1. Diagnosis and Repair 2nd degree tears and episiotomy

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

3. 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

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

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

6. 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

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

8. 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

9. Perineal haematoma
Before
After

10. Evidence based practice
Which suture material?

11. 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)

12. Evidence based practice
Which technique?

13. 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.

14. 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.

15. 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

16. 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

17. 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

18. 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

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

20. 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

21. 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%)

22. 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.

23. 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 + + +

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

25. 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.

26. 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.

27. 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)

28. Diagnosis
History
Examination
Special Investigation

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

30. Identification of EAS

33. End-to-end primary anal sphincter repair

34. Primary end-to-end sphincter repair

35. I

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

39. 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

40. 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

41. 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 PDS or Vicryl 2-0
Lactulose 15mls bd for 2 week
Antibiotics
Ensure bowels opened
hospital by a senior obstetrician

42. 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.

43. 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.

44. 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

45. 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.

46. 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.

47. Thank You

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

50. 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

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

52. 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)

53. 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)

54. 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

55. 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