Royal Society of Medicine Forum: Are you sitting comfortably? Issues around perineal trauma.

This is a report of a meeting of the Forum on Maternity and the Newborn of the Royal Society of Medicine, held on Wednesday 5th June 2002. The meeting was chaired by Rona McCandlish, Professor of Midwifery, University of Southampton.

This report first appeared in the RCM Midwives Journal.

Describing perineal trauma.
Mrs. Katie Yiannouzis, Consultant Midwife with a special interest in labour, King’s College Hospital, London.

The development of an assessment tool (with Clare Gomme and Dr. Rosina Ullman).

Although 70% of women delivering vaginally sustain perineal trauma and there is strong anecdotal evidence of associated postnatal morbidity, there is limited research on the subject. During the 1990s there has been an increasing trend among midwives not to suture some second-degree tears which previously would have been repaired, and this, with the variable quality of repair techniques, has highlighted the need for a randomised prospective trial. This trend may be the result of increased midwife autonomy, poor staffing and pressure for throughput, insufficient midwife teachers, and the greater involvement of mothers themselves. The change in practice has evolved on the strength of limited evidence and midwives often disagree on what constitutes a tear which needs suturing.

The purpose of this study, undertaken in the year from May 2000, was to develop a tool to ensure a unified approach to the assessment of perineal trauma. Although not intended for the purpose, the tool could also be used to enhance the validity of an evaluation of suturing and non-suturing of second-degree trauma. However, there were threats to the validity of the research, including different suturing techniques and materials, and the difficulties of standardising tears by their size or complexity. The text book definitions of tears are crude; although there is good agreement on the definitions of first and third degree tears and their management, those of second degree tears vary greatly; they may be simple or complicated and multi-directional, perhaps depending on the length of the perineum and other anatomical variations. The issue has been made sharper by the practice of leaving some trauma unsutured; when all tears are sutured assessment is not an issue. Labial tearing will be included in future developments of the tool.

As this was a concern arising directly out of practice, a collaborative research design was used. The development of a tool was funded by King’s College London when £35,000 was won in competitive bidding; a job share employed two researchers for over a year. Ethical approval was gained from two inner London NHS trusts. The aims of the study were to investigate assessment criteria and to develop a tool using these criteria. The first of the three phases of the project involved taking a range of photographs of perineal trauma, prior to repair. Women were informed about the study in the antenatal period, and 40 of the 108 women approached (by 59 visits to the antenatal ward over a 4 month period) consented to take part, although eventually only nine sets of photographs were obtained. English speaking women were recruited; they were required to have healthy babies and no immediate postnatal problems, but these mothers were of course the least likely to deliver vaginally, and those excluded had not delivered vaginally, or sustained no tears, or delivered in the absence of a researcher.

In the second phase the photographs obtained were used in focus group discussions with midwives to promote discussion of the criteria they used for assessing perineal trauma. Attendance was encouraged by varying the days, locations, and times; nine hospital midwives made up four groups, and 31 community midwives formed three groups. The discussions were transcribed from tape recordings. Finally the data so derived were used to develop the perineal assessment tool by identification of key issues using the words of the midwives’ own descriptions.

The tool was then introduced into practice and assessed for reliability. In a pilot study, the tool was tested, both by the attending midwife and by a researcher, on a convenience sample of 52 women with perineal trauma. Although the results of the pilot study are encouraging, with high levels of agreements between the two assessors, statistical analysis (using Cohen's Kappa ) indicates that the tool had not been tested across the full range of perineal trauma as most of the tears assessed were moderate. The overall agreement between observers was 43% by this analysis, judged to be fair, but looking at bleeding, the distance of tearing into the vagina, muscle involvement, and simplicity versus complexity, inter-rater agreement varied from 68% to 96% and was judged to be only fair or low; assessment of the distance of tears from the anus (more or less than one centimetre, or reaching the anal margin) was judged good at 88% agreement , but the assessment of the alignment of tears (correct apposition versus gaping or incorrectly aligned) achieved no agreement. The narrow range of scores indicated a lack of rigour in testing, and further investigation is needed using a significant sample of women with both minimal and extensive trauma.

Correspondence to Katie Yiannouzis, King's College Hospital, Denmark Hill, London SES 9RS tel. 020 7346 1517 Email Enquiries - CLICK HERE


Materials and methods for perineal repair.
Christine Kettle, Research Fellow, Department of Obstetrics, North Staffordshire Hospital.

Morbidity associated with perineal injury related to childbirth constitutes a major health problem worldwide. In the United Kingdom alone 350,000 women require suturing annually, and 20% have long term problems. There is wide variation in practice in both suture methods and materials used for perineal repair. Systematic reviews suggest that a continuous subcutaneous repair method for perineal skin closure may be associated with better outcomes, but midwives are usually taught to suture using the interrupted transcutaneous method, deemed to be an easier technique to learn. Reviews also show that synthetic absorbable materials are associated with a reduction in perineal pain when compared to traditional catgut, but concerns remain regarding the increased need to have sutures of this material removed postpartum. The Methods or Materials Study (MOMS) reported here was planned to build on previous research, evaluating the short and long term effects of two different suturing techniques by a randomised controlled trial (RCT), and a double blind trial of suture materials used for perineal repair following childbirth using a 2X2 factorial design.

An approach to the achievement of quality care, with the objectives of reducing perineal discomfort and associated complications was addressed under various headings.

Questioning practice.
Is our practice based on tradition, personal preference, or reliable evidence? Are we using the best materials and methods? Is training in the management up to date? Do we have a systematic approach to aftercare? Is the care appropriate, effective, and cost efficient? Are women satisfied with the service?

Applying the evidence.
This requires a systematic review of the literature, with attention paid to the levels of evidence. There are two relevant Cochrane reviews1,2.
Local guidelines on perineal repair and episiotomy; reports recommending a change from the use of catgut to synthetic absorbable sutures; Fleming’s 19903 description of the continuous method; and the development of a more rapidly absorbed synthetic material – from standard Vicryl to Vicryl Rapide.

Audit.
76 midwives took part in 1995. The responses were: 84% had not received formal training; 93% agreed that they needed more training; 38% did not feel confident to perform perineal repair unless supervised. 71% had received supervision on the basis See one, do two, now you’re on your own, and 20% of doctors and 48% of midwives considered that their training in perineal repair had been adequate.
The plan thereafter was to introduce a training programme prior to undertaking research, and to repeat the audit to assess benefit. Only midwives entered the subsequent study as their technique had become standardised by the speaker’s input.

Methods.
The null hypothesis was: The suturing techniques and materials used for perineal repair following spontaneous vaginal delivery have no effect on the amount of pain and superficial dyspareunia experienced by women in the short or long-term postpartum period.
The interventions employed were either interrupted or continuous suture, and either Vicryl or Vicryl Rapide 2/0 suturing material; this requires training in the use of square surgeon’s knots. The main outcome measures were pain at ten days and superficial dyspareunia at three months postpartum. The sample was 1,542 women requiring suture of a second degree perineal tear or episiotomy by a midwife following spontaneous vaginal birth. Data collection was by questionnaires at two and ten days postpartum, three months and one year. The response rate to these was excellent. (The continuous method of repair was described and illustrated).

Findings.
There was a significant reduction in pain associated with the continuous suture method (p<0.0001), and a non-significant reduction in pain associated with the use of Vicryl Rapide. Neither method nor material improved later superficial dyspareunia. There was significantly less need for the removal of suture material at three months with the continuous method and when Vicryl Rapide was used 3.

Interpretation.
The continuous method prevents one woman in six from suffering early postpartum pain; its worldwide use would reduce such pain for millions of women.

Re-audit.
In 1999 of 79 midwives 6% had not received formal training (compared with 84% in 1995); 54% requested further training (93%); 18% did not feel confident undertaking perineal repair unsupervised (38%); 54% were supervised for more than four repairs before being left unsupervised. The conclusion is that there is now more supervision and more satisfaction with training, which needs to be ongoing and available for all levels of staff.

Training and development.
The education and training of all involved professionals is systematic and multidisciplinary, with a rolling program of workshops, a study day, and a training video; support is continuous and supervision is logged, and a formal perineal repair record has become an accepted part of the intrapartum notes.

MOMS has improved performance through learning from adverse incidents and by the application of the foregoing principles. Feedback on performance is both positive and negative; it is understood that learning and the maintenance of skills are lifelong processes. The training programme should involve all levels of staff, and must include awareness and increased recognition of third and fourth degree tears, with training for registrars in their repair. The subject deserves national guidelines to reduce harm and litigation, with sensitive treatment, prompt reporting of untoward incidents, the development of a blame-free culture, rapid handling of complaints, and support for women, who might themselves be involved in the development of the service. It is clear that audit should be repeated continuously.

Advances in care such as these could well be broadcast widely and the principles applied throughout health care.

References.

         1. Kettle C, Johanson RB. Absorbable synthetic versus catgut suture material for perineal repair (Cochrane Review). In Cochrane Library, Issue 1. Oxford: Update Software; 2002. Updated quarterly.

2. Kettle C, Johanson RB. Continuous versus interrupted sutures for perineal repair. In Cochrane Library, Issue 1. Oxford: Update Software; 2002. Updated quarterly.

3. Fleming N. Can the Suturing Method make a Difference in Postpartum Perineal Pain? Journal of Nurse-Midwifery 1990; 35(1): 19-25

Have I missed a third degree tear? The identification, treatment and follow-up of women who experience perineal trauma.
Mr. Abdul Sultan, Consultant Obstetrician and Gynaecologist, Mayday University Hospital, Croydon.

This presentation highlights large areas of ignorance and differences of opinion among consultants concerning obstetric anal sphincter injury (OASI), its identification and management.

Midwives outperform doctors in episiotomy and in repair of both episiotomy and tears. Only 31% of doctors were fully aware of the muscles cut at uncomplicated mediolateral episiotomy. This, the commonest operation in obstetrics, is too often performed by the untrained and is of doubtful benefit; additional tearing is not infrequent. It is overdue for reappraisal. It is responsible for increased risk of haemorrhage, trauma to the posterior perineum including the anal sphincter, and associated postpartum pain. Woolley (1995b)2 concluded: "There is no evidence that episiotomy reduced the incidence of early postpartum urinary incontinence or that it moderates the normal loss of pelvic floor muscle strength usually experienced after vaginal delivery.

Prospective studies have revealed that up to 35% of primiparous women sustain trauma to the anal sphincters that are unrecognised at delivery3 It is unclear as to whether these sonographic anal sphincter defects represent missed tears or true "occult" defects. 13% had new symptoms related to defaecation, and 5% developed anal incontinence.

The degrees of perineal tearing have been defined hitherto as: first – vaginal epithelium; second – same, with involvement of perineal muscles; third – same, with anal sphincter torn. In the fourth degree tear anal epithelium also is involved. When groups of professionals (midwives, trainees, and consultants) are compared for their ability to classify and identify all forms of perineal trauma there are marked variations.

In Sultan et al. 19951 16% of doctors and 39% of midwives recognised third degree tears. Groom and Paterson-Brown4 conducted a study in which they demonstrated that the rate of third degree tears rose to 15% when all "2nd degree tears" were examined by a second person, confirming that at least some tears are missed. Of course if a third degree tear is incorrectly classified as second degree, then inappropriate repair is likely to result in sub-optimal outcome. This reflects inadequate training and was highlighted by Sultan et al1, who reported that 91% of doctors who had received at least 6 months of training in obstetrics and 60% of midwives indicated inadequate training in perineal anatomy; 84% and 61% respectively reported inadequate training in identifying 3rd degree tears. When an assessment of accuracy in diagnosing third degree tears was undertaken, twice the incidence was found than was claimed in a control group; with appropriate training there was an almost fourfold increase in the diagnosis over a six month period4.

Another possible reason for under-diagnosis, apart from inadequate training, is that tears of the anal sphincter have been wrongly classified, and therefore have been under-reported; texts published by the Royal College of Obstetricians and Gynaecologists (RCOG) have not escaped this charge. Sultan6 has therefore proposed the following classification, incorporated in the RCOG Green Top guidelines:

First degree: laceration of the vaginal epithelium or perineal skin only.

Second degree: involvement of the vaginal epithelium, perineal skin, perineal muscles and fascia but not the anal sphincter.

Third degree: disruption of the vaginal epithelium, perineal skin, perineal body and anal sphincter muscles. This should be further subdivided into:
3a: partial tear of the external sphincter involving less than 50% thickness.
3b: complete tear of the external sphincter.
3c: internal sphincter torn as well.

Fourth degree: a third degree tear with disruption of the anal epithelium.

The prevalence of anal incontinence following immediate repair of acute obstetric anal sphincter rupture ranges between 15 and 59%; a review of papers on the subject worldwide (years 1988 to 2000) showed an average incidence of 37%. The symptom has a major impact on a woman's quality of life, the incidence increasing with the degree of trauma, as was shown in a 14 year follow-up (de Leeuw et al. 2001). Even with recognition and 'primary' repair, the incidence of anal incontinence has been reported as over 50% and the actual incidence may be even higher The high prevalence may reflect sub-optimal surgical technique and post-operative management. It is time for a critical re-appraisal of these issues in order to minimise morbidity by standardising classification and the management of perineal tears.7

Management.
The Parks overlap technique for repair was illustrated, and compared with end-to-end repair. A modification of an overlapping technique for sphincter repair, described by Parks for the secondary repair of OASI, was first described by Sultan in 19996. The technique includes identifying the internal anal sphincter which, if torn, is repaired as a separate layer. Using this technique the authors found a significant reduction in anal incontinence (to 8%), which can be compared with 41%, seen in a previous study where the end-to-end technique was employed. There is only one published, prospective randomised study, comparing end-to-end and the overlap techniques. In this series of 112 primiparous women, no significant difference in continence was identified at 3 months' follow-up. The techniques used in this study were different to those described by Sultan; in particular, internal sphincter injury was not identified and repaired separately. A RCT is needed to clarify whether the benefits are due to the technique or to the operator. 43% of obstetric trainees and 34% of consultants admitted that they had no formal training in the techniques.

When the question of the advantages of immediate repair is addressed 5, this is recommended to control haemorrhage, to prevent infection, when epidural analgesia is in effect, and in the interests of promoting breast feeding and bonding between mother and baby. Colorectal surgeons when asked gave the following responses: 37% immediate; 40% under 24 hours; 15% didn’t know. However 96% of colorectal surgeons are involved in one or less acute tears annually. 28% of them believe that a colostomy is necessary for 4th degree tears; 2.2% advise it always. 89% recommend the overlap method, which is the method of choice for only about 50% of trainees and consultant obstetricians. 71% advise caesarian section (CS) in subsequent pregnancies, while 30% of obstetricians are content for episiotomy to be used.

In the prospective study from Fynes and colleagues9, women with transient anal incontinence or occult sphincter injury after first delivery were at high risk of faecal incontinence after a second vaginal delivery. However it is not clear whether or not pregnancy per se influences postpartum anal incontinence. Symptomatic anal incontinence has been reported after both elective and emergency caesarean deliveries. The management of subsequent pregnancies after 3rd and 4th degree tears should be CS unless the mother is free of symptoms due to the trauma and the baby is not deemed to be excessively large, in which case delivery should be undertaken by an experienced professional; prophylactic episiotomy has not been shown to be of benefit.

The current RCOG recommendations for perineal trauma include a new classification, the institution of training workshops, use of the overlap method of repair by a trained operator, and labour ward protocols for severe cases. An example of the last ends this report:

          · Repair by a trained doctor, in the operating theatre and using regional or general anaesthesia.
· Both internal and external anal sphincters to be visualised and repaired if necessary, using monofilament sutures (3/0 PDS – Polydioxanone or Vicryl).
· A Foley catheter to be inserted.
· Antibiotics and lactulose and Fybogel to be prescribed.
· Detailed notes to be kept and an explanation of the procedure to be given to the mother.
· The general practitioner to be informed and hospital follow-up arranged.

References.
1.Sultan AH, Kamm MA, Hudson CN. Obstetric perineal tears: an audit of training. ObstetGynaecol 1995;15:19-23.

2.Woolley RJ. Benefits and risks of episiotomy: A review of the English-language literature since 1980. Part I and II. Obstet Gynecol Survey 1995; 50:806-802.

3. Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal sphincter disruption during vaginal delivery. N Engl J Med 1993;329:1905-1911

4. Groom KM, Paterson-Brown S. Can we improve on the diagnosis of third degree tears? Europ J Obstet Gynecol Rep Biol 2002;101:19-21

5. Fernando RJ, Sultan AH, Radley S, Jones PW, Johanson RE. Management of obstetric anal sphincter injury: A systematic review and national practice survey. BMC Health Services Research 2002,2:9

6. Sultan AH. Editorial: Obstetric perineal injury and anal incontinence. Clinical Risk 1999;5: 193-6.

7. Sultan AH, Thakar R. Lower genital tract and anal sphincter trauma. Best Practice & Research 2002;16(1):99-116


8. de Leeuw JW; Vierhout ME; Struijk PC; and others: Anal sphincter damage after vaginal delivery: functional outcome and risk factors for fecal incontinence. Acta Obstetrica et Gynecologica Scandinavica , September 2001, 80:(9) 830-834

9. M Fitzpatrick, M Fynes, M Cassidy, M Behan, PR O'Connell, C O'Herilhy: Prospective study of the influence of parity and operative technique on the outcome of primary anal sphincter repair following obstetrical injury. European Journal of Obstetrics and Gynecology and Reproductive Biology 2000, 89: 159-163


Discussion.

The great importance of identifying neurological damage was emphasised; this may occur with an intact perineum, and is just as disabling as any of the sequelae of tears.

Pelvic floor exercises.
Compliance by mothers is poor. Some recommend lifelong exercising, particularly in water. There is evidence that the exercises can prevent back pain, and this is an incentive to compliance. Benefit has been shown in urinary incontinence and the quality of orgasm, but there is no information on benefit in faecal incompetence. There is uncertainty as to when exercising should commence. More research is needed.

Midwives are currently reluctant to carry out episiotomy, although the speakers agreed that it may be essential.

The appropriate repair of a 3rd degree tear may nonetheless be followed by urinary incontinence.

Examination in the lateral position, common at home, is likely to result in labial adhesions being overlooked.

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