Transcript Trends in the Management of Labour

Max Brinsmead MB BS PhD
July 2015
 Classification
 Some
anatomy
 Repair
 Risk
 The
of 2nd degree obstetric injury
factors for 3rd & 4th degree tears
identification of 30 & 40 tears
 Management
 Avoiding
of 30 & 40 tears
obstetric injury
 Pregnancy
after previous 30 & 40 tears
 Cochrane
database
 Pubmed
 RCOG
Guidelines (July 2015)
 NICE
Guidelines for Intrapartum Care
(September 2007)
 Google
 Personal
experience
 1st degree perineal injury
• Involves skin only
 2nd degree injury
• Involves perineal muscles (or perineal body) but
not the anal sphincter
 3rd degree tear
• Involves the anal sphincter complex but not the
mucosa of the anal canal or rectum
• 3a = Less than 50% of the external AS
• 3b = More than 50% of the external AS but the
internal anal sphincter is intact
• 3c = Both external & internal AS torn
 4th degree tear
• Both external & internal AS is torn and the
 If
epithelium of the anal canal or rectum is breached
in doubt classify higher
 2nd
degree trauma occurs in 16 – 90% of
deliveries
 Depends largely on whether restricted or liberal use
of episiotomy is practised
 Overall
incidence of 3rd & 4th degree
tears is 1:100 deliveries (1%)
 But
studies with endoanal ultrasound
indicate that damage to the EAC occurs
in up to 40% of vaginal births
RISK FACTOR
Nulliparity (primigravidity)
Short perineal body
Instrumental delivery, overall
ODDS RATIO
3–4
8
3
Forceps-assisted delivery
3–7
Vacuum-assisted delivery
3
Forceps vs vacuum
Forceps with midline episiotomy
2.88*
25
Prolonged second stage of labor (>1
hour)
1.5–4
Epidural analgesia
1.5–3
Intrapartum infant factors:
Birthweight over 4 kg
2
Persistent occipitoposterior
position
2–3
Episiotomy, mediolateral
1.4
Episiotomy, midline
3–5
Previous anal sphincter tear
All variables are statistically significant at P<.05.
4
 Prediction
injury…
 Or
 Is
of obstetric anal sphincter
OASIS
NOT possible
 And
this needs to be conveyed to
patients during counselling
 Requires
systematic exam by a
competent & experienced person
 Extent of injury to be determined
before repair commences
 Analgesia
• May require GA or regional block
 Good
light and exposure
 Must do a PR if any sphincter damage
or 4th degree trauma is suspect
• Use a second glove and discard
A
PR after repair is also routinely
recommended

Use inert rapidly dissolving absorbable
suture material.
• 3/0 Vicryl not PDS for anal mucosa

Use continuous suturing for all layers not
interrupted
 Less pain
Bury the knots and warn the women about
how long the suture may be present
 To theatre for GA or regional block if 30 or 40
tear is diagnosed or suspected

• Some 3a trauma is suitable for repair under LA by
infiltration
Use 2/0 Vicryl or 3/0 monofilament PDS for
sphincter repair
 Retrieve and repair retracted sphincter end to
end or by overlap separate suture

• End to end for 3A – B injury

Use NSAID as a rectal suppository
 End
to
end
repair
 Overlap
repair

Antibiotics after 30 or 40 tear

Laxatives for 7 – 10 days

Offer physio with pelvic floor exercises

Review by obstetrician after 6 – 8w

Assess symptoms systematically


• One RCT in support
• Use broad spectrum plus Metronidazole
• Use stool softener and bulking agent
Refer for endoanal ultrasound and rectal
manometry if there are symptoms of
incontinence
The relevance of ultrasound abnormalities in
asymptomatic women is uncertain
1. Passage of any flatus when socially undesirable
2. Any incontinence of liquid stool
3. Any need to wear a pad because of anal symptoms
4. Any incontinence of solid stool
5. Any fecal urgency (inability to defer defecation for more than 5 minutes)
SCALE
0
Never
1
Rarely (<1/month)
2
Sometimes (1/week–1/month
3
Usually (1/day–1/week)
4
Always (>1/day)
A score of 0 implies complete continence and 20 complete incontinence.
A score of 6 suggested as a cut-off to determine need for evaluation.
An evidence-based approach
 Seven
RCT’s with 5001 women and 8
cohort studies with 6463 women. Meta
analysis confirms that restricted
episiotomy will result in:
 Less posterior trauma (RR 0.87, CI 0.83 - 0.91)
 More anterior trauma (RR 1.75, CI 1.52 - 2.01)
 Fewer 30 and 40 tears (RR 0.74, CI 0.42 - 1.28)
 Some studies also point to:
 Overall more intact perineums
 Less perineal pain
 Quicker return to coitus with restricted use of
episiotomy and
 More anal sphincter damage with liberal episiotomy
 But no difference in…
 Sexual function at 3m & 3 yrs or bladder function

Routine episiotomy is not recommended for
spontaneous birth

Episiotomy should be performed when
clinically indicated
• e.g. fetal compromise suspected or instruments
required
• RCOG recommends mediolateral episiotomy for all
instrumental births

Mediolateral episiotomy is best
• i.e. start at the posterior fouchette and proceed at an
angle of 45 - 60 degrees

Tested anaesthesia is required
• Except in an extreme emergency
A
case control study showed that
episiotomies that:
• Begin close to the posterior fourchette
• Are <15 and >60 degrees from the axis
• Are too short
• Or not deep enough
 Are
associated with an increased risk of
anal sphincter injury

One large RCT in Australia (1340 women in 3
sites) of midwife massage between
contractions in the second stage:
 No effect on any measure of obstetric trauma, pain, return to
coitus or urinary and bowel function



There was no apparent measure of compliance
But the study is confirmed by a US RCT of 1211
women in which compliance was high
Cochrane concludes that the number needed to
treat is 15
• and the rate of severe injury is not reduced

The Epi-No device (a self-performed
progressive dilation of the perineum from 36
weeks) significantly increases the rate of
intact perineum in nullipara and appears safe

2001 – a prospective trial of 50 nullipara
(published in German)
• Significant reduction in the rate of episiotomy (49% vs 82%)
• Fewer “perineal tears” (2% vs 4%)
• Shorter 2nd stage (mean 29 vs 54 minutes)

2004 – a prospective trial of 31 nullipara in
Singapore
• Used the device for a mean of 2.1 weeks
• Fewer episiotomies (50% vs 93%)
• Overall trauma rate 90% vs 97% but the trauma appeared
“less severe”
• The device was “safe”

2004 – Pilot study from Melbourne Aust. of 48
nullipara
•
•
•
•
Significantly more intact perineums (46% vs 17%)
Reduced rate of episiotomy (26% vs 34%)
Shorter second stage (mean 61 vs 81 minutes)
No effect on instrumental delivery rate or Apgars
 2009
– A RCT of 276 German
nullipara (published in AustNZ J O&G)
• Significantly more intact perineums (37.4% vs
25.7%)
• A trend towards fewer episiotomies
• No effect on the rate of “tears”, duration of 2nd
stage or pain
• No increased risk of infection
 Cochrane
concludes that the
application of a warm compress to
the perineum continuously between
contractions…
 Reduces
 RR
the risk of trauma
0.48 (CI 0.28 – 0.84)
 One large UK RCT of 5316 ♀ found:
 A small reduction in perineal pain at 10 days from
“hands on”
 No difference in any measure of obstetric trauma
 Inexplicably fewer manual removals in the “hands
poised” group (2.6% vs 1.5%)
 Broadly similar findings in an Austrian
study of 1076 women
 But episiotomy was more common in the “hands on”
group
 RCOG
concludes that a “hands on”
technique, previously rehearsed, is best
 And mothers advised NOT TO PUSH during
crowning
 One
RCT of 185 women found that:
 No effect on perineal pain
 But less dyspareunia when coitus was resumed
 And fewer second degree tears in the treated group
(RR 0.63, CI 0.42 – 0.93)
 But
NICE concludes that Lignocaine
spray should not be used
 There
are no prospective trials and only a
few retrospective studies
 The risk of repeat 30 and 40 trauma is
similar to the original incidence
 There is some evidence that if the woman
is asymptomatic then vaginal birth does
not further increase the risk of those
symptoms
 There is some evidence that for
symptomatic women then vaginal birth
does increase the severity of those
symptoms


Routine episiotomy is not recommended
Discussion about intrapartum care should
cover…






Current symptoms of dysfunction of the anal sphincter
The previous trauma
The risk of recurrence
Success of previous repair
Psychological aspects of the trauma
Then a combined decision concerning
subsequent mode of birth and intrapartum
care can be made
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