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Chapter 8 - Previous Third and Fourth Degree Tears

Published online by Cambridge University Press:  14 July 2023

By
Nicola Adanna Okeahialam ,
Abdul H. Sultan  and
Ranee Thakar
Edited by
Swati Jha  and
Priya Madhuvrata
Swati Jha
Affiliation:
Sheffield Teaching Hospital NHS Foundation Trust
Priya Madhuvrata
Affiliation:
Sheffield Teaching Hospital NHS Foundation Trust
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Summary

Consequences of obstetric anal sphincter injuries (OASIs) such as anal incontinence can lead to long-term physical and psychological sequelae. As OASIs occur more frequently in nulliparous women, women will probably present in a subsequent pregnancy. A subsequent delivery can increase the risk of developing or deteriorating anal incontinence symptoms. Therefore, counselling and mode of delivery recommendations should occur in the antenatal period to allow women to make an informed choice about their subsequent delivery. Intrapartum, obstetric practice can be adapted by clinicians, taking into account modifiable risk factors associated with repeat OASIs. However, approaches to prevention of sequelae such as anal incontinence in the long term remains unclear. Conservative options such as pelvic floor muscle training should be encouraged and in cases of intractable symptoms, surgical options are available but these should usually be considered in women who have completed their family.

Keywords

obstetric anal sphincter injuryanal incontinenceinflammatory bowel diseaseendoanal ultrasoundanal manometrypelvic floor muscle trainingmanual perineal protectionvaginal birthCaesarean section
Type
Chapter
Information
Gynaecology for the Obstetrician , pp. 72 - 82
Publisher: Cambridge University Press
Print publication year: 2023

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References

Sultan, A. H.. Obstetric perineal injury and anal incontinence. AVMA Medical & Legal Journal, 5 (1999), 193–6.Google Scholar
Thiagamoorthy, G., Johnson, A., Thakar, R. and Sultan, A. H.. National survey of perineal trauma and its subsequent management in the United Kingdom. International Urogynecology Journal, 25 (2014), 1621–7.Google Scholar
Laine, K., Gissler, M. and Pirhonen, J.. Changing incidence of anal sphincter tears in four Nordic countries through the last decades. European Journal of Obstetrics & Gynecology and Reproductive Biology, 146 (2009), 71–5.Google Scholar
Ampt, A. J., Ford, J. B., Roberts, C. L. and Morris, J. M.. Trends in obstetric anal sphincter injuries and associated risk factors for vaginal singleton term births in New South Wales 2001–2009. Australian and New Zealand Journal of Obstetrics and Gynaecology, 53 (2013), 9–16.Google Scholar
Gurol-Urganci, I., Cromwell, D., Edozien, L., et al. Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: Time trends and risk factors. BJOG: International Journal of Obstetrics & Gynaecology, 120 (2013), 1516–25.Google Scholar
Baghurst, P. A.. The case for retaining severe perineal tears as an indicator of the quality of obstetric care. Australian and New Zealand Journal of Obstetrics and Gynaecology, 53 (2013), 3–8.CrossRefGoogle ScholarPubMed
Dudding, T. C., Vaizey, C. J. and Kamm, M. A.. Obstetric anal sphincter injury: Incidence, risk factors, and management. Annals of Surgery, 247 (2008), 224–37.Google Scholar
Barba, M., Bernasconi, D. P., Manodoro, S. and Frigerio, M.. Risk factors for obstetric anal sphincter injury recurrence: A systematic review and meta‐analysis. International Journal of Gynecology & Obstetrics, 00 (2021), 1–8.Google Scholar
Bols, E. M. J., Hendriks, E. J. M., Berghmans, B. C. M., et al. A systematic review of etiological factors for postpartum fecal incontinence. Acta Obstetricia et Gynecologica Scandinavica, 89 (2010), 302–14.CrossRefGoogle ScholarPubMed
Scott, S. M. and Lunniss, P. J.. Investigations of anorectal function. In Sultan, A. H., Thakar, R. and Fenner, D. E., eds., Perineal and Anal Sphincter Trauma: Diagnosis and Clinical Management [Internet]. (New York; London: Springer, 2009), pp. 102–22. https://doi.org/10.1007/978-1-84628-503-5Google Scholar
Sideris, M., McCaughey, T., Hanrahan, J. G., et al. Risk of obstetric anal sphincter injuries (OASIS) and anal incontinence: A meta-analysis. European Journal of Obstetrics & Gynecology and Reproductive Biology, 252 (2020), 303–12.Google Scholar
van der Woude, C. J., Kolacek, S., Dotan, I., et al. European evidenced-based consensus on reproduction in inflammatory bowel disease. Journal of Crohn’s and Colitis, 4 (2010), 493–510.Google Scholar
Singh, B., McC Mortensen, N. J., Jewell, D. P. and George, B.. Perianal Crohn’s disease. British Journal of Surgery, 91 (2004), 801–14.CrossRefGoogle ScholarPubMed
Roper, J. C., Amber, N., Wan, O. Y. K., Sultan, A. H. and Thakar, R.. Review of available national guidelines for obstetric anal sphincter injury. International Urogynecology Journal, 31 (2020), 2247–59.CrossRefGoogle ScholarPubMed
Royal College of Obstetrics and Gynaecology. Management of Third and Fourth Degree Perineal Tears. Greentop Guideline Number 29 [Internet]. (RCOG Press, 2015). www.rcog.org.uk/globalassets/documents/guidelines/gtg-29.pdfGoogle Scholar
Sultan, A. H., Monga, A., Lee, J., et al. An International Urogynecological Association (IUGA)/International Continence Society (ICS) joint report on the terminology for female anorectal dysfunction. International Urogynecology Journal, 28 (2017), 5–31.CrossRefGoogle ScholarPubMed
Gommesen, D., Nohr, EAa., Qvist, N. and Rasch, V. Obstetric perineal ruptures – risk of anal incontinence among primiparous women 12 months postpartum: A prospective cohort study. American Journal of Obstetrics and Gynecology, 222 (2020), e1–e11.Google Scholar
Mahony, R., Behan, M., Daly, L., et al. Internal anal sphincter defect influences continence outcome following obstetric anal sphincter injury. American Journal of Obstetrics and Gynecology, 196 (2007), e1–e5.CrossRefGoogle ScholarPubMed
Woodley, S., Lawrenson, P., Boyle, R., et al. Pelvic floor muscle training for preventing and treating urinary and faecal incontinence in antenatal and postnatal women. Cochrane Database of Systematic Reviews [Internet]. (John Wiley & Sons, Ltd., 2020). http://dx.doi.org/10.1002/14651858.CD007471.pub4CrossRefGoogle Scholar
Norton, C., Dibley, L. B. and Bassett, P.. Faecal incontinence in inflammatory bowel disease: Associations and effect on quality of life. Journal of Crohn’s and Colitis, 7 (2013), e302–11.Google Scholar
Mégier, C., Bourbao-Tournois, C., Perrotin, F., et al. Long-term evaluation of the impact of delivery modalities on anal continence in women with Crohn’s disease. Journal of Visceral Surgery [Internet], (2021). www.sciencedirect.com/science/article/pii/S1878788621001296Google Scholar
van der Woude, C. J., Ardizzone, S., Bengtson, M.B., et al. The second European evidenced-based consensus on reproduction and pregnancy in inflammatory bowel disease. Journal of Crohn’s and Colitis, 9 (2015), 107–24.CrossRefGoogle ScholarPubMed
Hatch, Q., Champagne, B. J., Maykel, J. A., et al. Crohn’s Disease and pregnancy: The impact of perianal disease on delivery methods and complications. Diseases of the Colon & Rectum, 57 (2014), 174–8.Google Scholar
Okeahialam, N. A., Thakar, R. and Sultan, A. H.. Effect of a subsequent pregnancy on anal sphincter integrity and function after obstetric anal sphincter injury (OASI). International Urogynecology Journal [Internet], (2020). http://link.springer.com/10.1007/s00192–020-04607-8Google Scholar
Lone, F., Sultan, A. and Thakar, R.. Obstetric pelvic floor and anal sphincter injuries. Obstetrics & Gynecology, 14 (2012), 257–66.Google Scholar
Jóźwik, M. and Jóźwik, M.. Partial denervation of the pelvic floor during term vaginal delivery. International Urogynecology Journal, 12 (2001), 81–2.CrossRefGoogle ScholarPubMed
Sultan, A. H., Kamm, M. A. and Hudson, C. N.. Pudendal nerve damage during labour: Prospective study before and after childbirth. BJOG: An International Journal of Obstetrics & Gynaecology, 101 (1994), 22–8.CrossRefGoogle ScholarPubMed
Taithongchai, A., Thakar, R. and Sultan, A. H.. Management of subsequent pregnancies following fourth-degree obstetric anal sphincter injuries (OASIS). European Journal of Obstetrics & Gynecology and Reproductive Biology, 250 (2020), 80–5.Google Scholar
Jordan, P. A., Naidu, M., Thakar, R. and Sultan, A. H.. Effect of subsequent vaginal delivery on bowel symptoms and anorectal function in women who sustained a previous obstetric anal sphincter injury. International Urogynecology Journal, 29 (2018), 1579–88.Google Scholar
Karmarkar, R., Bhide, A., Digesu, A., Khullar, V. and Fernando, R.. Mode of delivery after obstetric anal sphincter injury. European Journal of Obstetrics & Gynecology and Reproductive Biology, 194 (2015), 7–10.CrossRefGoogle ScholarPubMed
Cassis, C., Giarenis, I., Mukhopadhyay, S. and Morris, E.. Mode of delivery following an OASIS and caesarean section rates. European Journal of Obstetrics & Gynecology and Reproductive Biology, 230 (2018), 28–31.Google Scholar
Fitzpatrick, M., Cassidy, M., Barassaud, M. L., et al. Does anal sphincter injury preclude subsequent vaginal delivery? European Journal of Obstetrics & Gynecology and Reproductive Biology, 198 (2016), 30–4.Google Scholar
Jha, S. and Parker, V.. Risk factors for recurrent obstetric anal sphincter injury (rOASI): A systematic review and meta-analysis. International Urogynecology Journal, 27 (2016), 849–57.CrossRefGoogle ScholarPubMed
Okeahialam, N. A., Thakar, R., Naidu, M. and Sultan, A. H.. Outcome of anal symptoms and anorectal function following two obstetric anal sphincter injuries (OASIS) – a nested case-controlled study. International Urogynecology Journal [Internet], (2020). http://link.springer.com/10.1007/s00192–020-04377-3Google Scholar
Bøgeskov, R. A., Nickelsen, C. N. A. and Secher, N. J.. Anal incontinence in women with recurrent obstetric anal sphincter rupture: A case control study. The Journal of Maternal-Fetal & Neonatal Medicine, 28 (2015), 288–92.CrossRefGoogle ScholarPubMed
Roper, J. C., Thakar, R. and Sultan, A. H.. Isolated rectal buttonhole tears in obstetrics: Case series and review of the literature. International Urogynecology Journal [Internet], (2020). http://link.springer.com/10.1007/s00192–020-04502-2Google Scholar
Sultan, A. H. and Kettle, C.. Diagnosis of perineal trauma. In Sultan, A. H., Thakar, R. and Fenner, D. E., eds., Perineal and Anal Sphincter Trauma. (Springer, 2007), pp. 13–20.Google Scholar
Homsi, R., Daikoku, N. H., Littlejohn, J. and Wheeless, C. R.. Episiotomy: Risks of dehiscence and rectovaginal fistula. Obstetrical & Gynecological Survey, 49 (1994), 803–8.CrossRefGoogle ScholarPubMed
Sultan, A. H. and Stanton, S. L.. Preserving the pelvic floor and perineum during childbirth-elective caesarean section? BJOG: An International Journal of Obstetrics & Gynaecology, 103 (1996), 731–4.Google Scholar
Hals, E., Øian, P., Pirhonen, T., et al. A multicenter interventional program to reduce the incidence of anal sphincter tears. Obstetrics & Gynecology, 116 (2010), 901–8.Google Scholar
Rasmussen, O. B., Yding, A., Anh, Ø. J., Sander Andersen, C. and Boris, J.. Reducing the incidence of obstetric sphincter injuries using a hands-on technique: An interventional quality improvement project. BMJ Quality Improvement Reports, 5 (2016), u217936.w7106.Google Scholar
Edozien, L., Gurol-Urganci, I., Cromwell, D., et al. Impact of third- and fourth-degree perineal tears at first birth on subsequent pregnancy outcomes: A cohort study. BJOG: An International Journal of Obstetrics & Gynaecology, 121 (2014), 1695–703.Google Scholar
Bulchandani, S., Watts, E., Sucharitha, A., Yates, D. and Ismail, K.. Manual perineal support at the time of childbirth: A systematic review and meta-analysis. BJOG: International Journal of Obstetrics & Gynaecology, 122 (2015), 1157–65.Google Scholar
D’Souza, J. C., Monga, A., Tincello, D. G., et al. Maternal outcomes in subsequent delivery after previous obstetric anal sphincter injury (OASI): A multi-centre retrospective cohort study. International Urogynecology Journal [Internet], (2019). http://link.springer.com/10.1007/s00192–019-03983-0Google Scholar
Brandt, L. J., Estabrook, S. G. and Reinus, J. F.. Results of a survey to evaluate whether vaginal delivery and episiotomy lead to perineal involvement in women with Crohn’s disease. American Journal of Gastroenterology, 90 (1995), 1918–22.Google Scholar
Carroli, G. and Mignini, L.. Episiotomy for vaginal birth. In: The Cochrane Collaboration, ed., Cochrane Database of Systematic Reviews [Internet]. (Chichester, UK: John Wiley & Sons, Ltd., 2009), CD000081.pub2. https://doi.wiley.com/10.1002/14651858.CD000081.pub2CrossRefGoogle Scholar
Von Bargen, E., Haviland, M. J., Chang, O. H., et al. Evaluation of postpartum pelvic floor physical therapy on obstetrical anal sphincter injury: A randomized controlled trial. Female Pelvic Medicine and Reconstructive Surgery, 27 (2021), 315–21.CrossRefGoogle ScholarPubMed
Barbosa, M., Glavind‐Kristensen, M., Moller Soerensen, M. and Christensen, P.. Secondary sphincter repair for anal incontinence following obstetric sphincter injury: Functional outcome and quality of life at 18 years of follow‐up. Colorectal Disease, 22 (2020), 71–9.Google Scholar
Rydningen, M. B., Riise, S., Wilsgaard, T., Lindsetmo, R. O. and Norderval, S.. Sacral neuromodulation for combined faecal and urinary incontinence following obstetric anal sphincter injury. Colorectal Disease, 20 (2018), 59–67.Google Scholar
Abramowitz, L., Mandelbrot, L., Bourgeois Moine, A., et al. Cesarean section in the second delivery to prevent anal incontinence after asymptomatic obstetrical anal sphincter injury: The EPIC multicenter randomized trial. BJOG: An International Journal of Obstetrics & Gynaecology, (2020), 1471-0528.16452.Google Scholar

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