Obstetric anal sphincter injury can worsen over time

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Anal function after anal sphincter injury during vaginal delivery may worsen over time and with subsequent vaginal deliveries, according to a report from Sweden.

Anal sphincter injuries can affect “pelvic floor stability, sexuality, and continence and should be reconstructed with care after every delivery,” Dr. Eva Uustal Fornell from University Hospital, Linkoping, told Reuters Health.

Fornell and colleagues reexamined a group of 26 women who had participated 10 years earlier in a study of the consequences of anal sphincter damage that occurred during vaginal delivery. 

The findings are reported in BJOG: an International Journal of Obstetrics and Gynaecology.

Women with obstetric anal sphincter rupture continued to report more severe incontinence for flatus and liquid stool than did a comparison group 10 years after the original study, the team found. Those who had another vaginal delivery after the initial injury fared even worse.

Tests measuring anal sphincter function remained below normal in all women with anal sphincter injuries, and were lower in women with complete tears than in women with partial tears.

However, libido, ability to orgasm, and enjoyment of sexual intercourse did not differ between women with obstetric anal sphincter rupture and the comparison group of women, the report indicates.

“Bleeding, pain, and the difficulty in identifying the tissue postpartum has caused many midwives and doctors to abandon the idea of making a good repair just to give the patient some peace,” Fornell noted. However, she believes obstetric anal sphincter rupture “should be sutured by well-educated staff under optimal conditions.” That includes “operating theatres with good light, helping hands, a wide choice of materials, and good anesthesia for the woman.”

Prevention would be even better, Fornell said. She offered some recommendations to avoid anal sphincter injuries.

Forceps deliveries should be avoided unless there is acute danger for the baby’s life. Vacuum extractor is less traumatic for the woman and should be chosen instead.

Pressure on the uterus from the outside gives a higher risk for anal sphincter rupture and should be avoided.

The final part of the delivery should be attended by skilled staff-midwife or physician who can deliver the baby’s head while manually protecting the perineum as the baby’s head passes.

Midline episiotomy and probably also episiotomy to the side should be avoided.

“In women with previous injury who have any symptoms of pelvic floor dysfunction --Urinary Incontinence, anal incontinence, or signs of nerve injury, I would recommend elective c-section in future pregnancies,” Fornell concluded.

“For women without symptoms, the couple should be told the results of the current studies on long-term effects and decide themselves.”

SOURCE: BJOG: an International Journal of Obstetrics and Gynaecology, March 2005.

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