Techniques for Repair of Obstetric Anal Sphincter Injuries

Abstract

Importance: Obstetric anal sphincter injuries (OASISs) complicate up to 11% of vaginal deliveries; obstetricians must be able to recognize and manage these technically challenging injuries.

Objective: The aim of this study was to share our approach for management of these challenging complications of childbirth based on a multidisciplinary collaboration between general obstetrician-gynecologists, maternal fetal medicine specialists, and female pelvic medicine and reconstructive surgeons established at our institution.

Evidence acquisition: A systematic literature search was performed in 3 search engines: PubMed 1946-, EMBASE 1947-, and the Cochrane Database of Systematic Reviews using keywords obstetric anal sphincter injuries and episiotomy repair.

Results: Identification should begin with an assessment of risk factors, notably nulliparity and operative vaginal delivery, consistently associated with the highest risk of OASISs, and proceed with a thorough examination to grade the degree of laceration. Repair should be performed or supervised by an experienced clinician in an operating room with either regional or general anesthesia. The external anal sphincter may be repaired using either an overlapping or end-to-end anastomosis. Providers should be comfortable with both approaches as the degree of laceration may necessitate one approach over the other. We advocate for use of monofilament suture on all layers to decrease risk of bacterial seeding, as well as preoperative antibiotics and postoperative bowel regimen, which are associated with improved outcomes.

Conclusions and relevance: Long-term sequelae, including pain, dyspareunia, and fecal incontinence, significantly impact quality of life for many patients who suffer OASISs and may be avoided if evidence-based guidelines for recognition and repair are utilized.

Figure 1

Repair of lacerated perineum. Principles of obstetric anal sphincter laceration repair are depicted. Begin with closure of the rectal mucosa with running suture (2) and repair of lacerated anal sphincter using interrupted suture (4). Deep vaginal tissue (3) and perineal body (5, 6) should be repaired with interrupted suture. Closure of perineal skin is completed using continuous intracutaneous stiches (7).