The prevention of perineal trauma during vaginal birth.

Perineal trauma after vaginal birth is common, with approximately 9 of 10 women being affected. Second-degree perineal tears are twice as likely to occur in primiparous births, with a incidence of 40%. The incidence of obstetrical anal sphincter injury is approximately 3%, with a significantly higher rate in primiparous than in multiparous women (6% vs 2%). Obstetrical anal sphincter injury is a significant risk factor for the development of anal incontinence, with approximately 10% of women developing symptoms within a year following vaginal birth. Obstetrical anal sphincter injuries have significant medicolegal implications and contribute greatly to healthcare costs. For example, in 2013 and 2014, the economic burden of obstetrical anal sphincter injuries in the United Kingdom ranged between £3.7 million (with assisted vaginal birth) and £9.8 million (with spontaneous vaginal birth). In the United States, complications associated with trauma to the perineum incurred costs of approximately $83 million between 2007 and 2011. It is therefore crucial to focus on improvements in clinical care to reduce this risk and minimize the development of perineal trauma, particularly obstetrical anal sphincter injuries. Identification of risk factors allows modification of obstetrical practice with the aim of reducing the rate of perineal trauma and its attendant associated morbidity. Risk factors associated with second-degree perineal trauma include increased fetal birthweight, operative vaginal birth, prolonged second stage of labor, maternal birth position, and advanced maternal age. With obstetrical anal sphincter injury, risk factors include induction of labor, augmentation of labor, epidural, increased fetal birthweight, fetal malposition (occiput posterior), midline episiotomy, operative vaginal birth, Asian ethnicity, and primiparity. Obstetrical practice can be modified both antenatally and intrapartum. The evidence suggests that in the antenatal period, perineal massage can be commenced in the third trimester of pregnancy to increase muscle elasticity and allow stretching of the perineum during birth, thereby reducing the risk of tearing or need for episiotomy. With regard to the intrapartum period, there is a growing body of evidence from the United Kingdom, Norway, and Denmark suggesting that the implementation of quality improvement initiatives including the training of clinicians in manual perineal protection and mediolateral episiotomy can reduce the incidence of obstetrical anal sphincter injury. With episiotomy, the International Federation of Gynecology and Obstetrics recommends restrictive rather than routine use of episiotomy. This is particularly the case with unassisted vaginal births. However, there is a role for episiotomy, specifically mediolateral or lateral, with assisted vaginal births. This is specifically the case with nulliparous vacuum and forceps births, given that the use of mediolateral or lateral episiotomy has been shown to significantly reduce the incidence of obstetrical anal sphincter injury in these groups by 43% and 68%, respectively. However, the complications associated with episiotomy including perineal pain, dyspareunia, and sexual dysfunction should be acknowledged. Despite considerable research, interventions for reducing the risk of perineal trauma remain a subject of controversy. In this review article, we present the available data on the prevention of perineal trauma by describing the risk factors associated with perineal trauma and interventions that can be implemented to prevent perineal trauma, in particular obstetrical anal sphincter injury.

Cost-Effectiveness of 2 Models of Pessary Care for Pelvic Organ Prolapse: Findings From the TOPSY Randomized Controlled Trial.

OBJECTIVES: Pelvic organ prolapse is the descent of one or more reproductive organs from their normal position, causing associated negative symptoms. One conservative treatment option is pessary management. This study aimed to to investigate the cost-effectiveness of pessary self-management (SM) when compared with clinic-based care (CBC). A decision analytic model was developed to extend the economic evaluation. METHODS: A randomized controlled trial with health economic evaluation. The SM group received a 30-minute SM teaching session, information leaflet, 2-week follow-up call, and a local helpline number. The CBC group received routine outpatient pessary appointments, determined by usual practice. The primary outcome for the cost-effectiveness analysis was incremental cost per quality-adjusted life year (QALY), 18 months post-randomization. Uncertainty was handled using nonparametric bootstrap analysis. In addition, a simple decision analytic model was developed using the trial data to extend the analysis over a 5-year period. RESULTS: There was no significant difference in the mean number of QALYs gained between SM and CBC (1.241 vs 1.221), but mean cost was lower for SM (£578 vs £728). The incremental net benefit estimated at a willingness to pay of £20 000 per QALY gained was £564, with an 80.8% probability of cost-effectiveness. The modeling results were consistent with the trial analysis: the incremental net benefit was estimated as £4221, and the probability of SM being cost-effective at 5 years was 69.7%. CONCLUSIONS: Results suggest that pessary SM is likely to be cost-effective. The decision analytic model suggests that this result is likely to persist over longer durations.

UK survey of colorectal surgeons on the management of acute obstetric anal sphincter injuries.

AIM: The role of colorectal surgeons in the management of acute obstetric anal sphincter injury (OASI) is an ongoing debate. Their expertise in operating in the anorectal region lends itself to assisting in OASI repair. The aim of this study was to establish the current involvement and recommended management of acute OASI by colorectal surgeons. METHOD: An online survey of consultant colorectal surgeons was sent to members of the Pelvic Floor Society to assess current involvement in acute OASI management and repair. RESULTS: Forty completed surveys were collated and analysed. Sixty-five per cent of respondents had seen an acute OASI since being a consultant and 50% stated they were involved in the repair of OASI less than once per year. 37.5% felt that a de-functioning stoma was still necessary sometimes. Many agreed with current guidelines for OASI repair in terms of antibiotics, laxatives and follow-up. CONCLUSIONS: Colorectal surgeons have varied opinions on the management of OASI. We suggest that multidisciplinary training of obstetricians and colorectal surgeons could lead to more collaboration regarding the management of women with acute OASI.

The incidence of anal incontinence following obstetric anal sphincter injury graded using the Sultan classification: a network meta-analysis.

OBJECTIVE: This study aimed to systematically determine and compare the incidence of anal incontinence between those with different grades of obstetric anal sphincter injury. DATA SOURCES: Ovid MEDLINE, Embase, and the Cochrane Library were searched from January 2000 to April 2021. STUDY ELIGIBILITY CRITERIA: Observational studies investigating the incidence of anal incontinence following an obstetric anal sphincter injury that was graded using the Sultan classification were eligible for inclusion. To allow comparison between individual tear grades (3a, 3b, 3c, fourth), a network meta-analysis was performed using Stata (version 15.1). METHODS: For binary outcomes, odds ratios with corresponding 95% confidence intervals were reported. Obstetric anal sphincter injury grades were ranked from the best clinical outcome to the worst clinical outcome. The percentage chance of each grade taking each rank with regards to outcome was calculated. Study quality and risk of bias was assessed using the relevant tool from the Joanna Briggs Institute. RESULTS: Of the 696 studies identified, 10 were eligible for inclusion and were included in the network meta-analysis (n=2467 women). The mean incidence of anal incontinence among those with 3a tears was 22.4% (range, 6.1%-51.2%), 24.9% (range, 6.9%-46.7%) among those with 3b tears, 26.8% (range, 0%-55.6%) among those with 3c tears, and 28.6% (0%-71.4%) among those with fourth-degree tears. Anal incontinence incidence was found to be significantly higher among those with 3c (odds ratio, 1.79; 95% confidence interval, 1.09-2.94) and fourth-degree tears (odds ratio, 2.37; 95% confidence interval, 1.40-4.02) than among those with 3a tears. In addition, anal incontinence incidence was significantly higher among those with fourth-degree tears (odds ratio, 1.89; 95% confidence interval, 1.10-3.22) than among those with 3b tears. Those with 3a tears had the highest probability of having the best clinical outcome; those with 3b; second-, 3c; third- and fourth-degree tears had the highest probability of having the worst clinical outcome. Overall, all studies had a high or unclear risk of bias across 1 or more assessed element. CONCLUSION: This was a network meta-analysis comparing the incidence of anal incontinence among those with different grades of obstetric anal sphincter injury. Increasing tear-grade severity is associated with worse clinical outcomes. This study provides useful, clinically applicable information that can assist clinicians in the counseling of women following an obstetric anal sphincter injury. In addition, it highlights the importance of accurately diagnosing the obstetric anal sphincter injury grade and subsequently performing the appropriate repair.

Diagnosis, management and training in perineal trauma: a UK national survey of obstetricians.

INTRODUCTION AND HYPOTHESIS: Perineal trauma during vaginal delivery is very common. Training in diagnosis and repair of trauma, including obstetric anal sphincter injuries, varies in the UK. We aimed to investigate the current knowledge and training received by obstetric physicians. METHODS: A national, validated survey was conducted online, using Qualtrics. The National Trainees Committee distributed the survey. It was also sent directly to consultants via email. RESULTS: A total of 302 physicians completed the survey and were included in the analysis. 3.9% of participants described their training in obstetric perineal trauma as "very poor" or "poor". 20.5% said they have not received training. 8.6% of physicians practising for more than 10 years had not had training for over 10 years. 70.5% responded "somewhat agree" or "strongly agree" when asked if they would like more training. Identification of first, second, third-, and fourth-degree tears from images and descriptions was very good (more than 80% correct for all categories). Classification of other perineal trauma was less consistent, with many incorrectly using the Sultan Classification. "Manual perineal support" and "Controlled or guided delivery" were the most frequently selected methods for the prevention of obstetric anal sphincter injury (OASI). CONCLUSIONS: Training experience for physicians in obstetric perineal trauma varies. Further improvement in training and education in perineal trauma, particularly in OASI, is needed for physicians. Perineal trauma that is not included in the Sultan Classification is often misclassified.

Oestrogen therapy for treating pelvic organ prolapse in postmenopausal women.

BACKGROUND: Pelvic organ prolapse (POP) is the descent of a woman's uterus, bladder, or rectum into the vagina. It affects 50% of women over 50 years old who have given birth to at least one child, and recognised risk factors are older age, higher number of births, and higher body mass index. This review assesses the effects of oestrogen therapy, alone or in combination with other treatments, on POP in postmenopausal women. OBJECTIVES: To assess the benefits and harms of local and systemic oestrogen therapy in the management of pelvic organ prolapse symptoms in postmenopausal women, and to summarise the principal findings of relevant economic evaluations. SEARCH METHODS: We searched the Cochrane Incontinence Specialised Register (up to 20 June 2022), which includes CENTRAL, MEDLINE, two trials registers, and handsearching of journals and conference proceedings. We also checked the reference lists of relevant articles for additional studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs), quasi-RCTs, multi-arm RCTs, and cross-over RCTs that evaluated the effects of oestrogen therapy (alone or in combination with other treatments) versus placebo, no treatment, or other interventions in postmenopausal women with any grade of POP. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data from the included trials using prespecified outcome measures and a piloted extraction form. The same review authors independently assessed the risk of bias of eligible trials using Cochrane's risk of bias tool. Had data allowed, we would have created summary of findings tables for our main outcome measures and assessed the certainty of the evidence using GRADE. MAIN RESULTS: We identified 14 studies including a total of 1002 women. In general, studies were at high risk of bias in terms of blinding of participants and personnel, and there were also some concerns about selective reporting. Owing to insufficient data for the outcomes of interest, we were unable to perform our planned subgroup analyses (systemic versus topical oestrogen, parous versus nulliparous women, women with versus without a uterus). No studies assessed the effects of oestrogen therapy alone versus no treatment, placebo, pelvic floor muscle training, devices such as vaginal pessaries, or surgery. However, we did identify three studies that assessed oestrogen therapy in conjunction with vaginal pessaries versus vaginal pessaries alone and 11 studies that assessed oestrogen therapy in conjunction with surgery versus surgery alone. AUTHORS' CONCLUSIONS: There was insufficient evidence from RCTs to draw any solid conclusions on the benefits or harms of oestrogen therapy for managing POP symptoms in postmenopausal women. Topical oestrogen in conjunction with pessaries was associated with fewer adverse vaginal events compared with pessaries alone, and topical oestrogen in conjunction with surgery was associated with reduced postoperative urinary tract infections compared with surgery alone; however, these findings should be interpreted with caution, as the studies that contributed data varied substantially in their design. There is a need for larger studies on the effectiveness and cost-effectiveness of oestrogen therapy, used alone or in conjunction with pelvic floor muscle training, vaginal pessaries, or surgery, for the management of POP. These studies should measure outcomes in the medium and long term.

Postpartum perineal wound infection and its effect on anal sphincter integrity: Results of a prospective observational study.

INTRODUCTION: Perineal wound infection can affect tissues at superficial, deep, and organ space levels. Women with obstetric anal sphincter injuries (OASIS) are at risk of infection; however, no study to date has investigated if infection can extend to affect the anal sphincter integrity. The aim of this study was to evaluate the clinical progression of perineal wound infection and its effect on the anal sphincter in women with or without OASIS using three-dimensional endoanal ultrasound (3D-EAUS). MATERIAL AND METHODS: Women were recruited into the Prospective Observational Study Evaluating the Sonographic Appearance of the Anal Sphincter in Women With Perineal Wound Infection Following Vaginal Delivery (PERINEAL Study) between August 2020 and August 2021 (NCT04480684). 3D-EAUS was performed weekly until complete wound healing. Significant bacterial colonization was diagnosed using the MolecuLight i:X camera. The primary study outcome was a change in a sphincter defect angle from baseline (wound infection) until wound healing. A robust Poisson regression model was used to analyze the effect of significant bacterial loads on the anal sphincter. RESULTS: Seventy-three women were included. A median of two ultrasound scans were performed in each patient (range 1-16). Five women (6.8%) had an OASI clinically diagnosed at delivery. In total, 250 EAUS were performed. An external anal sphincter defect was found on EAUS in 55 (22.0%) scans (n = 10 women). An external anal sphincter and internal anal sphincter defect was found in 26 scans (10.4%) (n = 3 women). During the course of the wound healing process, there was no significant change in defect size in wounds with or without significant bacterial colonization. In cases of an intact anal sphincter, wound infection did not disrupt its integrity. CONCLUSIONS: We found that perineal wound infection does not disrupt an intact anal sphincter or OASIS. This new information can provide important information for clinicians and patients. As there are myths frequently encountered in cases of litigation when disruption of sphincter integrity is attributed to perineal infection, the findings of this study should be tested in larger studies in the future.

The incidence of wound complications following primary repair of obstetric anal sphincter injury: a systematic review and meta-analysis.

OBJECTIVE: We aimed to systematically determine the incidences of wound infection and dehiscence after primary obstetric anal sphincter injury repair. DATA SOURCES: MEDLINE, Embase, CINAHL, EmCare, the Cochrane Library, and Trip Pro databases were searched from inception to February 2021. STUDY ELIGIBILITY CRITERIA: We included observational clinical studies reporting the incidences of wound infection and dehiscence after primary obstetric anal sphincter injury repair. Case series and reports were excluded. Conference articles and observational study abstracts were included if they contained enough information regarding study design and outcome data. METHODS: Data were analyzed as incidence (percentage) with 95% confidence intervals. Moreover, the prediction intervals were calculated to provide a predicted range for the potential incidence of wound complications when applied to an individual study setting. Study quality and risk of bias were assessed using the relevant tool from the Joanna Briggs Institute. RESULTS: Of 956 studies found, 39 were selected for full-text review. Moreover, 10 studies (n=4767 women) were eligible and included in the meta-analysis. All 10 studies were conducted in high-income countries (Denmark [n=1], the United Kingdom [n=3], and the United States [n=6]). The incidences of wound infection (n=4593 women) and wound dehiscence (n=3866 women) after primary obstetric anal sphincter injury repair ranged between 0.1% to 19.8% and 1.9% to 24.6%, respectively. The overall incidences were 4.4% (95% confidence interval, 0.4-8.4) for wound infection and 6.9% (95% confidence interval, 1.6-12.2) for wound dehiscence. The prediction intervals were wide and suggested that the true incidences of wound infection and dehiscence in future studies could lie between 0.0% to 11.7% and 0.0% to 16.4%, respectively. Overall, 8 studies had a high or unclear risk of bias across ≥1 assessed element. None of the studies used the same set of clinical parameters to define wound infection or dehiscence. Furthermore, microbiological confirmation with wound swabs was never used as a diagnostic measure. CONCLUSION: This was a systematic review and meta-analysis of wound infection and dehiscence incidences after primary obstetric anal sphincter injury repair. The incidence estimates from this review will be useful for clinicians when counseling women with obstetric anal sphincter injury and when consenting them for primary surgical repair.

Under-classified obstetric anal sphincter injuries.

INTRODUCTION AND HYPOSTHESIS: Obstetric anal sphincter injuries (OASIs) that are missed at delivery can have long-term consequences. OASIs that are under-classified at delivery are likely to be inadequately repaired, resulting in a persistent anal sphincter defect. We aimed to identify women who have persistent defects on endoanal ultrasound, inconsistent with the original diagnosis, and compare the effect on St Mark's incontinence scores (SMIS). We also aimed to look for changes in numbers of under-classification over time. METHODS: Records of women attending a perineal clinic who had endoanal ultrasound from 2012 to 2020 were reviewed. Women who had a modified Starck score implying a defect greater than the classification [indicated by the depth of external anal sphincter or internal anal sphincter (IAS) defect] at delivery were identified. RESULTS: A total of 1056 women with a diagnosis of 3a or 3b tears were included. Of these, 120 (11.36%) were found to have a defect greater than the original diagnosis and therefore were incorrectly classified at delivery. Women who had a 3b tear diagnosed at delivery, but had an IAS defect, had a significantly higher SMIS (p < 0.01). When comparing two 4-year periods, there was a significant improvement in the diagnosis of IAS tears. CONCLUSION: Some women with OASIs that have under-classified OASIs are associated with worse anorectal symptoms. This is likely because of an incomplete repair. Some improvement in diagnosis of IAS tears has been noted. We propose improved training in OASIs can help reduce the number of incorrectly classified tears and improve repair.

Mediolateral/lateral episiotomy with operative vaginal delivery and the risk reduction of obstetric anal sphincter injury (OASI): A systematic review and meta-analysis.

INTRODUCTION AND HYPOTHESIS: OASI complicates approximately 6% of vaginal deliveries. This risk is increased with operative vaginal deliveries (OVDs), particularly forceps. However, there is conflicting evidence supporting the use of mediolateral/lateral episiotomy (MLE/LE) with OVD. The aim of this study was to assess whether MLE/LE affects the incidence of OASI in OVD. METHODS: Electronic searches were performed in OVID Medline, Embase and the Cochrane Library. Randomised and non-randomised observational studies investigating the risk of OASI in OVD with/without MLE/LE were eligible for inclusion. Pooled odds ratios (OR) were calculated using Revman 5.3. Risk of bias of was assessed using the Cochrane RoB2 and ROBINS-I tool. The quality of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation (GRADE). RESULTS: A total of 703,977 patients from 31 studies were pooled for meta-analysis. MLE/LE significantly reduced the rate of OASI in OVD (OR 0.60 [95% CI 0.42-0.84]). On sub-group analysis, MLE/LE significantly reduced the rate in nulliparous ventouse (OR 0.51 [95% CI 0.42-0.84]) and forceps deliveries (OR 0.32 [95% CI 0.29-0.61]). In multiparous women, although the incidence of OASI was lower when a ventouse or forceps delivery was performed with an MLE/LE, this was not statistically significant. Heterogeneity remained significant across all studies (I2 > 50). The quality of all evidence was downgraded to "very low" because of the critical risk of bias across many studies. CONCLUSIONS: MLE/LE may reduce the incidence of OASI in OVDs, particularly in nulliparous ventouse or forceps deliveries. This information will be useful in aiding clinical decision-making and counselling in the antenatal period and during labour.

Can transperineal ultrasound improve the diagnosis of obstetric anal sphincter injuries?

INTRODUCTION AND HYPOTHESIS: Women with missed obstetric anal sphincter injuries (OASIs) are at an increased risk of anal incontinence. Our aim was to assess the accuracy of three-dimensional (3D) transperineal ultrasound (TPUS) compared with clinical examination for detecting OASIs. METHODS: A cross-sectional study of women undergoing their first vaginal delivery. Perineal trauma was initially assessed by the doctor or midwife performing the delivery (accoucheur) and women were then re-examined by the trained research fellow (KW). A 3D TPUS was performed immediately after delivery before suturing to identify OASIs. The research fellow's clinical diagnosis was used as the reference standard. A power calculation determined that 216 women would be required for the study. RESULTS: Two hundred and sixty-four women participated and 226 (86%) delivered vaginally. Twenty-one (9%) sustained OASIs. Six (29%) of these tears were missed by the accoucheur but were identified by the research fellow. TPUS identified 19 of the 21 (90.5%) OASIs. One percent (n = 2) had sonographic appearances of an anal sphincter defect that was not seen clinically. The positive and negative predictive value of TPUS to detect OASIs was 91% and 99% respectively. TPUS identified 91% of OASIs compared with 71% detected by the accoucheur, which was not statistically significant. CONCLUSIONS: The detection rate of OASIs with TPUS and with the clinical findings of the accoucheur was similar. Given the training and financial implications needed for TPUS, attention needs to be focused on the training of midwives and doctors to identify anal sphincter injuries by clinical examination.

Risk of reoperation 10 years after surgical treatment for stress urinary incontinence: a national population-based cohort study.

BACKGROUND: There is a debate about the safety and effectiveness of surgical treatments for stress urinary incontinence. Controversy about the use of synthetic mesh sling insertion has led to an increased uptake of retropubic colposuspension and autologous sling procedures. Comparative evidence on the long-term outcomes from these procedures is needed. OBJECTIVE: To compare the risk of reoperation at 10 years after operation between women treated for stress urinary incontinence with retropubic colposuspension, mesh sling insertion, and autologous sling procedures. STUDY DESIGN: The records of admissions to National Health Service hosptials were used to identify women who had first-time stress incontinence surgery between 2006 and 2013 in England. The first incidence of the following outcomes was assessed: further stress incontinence surgery, surgery for a complication (either mesh removal, prolapse repair, or incisional hernia repair), and any reoperation (either further stress incontinence surgery, mesh removal, prolapse repair, or incisional hernia repair). The cumulative incidence of each of these outcomes up to 10 years after surgery was calculated, considering death as a competing event. Multivariable modeling was then used to estimate the reoperation hazard ratios for the different initial surgery types with adjustments for patient characteristics and concurrent prolapse surgery or hysterectomy. RESULTS: The analysis included 2262 women treated with retropubic colposuspension, 92,524 treated with mesh sling insertion, and 1234 treated with autologous sling. The cumulative incidence of any first reoperation at 10 years was 21.3% (95% confidence interval, 19.5-23.0) after retropubic colposuspension, 10.9% (10.7-11.1) after mesh sling insertion, and 12.0% (10.2-13.9) after autologous sling procedures. The women who had a retropubic colposuspension were significantly more likely to have a reoperation than women who had an autologous sling (adjusted hazard ratio for any reoperation: 1.79 [1.47-2.17]; for further stress incontinence surgery: 1.64 [1.19-2.26]; for surgery for complications: 1.89 [1.49-2.40]), whereas the women who had mesh slings had a similar hazard (for any reoperation: 0.90 [0.76-1.07]; for further stress incontinence surgery: 0.75 [0.57-0.99]; for surgery for complications: 1.11 [0.89-1.36]). A sensitivity analysis excluding the women who had concurrent prolapse surgery or hysterectomy produced similar results. CONCLUSION: Retropubic colposuspension is associated with higher risk of reoperation at 10 years after surgery than mesh sling insertion or autologous sling procedures, with 1 in 5 women requiring reoperation.

Early secondary repair of obstetric anal sphincter injuries (OASIs): experience and a review of the literature.

INTRODUCTION AND HYPOTHESIS: Secondary anal sphincter repair for a dehisced obstetric anal sphincter injury (OASI) is required following 2.6% of primary repairs. There is growing evidence that instead of delaying repair for 3-6 months, early secondary repair of the anal sphincter can be completed within 14 days. Our aims were to review the literature and to describe experiences in our unit. METHODS: This is a narrative review of all published cases reporting outcomes of early secondary repair of dehisced OASIs. In addition, we report a series from Croydon University Hospital (CUH) between 2010 and 2019. RESULTS: Ninety patients from five studies were identified on literature search. Six patients from CUH were included in the case series. Overall, the most common complications following secondary repair included skin dehiscence [10.3% (n = 10)], infection [5.2% (n = 5)] and fistula formation [8.2% (n = 8)]. In our case series, following secondary repair, normal manometric incremental squeeze pressure was found in five women (83%). Also, on endoanal ultrasound, internal anal sphincter (IAS) defects were found in 75% with a history of IAS injury (n = 4). There were no full-thickness external anal sphincter defects. Compared to those requiring primary repair alone, residual defects were significantly larger in those who also underwent secondary repair (Starck score 2.1 vs. 5.7, p = 0.01). CONCLUSION: Early secondary repair is a feasible surgical procedure for the reconstruction of dehisced OASIs. This case series and review of the literature can be used to support clinicians in the management of primary OASI repair dehiscence.

Isolated rectal buttonhole tears in obstetrics: case series and review of the literature.

INTRODUCTION AND HYPOTHESIS: The management of isolated rectal buttonhole tears is not standardised and can be challenging in an acute obstetric setting. Our aim was to review the published literature and describe management and repair techniques in a case series. METHODS: A literature search was carried out. All results were screened and reviewed. Rectal buttonhole tears following vaginal delivery between April 2012 and January 2020 in our institution were identified. Repair technique and post-operative management were recorded. RESULTS: There were nine published case reports (four instrumental deliveries, two vaginal breech and three normal vaginal deliveries). Four case reports described a two-layer closure and five described a three-layer closure. Two cases were repaired in collaboration with colorectal surgeons. All nine cases made an uneventful recovery. We identified three patients with buttonhole tears all of whom had instrumental deliveries. A colorectal surgeon repaired the tear in two layers in one case, and an obstetrician performed the repair in the other two cases, one in three layers and the other in two layers. One patient had a de-functioning stoma at a later date due to a second breakdown of the recto-vaginal fistula repair. CONCLUSION: Buttonhole tears are rare but techniques of repair vary. Most cases reviewed had an uneventful recovery after repair. We provide standardised steps for repair and management of isolated rectal buttonhole tears along with a video demonstrating the repair technique in an animal tissue (pig) model.

Effect of a subsequent pregnancy on anal sphincter integrity and function after obstetric anal sphincter injury (OASI).

INTRODUCTION AND HYPOTHESIS: Endoanal ultrasound (EAUS) and anal manometry are used in the assessment women with a history of obstetric anal sphincter injury (OASI), both postpartum and in a subsequent pregnancy, to aid counselling regarding mode of delivery (MOD). METHODS: A prospective observational study between 2012 to 2020 was completed. Women were reviewed 3 months postpartum following OASI and in the second half of a subsequent pregnancy. Anorectal symptoms were measured using the validated St Mark's Incontinence Score (SMIS: asymptomatic to mild symptoms = ≤ 4). Anal manometry (incremental maximum squeeze pressure [iMSP: normal = > 20 mmHg]) and EAUS (abnormal = sphincter defect > 1 h in size) were performed. RESULTS: One hundred forty-six women were identified and 67.8% had an anal sphincter defect ≤ 1 h in size postnatally. In those with a defect ≤ 1 h, postpartum mean iMSP and SMIS significantly improved in a subsequent pregnancy (p = 0.04 and p = 0.01, respectively). In women with a defect > 1 h, there was no significant difference between the mean iMSP or SMIS score postnatally compared to a subsequent pregnancy. At both time points, significantly more women had an anal sphincter defect ≤ 1 h and SMIS of ≤ 4 (p = 0.001 and p < 0.001 respectively) compared to those with a defect < 1 h. In addition, significantly more women had an anal sphincter defect ≤ 1 h and iMSP ≥ 20 mmHg (p < 0.001). Overall, out of the 146 women included in this study, 76 (52.1%) with a defect ≤ 1 h also had an iMSP ≥ 20 mmHg and SMIS ≤ 4 at 3 months postpartum. CONCLUSIONS: Women who remain asymptomatic with normal anal manometry and no abnormal sphincter defects on EAUS postnatally do not need to have these investigations repeated in a subsequent pregnancy and can be recommended to have a vaginal delivery. If our protocol was modified, over half of the women in this study could have had their MOD recommendation made in the postnatal period alone.

A meta-synthesis of qualitative literature on female chronic pelvic pain for the development of a core outcome set: a systematic review.

INTRODUCTION AND HYPOTHESIS: Qualitative research has an increasing role in the development of core outcome sets (COS) adding patient perspectives to the considerations of core outcomes. We aimed to identify priorities of women with experience of chronic pelvic pain (CPP). METHODS: The search strategy was a systematic review of qualitative studies identified from Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, EMBASE, MEDLINE and PsycInfo databases. Selection criteria were qualitative studies exploring the experience of women with CPP. Two independent researchers extracted data and summarized findings using thematic analysis. A CERQual assessment was performed to assess the confidence of review findings. RESULTS: We identified pertinent issues affecting women with CPP including the lack of holistic care, influence of psychosocial factors and the impact of pain on quality of life. Five meta-themes central to delivering a patient-centred approach were highlighted: acceptance of pain, quality of life, management of CPP, communication and support. Management of CPP was the most commonly reported meta-theme across seven studies and half of studies reported quality of life, management, communication and support. Quality appraisal of included studies identified only a single study that met all CASP (Critical Appraisal Skills Programme) criteria. There was high confidence in the evidence for acceptance of pain, quality of life and communication meta-themes. CONCLUSION: Meta-themes revealed by this review should be considered as a priority and reflected in outcomes reported by future studies evaluating interventions for CPP. In addition, these themes should be considered by clinicians managing women with CPP.

Imaging modalities for the detection of posterior pelvic floor disorders in women with obstructed defaecation syndrome.

BACKGROUND: Obstructed defaecation syndrome (ODS) is difficulty in evacuating stools, requiring straining efforts at defaecation, having the sensation of incomplete evacuation, or the need to manually assist defaecation. This is due to a physical blockage of the faecal stream during defaecation attempts, caused by rectocele, enterocele, intussusception, anismus or pelvic floor descent. Evacuation proctography (EP) is the most common imaging technique for diagnosis of posterior pelvic floor disorders. It has been regarded as the reference standard because of extensive experience, although it has been proven not to have perfect accuracy. Moreover, EP is invasive, embarrassing and uses ionising radiation. Alternative imaging techniques addressing these issues have been developed and assessed for their accuracy. Because of varying results, leading to a lack of consensus, a systematic review and meta-analysis of the literature are required. OBJECTIVES: To determine the diagnostic test accuracy of EP, dynamic magnetic resonance imaging (MRI) and pelvic floor ultrasound for the detection of posterior pelvic floor disorders in women with ODS, using latent class analysis in the absence of a reference standard, and to assess whether MRI or ultrasound could replace EP. The secondary objective was to investigate differences in diagnostic test accuracy in relation to the use of rectal contrast, evacuation phase, patient position and cut-off values, which could influence test outcome. SEARCH METHODS: We ran an electronic search on 18 December 2019 in the Cochrane Library, MEDLINE, Embase, SCI, CINAHL and CPCI. Reference list, Google scholar. We also searched WHO ICTRP and clinicaltrials.gov for eligible articles. Two review authors conducted title and abstract screening and full-text assessment, resolving disagreements with a third review author. SELECTION CRITERIA: Diagnostic test accuracy and cohort studies were eligible for inclusion if they evaluated the test accuracy of EP, and MRI or pelvic floor ultrasound, or both, for the detection of posterior pelvic floor disorders in women with ODS. We excluded case-control studies. If studies partially met the inclusion criteria, we contacted the authors for additional information. DATA COLLECTION AND ANALYSIS: Two review authors performed data extraction, including study characteristics, 'Risk-of-bias' assessment, sources of heterogeneity and test accuracy results. We excluded studies if test accuracy data could not be retrieved despite all efforts. We performed meta-analysis using Bayesian hierarchical latent class analysis. For the index test to qualify as a replacement test for EP, both sensitivity and specificity should be similar or higher than the historic reference standard (EP), and for a triage test either specificity or sensitivity should be similar or higher. We conducted heterogeneity analysis assessing the effect of different test conditions on test accuracy. We ran sensitivity analyses by excluding studies with high risk of bias, with concerns about applicability, or those published before 2010. We assessed the overall quality of evidence (QoE) according to GRADE. MAIN RESULTS: Thirty-nine studies covering 2483 participants were included into the meta-analyses. We produced pooled estimates of sensitivity and specificity for all index tests for each target condition. Findings of the sensitivity analyses were consistent with the main analysis. Sensitivity of EP for diagnosis of rectocele was 98% (credible interval (CrI)94%-99%), enterocele 91%(CrI 83%-97%), intussusception 89%(CrI 79%-96%) and pelvic floor descent 98%(CrI 93%-100%); specificity for enterocele was 96%(CrI 93%-99%), intussusception 92%(CrI 86%-97%) and anismus 97%(CrI 94%-99%), all with high QoE. Moderate to low QoE showed a sensitivity for anismus of 80%(CrI 63%-94%), and specificity for rectocele of 78%(CrI 63%-90%) and pelvic floor descent 83%(CrI 59%-96%). Specificity of MRI for diagnosis of rectocele was 90% (CrI 79%-97%), enterocele 99% (CrI 96%-100%) and intussusception 97% (CrI 88%-100%), meeting the criteria for a triage test with high QoE. MRI did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of MRI performed with evacuation phase was higher than without for rectocele (94%, CrI 87%-98%) versus 65%, CrI 52% to 89%, and enterocele (87%, CrI 74%-95% versus 62%, CrI 51%-88%), and sensitivity of MRI without evacuation phase was significantly lower than EP. Specificity of transperineal ultrasound (TPUS) for diagnosis of rectocele was 89% (CrI 81%-96%), enterocele 98% (CrI 95%-100%) and intussusception 96% (CrI 91%-99%); sensitivity for anismus was 92% (CrI 72%-98%), meeting the criteria for a triage test with high QoE. TPUS did not meet the criteria to replace EP. Heterogeneity analysis showed that sensitivity of TPUS performed with rectal contrast was not significantly higher than without for rectocele(92%, CrI 69%-99% versus 81%, CrI 58%-95%), enterocele (90%, CrI 71%-99% versus 67%, CrI 51%-90%) and intussusception (90%, CrI 69%-98% versus 61%, CrI 51%-86%), and was lower than EP. Specificity of endovaginal ultrasound (EVUS) for diagnosis of rectocele was 76% (CrI 54%-93%), enterocele 97% (CrI 80%-99%) and intussusception 93% (CrI 72%-99%); sensitivity for anismus was 84% (CrI 59%-96%), meeting the criteria for a triage test with very low to moderate QoE. EVUS did not meet the criteria to replace EP. Specificity of dynamic anal endosonography (DAE) for diagnosis of rectocele was 88% (CrI 62%-99%), enterocele 97% (CrI 75%-100%) and intussusception 93% (CrI 65%-99%), meeting the criteria for a triage test with very low to moderate QoE. DAE did not meet the criteria to replace EP. Echodefaecography (EDF) had a sensitivity of 89% (CrI 65%-98%) and specificity of 92% (CrI 72%-99%) for intussusception, meeting the criteria to replace EP but with very low QoE. Specificity of EDF for diagnosis of rectocele was 89% (CrI 60%-99%) and for enterocele 97% (CrI 87%-100%); sensitivity for anismus was 87% (CrI 72%-96%), meeting the criteria for a triage test with low to very low QoE. AUTHORS' CONCLUSIONS: In a population of women with symptoms of ODS, none of the imaging techniques met the criteria to replace EP. MRI and TPUS met the criteria of a triage test, as a positive test confirms diagnosis of rectocele, enterocele and intussusception, and a negative test rules out diagnosis of anismus. An evacuation phase increased sensitivity of MRI. Rectal contrast did not increase sensitivity of TPUS. QoE of EVUS, DAE and EDF was too low to draw conclusions. More well-designed studies are required to define their role in the diagnostic pathway of ODS.

Women's experiences of the OASI Care Bundle; a package of care to reduce severe perineal trauma.

INTRODUCTION AND HYPOTHESIS: Obstetric anal sphincter injury (OASI) is a severe form of perineal trauma that can occur during vaginal birth. Long-term morbidities include anal incontinence and psychosocial disorders. To reduce these injuries within England, Scotland and Wales, the OASI Care Bundle was introduced to 16 maternity units (January 2017-March 2018). The OASI Care Bundle comprises four elements: (1) antenatal information, (2) manual perineal protection, (3) medio-lateral episiotomy (when indicated) and 4) recognition and diagnosis of tears. As part of the project evaluation, a qualitative study was conducted to explore women's experiences of the OASI Care Bundle. METHODS: Semi-structured interviews were conducted with women (n = 19) who received the OASI Care Bundle as part of their maternity care. This was to explore their experience of each element. A thematic analysis of the interview data was performed. RESULTS: Three themes were identified: (1) memories of touch, whereby women reported that a 'hands-on' approach to perineal protection was a positive experience; (2) midwife as a supportive guide, where women reported that good communication facilitated a calm birth and post-birth diagnosis; (3) education: women need more information about perineal trauma. CONCLUSION: This study contributes to the literature through its exploration of women's experiences of perineal protection techniques and diagnosis of perineal trauma. Interviewed women indicated that they did not experience any of the care bundle elements as an intrusion of their physical integrity. Additionally, an urgent need was identified for more information about perineal trauma in terms of risk, prevention and recovery.

The OASI care bundle quality improvement project: lessons learned and future direction.

Rising rates of obstetric anal sphincter injury (OASI) led to a collaborative effort by the Royal College of Obstetricians and Gynaecologists (RCOG) and the Royal College of Midwives (RCM) to develop and evaluate the OASI Care Bundle (OASI-CB). The OASI-CB comprises four practices (antenatal discussion about OASI, manual perineal protection, mediolateral episiotomy at 60° from the midline, and systematic examination of the perineum, vagina and ano-rectum after vaginal birth) and was initially implemented as part of a quality improvement (QI) project-"OASI1"-in 16 maternity units across Great Britain. Evaluation of the OASI1 project found that the care bundle reduced OASI rates and identified several barriers and enablers to implementation. This paper summarises the key findings, including strengths, limitations and lessons learned from the OASI1 QI project, and provides rationale for further evaluation of the OASI-CB.

The Use of Copper as an Antimicrobial Agent in Health Care, Including Obstetrics and Gynecology.

Health care-associated infections (HAIs) are a global problem associated with significant morbidity and mortality. Controlling the spread of antimicrobial-resistant bacteria is a major public health challenge, and antimicrobial resistance has become one of the most important global problems in current times. The antimicrobial effect of copper has been known for centuries, and ongoing research is being conducted on the use of copper-coated hard and soft surfaces for reduction of microbial contamination and, subsequently, reduction of HAIs. This review provides an overview of the historical and current evidence of the antimicrobial and wound-healing properties of copper and explores its possible utility in obstetrics and gynecology.