Outcome of anal symptoms and anorectal function following two obstetric anal sphincter injuries (OASIS)-a nested case-controlled study.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injury (OASI) is a significant risk factor for developing anal incontinence. It can therefore be hypothesised that recurrent OASI in a subsequent delivery may predispose women to further anal sphincter dysfunction. METHODS: A nested case-controlled study based on data collected prospectively between 2006 and 2019. Women matched for age and ethnicity, with a history of one OASI and no sphincter damage in a subsequent delivery (control) were compared to women sustaining a second OASI. Assessment was carried out using the St Mark's score (SMIS), anorectal manometry and endoanal ultrasound scan (findings quantified using the modified Starck score). RESULTS: Eighty-four women were included and equally distributed between the two groups, who were followed up 12 weeks postnatally. No difference in SMIS scores was found. Maximum resting pressure (MRP, mmHg) and maximum squeeze pressure (MSP, mmHg) were significantly reduced in the study group. Median (IQR) MRP in the study group was 40.0 (31.3-54.0) versus 46.0 (39.3-61.5) in the control group (p = 0.030). Median (IQR) MSP was 73.0 (58.3-93.5) in the study group versus 92.5 (70.5-110.8) (p = 0.006) in the control group. A significant difference (p = 0.002) was found in the modified Starck score between the study group (median 0.0 [IQR 0.0-6.0]) and control group (median 0.0 [IQR 0.0-0.0]). CONCLUSIONS: We have demonstrated that women with recurrent OASI do not have significant anorectal symptoms compared to those with one OASI 12 weeks after delivery, but worse anal sphincter function and integrity. Therefore, on long-term follow-up, symptoms may possibly develop. This information will be useful when counselling women in a subsequent pregnancy.

Effect of subsequent vaginal delivery on bowel symptoms and anorectal function in women who sustained a previous obstetric anal sphincter injury.

INTRODUCTION AND HYPOTHESIS: Our primary objective was to prospectively evaluate anorectal symptoms, anal manometry and endoanal ultrasound (EAUS) in women who followed the recommended mode of subsequent delivery following index obstetric anal sphincter injuries (OASIs) using our unit's standardised protocol. Our secondary objectives were to evaluate the role of internal anal sphincter defects and also to compare outcomes in a subgroup of symptomatic women with normal anorectal physiology. METHODS: This is a prospective follow-up study of pregnant women with previous OASIs who were counselled regarding subsequent mode of delivery between January 2003 and December 2014. Assessment involved the St Mark's Incontinence Score (SMIS), anal manometry and EAUS at both antepartum and 3-month postpartum visits. Data were analysed using Wilcoxon and Mann-Whitney U tests. RESULTS: Three hundred and fifty women attended the perineal clinic over the study period, of whom 122 met the inclusion criteria (99 vaginal delivery [VD], 23 caesarean section). No significant worsening of anorectal symptoms was observed following subsequent delivery in the VD group (p = 0.896), although a reduced squeeze pressure was observed at 3 months postpartum (p < 0.001). There were no new defects on EAUS in either group. CONCLUSIONS: This study showed no significant worsening of bowel symptoms and sphincter integrity apart from lower squeeze pressures at 3 months postpartum in the VD group when our standardised protocol was used to recommend subsequent mode of delivery. In the absence of a randomised study, use of this protocol can aid clinicians in their decision-making.

Reducing obstetric anal sphincter injuries using perineal support: our preliminary experience.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injuries (OASIs) are associated with significant short-term and long-term morbidity. Over the past decade, there has been a steady rise in the rate of OASIs. There is therefore a compelling need to identify strategies to minimize OASIs. The objective of this study was to determine if perineal support at the time of vaginal delivery can reduce the incidence and severity of OASIs. METHODS: All labour ward staff including midwives and doctors were invited to train in the technique of perineal support during vaginal delivery. Two experts from Norway conducted workshops with practical hands-on training on pelvic models. The midwives and doctors underwent further training with women in labour, and mandatory training was continued within the department. All midwives and doctors were instructed to support the perineum during both spontaneous and assisted vaginal delivery. RESULTS: From April 2011 to November 2014, 11,135 women underwent vaginal delivery. The OASI rate decreased from 4.7 % to 4.1 % (p = 0.11). There was a significant reduction (0.9 % to 0.3 %, p < 0.001) in 3c third-degree and fourth-degree tears (major OASIs). In a multivariate analysis, perineal support was associated with a significant reduction in the rates of OASIs (23 %; OR 0.77, 95 % CI 0.63 - 0.95, p = 0.01]) and major OASIs (71 %; OR 0.34, 95 % CI 0.17 - 0.69, p = 0.03). CONCLUSIONS: This interventional study showed that perineal support during vaginal delivery can reduce the risk of major OASIs. With sustained reinforcement of this intervention programme, we anticipate a further reduction in OASI rates.

Digital assessment and quantification of pelvic organ prolapse (DPOP-Q): a randomised cross-over diagnostic agreement trial.

INTRODUCTION: Pelvic Organ Prolapse Quantification (POP-Q) system, measured in centimetres using a ruler (e.g. POPstix®), is recommended to quantify prolapse severity. POPstix® are costly (US $1/ruler). Home-made devices are used instead, but these have not been shown to be reproducible. HYPOTHESIS: Digitally assessed POP-Q (DPOP-Q) is as reliable, reproducible and acceptable as POP-Q assessed using POPstix®. METHODS: In this randomised crossover diagnostic agreement trial, each assessor measured the index finger of their dominant hand using a ruler. At visit one, patients were randomised to either POPstix® POP-Q assessment in a modified lithotomy position or DPOP-Q in both modified a lithotomy and a standing position. After the first clinician conducted this assessment, a second blinded clinician then carried out the remaining assessment on the same patient. For each examination, duration was recorded, along with a patient-completed discomfort score. Twenty-five women were invited for visit two, at which DPOP-Q was recorded by the same clinician who undertook DPOP-Q at the first visit. This allowed evaluation of inter- and intraobserver agreement together with examination acceptability. RESULTS: One hundred and nine women were recruited [median age 55 years, parity 2, body mass index (BMI) 27.1]. Of the 25 patients invited, 23 returned for visit two. DPOP-Q had high interobserver reliability [κ = 0.94, 95 % confidence interval (CI) 0.878-0.996] and intraobserver reliability (α = 0.96) with POPstix®. DPOP-Q was significantly quicker (p = 0.02) and less uncomfortable (p < 0.01) than POPstix® POP-Q. CONCLUSION: DPOP-Q is reliable, acceptable and cost effective.

Cutting an episiotomy at 60 degrees: how good are we?

INTRODUCTION AND HYPOTHESIS: Episiotomy is regarded as the most common maternal obstetric surgical procedure. It is associated with a significant increase in blood loss, lower pelvic floor muscle strength, dyspareunia, and perineal pain compared with a perineal tear. We tested the hypothesis that all doctors and midwives can perform an episiotomy when prompted to, specifically cut at 60° from the midline (in a simulation model). METHODS: Doctors and midwives attending the BMFMS Annual Meeting (2014), Croydon Perineal Trauma Course and staff at Poole General Hospital were invited to cut a paper replica of the perineum with a commonly used episiotomy incision pad. Participants were prompted to cut an episiotomy at 60° to the perineal midline with the anus as a reference point. The angles and distances were measured using protractors and rulers. A 58-62° band was deemed acceptable to account for measurement errors. RESULTS: A total of 106 delegates participated. Only 15 % of doctors and midwives cut an episiotomy between 58 and 62°. Over one third (36 %) cut the episiotomy between 55 and 65° (inclusive). Nearly two thirds either underestimated the angle (<55°; 44 %), or overestimated the angle (>66°; 18 %). Thirty-six and 7.5 % of episiotomies were cut at <50 and >70° respectively. The origination point of the episiotomy was 5 mm away from the midline (IQR 1-8 mm). CONCLUSIONS: This original observational study shows that doctors and midwives were poor at cutting at the prompted episiotomy angle of 60°. This highlights the need to develop structured training programmes to improve the visual accuracy of estimating angles or the use of fixed angle devices to help improve the ability to estimate the desired angle.

Getting the size right: Are clinicians ready for it?

Objectives Digital examination has many uses in obstetrics and gynaecology, including cervical assessment in labour and measuring for vaginal pessaries. Clinicians must be adequately trained to perform accurate digital assessments and use this information to make decisions. We aimed to evaluate the accuracy of a clinician's estimate for three different measuring tasks and assess whether there was any difference in the accuracy in relation to seniority or job role. Study design Doctors and midwives were recruited from two perineal trauma training events. Estimates and measurements for three different activities were recorded: length of own index finger, length of an anal sphincter model and cervical dilatation at two different dilatations (7 cm and 9 cm) using a pocket guide cervical dilatation tool. The results were analysed for accuracy of measurements according to job role and seniority. Results A total of 369 participants took part. Only 4.6% of participants accurately (to 0.1 cm) estimated the length of their index finger (0% of midwives and 5.5% of doctors). There was a significant difference (p < 0.05) when comparing average differences between estimated and actual lengths measured for doctors and midwives for almost all measurements. When comparing doctors based on seniority there was no significant difference in the accuracy of estimated lengths. A higher percentage of midwives than doctors were accurate at both 7 cm (22% vs 16.1%) and 9 cm (30.5% vs 29.5%) dilated. Conclusion We found that accuracy was poor for both doctors and midwives when asked to estimate various measurements. We suggest that training will improve awareness of finger length and therefore improve accuracy when performing digital examinations in clinical practice.

Outcomes of minimally invasive suburethral slings with and without concomitant pelvic organ prolapse surgery.

OBJECTIVE: To assess subjective outcomes among patients who underwent minimally invasive suburethral sling (MIS) surgery for stress urinary incontinence with or without concurrent pelvic organ prolapse (POP) surgery. METHODS: In a prospective study between 2002 and 2010, patients who underwent MIS surgery with or without concomitant POP surgery at Croydon University Hospital, UK, completed the ICIQ-FLUTS and ICIQ-LUTSqol questionnaires on lower urinary tract symptoms and quality of life before and 12 months after surgery. RESULTS: Overall, 203 patients underwent MIS surgery alone and 91 underwent concomitant POP and MIS surgery. At 12 months, the response rate was 64.3%. Before surgery, there was no significant difference between the groups in any domain of ICIQ-FLUTS and ICIQ-LUTSqol, except for in the incontinence domain of ICIQ-FLUTS, for which scores were significantly worse in the MIS group (P=0.018). All domains of ICIQ-FLUTS and ICIQ-LUTSqol had improved after 1 year in both groups, except for the voiding domain of the ICIQ-FLUTS in the MIS group (P=0.054). After surgery, there was no difference between the groups in any domain (P>0.05). Complication rates were low in both groups. CONCLUSION: MIS with concomitant POP surgery is as safe and effective as MIS surgery alone.