severe perineal tear (grade iii): is it reasonable to ... · perineal trauma antenatal digital...

Severe Perineal Tear (Grade III):

Is It Reasonable to Allow

Vaginal Delivery Afterwards?

Oz Gavish, MD, MHA

Perinatal Meeting, June 2013

Helen Schneider Hospital for Women

Rabin Medical Center, Beilinson Campus

YES


Is It Reasonable to Allow

Vaginal Delivery Afterwards?

The Dilemma and The Reality

VD CS

Severe Perineal Tear & Subsequent Vaginal Delivery OG, 2013 3

C/S Rate and Concequences

Surgical complications

Anesthetic complications

Post-op risks

Severe Perineal Tear & Subsequent Vaginal Delivery

Pain

Longer recovery

Complications from multiple abdominal surgeries

OG, 2013 4

The Dilemma and The Target

VD CS


Questions of Interest

Patient’s Questions

What is the risk of recurrence? Is it so high to justify CD?

What is the risk for deterioration of anal function?

Is it possible to reduce the risk of recurrence in the

subsequent vaginal delivery?

Questions we must ask ourselves

Do we have enough evidence to support dogmatic thinking?

Can we influence the prevalence and the risk of recurrence?


What is the Recommended Mode of Delivery after 3rd Degree Perineal Tear?

Risk of worsening anal symptoms

1-3 years follow-up

Risk of SPT recurrence

Randomization by Subclassification

Susequent Pregnancy after 3rd degree Perineal Tear

Vaginal Delivery

2070

3%

2%

Elective C/S

2130

0%

1%


NS

P<0.05

s/p 2nd Degree Perineal Tear

(Episiotomy)

Rate of SPT

Rate of Anal Incontinence

Fantasy et al, NEJM, 2030 ?

OG, 2013 7

Classification of Perineal Tears


1st Degree Perineal Tear

2nd Degree Perineal Tear

3rd Degree Perineal Tear

4th Degree Perineal Tear

OG, 2013 8

Anal Sphincters Anatomy & Physiology


Sub Classification of Grade III Tears

3a – Less than 50% of EAS thickness torn

3b – More than 50% of EAS thickness torn

3c – Both EAS and IAS torn


3a ~ 2 3c ~ 4 3b ~ ?

Grade Sub classification rd3: Assumption is related to continence outcome

Grade Sub classification rd3: Problem is not part of most trials designs

OG, 2013 10

Perineal Tears – Variations

IAS tear alone

Levator ani defects

Buttonhole tear


SPT is a Diagnostic Challenge


Incidence

Prevalence

Huge variability

1.5 – 20% in Primiparous

Israel < 1% ??

Increasing incidence

Awareness ?

Better diagnostic tools ?

Better reporting norms ?


Groutz et al, AJOG, 2011 Gavish et al, JFMNM, 2013

OG, 2013 13

Incidence in Israel – Too Good To Be True


Under-Diagnosis? Misdiagnosis


Overdiagnosis

> 15%

Underdiagnosis

< 1%

~ 5%

Misdignosis, Misreporting and Miscoding !!!

Can old retrospective trials can be trusted ??? Brubaker et al, O&G, 2007

Under-Reporting ?

Miscoding

OG, 2013 15

Risk Factors

Non-Modifiable

Nulliparity (AOR = 4 – 10)

POP position

Shoulder dystocia

Precipitate labor


Modifiable

Forceps delivery (AOR = 5 – 25)

Instrumental delivery

Midline episiotomy

Prolonged II stage

LGA infant

Induction of labor

Epidural analgesia

OG, 2013 16

Hamilton, AJOG, 2007

C/S for the Prevention of Anal Incontinence Cochrane Review, 2010

• 21 trials, 31,698 women (6,028 CDs and 25,170 VDs)

• No randomized study

• The greater the quality of the report, the closer its OR

approached 1.0

• No difference in continence preservation in women have

emergency versus elective CD


Preservation of anal continence should not be used as a criterion for choosing elective primary CD

OG, 2013 17

Risk of Recurrence


AOR Rate of Recurrence

No. of Women 3rd

Deg Tear and subsequent VD

Trial

2.5 7.5% 774 Peleg, O&G, 1999

3.4 10.7% 178 Payne, IJGO, 1999

Decreased 1.8% 132 Samuelsson, AOGS, 2002

2.5 – 5 4.4% 56 Harkin, EJOGRB, 2003

Decreased, NS 4.7% 14,990 Dandolu, O&G, 2005

4.3 3.7% 9558 Spydslaug, O&G, 2005

Decreased, NS 2.4% 271 Edwards, JMFNM, 2006

4.7 Elfaghi, BJOG, 2004

3 7.2% 1054 Lowder, AJOG, 2007

No Deterioration in function or QoL

6.8% 73 Scheer, IUJPFD, 2009

4 – 10.6 3.1 – 9.5% 5334 Baghestan, BJOG, 2011

0.9, NS 1105 Priddis, BMCPC, 2013

Risk of Recurrence


Dandolu et al, Obstet & Gynecol, 2005

OG, 2013 19

Baghestan et al, BJOG, 2011

Risk of Recurrence – Critical Look

AOR

Compared to subsequent VD after VD without SPT

Clinical alternative: compare to prevalence/ risk at 1st VD

SPT = 3rd + 4th degree tears

No information about mode of repair and

inter-pregnancy interval

No special intervention applied


Risk of Incontinence


Scheer et al, Int Urogynecol J Pelvic Floor Dysfunct, 2005

No significant change in symptoms or QoL

No significant change in Manometry – before and after delivery

OG, 2013 21

Outcomes after Repair


~ 80% Asymptomatic in 12 months

End-to-end technique Overlap technique

↓ Fecal urgency (RR=0.12) ↓Deterioration of anal incontinence > 1 y (RR=0.26)

Fernando et al, Cochrane Review, 2010

OG, 2013 22

Endoanal Sonography


Sultan et al, NEJM, 1983

• Occult sphincter defects are common after VD

• Only 1/3 have Symptoms !

Clinical Relevance ?

OG, 2013 23

Occult Sphincter Defects & Prediction


Richter et al, Obstet Gynecol, 2005

Harkin et al, Eur J Obstet Gynecol Reprod Biol, 2003

Recurrence was not predictable using pre-delivery anal physiology testing

OG, 2013 24

Improving Outcome with US


Postpartum perineal US improves the diagnosis of anal sphincter tears, and their immediate repair decreases the

risk of severe fecal incontinence

Faltin et al, Obstet Gynecol, 2005

OG, 2013 25

Physiologic Tests Manometry, Perineometry, Nerve Latency


Clinical Relevance ?

Sultan et al, NEJM, 1983

OG, 2013 26

Intervention Strategy for SPT Prevention

Diagnostic skills

Restrictive episiotomy

Manual assistance

during the final part

of the second stage

of labor


Episiotomy for Vaginal Birth

Restrictive episiotomy policy appears to have a

number of benefits:

Less SPT – RR=0.64

Less Suturing – RR=0.71

Disadvantage: More anterior perineal trauma – RR=1.84


8 Trials: 5541 Women

Cochrane Review, 2009

OG, 2013 28

Antenatal Perineal Massage for Reducing Perineal Trauma

Antenatal digital perineal massage reduces

the likelihood of perineal trauma

Primipara

Suturing – RR=0.91 (95% CI 0.86-0.96), NNT=15

Episiotomy – RR=0.84, NNT=21

Multipara

Postpartum pain – RR=0.45, NNT=13


4 Trials: 2497 Women

Cochrane Review, April 2013

OG, 2013 29

Perineal Techniques during the Second Stage of Labor for Reducing Perineal Trauma

The use of warm compresses on the perineum is

associated with a decreased occurrence of perineal

trauma

Severe Perineal Tear (SPT, 3rd or 4th degree)

• RR=0.48 with warm compresses;

• RR=0.52 with perineal massage


8 Trials: 11,651 Women

Cochrane Review, 2011

OG, 2013 30

What Can Be Learnt from the Evidence?

Controversy regarding risk of recurrence

Absolute risk of recurrence is low

Modifiable risk factors

High rate of success of TOLASPT

Interventions decrease prevalence and risk of

recurrence


The Key: Rational Patients Selection

Perineal tear grade IIIa (and maybe IIIb) Special circumstances/ tears ?

Asymptomatic

Wish & consent, Awareness, Perineal protection available

Modifiable / non-repeated risk factors Midline episiotomy Macrosomia Prolonged II stage Instrumental delivery

Severe perineal tear happened once among multiparity


Strong Recommendation against VD after SPT

High degrees: IIIc or IV

Symptoms of anal incontinence

Monometry or endoanal US suggestive of

significant residual defects – ??


Summary: What are we afraid of?

SPT Recurrence – Not so high as assumed

Deterioration of sphincter function – No

Long-term prognosis – Good

VD success rate – High

Prevention feasible – Yes

Subgroups with lower risk – Yes

CD protect from future Incontinence – No


Decision-making Process

Tailor Made Decision

Symptoms

Tear Parity


YES, We Can !

YES, Oui, כן


Can We Allow Vaginal Delivery

Afterwards?

There are in fact two things: science and opinion.

The first begets knowledge, the second – ignorance…

The Oath and Law of Hippocrates

Thank You

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