DR ASHRAF ATIA DEWIDAR AND MANAGEMENT OF PERINEAL TEARS

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DR ASHRAF ATIA DEWIDAR AND MANAGEMENT OF PERINEAL TEARS

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DR ASHRAF ATIA DEWIDAR MD MRCOG

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DR . ASHRAF ATIA DEWIDAR MD MRCOG DR ASHRAF ATIA DEWIDAR MD MRCOG

THE MANAGEMENT OF THIRD- AND FOURTH-DEGREE PERINEAL TEARS:

THE MANAGEMENT OF THIRD- AND FOURTH-DEGREE PERINEAL TEARS Green-top Guideline No. 29 March 2007 DR ASHRAF ATIA DEWIDAR MD MRCOG

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DR ASHRAF ATIA DEWIDAR MD MRCOG

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The overall risk of obstetric anal sphincter injury is 1% of all vaginal deliveries increased awareness and training, increase THE detection of anal sphincter injury . DR ASHRAF ATIA DEWIDAR MD MRCOG

Prediction and prevention of obstetric anal sphincter injury:

Prediction and prevention of obstetric anal sphincter injury 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 Where episiotomy is indicated, then mediolateral technique is recommended, with careful attention to the angle cut away from the midline. DR ASHRAF ATIA DEWIDAR MD MRCOG

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● birth weight over 4 kg (up to 2%) ● persistent occipitoposterior position (up to 3%) ● nulliparity (up to 4%) ● induction of labour (up to 2%) ● epidural analgesia (up to 2%) ● second stage longer than 1 hour (up to 4%) ● shoulder dystocia (up to 4%) ● midline episiotomy (up to 3%) ● forceps delivery (up to 7%). DR ASHRAF ATIA DEWIDAR MD MRCOG

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DR ASHRAF ATIA DEWIDAR MD MRCOG

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DR ASHRAF ATIA DEWIDAR MD MRCOG

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DR ASHRAF ATIA DEWIDAR MD MRCOG

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50% relative reduction in risk of sustaining third-degree tear observed for every 6 degrees away from the perineal midline that an episiotomy was cut. DR ASHRAF ATIA DEWIDAR MD MRCOG

Classification and terminology :

Classification and terminology It is recommended that the classification outlined in this guideline be used when describing any obstetric anal sphincter injury If there is any doubt about the grade of third-degree tear, it is advisable to classify it to the higher degree rather than lower degree DR ASHRAF ATIA DEWIDAR MD MRCOG

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First degree Injury to perineal skin only. Second degree Injury to perineum involving perineal muscles but not involving the anal sphincter. Third degree Injury to perineum involving the anal sphincter complex: 3a: Less than 50% of EAS thickness torn. 3b: More than 50% of EAS thickness torn. 3c: Both EAS and IAS torn. Fourth degree Injury to perineum involving the anal sphincter complex (EAS and IAS) and anal epithelium DR ASHRAF ATIA DEWIDAR MD MRCOG

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DR ASHRAF ATIA DEWIDAR MD MRCOG

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DR ASHRAF ATIA DEWIDAR MD MRCOG

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DR ASHRAF ATIA DEWIDAR MD MRCOG

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DR ASHRAF ATIA DEWIDAR MD MRCOG

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DR ASHRAF ATIA DEWIDAR MD MRCOG

(buttonhole tear):

( buttonhole tear ) DR ASHRAF ATIA DEWIDAR MD MRCOG

Grade 3b tear:

Grade 3b tear DR ASHRAF ATIA DEWIDAR MD MRCOG

Identification of obstetric anal sphincter injuries:

Identification of obstetric anal sphincter injuries All women having a vaginal delivery with evidence of genital tract trauma should be examined systematically to assess the severity of damage prior to suturing. All women having an operative vaginal delivery or who have experienced perineal injury should be examined by an experienced practitioner trained in the recognition and management of perineal tears. DR ASHRAF ATIA DEWIDAR MD MRCOG

Injury obscured by intact skin:

Injury obscured by intact skin DR ASHRAF ATIA DEWIDAR MD MRCOG

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DR ASHRAF ATIA DEWIDAR MD MRCOG

Surgical techniques:

Surgical techniques For repair of the external anal sphincter, either an overlapping or end-to-end (approximation) method can be used, with equivalent outcome. Where the IAS can be identified, it is advisable to repair separately with interrupted sutures DR ASHRAF ATIA DEWIDAR MD MRCOG

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DR ASHRAF ATIA DEWIDAR MD MRCOG

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Repair of transverse perineal muscles with single interrupted suture Repair of bulbocavernosus muscle with single interrupted suture DR ASHRAF ATIA DEWIDAR MD MRCOG

E-E AND OVERLAPPING:

E-E AND OVERLAPPING DR ASHRAF ATIA DEWIDAR MD MRCOG

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DR ASHRAF ATIA DEWIDAR MD MRCOG

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DR ASHRAF ATIA DEWIDAR MD MRCOG

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DR ASHRAF ATIA DEWIDAR MD MRCOG

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DR ASHRAF ATIA DEWIDAR MD MRCOG

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Repair of third- and fourth-degree tears should be conducted in an operating theatre, under regional or general anaesthesia. DR ASHRAF ATIA DEWIDAR MD MRCOG

Choice of suture materials:

Choice of suture materials When repair of the EAS muscle is being performed, either monofilament sutures such as polydiaxanone (PDS) or modern braided sutures such as polyglactin (Vicryl ® ) can be used with equivalent outcome DR ASHRAF ATIA DEWIDAR MD MRCOG

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When repair of the IAS muscle is being performed, fine suture size such as 3-0 PDS and 2-0 Vicryl may cause less irritation and discomfort DR ASHRAF ATIA DEWIDAR MD MRCOG

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When obstetric anal sphincter repairs are being performed, burying of surgical knots beneath the superficial perineal muscles is recommended to prevent knot migration to the skin. DR ASHRAF ATIA DEWIDAR MD MRCOG

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Women should be warned of the possibility of knot migration to the perineal surface, with long-acting and non-absorbable suture materials DR ASHRAF ATIA DEWIDAR MD MRCOG

Surgical competence:

Surgical competence Obstetric anal sphincter repair should be performed by appropriately trained practitioners. Formal training in anal sphincter repair techniques is recommended as an essential component of obstetric training. DR ASHRAF ATIA DEWIDAR MD MRCOG

Postoperative management:

Postoperative management The use of broad-spectrum antibiotics is recommended following obstetric anal sphincter repair to reduce the incidence of postoperative infections and wound dehiscence DR ASHRAF ATIA DEWIDAR MD MRCOG

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The use of postoperative laxatives is recommended to reduce the incidence of postoperative wound dehiscence. Local protocols should be implemented regarding the use of antibiotics, laxatives, examination and follow-up of women with obstetric anal sphincter repair. DR ASHRAF ATIA DEWIDAR MD MRCOG

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All women should be offered physiotherapy and pelvic-floor exercises for 6 – 12 weeks after obstetric anal sphincter repair. All women who have had obstetric anal sphincter repair should be reviewed 6 – 12 weeks postpartum by a consultant obstetrician and gynaecologist DR ASHRAF ATIA DEWIDAR MD MRCOG

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If a woman is experiencing incontinence or pain at follow-up, referral to a specialist gynaecologist or colorectal surgeon for endoanal ultrasonography and anorectal manometry should be considered. small number of women may require referral to a colorectal surgeon for consideration of secondary sphincter repair DR ASHRAF ATIA DEWIDAR MD MRCOG

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DR ASHRAF ATIA DEWIDAR MD MRCOG

Prognosis:

Prognosis Women should be advised that the prognosis following EAS repair is good, with 60 – 80% asymptomatic at 12 months. Most women who remain symptomatic describe incontinence of flatus or faecal urgency DR ASHRAF ATIA DEWIDAR MD MRCOG

Future deliveries:

Future deliveries What advice should women be given following an obstetric anal sphincter injury concering future pregnancies and mode of delivery? DR ASHRAF ATIA DEWIDAR MD MRCOG

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All women who sustained an obstetric anal sphincter injury in a previous pregnancy should be counselled about the risk of developing anal incontinence or worsening symptoms with subsequent vaginal delivery DR ASHRAF ATIA DEWIDAR MD MRCOG

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All women who sustained an obstetric anal sphincter injury in a previous pregnancy should be advised that there is no evidence to support the role of prophylactic episiotomy in subsequent pregnancies DR ASHRAF ATIA DEWIDAR MD MRCOG

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All women who have sustained an obstetric anal sphincter injury in a previous pregnancy and who are symptomatic or have abnormal endoanal ultrasonography and/or manometry should have the option of elective caesarean birth. DR ASHRAF ATIA DEWIDAR MD MRCOG

Risk management:

Risk management There is a steady increase in litigation related to obstetric anal sphincter injury the occurrence of obstetric anal sphincter injury is not considered substandard care because it is a known complication of vaginal delivery . failure to recognise anal sphincter damage and to carry out a repair may be considered substandard care DR ASHRAF ATIA DEWIDAR MD MRCOG

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When third- and fourth-degree repairs are performed, it is essential to ensure that the anatomical structures involved, method of repair and suture materials used are clearly documented and that instruments, sharps and swabs are accounted for DR ASHRAF ATIA DEWIDAR MD MRCOG

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The woman should be fully informed about the nature of her injury and the benefits to her of follow-up. This should include written information where possible. DR ASHRAF ATIA DEWIDAR MD MRCOG

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تمت بحمد الله DR ASHRAF ATIA DEWIDAR MD MRCOG

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