Third- and fourth-

degree tears

RCOG GUIDELINES

Prof Aboubakr Elnashar

Benha university Hospital, Egypt

ABOUBAKR ELNASHAR

3rd DT:

Any part of anal sphincter complex (ext & internal

sphincters)

3a: <50% of EAS is torn

3b: >50% of EAS is torn

3c: IAS (almost always EAS is completely disrupted)

4th DT: rectal mucosa

ABOUBAKR ELNASHAR

Incidence

Internal anal sphincter incompetence:

insensible faecal incontinence

External anal sphincter incompetence:

faecal urgency.

3rd DT:

PG: 2.8%

MG: 0.4 %

Depend on rates of instrumental delivery.

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New-onset symptoms of faecal incontinence

PG: At 10 months

10% instrumental VD

3% spontaneous VD.

{pudendal neuropathy}

5% emergency CS

very uncommon after elective CS.

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Faecal urgency:

{occult anal sphincter damage}

44% five years following instrumental delivery of

their first baby.

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US visible anal sphincter defects:

82%: forceps delivery

48% ventouse deliveries

Most women: infrequent problems

40% after vaginal delivery of their first baby

2/3: asymptomatic.

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Important facts:

1. Women are uncomfortable about faecal problems

after childbirth

2. Anal sphincter damage is mainly limited to first

deliveries, whereas pudendal nerve damage can

be cumulative.

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3. US demonstrated lesions

do not translate into confirmed problems of faecal

continence

can be demonstrated in women who were

demonstrated to have an intact anal sphincter at

the time of delivery.

{infection or haematoma formation, or partial

unrecognized sphincter ruptures.}

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4. Pudendal nerve damage

{during labour as the nerve becomes compressed

and stretched}

Delivery late in the first stage or second stage by CS

does not prevent this.

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Risk factors

Cumulative

Primigravida: 2-7

Second stage of labour of >60 minutes(including

passive second stage): 2

Instrumental vaginal delivery: 1.7-7

Midline episiotomy: 5-11

Macrosomia (>4 kg): 2.9

Persistent occipitoposterior position: 1. 7

Epidural analgesia: 1.5

Prior third-degree tear: 4

Induction of labour: 2

Shoulder dystocia: 4

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Repair Identification of extent of damage Careful EX

Assess the severity of damage to the perineum,

vagina and rectum.

Diagnose anal sphincter injury.

rectal extension, as small buttonhole tears

can be overlooked and lead to fistula formation.

1. When disrupted, the anal sphincter retracts,

forming a dimple on either side of the anal canal.

2. Rupture of the rectal mucosa will almost always

involve damage to both the internal and external anal

sphincters.

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Conduct of the repair Cochrane review:

overlap technique: lower incidence in

faecal urgency

anal incontinence score

risk of deterioration of anal incontinence symptoms

over 12 months

No difference in:

perineal pain

dyspareunia

flatus incontinence

faecal incontinence

quality of life.

ABOUBAKR ELNASHAR

Two subsequent trials:

no differences in outcome.

RCOG guideline:

no evidence to suggest that an overlap technique is

better than end-to-end approximation of the muscle

{A}.

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Principles:

Adequate analgesia: regional or general

{local infiltration does not allow sufficient relaxation of

the sphincter to allow a satisfactory repair}.

Adequate lighting

Assistant: repair should be undertaken in the

operating theatre.

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Method:

.3a tears:

end-to-end technique {majority of the sphincter fibres

remain intact}.

3b tears:

cutting the remaining fibres to perform an overlap

repair.

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Steps & sutures:

Eensure that the muscle is correctly approximated

with long-acting sutures: adequate time to heal.

1. Repair of the rectal mucosa first.

2:0 polyglycolic acid interrupted sutures with the

knots placed on the mucosal side

2. Next, the layers of the internal sphincter should be

replicated across the defect with interrupted sutures

of 2:0 or 3:0 Vicryl or polydioxanone suture (PDS).

3. The torn external sphincter is then repaired.

This should be re-approximated with either three or

four figure-of-eight sutures, or an overlap technique.

A 2.0 or 3.0 PDS is ideal.

Polyglycolic acid is also used.

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A single study comparing the two showed no

difference in outcomes at 12 months [B].

However, the longer tensile retention of PDS and its

monofilament characteristics make it especially

suitable.

Short half-life treated polyglactin sutures (Vicryl

Rapide) are not acceptable as they do not have a

long enough half-life to ensure muscle healing.

Non-absorbable sutures should not be used in the

acute setting as these can form a focus for infection,

requiring removal.

The knots should be buried beneath the superficial

perineal muscles, to minimize knot migration.

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4. The remainder of the perineal repair is undertaken

as for second-degree trauma.

5. Retention of urine secondary to the anaesthesia or

repair is common and a urinary catheter should be

inserted until spontaneous voiding is achieved.

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Post-operative precautions

It is common practice after delayed anal sphincter

repair to use a constipating regimen to allow the

repair to heal before stools are passed. This is

difficult in recently delivered women who have very

different needs from those of the surgical patient.

Constipative regimens have been compared with

stool-softening regimens. It is concluded that

constipative management leads to more pain and a

longer post-operative stay compared to stool-

softening regimens, but with no difference in repair

success.

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1. Lactulose and a bulk agent, such as Fybogel: for

5-10 days.

2. Broad-spectrum antibiotic.

cover anaerobic e.g. metronidazole. prescribed orally

rather than per rectum.

3. Oral analgesia:

Paracetamol, non-steroidal anti-inflammatory drugs

and opioid.

opioids used alone can exacerbate constipation, and

thus the former should be used first.

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Before the woman goes home,

· Analgesia and stool softeners;

· Advise on perineal hygiene;

· counsel that 60-80% of women will be

asymptomatic following healing of the repair;

· make an initial plan for short-term management with

a physiotherapist;

· counsel that sutures occasionally migrate and

fragments may be passed per vaginum or,

occasionally, per rectum;

· give an appointment for follow up.

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Follow up

A team approach

Physiotherapy should include augmented

biofeedback {improve continence}.

At 6-12 weeks, a full evaluation of the degree of

symptoms:

Questioning with regard to faecal and urinary

symptoms. A standard questionnaire

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1. Symptomatic women:

Investigation: endoanal ultrasound and manometry.

2. Asymptomatic women with low squeeze pressures

and a demonstrable sphincter defect of more than a

quadrant should be counselled regarding the pros

and cons of future deliveries.

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3. Women with ongoing severe symptoms should be

considered for secondary surgery.

As pudendal neuropathy can take at least six months

to improve, any further surgical intervention is best

deferred until at least this time; however,

in exceptional cases in which sphincter disruption is

demonstrated and faecal incontinence is debilitating,

surgery may be required earlier.

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4. Women with mild symptoms

avoid gas-producing foods and bulking agents,

constipating agents and biofeedback offered.

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Counseling about subsequent

delivery 1. Previous third/fourth-degree tear, no

ongoing symptoms: 4% risk of further anal sphincter damage in a

subsequent vaginal delivery. canot predicted

antenatalIy.

Women who were transiently incontinent after their

first delivery are particularly at risk of worsening of

symptoms, and 17-24% may develop worsening

symptoms after subsequent delivery

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When women opt for subsequent vaginal delivery,

-every effort to avoid instrumental vaginal delivery.

-No evidence that episiotomy prevents muscle

damage, and most women appreciate an intact

perineum if that can be achieved.

-The second stage should not be prolonged.

Where anal sphincter damage does not occur, new-

onset symptoms are usually attributable to pudendal

neuropathy, which usually improves with time.

Transient flatus incontinence is reported by 10% of

women delivered without further sphincter damage.

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2. Women who continue to be

symptomatic The majority of these women will have a

demonstrable defect on ultrasound.

There is a risk of worsening of symptoms, which may

then make life much more difficult.

Women should be carefully counselled with regard to

additional effects of worsening pudendal damage and

small risk of further muscle damage.

The majority of women in this group may opt for

caesarean section, but for choosing vaginal delivery,

every effort should be made avoid operative vaginal

delivery and lengthy second stage.

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3. Women who have undergone a

secondary anal sphincter repair should be delivered by , cesarean section [E].

However, there are no data to advise women who

wish to try for a vaginal delivery.

Again, instrumental delivery and long second stage

should be avoided where possible.

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4. Women who are asymptomatic, but

have demonstrable anal sphincter

defects or abnormal manometry on

testing These women are at risk of new symptoms following

subsequent delivery.

Those at most risk appear to be women with a full

quadrant defect, and these women may wish to

choose caesarean section next ,time [C]

The plan for delivery must be clearly documented in

the case notes.

ABOUBAKR ELNASHAR

ABOUBAKR ELNASHAR