1. Third- and fourth-degree tears involve damage to the anal sphincter complex during childbirth and can cause symptoms of faecal incontinence. 2. Risk factors for these tears include instrumental vaginal delivery, prolonged second stage of labor, episiotomy, and prior history of anal sphincter tear. The repairs require identification of the full extent of damage and careful suturing to reapproximate the torn tissues. 3. Follow up is important to assess for symptoms and potential need for further treatment like physiotherapy or surgery. Counseling discusses risks of subsequent deliveries and aims to minimize further trauma for women with a history of anal sphincter tear.

1. Third- and fourth-
degree tears
RCOG GUIDELINES
Prof Aboubakr Elnashar
Benha university Hospital, Egypt
ABOUBAKR ELNASHAR

2. 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

3. 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.
ABOUBAKR ELNASHAR

4. 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.
ABOUBAKR ELNASHAR

5. Faecal urgency:
{occult anal sphincter damage}
44% five years following instrumental delivery of
their first baby.
ABOUBAKR ELNASHAR

6. 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.
ABOUBAKR ELNASHAR

7. 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.
ABOUBAKR ELNASHAR

8. 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.}
ABOUBAKR ELNASHAR

9. 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.
ABOUBAKR ELNASHAR

10. 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
ABOUBAKR ELNASHAR

11. 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.
ABOUBAKR ELNASHAR

12. 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

13. 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}.
ABOUBAKR ELNASHAR

14. 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.
ABOUBAKR ELNASHAR

15. 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.
ABOUBAKR ELNASHAR

16. 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.
ABOUBAKR ELNASHAR

17. 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.
ABOUBAKR ELNASHAR

18. 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.
ABOUBAKR ELNASHAR

19. 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.
ABOUBAKR ELNASHAR

20. 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.
ABOUBAKR ELNASHAR

21. 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.
ABOUBAKR ELNASHAR

22. 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
ABOUBAKR ELNASHAR

23. 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.
ABOUBAKR ELNASHAR

24. 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.
ABOUBAKR ELNASHAR

25. 4. Women with mild symptoms
avoid gas-producing foods and bulking agents,
constipating agents and biofeedback offered.
ABOUBAKR ELNASHAR

26. 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
ABOUBAKR ELNASHAR

27. 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.
ABOUBAKR ELNASHAR

28. 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.
ABOUBAKR ELNASHAR

29. 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.
ABOUBAKR ELNASHAR

30. 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

31. ABOUBAKR ELNASHAR