Obstetric Perineal Injury

1. Obstetric Perineal Injury Max Brinsmead PhD FRANZCOG March 2013

2. Subjects to be covered: • Definitions • Some anatomy • Repair of 2nd degree obstetric injury • Risk factors for 3rd & 4th degree tears • The identification of 30 & 40 tears • Management of 30 & 40 tears • Avoiding obstetric injury • Pregnancy after previous 30 & 40 tears

3. Resources: • Cochrane database • Pubmed • RCOG Guidelines (March 2007) • NICE Guidelines for Intrapartum Care (September 2007) • Google • Personal experience

4. Definitions: • 1st degree perineal injury • Involves skin only • 2nd degree injury • Involves perineal muscles (or perineal body) but not the anal sphincter • 3rd 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 • 4th degree tear • Both external & internal AS is torn and the epithelium of the anal canal or rectum is breached

6. Incidence: • 2nd degree trauma occurs in 16 – 90% of deliveries • Depends largely on whether restricted or liberal use of episiotomy is practised • Overall incidence of 3rd & 4th 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

9. Risk Factors for Obstetric Injury

10. Diagnosis: • 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 4th degree trauma is suspect • Use a second glove and discard • When the extent of injury is uncertain it is best to presume the worst

11. Repair: • 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 30 or 40 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

12. End to end repair • Overlap repair

13. Postoperative Care: • Antibiotics after 30 or 40 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

14. Evaluation of symptoms:

15. Avoiding Obstetric Injury An evidence-based approach

16. Routine or restricted use of episiotomy? • 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 0.83 - 0.91) • More anterior trauma (RR 1.75, CI 1.52 - 2.01) • Fewer 30 and 40 tears (RR 0.74, CI 0.42 - 1.28) • 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

17. NICE recommendations for the use of episiotomy • 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 45 - 60 degrees • Tested anaesthesia is required • Except in an extreme emergency

18. What sort of episiotomy?

19. What sort of episiotomy? • A case control study showed that episiotomies that: • Begin close to the posterior fourchette • Are <15 and >60 degrees from the axis • Are too short • Or not deep enough • Are associated with an increased risk of anal sphincter injury

20. Perineal Massage • 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

21. The Epi-No Device • 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 2nd 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

22. The Epi-No Device cont’d • 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 2nd stage or pain • No increased risk of infection

23. The Epi-No Device

24. Hot Compresses for the Perineum? • 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 20 tears in both • But this was not confirmed by another US RCT of 1211 women

25. “Hands on” or “Hands poised” during delivery of the fetal head? • 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

26. Lignocaine spray for the perineum? • 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

27. Birth after Previous 30 and 40 Trauma There are no prospective trials and only a few retrospective studies The risk of repeat 30 and 40 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

28. NICE recommendations for the care of patients with previous 30 and 40 trauma • 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