*Małgorzata Kołodziejczak1, Przemysław Ciesielski1, 2, Fabian Kamiński3, 4
A surgeon in the delivery room
Chirurg na sali porodowej
1Warsaw Proctology Centre, Saint Elizabeth’s Hospital, Mokotów Medical Centre
Head of Centre: Associate Professor Małgorzata Kołodziejczak, PhD
2Department of General Surgery, County Hospital in Wołomin
Head of Department: Krzysztof Górnicki, MD, PhD
3Department of General Surgery, Hospital in Białystok
Head of Department: Professor Janusz Kuźmiuk, MD, PhD
41st Department of General and Endocrine Surgery, University Teaching Hospital, Białystok, General Surgery Unit of Ministry of the Interior and Administration Hospital in Białystok
Head of Department: Professor Jacek Dadan, MD, PhD
Większość położniczych uszkodzeń krocza ginekolodzy zaopatrują sami i chirurg rzadko proszony jest o konsultację na salę porodową. Najczęściej ma to miejsce w sytuacji dużych uszkodzeń zwieraczy odbytu oraz ściany odbytnicy, czyli w przypadku pęknięcia krocza IV stopnia. Szczególnie w szpitalach wieloprofilowych, w których istnieje zarówno oddział ginekologiczno-położniczy, jak i chirurgiczny, może zaistnieć konieczność sprostania powyższej sytuacji. W artykule autorzy przypominają zasady doraźnego zaopatrzenia położniczych uszkodzeń mięśni zwieraczy, w oparciu o aktualne wytyczne postępowania w tym zakresie opracowane przez Royal College Obstetricians and Gynaecologists oraz o najnowsze piśmiennictwo. Przekazują też własne obserwacje praktyczne z przeprowadzania operacji rekonstrukcyjnych po uszkodzeniach położniczych zwieraczy odbytu. Prawidłowo przeprowadzona doraźna rekonstrukcja zwieraczy w większości przypadków nie pozostawia trwałych ubytków czynnościowych u pacjentki, natomiast źle zaopatrzone pęknięcie krocza III i IV stopnia może dać powikłania w postaci: gorszego trzymania gazów i stolca, przetoki odbytowo-pochwowej, przetoki odbytniczo-pochwowej, krwiaka, infekcji rany, ropnia, a w krańcowych przypadkach doprowadzić do ciężkich powikłań septycznych.
Most of perineal tears are managed by gynaecologists, who rarely consult with surgeons. Consultation most often takes place in the case of extensive damage to the anal sphincters and rectal wall, i.e. fourth-degree perineal tears. This situation is particularly likely in multispeciality hospitals featuring both gynaecological/obstetric and surgical departments. The paper discusses the guidelines for urgent management of perineal sphincter tears based on the current guidelines developed by the Royal College Obstetricians and Gynaecologists as well as recent literature. We also wish to share our practical observations from reconstructive surgeries after obstetric anal sphincter injuries. In most cases, a correctly performed anal sphincter repair causes no permanent dysfunctions, whereas inappropriately managed third- or fourth-degree perineal tears may lead to complications, such as poor gas and faecal continence, anovaginal or rectovaginal fistula, haematoma, wound infection, abscess and, in extreme cases, severe septic complications.
According to WHO reports, the incidence of anal sphincter injury during vaginal delivery ranges between 4% and 6.6% (1). A thorough American meta-analysis in a group of 22,741 women showed the incidence of obstetric anal sphincter injuries (OASIS) of 4.9%, including 3.6% for vaginal delivery and up to 24% for vacuum-assisted vaginal delivery (2). For comparison, there has been a 3-fold increase in the number of OASIS cases between 2000 and 2012 in England (1.8 vs. 5.9%), including 6.1% in primigravidas and 1.7% in multiparas (mean 2.9%) (3). The rates of obstetric anal sphincter injuries are 6.6% in Sweden, 3.6% in Denmark, 4.1% in Norway and 0.6% in Finland (4-6). The 2011 data from Austria indicates the incidence of third-degree and fourth-degree perineal tears of 1.5 and 0.1%, respectively (7). In Germany in 2012, the incidence of third-degree and fourth-degree perineal tears was 0.95 and 0.09%, respectively (with no significant differences between primigravidas and multiparas) (8).
Surprisingly, sphincter damage is reported to account for only 0.4% of deliveries in Poland (9). This is uncommon compared to the above mentioned data from Western countries. However, it should be noted that these findings not necessarily reflect the actual scale of the problem in a given country and may indicate better or worse diagnosability of sphincteric trauma.
Researchers are not unanimous on the grading of risk factors for obstetric anal sphincter injuries.
According to the 2015 Guidelines of the Royal College of Obstetricians and Gynaecologists, the risk factors for third- and fourth-degree perineal tear include (10):
– asian origin,
– primiparity (relative risk),
– birth weight greater than 4 kg,
– shoulder dystocia,
– persistent occiput posterior foetal position,
– prolonged second stage of delivery,
– instrument-assisted delivery.
According to the authors of one of the Polish studies, increased rates of perineal tear may be due to invasive delivery completion, the second stage of delivery lasting more than 1 hour and prostaglandin-induced delivery (9). Our study showed that (11) third- and fourth-degree perineal tear was the most important risk factor for postpartum incontinence.
Anatomical predisposing factors of sphincter damage in women include a particularly thin anterior circumference of the external anal sphincter (EAS) (about 90% of women lack the deep part of the external sphincter on the anterior circumference). If, additionally, the patient presents with the so-called low perineum, i.e. small distance between the vagina and the rectum, sphincter damage is more likely to occur.
The current classification of obstetric tears is the one developed by Sultan and Fernando, which was accepted during the 2012 Conference held by the College of Obstetricians and Gynaecologists (12, 13):
– first degree perineal tear – only the skin of the perineum is involved,
– second-degree tear – perineal muscles are involved, but intact anal sphincter,
– third-degree tear – injury to perineum involving the anal sphincter complex (classification suggested by Fernando and Sultan):
– 3a is a tear involving less than 50% of the EAS muscle,
– 3b is a tear involving more than 50% of the EAS muscle,
– 3c is a tear involving the whole EAS muscle and the internal anal sphincter muscle,
– fourth-degree tear is a tear involving perineum, the anal sphincter complex (external and internal sphincter) and rectal mucosa.
Interestingly, some authors distinguish a fifth-degree tear, when the anal sphincters are intact, but the anal mucosa is torn (14).
In the case of doubts about the extent of anal sphincter damage, higher classification group should be assumed (overdiagnosis is better than underestimation).
A surgeon in the delivery room – the proposed management
Most of perineal tears are managed by gynaecologists, who rarely consult with surgeons. Consultation most often takes place in the case of extensive damage to the anal sphincters and rectal wall, i.e. fourth-degree perineal tears. This situation is particularly likely in multispeciality hospitals featuring both gynaecological/obstetric and surgical departments.
In most cases, a correct urgent sphincter repair causes no permanent dysfunctions, whereas inappropriately managed third- or fourth-degree perineal tears may lead to serious complications, such as poor gas and faecal continence, anovaginal or rectovaginal fistula, haematoma, secondary wound infection, abscess and, in extreme cases, severe life-threatening septic complications.
The management in anal sphincter injury during vaginal delivery
Sphincter suturing should be regarded as a reconstructive surgery. The procedure should be performed in the operating block, under adequate anaesthesia and by/in the presence of the most experienced surgeon on duty. The sooner the reconstruction is performed, the better for the patient. The maximum time for primary reconstruction is disputable and it may be up to 48 hours for operating physicians with significant experience in proctological surgeries; however reconstruction should be performed within 6 hours of injury. The success of the surgery depends on factors such as operator’s experience in proctological surgeries, time from the injury, the volume of stool in the rectum as well as the function of other, undamaged muscles (e.g. the puborectalis).
Before reconstitution, the wound should be rinsed thoroughly with hydrogen peroxide, hematomas should be removed and careful haemostasis should be performed. Thin monofilament sutures, such as 3-0 PDS and 2-0 Vicryl, which cause only minor irritation and discomfort compared to other materials, are recommended.
For fourth-degree tears (rectal wall damage), the surgery begins with the repair of rectal mucosa, preferably using a continuous absorbable suture (e.g. Vicry 3.0). The first sutures should be placed above the injury site.
The stumps of the transected anal sphincters should be located and isolated. In the case of doubts on whether the isolated tissue is a muscle, an electrical stimulus may be used to induce muscle contraction. The extent of circumferential muscle loss should be assessed as well as it should be evaluated whether the damage is total (involving the entire muscle thickness) or partial and whether the internal anal sphincter is involved. In practice, differentiation between external and internal sphincter poses difficulty in this type of damage.
If the injury does not involve the entire muscle thickness, an end-to-end repair should be performed (fig. 1).
Fig. 1. An end-to-end anal sphincter reconstruction
If the entire muscle thickness is affected and the stumps of the transected muscle can be mobilised, an overlap technique is recommended (fig. 2).
Fig. 2. An overlapping anal sphincter reconstruction
Vaginal mucosa is repaired using a continuous locking stitch, with the first stitches placed about 0.5 cm above the top of the wound and the final stitches placed on the border of the vaginal vestibule (this stage may be performed by the gynaecologist).
Repair of the remaining perineal muscles and skin, preferably by placing vertical suture and raising the perineum.
The decision on whether to form a stoma is a disputable issue.
For urgent reconstructions immediately after sphincter injury, most patients with third- or fourth-degree tears do not require a stoma.
Stoma should be considered in patients:
– with extensive rectal wall damage,
– with late reconstruction (after 24 hours),
– with significantly contaminated wound (e.g. liquid stool-filled rectal ampulla).
Post-reconstructive management in third- and fourth-degree tears
Infection and secondary wound suppuration is in these cases synonymous with postoperative failure. Therefore, a comprehensive antibiotic therapy is recommended after reconstruction. Since most patients breastfeed, the antibiotic used should not be toxic for the child. Only isolated reports from studies assessing the efficacy of preventive antibiotic therapy in women after vaginal delivery complicated by third- and fourth-degree tear can be found in the available literature (15). Although the study demonstrated the efficacy of this type of management (a statistically significant reduction in septic complications after surgeries with prophylaxis was shown), the authors of the meta-analysis considered these findings to be uncertain due to the small size of the study group.
We found no clear recommendations on the postoperative use of laxatives or stool softeners in the available literature. However, lactulose administration and avoiding constipation-inducing drugs are recommended by some of gynaecological associations (e.g. the Royal College of Obstetricians and Gynaecologists) (10). Both, hard stools and diarrhoea should be avoided. Liquid stool, which penetrates between the sutures and may cause infection and wound dehiscence, is particularly harmful. In our practice, we recommend a 2-day strict diet followed by light diet in such cases.
Patients are advised to exercise sphincter muscles and pelvic floor muscles. Electrical stimulation, which should be monitored by a reference centre, may be sometimes needed after the wound heals.
Patients with third- or fourth-degree tears should report for a follow-up after a week, and then 6-12 weeks after delivery. Patients reporting reduced gas and faecal continence should be referred for transrectal ultrasound and proctological consultation.
Transrectal ultrasound imaging is the gold standard in such cases and it should show whether dehiscence of the repaired muscle stumps occurred (fig. 3). If sphincter continuity is maintained, rehabilitation may be initiated (biofeedback and electrical stimulation of the anal sphincter). If continuity of anal sphincter is not restored, as evidenced in transrectal ultrasound, a reconstructive surgery 4-6 months after delivery should be considered.
Fig. 3. An ultrasound scan of obstetric anal sphincter injury (by courtesy of professor Iwona Sudoł-Szopińska, MD, PhD)
Anal sphincter reconstruction after perineal damage should be performed as soon as possible, not later than 48 hours (in special cases) after delivery.
A surgeon consulted on the perineal injury is required to:
– assess the extent of damage,
– ensure the best possible conditions for the procedure (operating theatre, appropriate lightning, assistance),
– perform urgent reconstruction,
– consider stoma formation, taking into account the following factors: the extent of damage, time elapsed since injury, rectal content of faeces and experience in sphincteric repair,
– order full antibiotic therapy, strict diet for the first few days followed by light diet,
– if possible, follow-up the patient the following day and a week after the procedure,
– if the healing process proceeds efficiently, the next follow-up with continence evaluation should take place 6-8 weeks after the procedure (proctological examination, transrectal ultrasound),
– if the patient experiences reduced gas and faecal continence, rehabilitation (sphincter exercises, electrical stimulation) should be initiated.
Perineal trauma after vaginal delivery, particularly after instrumental delivery, affects a large proportion of patients. The percentage of women experiencing early and distant consequences of perineal injuries is underestimated. An appropriate primary perineal and sphincteric reconstruction yields good early and distant functional outcomes. However, proper management from the moment of diagnosis is the key to success. A quick action and engagement of experienced and trained medical personnel followed by adequate care and postoperative follow-up are necessary. Secondary sphincter reconstructions several months or even years after delivery are technically difficult and involve a higher risk of complications and failures compared to primary sphincter repair.
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