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A randomized control trial evaluating the prevalence of obstetrical anal sphincter injuries in primigravida in routine versus selective mediolateral episiotomy

Sulaiman AS, Ahmad S, Ismail NA, Rahman RA, Jamil MA, Mohd Dali AZ

Saudi Med J, 2013 Aug;34(8):819-23.
PMID: 23974453

To evaluate the prevalence of obstetrical anal sphincter injuries (OASIS), which include third and fourth degree perineal tears in primigravida in routine versus selective mediolateral episiotomy. Secondly, to determine the rate of episiotomy in local settings.

Matched MeSH terms: Anal Canal/injuries*
Pelvic floor ultrasound findings in Ugandan women with obstetric fistula, unrepaired fourth degree obstetric tear, and pelvic organ prolapse

Krause HG, Wong V, Ng SK, Tan GI, Goh JTW

Aust N Z J Obstet Gynaecol, 2019 08;59(4):585-589.
PMID: 31146301 DOI: 10.1111/ajo.12990

BACKGROUND: While pelvic floor ultrasound is commonly utilised in high-resource locations, our understanding of pelvic floor characteristics in women suffering with obstetric fistula and unrepaired fourth degree obstetric tears in low-resource areas is limited.
AIMS: This study aimed to assess the pelvic floor ultrasound characteristics of Ugandan women suffering with obstetric fistula, unrepaired fourth degree obstetric tears and pelvic organ prolapse, and determine whether obstructed labour resulting in obstetric fistula causes more levator muscle defects compared to parous women without a history of obstructed labour.
MATERIALS AND METHODS: This was a prospective study in western Uganda assessing 82 women with obstetric fistula, unrepaired fourth degree obstetric tears and pelvic organ prolapse with a pelvic floor ultrasound scan.
RESULTS: Demographic characteristics were significantly different, with women suffering pelvic organ prolapse being older and more parous. Hiatal area on Valsalva was significantly smaller in the obstetric fistula group (mean 21.45 cm2 ) compared to non-obstetric fistula group (unrepaired fourth degree obstetric tears and pelvic organ prolapse; mean 30.44 cm2 ); a mean difference of 9.0 cm2 (95% CI: 5.4-12.6 cm2 , P

Matched MeSH terms: Anal Canal/injuries*
Can Anal Sphincter Defects Be Identified by Palpation?

Shek KL, Atan IK, Dietz HP

Female Pelvic Med Reconstr Surg, 2016 Nov-Dec;22(6):472-475.
PMID: 27682743

OBJECTIVES: The aim of this study was to correlate clinical findings of anal sphincter defects and function with a sonographic diagnosis of significant sphincter defects.

METHODS: This is an observational cross-sectional study on women seen 6 to 10 weeks after primary repair of obstetric anal sphincter injuries (OASIs). All patients underwent a standardized interview including the St Mark incontinence score, a digital rectal examination, and 3-/4-dimensional transperineal ultrasound imaging.

RESULTS: Two hundred forty-five patients were seen after primary repair of OASIs. Mean age was 29 (17-43) years. They were assessed at a median of 58 (15-278) days postpartum. One hundred fifty-seven (64%) delivered normal vaginally, 72 (29%) delivered by vacuum, and 16 (7%) delivered by forceps. A comparison of external anal sphincter (EAS) and internal anal sphincter ultrasound volume data and palpation was possible in 220 and 212 cases, respectively. Sphincter defects at rest and on contraction were both detected clinically in 17 patients. Significant abnormalities of the EAS were diagnosed on tomographic ultrasound imaging in 99 cases (45%), and significant abnormalities of the internal anal sphincter were diagnosed in 113 cases (53%). Agreement between digital and sonographic findings of sphincter defect was poor (k = 0.03-0.08). Women with significant EAS defects on ultrasound were found to have a lower resistance to digital insertion (P = 0.018) and maximum anal squeeze (P = 0.009) on a 6-point scale. The difference was however small.

CONCLUSIONS: Digital rectal examination does not seem to be sufficiently sensitive to diagnose residual sphincter defects after primary repair of OASIs. Imaging is required for the evaluation of sphincter anatomy after repair.

Matched MeSH terms: Anal Canal/injuries*
Delivery mode, levator avulsion and obstetric anal sphincter injury: A cross-sectional study 20 years after childbirth

Lin S, Atan IK, Dietz HP, Herbison P, Wilson PD

Aust N Z J Obstet Gynaecol, 2019 08;59(4):590-596.
PMID: 30793279 DOI: 10.1111/ajo.12948

BACKGROUND: Levator ani muscle (LAM) and anal sphincter injuries are common after vaginal birth and are associated with pelvic organ prolapse and anal incontinence.
AIMS: Our objective was to investigate long-term association between delivery mode, LAM avulsion and obstetric anal sphincter injuries (OASIS) in women at least 20 years after their first birth.
METHODS: All women recruited at 'index birth' of the Dunedin (New Zealand) arm of ProLong (PROlapse and incontinence LONG-term research) Study, were invited to have translabial and transperineal ultrasound assessment of LAM and anal sphincters. Post-processing analysis of imaging data was performed blinded against delivery data. Statistical analysis was performed using the χ2 test and results are expressed as odds ratios (OR).
RESULTS: Of the initial 1250 participants, 196 women returned for examination. Mean age was 50.8 years with a mean body mass index of 27.6 and median parity was three. They were seen on average 23 years after their first delivery. Four data sets were unavailable and one declined ultrasound assessment, leaving 191 for analysis. LAM avulsion was diagnosed in 29 (15.2%), and 24 women (12.6%) had significant anal sphincter defect. LAM avulsion was associated with forceps delivery (OR 2.45, 95% CI 1.04-5.80, P = 0.041). Forceps conveyed a greater risk of OASIS (21%) compared to a spontaneous vaginal delivery (11%) but did not reach statistical significance.
CONCLUSIONS: Forceps delivery is associated with long-term injurious effect on pelvic floor structures. Discussions of the long-term negative impact of pelvic floor structures and their functions are necessary to achieve an informed consent toward an operative vaginal delivery.

Matched MeSH terms: Anal Canal/injuries*
Anal sphincter trauma and anal incontinence in urogynecological patients

Guzmán Rojas RA, Kamisan Atan I, Shek KL, Dietz HP

Ultrasound Obstet Gynecol, 2015 Sep;46(3):363-6.
PMID: 25766889 DOI: 10.1002/uog.14845

To determine the prevalence of evidence of residual obstetric anal sphincter injury, to evaluate its association with anal incontinence (AI) and to establish minimal diagnostic criteria for significant (residual) external anal sphincter (EAS) trauma.

Matched MeSH terms: Anal Canal/injuries*
The impact of variations in obstetric practice on maternal birth trauma

Kamisan Atan I, Lai SK, Langer S, Caudwell-Hall J, Dietz HP

Int Urogynecol J, 2019 06;30(6):917-923.
PMID: 30741317 DOI: 10.1007/s00192-019-03887-z

INTRODUCTION AND HYPOTHESIS: Forceps delivery and length of second stage are risk factors of maternal birth trauma, i.e., levator ani muscle (LAM) avulsion and anal sphincter trauma. The cesarean section (CS) rate has recently become the key performance indicator because of its increase worldwide. Attempts to reduce CS rates seem to have led to an increase in forceps deliveries and longer second stages. This study aimed to determine the association between variations in obstetric practice (between hospitals) and maternal birth trauma.
METHODS: This was a retrospective ancillary analysis involving 660 nulliparous women carrying an uncomplicated singleton term pregnancy in a prospective perinatal intervention trial at two Australian tertiary obstetric units. They had been seen antenatally and at 3-6 months postpartum for a standardized clinical assessment between 2007 and 2014. Primary outcome measures were sonographically diagnosed LAM and external anal sphincter (EAS) trauma.
RESULTS: The incidence of LAM avulsion (11.5% vs. 21.3%, P = 0.01) and composite trauma, i.e., LAM avulsion ± EAS injury (29.2% vs. 39.7%, P = 0.03) were higher in one of the two hospitals, where the forceps delivery rate was also higher (10.9% vs. 2.6%, P

Matched MeSH terms: Anal Canal/injuries*
It is the first birth that does the damage: a cross-sectional study 20 years after delivery

Kamisan Atan I, Lin S, Dietz HP, Herbison P, Wilson PD, ProLong Study Group

Int Urogynecol J, 2018 Nov;29(11):1637-1643.
PMID: 29564511 DOI: 10.1007/s00192-018-3616-4

INTRODUCTION AND HYPOTHESIS: Levator ani muscle (LAM) and anal sphincter tears are common after vaginal birth and are associated with female pelvic organ prolapse and anal incontinence. The impact of subsequent births on LAM and external anal sphincter (EAS) integrity is less well defined. The objective of this study was to determine the prevalence of LAM and EAS trauma in primiparous (VP1) and multiparous (VP2+) women who had delivered vaginally to assess if there were differences between the two groups. The null hypothesis was: there is no significant difference in the prevalence of LAM and EAS trauma between the two groups.
METHODS: This was a cross-sectional study involving 195 women, participants of the Dunedin arm of the ProLong study (PROlapse and incontinence LONG-term research study) seen 20 years after their index birth. Assessment included a standardized questionnaire, ICS POP-Q and 4D translabial ultrasound. Post-imaging analysis of LAM and EAS integrity was undertaken blinded against other data. Statistical analysis was performed using Fisher's exact test and results were expressed as odds ratios (OR).
RESULTS: LAM avulsion and EAS defects were diagnosed in 31 (16%) and 24 (12.4%) women respectively. No significant difference in the prevalence of levator avulsion and EAS defects between primiparous (VP1) and multiparous (VP2+) women who had delivered vaginally (OR 1.9, 95% CI 0.72-5.01, p = 0.26) and (OR 1.2, 95% CI 0.4-3.8, p = 0.76) respectively.
CONCLUSIONS: Most LAM avulsions and EAS defects seem to be caused by the first vaginal birth. Subsequent vaginal deliveries after the first were unlikely to cause further LAM trauma.

Matched MeSH terms: Anal Canal/injuries*