Diagnosis and Repair 2nd degree tears and episiotomy

Perineal trauma Episiotomy Spontaneous tears Tears not involving anal sphincter Tears involving anal sphincter Second Third Fourth First

Classification of Trauma First degree involving skin only Second degree involving the perineal muscles – bulbocavernosus transverse perineal if very deep may involve pubococcygeus but not the sphincter complex

Episiotomy “A surgical incision made intentionally to increase the diameter of the vulval outlet to facilitate delivery” RML episiotomy Midline episiotomy

Episiotomy When  routine -v- restrictive How  midline -v- mediolateral

Routine versus restrictive Carroli & Belizan Routine versus restrictive Carroli & Belizan. Cochrane library, Issue 3, 2004. Routine versus Restrictive (6 studies) After restrictive use: Less posterior perineal trauma Less suturing Fewer healing complications More anterior perineal trauma

Indications for episiotomy Minimise multiple & extensive tears Thick & inelastic perineum Forceps delivery Malpresentation & malposition Expedite delivery Suspected fetal distress Shoulder dystocia

Why do we repair perineal trauma? To control bleeding To prevent infection If the wound is left unsutured it will heal by secondary intention & healing occurs by the formation of granulation tissue which eventually contracts to form scar tissue

Perineal haematoma Before After

Evidence based practice Which suture material?

Vicryl Rapide vs Vicryl Suture Material Gemynthe et al 1996; McElhinney et al 2000; Kettle et al 2002 3 RCT (n = 2003 women) A more rapidly absorbed synthetic suture material (Vicryl Rapide™) versus absorbable synthetic material (Vicryl™) Significant reduction in pain when ‘walking’ (2 trials) Reduction in the need for pain relief (1 trial) Significant reduction in suture removal (3 trials) Reduction in superficial dyspareunia (1 trial)

Evidence based practice Which technique?

Repair Techniques Kettle C, Ismail K 2007 Cochrane systematic review - 7 RCT’s (n = 3822) found that continuous subcuticular stitches compared to interrupted is associated with : - Less short term pain at 10 days Reduction in analgesia use No significant difference in dyspareunia The morbidity associated with perineal injury and repair following childbirth constitutes a major health problem world-wide. Up to 85% of women who have a vaginal birth sustain some form of perineal trauma and a large proportion of these will require suturing. There are wide variations in both the type of suturing materials and methods used by operators. Two Cochrane systematic reviews of 12 RCT’s (continuous vs interrupted sutures & absorbable synthetic vs catgut suture material for perineal repair) carried out by Kettle & Johanson found that that a subcuticular repair with absorbable synthetic material was associated with a reduction in short-term pain. However, the long-term effects are less clear and concerns remain regarding the need to remove suture material up to 3 months postpartum. More recently, a new rapidly absorbed polyglactin synthetic material (Vicryl Rapide) became available and Fleming (1990) published her experience of using a continuous non-locking stitch for perineal repair with good results. So building on previous research and the need to evaluate the continuous method and Vicryl Rapide suture material within a RCT the Methods or Material Study (MOMS) was designed.

Recommended material and technique 2nd degree tears or episiotomy Level 1a evidence Vicryl Rapide suture material & The continuous non-locking technique for perineal repair - all layers The morbidity associated with perineal injury and repair following childbirth constitutes a major health problem world-wide. Up to 85% of women who have a vaginal birth sustain some form of perineal trauma and a large proportion of these will require suturing. There are wide variations in both the type of suturing materials and methods used by operators. Two Cochrane systematic reviews of 12 RCT’s (continuous vs interrupted sutures & absorbable synthetic vs catgut suture material for perineal repair) carried out by Kettle & Johanson found that that a subcuticular repair with absorbable synthetic material was associated with a reduction in short-term pain. However, the long-term effects are less clear and concerns remain regarding the need to remove suture material up to 3 months postpartum. More recently, a new rapidly absorbed polyglactin synthetic material (Vicryl Rapide) became available and Fleming (1990) published her experience of using a continuous non-locking stitch for perineal repair with good results. So building on previous research and the need to evaluate the continuous method and Vicryl Rapide suture material within a RCT the Methods or Material Study (MOMS) was designed.

Prior to commencing the repair Check extent of perineal trauma – perform per vaginal and per rectal examination Check equipment - suture pack, materials If needed ensure that appropriate supervision/support is available prior to commencing the repair Adequate lighting Ensure that the wound is adequately anaesthetised (10-20mls Lignocaine 1%) - don’t inject local through the skin

Step 1 - suturing the vagina Identify the apex of the vaginal wound Close the vaginal trauma with a loose continuous stitch Continue to suture the vagina until the hymenal remnants are reached and re-approximated At the fourchette insert the needle through the skin to emerge in the centre of the perineal trauma

Step 2 - suturing the muscle layer Check the depth of the trauma - it may be necessary to insert two layers of sutures Continue to close the perineal muscle with a continuous non-locking stitch - taking care not to leave any dead space

Step 3 - suturing the perineal skin At the inferior end of the wound bring the needle out under the skin surface The stitches are placed below the skin surface in the subcutaneous layer - thus avoiding the profusion of nerve endings Continue taking bites of tissue from each side of the wound until the hymenal remnants are reached Secure the finished repair with a loop knot tied in the vagina

Finally Check the finished repair is anatomically correct No bleeding PV - insert two fingers PR Check swabs & instruments Complete documentation

Rationale – continuous technique No knots – sutures accommodate themselves to swelling as it occurs Tight sutures cause pain especially if the wound becomes oedematous - may cause tissue hypoxia and delay healing Deep & superficial muscles closed in one layer Skin sutures inserted into subcutaneous layer thus avoiding nerve endings in skin surface – less pain Economical – single suture used

Risk factors for anal sphincter injuries birth weight over 4 kg (up to 2%) ● persistent occipitoposterior position (up to 3%) ● nulliparity (up to 4%) ● induction of labour (up to 2%) ● epidural analgesia (up to 2%) ● second stage longer than 1 hour (up to 4%) ● shoulder dystocia (up to 4%) ● midline episiotomy (up to 3%) ● forceps delivery (up to 7%)

Guidelines Clinicians need to be aware of the risk factors for obstetric anal sphincter injury but also recognise that known risk factors do not readily allow its prediction or prevention. Where episiotomy is indicated, the mediolateral technique is recommended, with careful attention to the angle -60 degree- cut away from the midline.

Anal Sphincter Rupture - Classification Sultan AH, Clinical Risk 1999;5:193-6 RCOG GreenTop Guidelines 2001; ICI 2002 1st degree = vaginal epithelium 2nd degree = perineal muscles 3rd degree = anal sphincter 3a = <50% external sphincter thickness 3b = > 50% external sphincter thickness 3c = internal sphincter torn 4th degree = anal epithelium torn + + +

Anal Sphincter Rupture - Classification Sultan AH, Clinical Risk 1999;5:193-6 RCOG GreenTop Guidelines 2001; ICI 2002

If there is any doubt about the grade of third-degree tear, it is advisable to classify it to the higherdegree rather than lower degree.

When repair of the EAS muscle is being performed, either monofilament sutures such as polydiaxanone (PDS) or modern braided sutures such as polyglactin (Vicryl®) can be used with equivalent outcome. When repair of the IAS muscle is being performed, fine suture size such as 3-0 PDS and 2-0 Vicryl may cause less irritation and discomfort.

Internal sphincter defects Mahony R et al 2007 500 consecutive OASIS Persistent internal sphincter defects independently associated with an severe anal incontinence OR 5.1 (95% CI = 1.5 – 22.9)

Diagnosis History Examination Special Investigation

Obstetric Anal Sphincter InjurieS OASIS History Vaginal delivery - undiagnosed - suboptimal repair

Identification of EAS

End-to-end primary anal sphincter repair

Primary end-to-end sphincter repair

I

Overlap vs end-to-end n = 64 Fernando R et al 2006 Faecal incontinence % Patients p=0.01 p=0.01

Suture materials Sultan AH, Thakar R 2002 Anal Mucosa - interrupted 3-0 Vicryl with knot in anal canal Internal Anal Sphincter - Mattress end-to-end 3-0 PDS/ Vicryl 2-0 External Anal Sphincter - Mattress/Overlap 3-0 PDS/ Vicryl 2-0

Principles of the overlap repair Sultan AH et al 1999 Operating theatre  Lighting and equipment Regional or general anaesthesia Antibiotics  Augmentin or ceph & met. Monofilament sutures  PDS but can use Vicryl Foleys catheter Laxatives  Lactulose

Recommended Practice Thakar R, Sultan AH 2003 Rectal examination after every delivery Adopt the new classification OASIS repair by experienced doctor in theatre Regional or GA External sphincter - end-to-end or overlap repair Repair torn internal sphincter - 3-0 PDS or Vicryl 2-0 Lactulose 15mls bd for 2 week Antibiotics Ensure bowels opened Follow-up @ hospital by a senior obstetrician

Post natal review All women should be offered physiotherapy and pelvic-floor exercises for 6–12 weeks after obstetric anal sphincter repair. All women who have had obstetric anal sphincter repair should be reviewed 6–12 weeks postpartum by a consultant obstetrician and gynaecologist.

When to refer? If a woman is experiencing incontinence or pain at follow-up, referral to a specialist gynaecologist or colorectal surgeon for endoanal ultrasonography and anorectal manometry should be considered. A small number of women may require referral to a colorectal surgeon for consideration of secondary sphincter repair.

Post delivery counseling Women should be advised that the prognosis following EAS repair is good, with 60–80% asymptomatic at 12 months. Most women who remain symptomatic describe incontinence of flatus or faecal urgency

Counseling Post delivery All women who sustained an obstetric anal sphincter injury in a previous pregnancy should be counselled about the risk of developing anal incontinence or worsening symptoms with subsequent vaginal delivery. All women who sustained an obstetric anal sphincter injury in a previous pregnancy should be advised that there is no evidence to support the role of prophylactic episiotomy in subsequent pregnancies. All women who have sustained an obstetric anal sphincter injury in a previous pregnancy and who are symptomatic or have abnormal endoanal ultrasonography and/or manometry should have the option of elective caesarean birth.

Documentation and Information When third- and fourth-degree repairs are performed, it is essential to ensure that the anatomical structures involved, method of repair and suture materials used are clearly documented and that instruments, sharps and swabs are accounted for. The woman should be fully informed about the nature of her injury and the benefits to her of follow-up. This should include written information where possible.

Thank You

Episiotomy: midline -v- mediolateral Coats et al 1980 Randomised 407 primiparae Incidence of OASIS midline = 12% mediolateral = 2%

Benefits of midline episiotomy  blood loss Easier to recognise 3o tear Easier to repair Better anatomical result pain  risk of infection  dyspareunia Disadvantage of midline episiotomy  30 and 40 tears

Angle of episiotomy Andrews et al 2005 Vagina Anal canal Episiotomy a c α b

Episiotomy Andrews et al BJOG 2004 Andrews et al Birth 2006 254 primips No midwife and only 13 (22%) doctors performed a truly mediolateral episiotomy (between 40 to 60 degrees from the midline) Episiotomies angled closer to the midline significantly associated with OASIS (26 vs 37 degrees)

Episiotomy Eogan et al BJOG 2006 Case-control study (54 versus 46 controls) Mean angle of episiotomy smaller (30% versus 38% p<0.001) 50% risk reduction for every 6°from midline The relationship of episiotomy angle with risk of OASIS was sig (p<0.001)

Training Sultan et al J Obstet Gynaecol 1995 Interviewed 75 doctors and 75 midwives Less than 20% of doctors and 50% of midwives were satisfied that they had a good level of training at the time of repairing their first episiotomy unsupervised

Conclusion It is imperative that women receive high quality evidenced based care wherever childbirth takes place Practices that reduce the adverse effects of perineal trauma and make vaginal birth more desirable are to be encouraged Improved perineal care may decrease the escalating interest in caesarean section as an alternative mode of delivery