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The claimant, an equity sales trader in the City of London, during the birth of her first child suffered an obstetric anal sphincter injury whilst in private obstetric care. This went undetected, leaving her with significant ongoing symptoms which caused embarrassment, inconvenience and distress, resulting in an impact on her career trajectory. It was claimed that the defendant performed a midline episiotomy which caused a third-degree tear affecting both her internal and external anal sphincter.
The need for perineal repair after childbirth affects millions of women worldwide. In the United Kingdom, approximately 85% of women sustain some form of perineal trauma during vaginal delivery, and 69% of these will require stitches.
Anal endosonography is regarded as the gold standard investigation in patients presenting with faecal incontinence. The endosonography is also useful in the diagnosis of anal pain, anorectal tumours, fistulae, abscesses and anismus. The advent of anal endosonography has enabled considerable research into obstetric related anal sphincter trauma, the major aetiological factor in the development of anal incontinence. The internal anal sphincter is a thickened continuation of the circular smooth muscle layer of the bowel and appears homogeneously hypoechoic. The external anal sphincter usually appears hyperechoic, but has a heterogeneous appearance. Magnetic resonance imaging (MRI) defines the striated components of the sphincter with greater clarity. In 1994, Sultan et al. first described transvaginal endosonography to image the anal sphincters at rest with a rotating probe. The development of anal endosonography added a new dimension to understanding the pathogenesis of anal incontinence and the diagnosis of obstetric anal sphincter injuries.
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