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Chapter 65 - Perineal Repair and Pelvic Floor Injury (Content last reviewed: 20th February 2020)

from Section 6 - Late Prenatal – Obstetric Problems

Published online by Cambridge University Press:  15 November 2017

David James
Affiliation:
University of Nottingham
Philip Steer
Affiliation:
Imperial College London
Carl Weiner
Affiliation:
University of Kansas
Bernard Gonik
Affiliation:
Wayne State University, Detroit
Stephen Robson
Affiliation:
University of Newcastle
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Summary

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.

Type
Chapter
Information
High-Risk Pregnancy
Management Options
, pp. 1842 - 1865
Publisher: Cambridge University Press
First published in: 2017

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References

McCandlish, R, Bowler, U, van Asten, H, et al. A randomised controlled trial of care of the perineum during second stage of normal labour. Br J Obstet Gynaecol 1998; 105: 1262–72.Google Scholar
Thiagamoorthy, G, Johnson, A, Thakar, R, Sultan, AH. National survey of perineal trauma and its subsequent management in the United Kingdom. Int Urogynecol J 2014; 25: 1621–7.CrossRefGoogle ScholarPubMed
Organisation for Economic Co-operation and Development (OECD). Health at a Glance: OECD Indicators 2013. Paris: OECD, 2013. http://dx.doi.org/10.1787/health_glance-2013-en (accessed March 2017).Google Scholar
Gurol-Urganci, I, Cromwell, DA, Edozien, LC, et al. Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors. BJOG 2013; 120:1 516–25.Google Scholar
Dietz, HP, Pardey, J, Murray, H. Pelvic floor and anal sphincter trauma should be key performance indicators of maternity services. Int Urogynecol J 2015; 26: 2932.Google Scholar
Sultan, AH, Kamm, MA, Hudson, CN, Thomas, JM, Bartram, CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med 1993; 329: 1905–11.CrossRefGoogle ScholarPubMed
Andrews, V, Sultan, AH, Thakar, R, Jones, PW. Occult anal sphincter injuries: myth or reality? BJOG 2006; 113: 195200.Google Scholar
Andrews, V, Thakar, R, Sultan, AH, Kettle, C. Can hands-on perineal repair workshops change clinical practice? Br J Midwifery 2005; 13: 4.Google Scholar
Lien, KC, Mooney, B, DeLancey, JO, Ashton-Miller, JA. Levator ani muscle stretch induced by simulated vaginal birth. Obstet Gynecol 2004; 103: 3140.Google Scholar
Schwertner-Tiepelmann, N, Thakar, R, Sultan, AH, Tunn, R. Obstetric levator ani muscle injuries: current status. Ultrasound Obstet Gynecol 2012; 39: 372–83.Google Scholar
Kettle, C, Dowswell, T, Ismail, KM. Continuous and interrupted suturing techniques for repair of episiotomy or second-degree tears. Cochrane Database Syst Rev 2012; (11): CD000947.CrossRefGoogle Scholar
Jiang, H, Qian, X, Carroli, G, Garner, P. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev 2017; (2): CD000081. doi: 10.1002/14651858.CD000081.pub3.Google Scholar
Barrett, G, Pendry, E, Peacock, J, et al. Women’s sexual health after childbirth. BJOG 2000; 107: 186–95.Google Scholar
Johnson, A, Thakar, R, Sultan, AH. Obstetric perineal wound infection: is there underreporting? Br J Nurs 2012; 21 (5): S28, S30, S32–5.Google Scholar
Sultan, AH, Thakar, R. Third and fourth degree tears. In Sultan, AH, Thakar, R, Fenner, D (eds), Perineal and Anal Sphincter Trauma: Diagnosis and Clinical Management. London: Springer-Verlag, 2007, pp. 3351.Google Scholar
Sultan, AH, Kamm, MA, Hudson, CN, Bartram, CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ 1994; 308: 887–91.Google Scholar
Goffeng, AR, Andersch, B, Andersson, M, Berndtsson, I, Hulten, L, Oresland, T. Objective methods cannot predict anal incontinence after primary repair of extensive anal tears. Acta Obstet Gynecol Scand 1998; 77: 439–43.Google Scholar
Pinta, TM, Kylanpaa, ML, Salmi, TK, Teramo, KA, Luukkonen, PS. Primary sphincter repair: are the results of the operation good enough? Dis Colon Rectum 2004; 47: 1823.Google Scholar
Mous, M, Muller, SA, de Leeuw, JW. Long-term effects of anal sphincter rupture during vaginal delivery: faecal incontinence and sexual complaints. BJOG 2008; 115: 234–8.Google Scholar
Sorensen, M, Tetzschner, T, Rasmussen, OO, Bjarnesen, J, Christiansen, J. Sphincter rupture in childbirth. Br J Surg 1993; 80: 392–4.Google Scholar
Engel, AF, Kamm, MA, Sultan, AH, Bartram, CI, Nicholls, RJ. Anterior anal sphincter repair in patients with obstetric trauma. Br J Surg 1994; 81: 1231–4.Google ScholarPubMed
Dietz, HP, Simpson, JM. Levator trauma is associated with pelvic organ prolapse. BJOG 2008; 115: 979–84.Google Scholar
Model, AN, Shek, KL, Dietz, HP. Levator defects are associated with prolapse after pelvic floor surgery. Eur J Obstet Gynecol Reprod Biol 2010; 15: 220–3.Google Scholar
Morgan, DM, Larson, K, Lewicky-Gaupp, C, Fenner, DE, DeLancey, JO. Vaginal support as determined by levator ani defect status 6 weeks after primary surgery for pelvic organ prolapse. Int J Gynaecol Obstet 2011; 114: 141–4.Google Scholar
Wong, V, Shek, K, Rane, A, et al. Is levator avulsion a predictor of cystocele recurrence following anterior vaginal mesh placement? Ultrasound Obstet Gynecol 2013; 42: 230–4.Google Scholar
Weemhoff, M, Vergeldt, TF, Notten, K, et al. Avulsion of puborectalis muscle and other risk factors for cystocele recurrence: a 2-year follow-up study. Int Urogynecol J 2012; 23: 6571.CrossRefGoogle ScholarPubMed
Dietz, HP, Chantarasorn, V, Shek, KL. Levator avulsion is a risk factor for cystocele recurrence. Ultrasound Obstet Gynecol 2010; 36: 7680.CrossRefGoogle ScholarPubMed
DeLancey, JO, Kearney, R, Chou, Q, Speights, S, Binno, S. The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol 2003; 101: 4653.Google Scholar
Dietz, HP, Lanzarone, V. Levator trauma after vaginal delivery. Obstet Gynecol 2005; 106: 707–12.Google Scholar
van Delft, K, Sultan, AH, Thakar, R, Schwertner-Tiepelmann, N, Kluivers, K. The relationship between postpartum levator ani muscle avulsion and signs and symptoms of pelvic floor dysfunction. BJOG 2014; 121: 1164–71.Google Scholar
Chan, SS, Cheung, RY, Yiu, KW, Lee, LL, Chung, TK. Effect of levator ani muscle injury on primiparous women during the first year after childbirth. Int Urogynecol J 2014; 25: 1381–8.Google Scholar
Chung, MY, Wan, OY, Cheung, RY, Chung, TK, Chan, SS. The prevalence of levator ani muscle injury and health related quality of life in primiparous Chinese women after instrumental deliveries. Ultrasound Obstet Gynecol 2015; 45: 728–33.Google Scholar
Dietz, HP, Kirby, A. Modelling the likelihood of levator avulsion in a urogynaecological population. Aust N Z J Obstet Gynaecol 2010; 50: 268–72.Google Scholar
Dietz, HP, Kirby, A, Shek, KL, Bedwell, PJ. Does avulsion of the puborectalis muscle affect bladder function? Int Urogynecol J Pelvic Floor Dysfunct 2009; 20: 967–72.Google Scholar
Heilbrun, ME, Nygaard, IE, Lockhart, ME, et al. Correlation between levator ani muscle injuries on magnetic resonance imaging and fecal incontinence, pelvic organ prolapse, and urinary incontinence in primiparous women. Am J Obstet Gynecol 2010; 202: 488.e1–6.Google Scholar
Weinstein, MM, Pretorius, DH, Jung, SA, Nager, CW, Mittal, RK. Transperineal three-dimensional ultrasound imaging for detection of anatomic defects in the anal sphincter complex muscles. Clin Gastroenterol Hepatol 2009; 7: 205–11.Google Scholar
Chantarasorn, V, Shek, KL, Dietz, HP. Sonographic detection of puborectalis muscle avulsion is not associated with anal incontinence. Aust N Z J Obstet Gynaecol 2011; 51: 130–5.CrossRefGoogle Scholar
van Delft, K, Thakar, R, Shobeiri, SA, Sultan, AH. Levator hematoma at the attachment zone as an early marker for levator ani muscle avulsion. Ultrasound Obstet Gynecol 2014; 43: 210–17.Google Scholar
Thakar, R, Fenner, D. Anatomy of the perineum and the anal sphincter. In Sultan, AH, Thakar, R, Fenner, D (eds), Perineal and Anal Sphincter Trauma: Diagnosis and Clinical Management. London: Springer-Verlag, 2007, pp. 112.Google Scholar
Kearney, R, Sawhney, R, DeLancey, JO. Levator ani muscle anatomy evaluated by origin-insertion pairs. Obstet Gynecol 2004; 104: 168–73.Google Scholar
Koelbl, H, Igawa, T, Salvatore, S, et al. Pathophysiology of urinary incontinence, faecal incontinence and pelvic organ prolapse. In Abrams, P, Cardozo, L, Khoury, S, Wein, A (eds), Incontinence, 5th edn. Paris: ICUD-EAU, 2013, pp. 261360.Google Scholar
Royal College of Obstetricians and Gynaecologists. The Management of Third- and Fourth-Degree Perineal Tears. Green-top Guideline No. 29. London, RCOG, 2015. https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg29/ (accessed March 2017).Google Scholar
Sultan, AH, Kettle, C. Diagnosis of perineal trauma. In Sultan, AH, Thakar, R, Fenner, D (eds), Perineal and Anal Sphincter Trauma: Diagnosis and Clinical Management. London: Springer-Verlag, 2007, pp. 1319.Google Scholar
McLeod, NL, Gilmour, DT, Joseph, KS, Farrell, SA, Luther, ER. Trends in major risk factors for anal sphincter lacerations: a 10-year study. J Obstet Gynaecol Can 2003; 25: 586–93.Google Scholar
Kalis, V, Laine, K, de Leeuw, JW, Ismail, KM, Tincello, DG. Classification of episiotomy: towards a standardisation of terminology. BJOG 2012; 119: 522–6.Google Scholar
Fenner, DE, Genberg, B, Brahma, P, Marek, L, DeLancey, JO. Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States. Am J Obstet Gynecol 2003; 189: 1543–9.Google Scholar
Eogan, M, Daly, L, O’Connell, PR, O’Herlihy, C. Does the angle of episiotomy affect the incidence of anal sphincter injury? BJOG 2006; 113: 190–4.Google Scholar
Andrews, V, Thakar, R, Sultan, AH, Jones, PW. Are mediolateral episiotomies actually mediolateral? BJOG 2005; 112: 1156–8.CrossRefGoogle ScholarPubMed
National Institute for Health and Care Excellence. Intrapartum Care for Healthy Women and Babies. NICE Clinical Guideline CG190. London: NICE, 2014. https://www.nice.org.uk/guidance/CG190 (accessed March 2017).Google Scholar
Kalis, V, Karbanova, J, Horak, M, et al. The incision angle of mediolateral episiotomy before delivery and after repair. Int J Gynaecol Obstet 2008; 103: 58.Google Scholar
Kalis, V, Landsmanova, J, Bednarova, B, et al. Evaluation of the incision angle of mediolateral episiotomy at 60 degrees. Int J Gynaecol Obstet 2011; 112: 220–4.Google Scholar
Kettle, C, Dowswell, T, Ismail, KM. Absorbable suture materials for primary repair of episiotomy and second degree tears. Cochrane Database Syst Rev 2010; (6): CD000006.Google Scholar
Kettle, C, Fenner, D. Repair of episiotomy, first and second degree tears. In Sultan, AH, Thakar, R, Fenner, D (eds), Perineal and Anal Sphincter Trauma: Diagnosis and Clinical Management. London: Springer-Verlag, 2007, pp. 2032.CrossRefGoogle Scholar
Sultan, AH, Thakar, R. Lower genital tract and anal sphincter trauma. Best Pract Res Clin Obstet Gynaecol 2002; 16: 99115.Google Scholar
Parks, AG, McPartlin, JF. Late repair of injuries of the anal sphincter. Proc R Soc Med 1971; 64: 1187–9.Google Scholar
Jorge, JM, Wexner, SD. Etiology and management of fecal incontinence. Dis Colon Rectum 1993; 36: 7797.Google Scholar
Malouf, AJ, Norton, CS, Engel, AF, Nicholls, RJ, Kamm, MA. Long-term results of overlapping anterior anal-sphincter repair for obstetric trauma. Lancet 2000; 355: 260–5.Google Scholar
Sultan, AH, Monga, AK, Kumar, D, Stanton, SL. Primary repair of obstetric anal sphincter rupture using the overlap technique. Br J Obstet Gynaecol 1999; 106: 318–23.Google Scholar
Nordenstam, J, Mellgren, A, Altman, D, et al. Immediate or delayed repair of obstetric anal sphincter tears: a randomised controlled trial. BJOG 2008; 115: 857–65.Google Scholar
Williams, A, Adams, EJ, Tincello, DG, et al. How to repair an anal sphincter injury after vaginal delivery: results of a randomised controlled trial. BJOG 2006; 113: 201–7.Google Scholar
Mahony, R, Behan, M, Daly, L, et al. Internal anal sphincter defect influences continence outcome following obstetric anal sphincter injury. Am J Obstet Gynecol 2007; 196: 217 e1–5.Google Scholar
Nichols, CM, Lamb, EH, Ramakrishnan, V. Differences in outcomes after third- versus fourth-degree perineal laceration repair: a prospective study. Am J Obstet Gynecol 2005; 193: 530–4.Google Scholar
Roos, AM, Thakar, R, Sultan, AH. Outcome of primary repair of obstetric anal sphincter injuries (OASIS): does the grade of tear matter? Ultrasound Obstet Gynecol 2010; 36: 368–74.Google Scholar
Fernando, RJ, Sultan, AH, Kettle, C, Thakar, R. Methods of repair for obstetric anal sphincter injury. Cochrane Database Syst Rev 2013; (12): CD002866.CrossRefGoogle Scholar
Hool, GR, Lieber, ML, Church, JM. Postoperative anal canal length predicts outcome in patients having sphincter repair for fecal incontinence. Dis Colon Rectum 1999; 42: 313–18.Google Scholar
Duggal, N, Mercado, C, Daniels, K, et al. Antibiotic prophylaxis for prevention of postpartum perineal wound complications: a randomized controlled trial. Obstet Gynecol 2008; 111: 1268–73.Google Scholar
Mahony, R, Behan, M, O’Herlihy, C, O’Connell, PR. Randomized, clinical trial of bowel confinement vs. laxative use after primary repair of a third-degree obstetric anal sphincter tear. Dis Colon Rectum 2004; 47: 1217.Google Scholar
Eogan, M, Daly, L, Behan, M, O’Connell, PR, O’Herlihy, C. Randomised clinical trial of a laxative alone versus a laxative and a bulking agent after primary repair of obstetric anal sphincter injury. BJOG 2007; 114: 736–40.Google Scholar
Sultan, AH, Nugent, K. Pathophysiology and nonsurgical treatment of anal incontinence. BJOG 2004; 111 (Suppl 1): 8490.Google Scholar
Harkin, R, Fitzpatrick, M, O’Connell, PR, O’Herlihy, C. Anal sphincter disruption at vaginal delivery: is recurrence predictable? Eur J Obstet Gynecol Reprod Biol 2003; 109: 149–52.Google Scholar
Jordan, PA, Naidu, M, Thakar, R, Sultan, AH. Effect of subsequent vaginal delivery on bowel symptoms and anorectal function in women who sustained a previous obstetric anal sphincter injury. Int Urogynecol J 2018; 29: 1579–88. doi: 10.1007/s00192-018-3601-y.Google Scholar
D’Souza, JC, Monga, A, Tincello, DG, et al. Maternal outcomes in subsequent delivery after previous obstetric anal sphincter injury (OASI): a multi-centre retrospective cohort study. Int Urogynecol J 2020; 31: 627–33. https://doi.org/10.1007/s00192-019-03983-0.Google Scholar
Sultan, AH, Stanton, SL. Preserving the pelvic floor and perineum during childbirth–elective caesarean section? Br J Obstet Gynaecol 1996; 103: 731–4.Google Scholar
Dietz, HP, Gillespie, AV, Phadke, P. Avulsion of the pubovisceral muscle associated with large vaginal tear after normal vaginal delivery at term. Aust N Z J Obstet Gynaecol 2007; 47: 341–4.Google Scholar
Shobeiri, SA, Chimpiri, AR, Allen, A, Nihira, MA, Quiroz, LH. Surgical reconstitution of a unilaterally avulsed symptomatic puborectalis muscle using autologous fascia lata. Obstet Gynecol 2009; 114: 480–2.Google Scholar
Dietz, HP, Shek, KL, Daly, O, Korda, A. Can levator avulsion be repaired surgically? A prospective surgical pilot study. Int Urogynecol J 2013; 24: 1011–15.Google Scholar
van Delft, K, Thakar, R, Sultan, AH, Schwertner-Tiepelmann, N, Kluivers, K. Levator ani muscle avulsion during childbirth: a risk prediction model. BJOG 2014; 121: 1155–63.Google Scholar

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