Risk factors and management of obstetric perineal injury

Perineal injury sustained during childbirth is a major aetiological factor in the development of perineal pain, sexual dysfunction, prolapse and disturbance in bowel and bladder function.

Preferential use of the vacuum extractor, restricting the use of episiotomy, repair of anal sphincter rupture by a trained doctor and selective caesarean section in these women can be beneficial in preventing complications.

More focused training of midwives and doctors in perineal and anal sphincter anatomy and repair is needed to minimize the morbidity associated with inadequate repair and missed tears.

Future research must address ways to predict and minimize severe perineal injury, and the management of subsequent pregnancies following anal sphincter injury.

Keywords: anal sphincter; childbirth; delivery; episiotomy; incontinence; perineum; third degree tears

Further reading

J.W. deLeeuw, P.C. Struijk, M.E. Viererhout and H.C.S. Wallenburg, Risk factors for third degree perineal ruptures during delivery, Br J Obstet Gynaecol 108 (2001), pp. 383–387.

R.J. Fernando, A.H. Sultan, C. Kettle, S. Radley, P.W. Jones and P.M.S. O’Brien, Repair techniques for obstetric anal sphincter injuries – a randomized controlled trial, Obstet Gynecol 107 (2006), pp. 1261–1268.

R. Fernando, A.H. Sultan, C. Kettle, R. Thakar and S. Radley, Methods of repair for obstetric anal sphincter injury, Cochrane Database Syst Rev 3 (2006) CD002866.

R.J. Fernando, A.H. Sultan, S. Radley, P.W. Jones and R.B. Johanson, Management of obstetric anal sphincter injury – a systematic review and national practice survey, BMC Health Serv Res 2 (2002), p. 9.

M. Fitzpatrick, M. Behan, R. O’Connell and C. O’Herlihy, A randomised clinical trial comparing primary overlap with approximation repair of third degree tears, Am J Obstet Gynecol 183 (2000), pp. 1220–1224.

V. Garcia, R.G. Rogers, S.S. Kim, R.J. Hall and D.N. Kammerer-Doak, Primary repair of obstetric anal sphincter laceration: a randomized trial of two surgical techniques, Am J Obstet Gynecol 192 (2005), pp. 1697–1701.

C. Kettle, R.K. Hills, P. Jones, L. Darby, R. Gray and R. Johanson, Continuous versus interrupted perineal repair with standard or rapidly absorbed sutures after spontaneous vaginal birth: a randomised controlled trial, Lancet 359 (2002), pp. 2217–2223.

C. Kettle and R.B. Johanson, The Cochrane library, Absorbable synthetic versus catgut suture material for perineal repair (Cochrane review) (issue 4) (2003) Oxford: Update Software.

A.H. Sultan and R. Thakar, Lower genital tract and anal sphincter trauma, Best Pract Res Clin Obstet Gynaecol 16 (2002), pp. 99–115.

R. Thakar and A.H. Sultan, Management of obstetric anal sphincter injury, Obstet Gynecol 5 (2003), pp. 72–78.

A. Williams, E.J. Adams, D.G. Tincello, Z. Alfirevic, S.A. Walkinshaw and D.H. Richmond, How to repair an anal sphincter injury after vaginal delivery: results of a randomised controlled trial, Br J Obstet Gynaecol 113 (2006), pp. 201–207

Ruwan J. Fernando
Ruwan J Fernando MS MD MRCOG Department of Urogynaecology, Ground Floor, Cambridge Wing, St Mary’s Hospital, Praed Street, London W2 1NY, UK

Obstetrics, Gynaecology &Reproductive Medicine

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