium of the anal canal or rectum is breached

 2 nd degree trauma occurs in 16 – 90% of deliveries  Depends largely on whether restricted or liberal use of episiotomy is practised  Overall incidence of 3 rd & 4 th degree tears is 1:100 deliveries (1%)  But studies with endoanal ultrasound indicate that damage to the EAC occurs in up to 40% of vaginal births

RISK FACTORODDS RATIO Nulliparity (primigravidity)3–4 Short perineal body 8 Instrumental delivery, overall3 Forceps-assisted delivery 3–7 Vacuum-assisted delivery 3 Forceps vs vacuum 2.88* Forceps with midline episiotomy 25 Prolonged second stage of labor (>1 hour) 1.5–4 Epidural analgesia1.5–3 Intrapartum infant factors: Birthweight over 4 kg 2 Persistent occipitoposterior position 2–3 Episiotomy, mediolateral1.4 Episiotomy, midline3–5 Previous anal sphincter tear4 All variables are statistically significant at P<.05.

 Requires systematic exam by a competent & experienced person  Extent of injury to be determined before repair commences  Analgesia May require GA or regional block  Good light and exposure  Must do a PR if sphincter damage or 4 th degree trauma is suspect Use a second glove and discard  When the extent of injury is uncertain it is best to presume the worst

 Use inert rapidly dissolving absorbable suture material  Use continuous suturing for all layers not interrupted  Less pain  Bury the knots and warn the women about how long the suture may be present  To theatre for GA or regional block if 3 0 or 4 0 tear is diagnosed or suspected Some 3a trauma is suitable for repair under LA by infiltration  Use 2/0 or 3/0 Vicryl or PDS for sphincter repair  Retrieve and repair retracted sphincter end to end or by overlap separate suture One study had better results from overlap repair  Use NSAID as a rectal suppository

 End to end repair  Overlap repair

 Antibiotics after 3 0 or 4 0 tear One RCT in support Use broad spectrum plus Metronidazole  Laxatives for 7 – 10 days Use stool softener and bulking agent  Offer physio with pelvic floor exercises  Review by obstetrician after 6 – 8w  Assess symptoms systematically  Refer for endoanal ultrasound and rectal manometry if there are symptoms of incontinence  The relevance of ultrasound abnormalities in asymptomatic women is uncertain

1. Passage of any flatus when socially undesirable 2. Any incontinence of liquid stool 3. Any need to wear a pad because of anal symptoms 4. Any incontinence of solid stool 5. Any fecal urgency (inability to defer defecation for more than 5 minutes) SCALE 0 Never 1 Rarely (<1/month) 2 Sometimes (1/week–1/month 3 Usually (1/day–1/week) 4 Always (>1/day) A score of 0 implies complete continence and 20 complete incontinence. A score of 6 suggested as a cut-off to determine need for evaluation.

An evidence-based approach

 Seven RCT’s with 5001 women and 8 cohort studies with 6463 women. Meta analysis confirms that restricted episiotomy will result in:  Less posterior trauma (RR 0.87, CI )  More anterior trauma (RR 1.75, CI )  Fewer 3 0 and 4 0 tears (RR 0.74, CI )  Some studies also point to:  Overall more intact perineums  Less perineal pain  Quicker return to coitus with restricted use of episiotomy and  More anal sphincter damage with liberal episiotomy  But no difference in…  Sexual function at 3m & 3 yrs or bladder function

 Routine episiotomy is not recommended for spontaneous birth  Episiotomy should be performed when clinically indicated e.g. fetal compromise suspected or instruments required  Mediolateral episiotomy is best i.e. start at the posterior fouchette and proceed at an angle of degrees  Tested anaesthesia is required Except in an extreme emergency

 A case control study showed that episiotomies that: Begin close to the posterior fourchette Are 60 degrees from the axis Are too short Or not deep enough  Are associated with an increased risk of anal sphincter injury

 One large RCT in Australia (1340 women in 3 sites) of midwife massage between contractions in the second stage:  No effect on any measure of obstetric trauma, pain, return to coitus or urinary and bowel function  There was no apparent measure of compliance  But the study is confirmed by a US RCT of 1211 women in which compliance was high  The Epi-No device (a self-performed progressive dilation of the perineum from 36 weeks) significantly increases the rate of intact perineum in nullipara and appears safe

 2001 – a prospective trial of 50 nullipara (published in German) Significant reduction in the rate of episiotomy (49% vs 82%) Fewer “perineal tears” (2% vs 4%) Shorter 2 nd stage (mean 29 vs 54 minutes)  2004 – a prospective trial of 31 nullipara in Singapore Used the device for a mean of 2.1 weeks Fewer episiotomies (50% vs 93%) Overall trauma rate 90% vs 97% but the trauma appeared “less severe” The device was “safe”  2004 – Pilot study from Melbourne Aust. of 48 nullipara Significantly more intact perineums (46% vs 17%) Reduced rate of episiotomy (26% vs 34%) Shorter second stage (mean 61 vs 81 minutes) No effect on instrumental delivery rate or Apgars

 2009 – A RCT of 276 German nullipara (published in AustNZ J O&G) Significantly more intact perineums (37.4% vs 25.7%) A trend towards fewer episiotomies No effect on the rate of “tears”, duration of 2 nd stage or pain No increased risk of infection

 One large US observational study (2595 women) found that:  Warm compresses reduced the need for episiotomy in nulliparas and was borderline for multiparas  Also reduced the rate of spontaneous 2 0 tears in both  But this was not confirmed by another US RCT of 1211 women

 One large UK RCT of 5316 ♀ found:  A small reduction in perineal pain at 10 days from “hands on”  No difference in any measure of obstetric trauma  Inexplicably fewer manual removals in the “hands poised” group (2.6% vs 1.5%)  Broadly similar findings in an Austrian study of 1076 women  But episiotomy was more common in the “hands on” group  NICE concludes that either technique is appropriate  And noted evidence that there is less trauma when the head delivers between contractions

 One RCT of 185 women found that:  No effect on perineal pain  But less dyspareunia when coitus was resumed  And fewer second degree tears in the treated group (RR 0.63, CI 0.42 – 0.93)  But NICE concludes that Lignocaine spray should not be used

 There are no prospective trials and only a few retrospective studies  The risk of repeat 3 0 and 4 0 trauma is similar to the original incidence  There is some evidence that if the woman is asymptomatic then vaginal birth does not further increase the risk of those symptoms  There is some evidence that for symptomatic women then vaginal birth does increase the severity of those symptoms

 Routine episiotomy is not recommended  Discussion about intrapartum care should cover…  Current symptoms of dysfunction of the anal sphincter  The previous trauma  The risk of recurrence  Success of previous repair  Psychological aspects of the trauma  Then a combined decision concerning subsequent mode of birth and intrapartum care can be made