Myra Fitzpatrick

Influence of persistent occiput posterior position on delivery outcome

OBJECTIVE To evaluate the influence of intrapartum persistent occiput posterior position of the fetal head on delivery outcome and anal sphincter injury, with reference to the association with epidural analgesia. METHODS We conducted a prospective observational study of 246 women with persistent occiput posterior position in labor during a 2‐year period, compared with 13,543 contemporaneous vaginal deliveries with occiput anterior position. RESULTS The incidence of persistent occiput posterior position was significantly greater among primiparas (2.4%) than multiparas (1.3%; P < .001; 95% confidence interval 1.4, 2.4) and was associated with significantly higher incidences of prolonged pregnancy, induction of labor, oxytocin augmentation of labor, epidural use, and prolonged labor. Only 29% of primiparas and 55% of multiparas with persistent occiput posterior position achieved spontaneous vaginal delivery, and the malposition was associated with 12% of all cesarean deliveries performed because of dystocia. Persistent occiput posterior position was also associated with a sevenfold higher incidence of anal sphincter disruption. Despite a high overall incidence of use of epidural analgesia (47% versus 3%), the institutional incidence of persistent occiput posterior position was lower than that reported 25 years ago. CONCLUSION Persistent occiput posterior position contributed disproportionately to cesarean and instrumental delivery, with fewer than half of the occiput posterior labors ending in spontaneous delivery and the position accounting for 12% of all cesarean deliveries for dystocia. Persistent occiput posterior position leads to a sevenfold increase in the incidence of anal sphincter injury. Use of epidural analgesia was not related to the malposition.

Randomised clinical trial to assess anal sphincter function following forceps or vacuum assisted vaginal delivery

Objective To compare, in a prospective, randomised controlled trial, differences in anal sphincter function following forceps or vacuum assisted vaginal delivery in an institution practising standardised management of labour.

A randomised clinical trial comparing the effects of delayed versus immediate pushing with epidural analgesia on mode of delivery and faecal continence

Objective To assess the effects of delayed vs immediate pushing in second stage of labour with epidural analgesia on delivery outcome, postpartum faecal continence and postpartum anal sphincter and pudendal nerve function.

Prospective study of the influence of parity and operative technique on the outcome of primary anal sphincter repair following obstetrical injury.

OBJECTIVE To determine the influence of parity and method of primary anal sphincter repair on outcome following obstetrical third degree perineal tear. STUDY DESIGN Prospective study of 154 women after primary repair following third degree tear conducted over 2 years. Postpartum evaluation included a continence questionnaire, anal manometry and endoanal ultrasound. RESULTS Third degree tears occurred in 1.6% primiparae and 0.6% multiparae during the study period; in 42/112 (38%) primiparae and 10/42 (24%) multiparae, these tears occurred at instrumental deliveries. Mean birthweight (3.8+/-0. 43 kg) was similar in both groups, but prolonged latent second stage of labour (P=0.003), use of epidural analgesia (P<0.0001) and episiotomy extension (P1 quadrant) anal sphincter defect. CONCLUSION Outcome of anal sphincter repair was not influenced by parity or mode of repair. Despite good symptomatic outcomes, ultrasound evidence of significant anal sphincter injury was found in one-third of patients.

Patterns of abnormal pudendal nerve function that are associated with postpartum fecal incontinence

OBJECTIVE The purpose of this study was to assess patterns of abnormal pudendal nerve function in women who complain of postpartum fecal incontinence. STUDY DESIGN During a 12-month period, a cohort of 83 women underwent neurophysiologic assessment as part of an evaluation of fecal incontinence after vaginal delivery. Pudendal nerve assessment consisted of the measurement of the clitoral-anal reflex and quantitative electromyography of the external anal sphincter. Endoanal ultrasound examination and anal manometry were also performed in each patient. RESULTS Thirty of 83 women (38%) with fecal incontinence were found to have abnormal neurophysiologic condition, among whom four identifiable patterns of abnormality emerged. Five women (17%) had evidence of pudendal nerve demylenation with a prolonged sensory threshold of the clitoral-anal reflex (>5.2 mA), although electromyography studies were normal. Eight women (27%) had abnormal electromyography results that were consistent with axonal neuropathy with or without reinervation, in whom the clitoral-anal reflex was normal. Thirteen women (43%) demonstrated a mixed demyelinating and axonal pudendal neuropathy, with evidence of reinervation. Four women (13%) had abnormal patterns of neurophysiologic condition that was not attributable directly to past obstetric trauma but to coincident medical problems. CONCLUSION Four abnormal patterns of pudendal nerve function may be identified, three of which (demyelinating, axonal, and mixed demyelinating/axonal) can be attributed to specific past obstetric events, although a fourth radicular pattern is due to coincident medical or orthopedic problems. Assessment of pudendal nerve function is important in women with postpartum fecal incontinence because particular patterns of abnormality correlate with different symptoms and can influence treatment options.

Experience with an obstetric perineal clinic

OBJECTIVE To review the characteristics of patients attending a dedicated perineal clinic in a maternity hospital. METHODS Case-note review of all new referrals over 2 years 1998 and 1999. RESULTS A total of 399 women were referred with mean age of 34 years (range 18-77), parity of 1.7 (range 1-13) and duration of symptoms of 14 (range 1-156) months. A total of 213 (53%) women were assessed following a recognized third degree perineal tear, 78 (20%) because of fecal incontinence, 45 (11%) for determination of future mode of delivery following a previous perineal injury, 37 (9%) women for treatment of perineal pain and 26 (7%) for other miscellaneous complaints. A total of 83 (21%) required physiotherapy, 42 (11%) received dietetic manipulation, 29 (7%) were treated for perineal pain and 12 (3%) underwent vaginal surgery. A total of 24 (6%) women were referred for consideration of secondary anal sphincter repair and 11 (3%) for specialist gastroenterological investigation. CONCLUSIONS The perineal clinic provides a valuable resource for investigation and treatment of postpartum perineal injury.

Levator ani injury in primiparous women with forceps delivery for fetal distress, forceps for second stage arrest, and spontaneous delivery

To compare levator ani muscle injury rates in primiparous women who had a forceps delivery owing to fetal distress with women delivered by forceps for second stage arrest; and to compare these injury rates with a historical control group of women who delivered spontaneously.

Short-term and long-term effects of obstetric anal sphincter injury and their management.

Purpose of review During the past decade increasing attention has focused on the problem of obstetric anal sphincter damage. Although risk factors are now well known, the effects of such damage have received less study. This review focuses on the early and long-term problems that may arise subsequent to anal sphincter injury following childbirth and assesses therapeutic options. Recent findings Up to 25% of women experience altered faecal continence after vaginal delivery, with 4% having persistent symptoms. In those women who have sustained a recognized tear to the sphincter, the quality of primary repair is crucial. Nevertheless, evidence clearly supporting the superiority of overlap over approximation repair is still lacking. The importance of pudendal nerve damage in the aetiology of postpartum faecal incontinence is gaining increasing attention. Augmented biofeedback physiotherapy is the gold standard for treatment of women with such injury, whereas sacral nerve stimulation represents a newer treatment option. Summary The short-term and long-term effects of obstetric anal sphincter injury warrant increased attention, because with increasing longevity more women are surviving into their 80s and the prevalence of faecal incontinence in this population will increase if measures are not taken to address the problem. Prevention of such injury is not always possible and management options must be further explored. Adequate primary treatment of third-degree tears is of paramount importance.

Randomised controlled trial comparing early home biofeedback physiotherapy with pelvic floor exercises for the treatment of third‐degree tears (EBAPT Trial)

To compare early home biofeedback physiotherapy with pelvic floor exercises (PFEs) for the initial management of women sustaining a primary third‐degree tear.

Does anal sphincter injury preclude subsequent vaginal delivery

OBJECTIVE To assess continence and anal sphincter integrity during a subsequent pregnancy and delivery in women known to have a previous anal sphincter injury. DESIGN Prospective observational study. SETTING The National Maternity Hospital, Dublin, Ireland. POPULATION Antenatal patients with a documented obstetric anal sphincter injury at a previous delivery. METHODS Women underwent symptom scoring, endoanal ultrasound and manometry. MAIN OUTCOME MEASURES Recommended and actual mode of delivery, continence scores and endoanal ultrasound findings after index delivery. RESULTS 557 women were studied. 293 (53%) had no symptoms of faecal incontinence, 189 (34%) had mild symptoms and 75 (13%) moderate or severe symptoms. 408 (73%) had an endoanal ultrasound. 383(94%) had a normal or small (<1 quadrant) defect in the internal anal sphincter and 390 (96%) had a scar or small (<1e quadrant) defect in the external anal sphincter. 393 (70%) delivered vaginally. 164 (30%) were delivered by caesarean section. 197/557 (35%) returned for follow-up. There was no significant change in continence following either vaginal or caesarean delivery. 20 (5.1%) women had a recognised second anal sphincter tear during vaginal delivery. CONCLUSIONS The majority of women who sustain a third degree tear have minimal or no symptoms of faecal incontinence when assessed antenatally in a subsequent pregnancy. 70% go on to have a vaginal delivery, with little impact on faecal continence. These findings provide reassurance for patients and clinicians about the safety of vaginal delivery following anal sphincter injury in appropriately selected patients.