Audit on management of third and fourth degree perineal tear

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Audit on management of third/fourth degree perineal tears (From October, 2013 to March, 2014):

Audit on management of third/fourth degree perineal tears (From October, 2013 to March, 2014) Dr Mya Kyar Phyu Trust Grade (OG) Stafford General Hospital

Introduction and background:

Introduction and background Overall risk of obstetric anal sphincter injury – 1% of all vaginal deliveries Increased awareness and training – increase in detection of anal sphincter injury Appropriately trained obstetricians – more likely to provide a consistent, high standard of anal sphincter repair Reduce extent of morbidity and litigation associated with anal sphincter injury

Definition of Obstetric anal sphincter injury:

Definition of Obstetric anal sphincter injury Third-degree perineal tear a partial or complete disruption of the anal sphincter muscles, which may involve either or both the external (EAS) and internal anal sphincter (IAS) muscles. Fourth-degree tear a disruption of the anal sphincter muscles with a breach of the rectal mucosa.

Risk factors:

Risk factors Birth weight over 4 kg ( upto 2%) Persistent OP position ( upto 3%) Nulliparity ( upto 4%) IOL ( upto 2%) Epidural analgesia ( upto 2%) 2 nd stage longer than 1 hour ( upto 4%) Shoulder dystocia ( upto 4%) Midline episiotomy ( upto 3%) Forceps delivery ( upto 7%) (RCOG greentop guideline No. 29, March 2007)

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Clinicians need to Be aware of the risk factors for obstetric anal sphincter injury but also recognise that known risk factors do not readily allow its prediction or prevention. (RCOG greentop guideline No.29, March 2007)

Perineum:

Perineum

Ultrasound findings of anal sphincter injury:

Ultrasound findings of anal sphincter injury

Specific Objectives:

Specific Objectives To assess adherence to the local third/ fourth degree tear guideline To ascertain correlations between fetal or maternal factors or health practitioner and the occurrence of perineal tears To determine the mode of delivery preceding a third/ fourth degree perineal tear To determine who carried out the repair and who was the most senior person at the time of repair

Specific Objectives (contd;):

Specific Objectives ( contd ;) To determine where the repair was carried out, the method, suture material used and the anaesthesia administered To determine whether intra/ postoperative antibiotics were administered To determine if women received postoperative laxatives To determine the nature of the follow-up arrangements

Method:

Method Audit proforma was created (CNST standards, local guidelines) Retrospective audit was conducted. Sample of 17 patients that occurred between October, 2013-March, 2014. Follow up appointments upto 3 months were analysed. No yellow notes for 3 patients Used hospital maternity records, notes including EDRM to gather data and analysed using SPSS version 16.0

Results Analysis:

Results Analysis

Incidence of OAS injury per vaginal births:

Incidence of OAS injury per vaginal births Month Oct Nov Dec Jan Feb Mar Total vaginal births 111 116 104 123 111 132 No of OAS injury 4 3 3 1 4 2 Incidence by % 3.6% 2.6% 2.9% 0.8% 3.6% 1.5%

Incidence of OAS injury per vaginal births:

Incidence of OAS injury per vaginal births

Age group:

Age group

Parity group:

Parity group

Ethnicity:

Ethnicity

Gestational age group:

Gestational age group

IOL:

IOL

Epidural anaesthesia:

Epidural anaesthesia

Duration of 1st stage:

Duration of 1 st stage

Duration of 2nd stage:

Duration of 2 nd stage

Persistent OP:

Persistent OP

Mode of delivery:

Mode of delivery

Correlation between MOD and type of perineal tear:

Correlation between MOD and type of perineal tear

Episiotomy:

Episiotomy

Correlation between episiotomy and type of perineal tear:

Correlation between episiotomy and type of perineal tear

Accoucher:

Accoucher

Shoulder dystocia:

Shoulder dystocia No of patients With shoulder dystocia 1 Without shoulder dystocia 13 Missing 3

Birth weight group:

Birth weight group

Correlation between birth weight group and type of perineal tear:

Correlation between birth weight group and type of perineal tear

Who diagnosed the repair?:

Who diagnosed the repair? No of patients MW 2 SHO 3 Registrar 10 Consultant 1 Missing 1

Who repair the tear?:

Who repair the tear? No of patients SHO 4 Registrar 12 Missing 1

Most senior person present at the time of repair:

Most senior person present at the time of repair No of patients SHO 1 Registrar 15 Missing 1

Place of repair and type of anaesthesia:

Place of repair and type of anaesthesia Standard A repair carried out in operation theatre, under regional or GA is likely to be associated with improved outcome (Grade C recommendation) 13/14 cases (92.9%) were carried out in theatre whereas only 1/14 case (7.1%) was carried out in the room

Type of anaesthesia:

Type of anaesthesia No of patients Valid percentage Local anaesthesia 1 7.1% Epidural 4 28.6% Spinal 9 64.3% Missing 3 13/14 (92.9%) of the repairs under regional anaesthesia and only 1 case (7.1%) was under local anaesthesia.

Method of repair:

Method of repair Standard Currently, there is no reliable evidence to show that the overlap method is superior to the end-to-end (approximation) method (Grade A recommendation) However, RCOG guideline does recommend the documentation of the method of repair

Method of repair:

Method of repair Out of 14 notes available, 11 cases (78.6%) were documented as end-to-end repair and 3 cases (17.6%) were not documented about method.

Suture material for anal sphincter:

Suture material for anal sphincter Standard The use of monofilament sutures, such as Polydioxanone , compared with sutures, such as catgut or polygalactin suture materials, may be associated with less infection and better long-term function of the anal sphincter complex (Good practice point)

Suture material for anal sphincter:

Suture material for anal sphincter Out of 14 notes available, 12 cases (85.7%) used PDS sutures whereas 2 cases (14.3%) used polygalactin (vicryl).

Broad spectrum antibiotics:

Broad spectrum antibiotics Standard The use of broad-spectrum antibiotics intraoperatively and in the postoperative period is associated with less postoperative infection and wound dehiscence (Grade C recommendation)

Broad spectrum antibiotics:

Broad spectrum antibiotics Intraoperatively out of14 cases, 9 cases (64.3%) received antibiotics and 5 cases (35.7%) did not receive or not documented about antibiotics. Postoperatively out of 17 cases, 16 cases (94.1%) received antibiotics and 1 case (5.9%) did not receive antibiotics.

Type of antibiotics used:

Type of antibiotics used Out of 16 cases which received postoperative antibiotics, 9 cases (56.2%) received IV Cefuroxime + Metronidazole followed by oral cephalexin and metronidazole 7 cases (43.8%) received IV augmentin + Metronidazole followed by oral augmentin and metronidazole.

Postoperative laxatives:

Postoperative laxatives Standard The use of postoperative laxatives is associated with less postoperative wound dehiscence (Grade C recommendation) Out of 17 cases, 16 cases (94.1%) were prescribed postoperative laxatives whereas one case (5.9%) did not received it.

PV and PR examination, Instrument count after repair:

PV and PR examination, Instrument count after repair Out of 14 notes available, 13 cases (92.9%) recorded PV and PR examination and 1 case (7.1%) was not documented about them. Out of 14 notes available, all cases (100%) counted and documented the instrument counting.

Postop catheterization:

Postop catheterization Out of 14 cases, 10 cases (71.4%) had postop indwelling catheterization, 3 cases (21.4%) had no catheter and 1 case (7.1%) did not record about postoperative catheterization.

Follow up arrangement:

Follow up arrangement

Physiotherapy and pelvic floor exercise:

Physiotherapy and pelvic floor exercise Out of 16 cases, 12 cases (75%) offered physiotherapy and pelvic floor exercise. 4 cases (25%) did not offer or document about them.

Endoanal USS and anorectal manometry:

Endoanal USS and anorectal manometry No cases needed or offered for them

Complications:

Complications No wound dehiscence occurred in all cases No fecal incontinence and no dyspareunia in all cases One case complained of bladder pain, constipation but no treatment needed. It did not affect her quality of life.

Complications:

Complications One case needed for follow up appointment with continence nurse but no major symptoms. One case complained of urinary and bowel urgency but bladder scan showed normal finding. She recovered from her symptoms after 5 months.

Incident form:

Incident form Out of 16 notes available, 6 cases (37.5%) filled incident forms 10 cases (62.5%) did not fill or document about incident forms.

Discussion and recommendations:

Discussion and recommendations Incidence of obstetric anal sphincter injury in Stafford hospital is slightly higher than that mentioned in greentop guideline (2.5% Vs 1%) Primigravidas are more prone to obstetric anal sphincter injury. Although IOL and epidural anaesthesia are risk factors for OAS injury, this study did not show association with them. (53% have no IOL and 59% were without epidural)

Discussion and recommendations:

Discussion and recommendations Prolonged1 st or 2 nd stage had no association with OAS injury in this study and even quicker deliveries were associated with it. (57.1% had <4 hours of 1 st stage and 64.3% had <1 hour of 2 nd stage) Although persistent OP has significant risk factor, 57.1% of cases had no persistent OP position.

Discussion and recommendations:

Discussion and recommendations Regarding mode of delivery, normal vaginal delivery and instrumental delivery had no statistical different in OAS injury although NVD had slightly lower data (47.1% Vs 52.9%) Episiotomy had no influence on OAS injury since equal percentage in both cases (50% Vs 50%) Even without episiotomy was associated with more minor type (3a) than 3b or 3c.

Discussion and recommendations:

Discussion and recommendations Birth weight had no influence on OAS injury since equal percentage in <4000 or >4000 g groups (50% Vs 50%) Even >4000 g group was associated with more minor type (3a) than 3b or 3c Although shoulder dystocia is significant risk factor, only one case was associated with it.

Discussion and recommendations:

Discussion and recommendations Majority of accouchers were registrars (41%) and that may be due to instrumental deliveries.

Discussion and recommendations:

Discussion and recommendations Majority of the cases followed RCOG recommendations regarding Place of repair Type of anaesthesia Documentation about method of repair Type of suture material used Use of broad spectrum antibiotics Postop laxatives PV, PR examination and instrument counting Postop catheterization Physiotherapy and pelvic floor exercise

Discussion and recommendations:

Discussion and recommendations No serious complications in all cases No wound dehiscence in all cases Although trust guideline recommended about follow up arrangement with consultant in 3b or 3c cases, majority of follow ups were arranged with GP. Incident forms reportations are recommended in trust guideline but only 37.5% of the cases documented about it.

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Thank you

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