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Essay ( 3rd degree perineal tear) m

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Essay ( 3rd degree perineal tear) m

Post by mandible on Mon Jul 05, 2010 3:09 am

A healthy 25 year old woman is found to have suffered a third degree perineal tear following a normal vaginal delivery. She has been assessed and consented for repair. (a) Discuss and justify your intra-operative and post-operative management [12 marks]. (b) She attends for follow-up 6 weeks post-partum. Discuss the information you will obtain from the history [3 marks]. (c) Discuss the prognosis of third degree tears and what you will tell the woman about planned mode of delivery in a future pregnancy [5 marks]
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Re: Essay ( 3rd degree perineal tear) m

Post by mandible on Mon Jul 05, 2010 3:10 am

a) Repair should be done in theatre by trained personnel. Adequate lighting, equipment and analgesia is required. It can be done under regional or general anaesthesia .This allows identification of the type of tear,approximation of the torn sphincteric ends and adequate analgesia . The torn ends are approximated using Allis tissue forceps and sutured with 3-0 PDS USING END TO END OR OVERLAP TECHNIQUE. cOLORECTAL SURGEONS PREFER OVERLAP TECHNIQUE.
3-0 PDS has long T1/2 and has reduced risk of infection. Knots should be buried to prevent knot migration Rest of the tear can be repaired using vicryl rapide. .Intrapartum broad spectrum antibiotics such as augmentin/cephalosporin + metronidazole should be give. Sharps, swabs and needles should be accounted for .P/R should be done at the start and end to assess repair . Indwelling catheter for 24 hrs is advised .
.Postoperatively, she should be advised laxatives, oral antibiotics and adequate analgeia. Debriefing should be done. Advice regarding perineal hygiene and diet should be given .Proper documentation with pictorial representation is best .Risk management form should be filled. Follow up at antenatal clinic at 6weeks/ 12 weeks should be arrang ed. She should have physiotherapy for 6-12 weeks.

b)She should be asked about flatus/faecal urgency .Bowel function questionnaire is helpful. Faecal urgency is defined as inabililty to defer defeacation for more than 5 min .Local examination may reveal absence of anal reflex, soiling .P/R may reveal loss of integrity of sphincter and perineal body .
c)Prognosis for external anal sphincter tears are good . 60-80 % are asymptomatic at 12 weeks following proper repair. There is a risk of developing anal incontinence or worsening symptoms with subsequent vaginal delivery . No role of prophylatic episiotomy . If symptomatic, woman should be counselled about caesarian section
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Re: Essay ( 3rd degree perineal tear) m

Post by mandible on Mon Jul 05, 2010 3:11 am

Y A healthy 25 year old woman is found to have suffered a third degree perineal tear following a normal vaginal delivery. She has been assessed and consented for repair. (a) Discuss and justify your intra-operative and post-operative management [12 marks].
A third degree perineal tear is partial or complete disruption of the anal sphincter muscles which may involve either or both the external or internal sphincter muscles.
Repair should be conducted in the theater under regional or general anaesthesia. This will allow to be performed under aseptic conditions with appropriate instruments, agequate light and assisstant.Either overlapping or end to end technique can be used with equivalent outcome. Where internal anal sphincter(IAS) can be identified, it should be repaired separetely with interrupted sutures. For external anal sphincter either PDS or Vicryl can be used with equivalent outcome. For IAS fine sutures as 3,0 PDS or 2,0 Vicryl may cause less irritation.Burying of surgical knots beneaththe superficial perineal muscles is recommended to prevent knot migration, but woman should be warnedof possibility of knot migration with non-absorbable suture.
The method of repair, structures involved suture materials should be clearly documented and the the instruments, swaps, sharps count is correct. The patient should be informed of the nature of her injuryand the benefits of follow up. Written information should be given.
Repair should be performed by appropriately trained doctor, formal training is recommended.
The use of broad spectrum antibiotic is redcommended to reduce postoperative wound dehiscence and infection. Use of postoperative laxatives for about 10 days postpartum associated with reduced incidence of wound dehiscence. Patient should be offered phisiotherapy and pelvic floor exercises for 6-12 weeks. Local protocols should be implemented regarding antibiotics, laxatives and follow up. Follow up appointment with consultant obstetrician should be arranged 6-12 weeks postpartum.
(b) She attends for follow-up 6 weeks post-partum. Discuss the information you will obtain from the history [3 marks].
The information if any incontinence at follow up referral should be made to specialist gynaecologist or colorectal surgeon for endoanal ultrasonography and anorectal manometry, sometimes secondary repair is necessary.

(c) Discuss the prognosis of third degree tears and what you will tell the woman about planned mode of delivery in a future pregnancy [5 marks]
Prognosis is good with 60-80% asymptomatic at 12 months. If symptomatic it is usually flatus or fecal urgency.
The patient should be counselled that the risk increased of developing anal incontinence or worsening symptoms with subsequent vaginal delivery. There is no role of prophylactic episiotomy in subsequent pregnancies. If patient is symptomatic she can have the option of elective caesarean section.
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Re: Essay ( 3rd degree perineal tear) m

Post by mandible on Mon Jul 05, 2010 3:17 am

The patient should be transferred to the theatre for repair as diagnosis has already been made. She must have adequate analgesia or anaesthesia.The repair should be done under aseptic condition with appropriate assistant , instruments & good source of light for optimum visualisation.. Thorough examination under anaesthesia to be done to assess the extent & nature of injury ( 3a, 3b or 3c according to Sultan’s classification ).Rectal examination should be done .The use of regional or general anaesthesia helps sphincter to relax & permits retrieval of retracted ends of the torn muscle.It also allows to bring the ends together without tension.This repair should be done by a trained operator or a trainee under direct supervision. Identification & repair of internal anal sphincter should be done separately using 3-0 Polydiaxanon or polyglactine interrupted stitches .Identification & repair of external anal sphincter will be done using same suture materials like external anal sphincter.These fine suture materials cause less irritation & discomfort. The repair of external anal sphincter can be done in two methods, overlapping & end to end with equivalent outcome.The knots in anal sphincter should be buried under superficial perineal muscle to avoid knot migration.Identification of apex of vaginal tear & repair of vaginal wall should be done with continuous non locking stitches using rapidly absorbable suture.Perineal muscle should be repaired with continuous non-locking stitches using same suture ( rapidly absorbable suture ).Perineal skin should be repaired with subcuticular stitches using same suture material .Rectal examination should be done to check that sutures have not been placed through rectal mucosa.Ensure all swabs & instruments are correct.Indwelling cather should be inserted & also prophylactic antibiotic should be given intraoperatively.
Postoperatively, broad spectrum antibiotics should be used to reduce postoperative wound infection & dehiscence.Also postoperative laxative is recommended to reduce wound dehiscence. Local protocol should be followed regarding antibiotic , laxative, examination & follow up of women with third degree perineal tear.Physiotherapy & pelvic floor exercise should be offered to this lady for 6-12 wks after repair.Finally, she should be given an follow up appointment in 6-12 wks postpartum with consultant obstetrician .

b. Information regarding wound healing, any problem like pain or incontinence of faeces or flatus, fecal urgency should be obtained.If the lady complains of pain or incontinence at follow up visit, she should be referred to specialist gynaecologist or colorectal surgeon for endoanal ultrasonography or manometry & if required secondary sphincter repair may be considered.

c. Prognosis following external anal sphincter repair is very good & 60-80% of patient being asymptomatic in 12 months time. Where women are symptomatic, the symptoms tend to be flatal incontinence or fecal urgency .
I would counsel her that there is a risk of developing anal incontinence or worsening of symptom in her subsequent vaginal delivery .I would also tell her that there is no evidence to support the role of prophylactic episiotomy in her subsequent pregnancies. I would also tell her that she might be offered elective caesarean section during her next pregnancies, if she is symptomatic or had abnormal endoanal ultrasonography and/or manometry. She should be counselled at booking visit during her subsequent pregnancy regarding the mode of delivery & it should be documented clearly in her notes.


(a) Discuss and justify your intra-operative and post-operative management [12 marks].

I will repair in operating theatre for getting aseptic environment with good light with proper instruments and good assistant. I will ensure proper analgesia or anaesthesia. It will give adequate relaxation of anal sphincters which is essential to retrieve torn ends of anal sphincters and to repair without tension. Through examination under anaesthesia would be done again before repair to identify nature and extent of injury. I will identify and repair internal anal sphincters(IAS) and external anal sphincters separately. Fine sutures (delayed absorbable polydiaxanone,3-0 or 2-0 polyglactin) are used which will cause less irritation and discomfort. IAS is repaired by interrupted stiches and EAS by end-to-end or by overlapping sutures. I will bury the knots in anal sphincters under perineal muscles to prevent knot migration / perineal irritation. I will identify the apex of vaginal wall injury and repair by continuous non-locking technique with rapidly absorbable suture ( polyglactin vicryl rapide). I will then repair the perineal muscles by same methods(continuous non-locking with rapidly absorbable sutures). After that I will repair perineal skin by sub-cuticular with rapidly absorbable sutures which will lower perineal pain. I will then perform rectal examination to see whether rectal mucosa were involved in sutures or not and to see sphincteric integrity . Instruments , sharps, swabs will be accounted for. Indweling bladder catheter to avoid urinary retention and prophylactic anbiotiocs to prevent infection.
Postopratively, I will prescribe broad-spectrum antibiotics (including metronidazole for anaerobes)to prevent post-oprative infection and dehiscence. Adequate laxatives like lactulose will be given for softening stool to prevent wound dehiscence. I will follow the unit protocol. I will discuss nature of injury with woman and her partner or family members and benefits of further follow-up visits( including physiotherapy , pelvic floor exercise, further managements). Clear documentation including structures involved , methods of repair, sutures materials. I will provide her written information

(b) She attends for follow-up 6 weeks post-partum. Discuss the information you will obtain from the history [3 marks].
I will ask about her incontinence of flatus or leakage of soft or hard stools suggestive of anal incontinence and severity of somptoms, impacts on quality of life. I will enquire about her perineal discomfort or pain. Also I will try to disclose about any problems of conjugal life such as dyspareunia(superficial).

(c) Discuss the prognosis of third degree tears and what you will tell the woman about planned mode of delivery in a future pregnancy [5 marks]
Prognosis is good, about 60-80% willl be asymptomatic at 12 months. Those who remain symptomatic, usually complain about incontinence of flatus or faecal urgency.
I will tell her that there will be risk of developing anal incontinence or worsening symptoms with subsequent vaginal delivery. I will inform her that no evidence to support prophylactic episiotomy in future pregnancy. If she has any symptoms of perineal dysfunctions or abnormal endo-anal untrasonogram and / or manometry I will give her option for elective casarean section delivery in future pregnancy. Her informed choice in future delivery plan must also be considered and respected.
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Re: Essay ( 3rd degree perineal tear) m

Post by mandible on Mon Jul 05, 2010 3:41 am

A
)I will undertake the repair in an operating theatre under regional or general anesthesia. This will allow the repair to be performed under aseptic conditions with appropriate instruments, adequate light and an assistant.Regional or general anesthesia will allow the anal sphincter to relax,which is essential to retrieve the torn ends of the anal sphincter.This also allows the ends of the sphincter to be brought together without tension.
The External anal sphinter would be repaired ,either by end to end or overlapping method,using either monofilament sutures such as PDS or braided sutures i.eVicryl.Both have been found to be equally effective.Internal anal sphincter repair is best performed by interrupted sutures,using fine suture size ,3-0 PDS or 2-0 vicryl,as this causes less irritation and discomfort.I would take care to bury the surgical knots beneath the superficial perineal muscles to prevent knot migration to the skin.Long acting and non absorbable suture material is avoided as there is possibility of knot migration to the perineal surface.
Postoperative care is crucial following the repair.Intraoperative and postoperative broad spectrum antibiotis and laxatives are given according to unit protocol to reduce the incidence of postoperative infections and wound dehiscence.This would also reduce the risk of anal incontinence and fistula formation.She should be offered physiotherapy for 6-12 weeks and reviewed by consultant obstetrician and gynaecologist.
Incident report is done.I would ensure that anatomical structures involved,method of repair and suture materials are clearly documented and instruments sharps and swabs are accounted .She should be fully informed of the nature of her injury and the benefits to her of follow-up.Written information will be given.
b)At follow-up,if facilities are available ,she should be seen in a dedicated perineal clinic.She should be enquired about incontinence of flatus or fecal urgency or pain.
c) Woman should be advised that the prognosis following EAS repair is good,with 60-80%asymptomatic at 12months.
She should be counselled at the booking,about the risk of developing anal incontinence or worsening symptoms with vaginal delivery in next pregnancy.and prophylactic episiotomy has not been found to be very useful.
If she is symptomatic and complains of anal incontinence,she should be referred to colorectal surgeon for endoanal ultrasound and anorectal manometry.In case of abnormal results,she should be given option of caesarean section.This information regarding mode of delivery should be clearly documented in her records ,

a)
Repair would be done in theatre under regional or general anesthesia to ensure adequate relaxation of the external anal sphincter ends and allows appropriate approximation. Repair done with proper exposure, adequate lighting and assistance. Repair done under aseptic technique and broad spectrum antibiotic cover such as intravenous Cefuroxime and Metronidazole to reduce risk of wound breakdown due to infection. Proper identification of the anal sphincters prior to repair to enable correct repair. End to end anastomosis or overlapping technique would be used as both has similar long term outcome. Polyglactin 2/0 or polydiaxanone 3/0 would be used as it causes less irritation and discomfort. If there is involvement of internal anal sphincter, it would be repaired vis interrupted technique before repairing the external anal sphincter. Knots would be buried beneath the perineal muscles to reduce risk of knot migration. Vaginal mucosa and submucosal layer is then repaired with rapid absorbable suture such as polyglactin rapid via continuous suture. Skin repaired via subcuticular method as it reduces post operative pain. Digital vaginal examination done to ensure no retained gauze and vaginal sutures correctly placed. Digital rectal examination done to ensure rectal mucosa not sutured as it is associated with increased risk of reco-vaginal fistula. Number of swabs and sutures are checked to ensure all counts are correct. Proper documentation of the nature of the injury, the type of suture used and the type of repair done for audit purpose and provides documentation incase of future litigation. Incident reporting would be initiated for risk management purpose. Post operatively, patient would be debriefed regarding the intraoperative findings and the repair done. Ensure adequate analgesia with oral NSAIDS. Patient would be placed on oral broad spectrum antibiotics such as Cefuroxime and Metronodazole for 10 days duration due to the risk of contamination of the wound by fecal organism resulting in wound dehiscence. Patient would be placed on laxatives such as Lactulose and bulking agents such as Fybogel for 10 days to reduce risk of postoperative wound dehiscence due to passage of hard stools. Offer physiotherapy and pelvic floor exercise for 6 to 12 weeks post repair by physiotherapist. Arrange for follow up by consultant gynecologist 6 to 12 weeks post repair for assessment of complications.

b) Features suggestive of anal incontinence such as fecal urgency or flatus incontinence to suggest sphincter weakness or dehiscence. Presence of pain on defecation which would warrant as assessment by consultant gynecologist or colorectal surgeon for endoanal ultrasound or manometry.

c) Prognosis is generally good with 60-80% of patients are asymptomatic 12 months after the repair. Vaginal delivery is associated with increased risk of anal incontinence and may cause worsening of the symptoms. Prophylatic episiotomy is not associated with a reduction in risk of third degree tears. Elective Caesarean section may be an option if patient is symptomatic of anal incontinence or has ultrasound or manometric evidence of sphincter deficiency. Written information would be given and reassessment in next pregnancy would be planned with regards to the mode of delivery.


a) intraoperative management - examination under anaesthesia and repair of perineal injury to be done in the operating theatre under aseptic technique and adequate analgesia. Anaesthesia can be either regional of general anaesthesia depending on the patients condition.Broad spectrum antibiotic cover together with metronidazole commenced on induction of anaesthesia to reduce the risk of infection.Patient in lithotomy position , with adequate lighting and assistants as this will provide better visualization and identification of the structures. Perform a good examination of the perineum to identify any urethral injuries, extended vaginal lacerations as these are the common complications associated with third degree tears. Access the anal sphincter to grade the injury depending on the external or / and internal sphincter involved and the extent of involvement of the external anal sphincter.Identify the external and internal anal sphincters. If internal anal sphincter is torn, suture using PDS or vicryl 2/0 or 3/0 in a interrupted manner.Identify the external anal sphincter and suture either overlapping or end to end anastomosis as , both have similar outcomes.The degree of perineal pain, flatus or fecal incontinence at 12 months is the same with either method .Suture material of choice is either PDS or vicryl 2/0 or 3/0 as these are monofilament , non braided thus reduces the chances of infection. The knots should be burried to reduce risk of migration of the knots and perineal pain.
Post operative- I will give the patient adequate analgesia , either orally or parenterally. continue the broad spectrum antibiotics and metronidazole for at least 1 week . Prescribe laxatives to soften the stool and reduce chance of wound breakdown.Refer to the physiotherapist for pelvic floor exercises to strengthen pelvic floor muscles.

B) I will ask her for any history of flatus or fecal incontinence as this is the commonest complication.Any history of fever , pain at perineum or fowl smelling discharge suggestive of infection.I will ask her any history of passing fecal matter via the vagina suggestive of recto- vaginal fistula.

c) The rate of recurrence of third degree tear in the subsequent delivery is 15-25 % .I will inform her that she has a higher risk of developing anal incontinence or worsening symptoms of anal incontinence if she has a subsequent vaginal delivery. I will also inform her that a episiotomy may not be able to prevent a third degree tear in her subsequent delivery.I will arrange for a endoanal ultrasound and anometry , if it is abnormal I will counsel for a elective caesarean section in the next pregnancy . If she has any symptoms of anal incontinence I will counsel her for a elective caesarean section in the next pregnancy.However the womens choice has to be taken into consideration and I will discuss the options with her.



(a)
Adequate analgesia in the form of either spinal or general anaesthesia is indicated as it will help relax the anal sphincter, thereby helpful in retrieving the torn end of the sphincter.
Repair should be done in theatre with adequate lighting and assistance to enable a good repair thereby helping in good recovery and less post operative complication.
A systematic assessment including a vaginal as well as rectal examination prior to commencement of repair, to identify the anatomical structures involved is done. This helps in the correct documentation of the same helping in audit and risk management as well as assist in choosing the appropriate suture materials.
Internal anal sphincter is sutured separately with 3-o pds or 2-o vicryl if injured. The external anal sphincter is sutured either by end to end anastamosis or by overlapping technique using either 3-o pds or 2-o vicryl. The finer suture materials reduce the discomfort and irritation. There has been no difference in the long term complication or results with either technique. The knot is buried under the perineal muscles and overlapped to prevent knot migration. The rest of the tear is repaired with vicryl rapide in a continuous method with sub cutaneous to skin.
Rectal examination and clear documentation of instrument, swab and needle count helps in audit and risk management.
Intra and post operative broad spectrum antibiotics help to reduce the risk of infection as sepsis can lead to breakdown of the repair leading to increased incidence of incontinence as well as development of fistulae formation. Addition of metronidazole need to be considered ,to cover anaerobes present in the faeces.
Laxatives including stool softerners like lactulose and bulking agents like fybogel help to reduce the strain and pressure associated with straining and are prescribed for 10 days.
Risk managent form need to be filled as it a nofifyable incident . Written information in the form of patient leaflet help with counselling.
Post natal appointment with the consultant at 6-12 weeks helps in de briefing as well as to elicit symptoms which might need referral to a colorectal surgeon. Physiotherapy and pelvic floor exercise for 6-12 weeks help to improve the results.
(b)I will inquire about any history of incontinence of faeces or flatus ,as well as any urgency or urge incontinence of faeces or flatus. Any history of pain need to be enquired .
Any of the above symptoms prompts a referral to colorectal surgeon with a special interest in 3rd degree tears for further investigations in the form of anal ultrasound and/or anorectal manometry.
(c) Women need to informed that the prognosis after surgery for external anal sphincter is good. 60-80% of women are asymptomatic after 12 months. In the symptomatic group of women the predominant symptoms are incontinence of flatus and fecal urgency.
Secondary surgery with a colorectal surgeon may be necessary if she remains symptomatic or there is abnormal anal ultrasound or anorectal manometry.
She needs to be informed that she can develop incontinence or worsening of symptoms after subsequent pregnancy and delivery.
Prophylactic episiotomy is not recommended as they have not been any documented benefit.
Mode of delivery need to be discussed and documented at booking and an elective ceaserean offered if she is symptomatic or there is abnormal anal ultrasound or anorectal manometry.



(a
) Third degree perineal tear should be sutured in operating theater and under regional or general anaesthesia.Appropriat instruments,adequate light and an assistant are required . Inespection of the rest of genital tract for any other injury.Repair will be either by overlapping or end to end method.No evidence to support of use of one method over the other. Internal anal sphincter (IAS) is identified and sutured separatly by fine suture (3-0) PDS or (2-0) vicryl to reduce irritation and discomfort. .External anal sphincter(EAS) repair is done by monofilament suture as (PDS) or braided suture as (vicryl) with equivilant outcome. Burying of surgical knots beneath the superficial muscle of perineam is recommended to prevent knot migration .Identification of apex of vaginal tear is repaired by continuous non locking suture . Suturing of perineal muscle in two layers and closure of skin by subcuticular suture to reduce pain is performed. Post operative managment include use of broad spectrum antibiotic + metronidazol for anaerobic bacteria to reduce risk of infection and wound dehiscence . Laxative use is recommended to reduce risk of wound dehiscence. Post operative analgesia as non steroidal anti inflammatory drugs are effective to control pain. I will provide post operative information about perineal care to reduce infection . I will offer physiotherapy and pelvic floor exercise for 6-12 weeks after repair. Incident form should be filled and documentation of procedures performed .

(b) I would ask her about any symptoms regarding incotinence of flatus or urgency of faeces.Also, i would ask her about perineal pain and pain during intercourse (dysparonia).

(c) Woman should be informed that the prognosis following EAS repair is good. 60-80% are asymptomatic at 12m . I would advice her that no evidence to support use of prophylactic episiotomy in subsequent pregnancy. Iwould inform her that she has the risk of developing anal incontinence or worsening of symptoms in subsequent vaginal delivery. I would inform her that if she have symptoms or abnormal endoanal ultrasound and/or manometry , she should have elective c/s in next pregnancy.


a
)Repair of a third degree laceration should be performed in the operating theatre by a person adequately trained for the procedure or under direct supervision. This provides adequate lighting in an aseptic environment. The patient is placed in lithotomy postion to allow for adequate visulisation.
The procedure can be performed under general or regional anaesthesia, since they both allow relaxation of the sphincter muscles and will also allow systematic examination of the perineum and the sphincter. A rectal examination should also be performed to identify the extent of the injury.
The internal anal sphincter should be indentified. If injury is present it should be repaired interupted with 3/0 polydiaxone suture. This fine monofilament suture reduced the risk of infection and causes less irritation and discomfort.
The external anal sphincter should be repaired separate from the internal anal sphincter. Either using an overlap technique or the end to end anastamosis using 2/0 polygalactin or polydiaxone sutures. Both methods are associated with similar outcomes. Knots should be buried in the anal sphincter under the superficial perineal muscles to reduce the risk of knot migration and perineal pain.
THe apex of the vaginal tear should be identified and repair of the vaginal wall should begin from this point. Continuous non interlocking rapidly absorbable suture eg. vicyl rapid should be used. Perineal muscle should be closed with a continuous non interlocking suture. Perineal skin should be closed subcuticular with a rapidly absorbed suture.
Digital rectal examination should be performed after the procedure to ensure that sutures have not been placed through the mucosa. Intraoperative antibiotics eg. 1.5g Cefuroxie and 500mg should be given to reduce the incidence of infection. Infectionis assocaited with a high risk of anal incontinence and fistula formation. Ensure all swabs and instruments are accounted for since foreign bodies can cause wound breakdown. An indwelling catheter should be inserted before the procedure is completed.
Post operative oral broad spectrum antibiotics with the inclusion of metronidazole to reduce contamination from fecal matter. Laxatives should be prescibed for at least 10 days post opertive to prevent wound dehisence. All women should be offered phyiotherapy and pelvic floor exercises for 6-12 weeks post partum.She should be reviewed by consultant obstetrician at 6 weeks post partum. She should be given written information about the nature of her injury and advised on the benefits of follow up.
b)Specific question should be asked about syptoms of anal incontinence. This should include fecal urgency, fecal incontinence and incontinence of flatus. Asked how her symptoms have affected her life. I would ask about associated symptoms of dyspareunia and perineal pain.
c) Prognosis of third degree tears is good. 60- 80% of patients are asymptomatic at 12 months. Of the women that are symptomatic, common symptoms include flatus and faecal urgency.
Mode of delivery in future pregnancies would be influenced by the presence of anal incontinence symptoms. If the patient is symptomatic or who have abnormal endoanal ultrasound or anal manometry she should be offered elective caesarean section. if she asymptomatic there is no clear evidence as to the best mode of delivery. However she should be counselled abou the risk of anal incontinence in future pregnancies.



a)
The third degree tear repair should be done by an appropriately trained practitioner as there is an increased risk of maternal morbidity with inexperienced attempts. It should be conducted in theatre under regional or general anaesthesia. This will allow the repair to be done under aseptic conditions with appropriate instruments, adequate light and an assistant. Regional or general anaesthetic will allow the anal sphincters to relax and the retracted torn ends can be brought together without any tension. Bladder should be catheterised to avoid painless filling due to regional anaesthesia. The repair of external anal sphincter(EAS) can be done with either monofilament sutures (polydiaxonone(PDS)) or braided suture ( vicryl) with equivalent outcome. The repair of internal anal sphincter should be done with 3-0 PDS and 2-0 vicryl. The use of fine sutures causes less irritation and discomfort. The surgical knots should be buried under the superficial perineal muscles to prevent knot migration to skin. A rectal examination should be done at the end to exclude if the sutures had gone through the rectal mucosa as it can lead to rectovaginal fistula if unidentified. Careful documentation of anatomical structures involved, method of repair and suture materials used and that instruments, swabs and sharps are accounted for, for risk management purposes. A critical incident form should also be filled for the same purpose.
Regular analgesics should be prescribed as it keeps the patient comfortable. Broad spectrum antibiotics is recommended as it can reduce the infection and wound dehiscence. Postoperative laxatives is recommended to reduce the incidence of postoperative wound dehiscence. These should be done in line with the local protocol. Physiotherapy and pelvic floor exercises should be offered for 6-12 weeks after repair of third degree tear as it can help in strengthening the pelvic floor and thereby reducing the incidence of faecal incontinence. She should be offered followup in 6-12 weeks by a consultant obstetrician and gynaecologist to discuss the injury sustained during childbirth, assess for symptoms, offer advise and or treatment and future mode of delivery. If any incontinence or pain at followup then a referral to a specialist gynaecologist or a colorectal surgeon should be made for consideration of secondary sphincter repair. The patient should be informed about the nature of injury and the benefits of followup and given written information where possible.
b) I will enquire if she has any pain in the perineum. I will also ask about incontinence to solid or liquid stools and flatus. Any abnormal foul smelling vaginal discharge suggestive of infection should also be asked. I will also find out if she has any dyspareunia.. I will also enquire for sumptoms of knot migration to skin such as sharp pain or if feeling the sutures.
c) I will advise her that the prognosis following EAS repair is good with 60-80% being asymptomatic at 12 months. She should be informed that ther is a risk of developing anal incontinence or worsening symptoms with subsequent vaginal delivery. If she has any symptoms of incontinence at followup or have any abnormal endoanal ultrasound or abnormal manometry then elective caesarean section should be offered at subsequent pregnancy.
R

a…
Third degree perineal tear involved injury to external and internal anal sphincter. The repair should be done under good lights with identification of the extent of injury is essentials. Regional or general anesthesia will assist relaxation of sphincter. Intraoperative antibiotic like ceftriaxone and IV metronidazole can reduce incidence of infection. Urinary catheter is fixed to empty the bladder. The internal and external sphincters are repaired separately using interrupted sutures. End to end suturing or overlapping techniques’ carry same out come regarding healing and continence rate. Long absorbable suture materials like polyglycolic acid or polygalactine are preferred to enhance healing and reduce infection. Clear documentation of extent of tear, suture materials used, technique and name of staff is essential.
Laxative is prescribed postoperatively to loosen bowel motion and reduce incidence of wound dehiscence, also adequate analgesia and antibiotic is continued. Foleys catheter left for 24 hours as the patient might have voiding difficulty due to pain. Then after the catheter is removed. The patient is monitored and she should void within 6 hours to ensure that there is no urine retention, other wise she will get lazy bladder. Good perineal hygiene is encouraged; also pelvic floor exercise is advisable to empower pelvic floor muscles. The patient provided with verbal and written information. Follow up appointment is arranged.
b…Symptoms of urgency and / or incontinence to flatus or feces are explored to assess integrity of anal sphincter. Presence of vaginal discharge with fecal smell is indicative of fistula formation. Presence of anal pain, swelling and offensive anal discharge reflect wound infection.

c… Majority of patient with third degree perineal tear do well after repair and they are continent to feces and flatus, so the prognosis is generally good. Minority may experience urgency or incontinence. Some asymptomatic patient may have anal sphincter weakness that is diagnosed or discovered by anal manometer.
In future, the patient is preferably delivered by CS as there is increased incidence of wound dehiscence with vaginal delivery. Episiotomy can not protect against wound dehiscence in majority of cases.



A
healthy 25 year old woman is found to have suffered a third degree perineal tear following a normal vaginal delivery. She has been assessed and consented for repair. (a) Discuss and justify your intra-operative and post-operative management [12 marks]. (b) She attends for follow-up 6 weeks post-partum. Discuss the information you will obtain from the history [3 marks]. (c) Discuss the prognosis of third degree tears and what you will tell the woman about planned mode of delivery in a future pregnancy [5 marks]

A) I will inform a senior obstetrician to attend because this operation is better done or supervised by an adequately trained personnel. I will then transfer patient to theatre making sure she is not seperated from her baby except if bleeding is ongoing moderately or severely. Theatre will ensure good lightening and relatively sterile environment. This repair is usually done under a spinal or epidural anaesthesia to ensure patient comfort. Patient is then placed on lithotomy for optimal visualisation and repair. I will then examine her thouroughly including a PR examination to properly dileanate extent of injury under aneasthesia. This will be a more accurate assessment compared to that done in the room. I will change my gloves and the patient is cleaned and draped to ensure sterility of operation site as much as possible. I will give intra operative antibiotics e.g IV augmentin 1.2 g stat dose.I will use a 3-0 PDS suture to appose the external anal sphinter in either an end to end anastomosis or overlap technique. There is no statistical significance in preference. I will then identify the apex of the vaginal tear and start vagino-perineal repair from there using 2-0 vicryl suture. This will be done in continuous fashion with the perineal skin being closed in a subcuticular fashion. I will ensure hemostasis. I will exam vaginall with sims speculum to ensure no further vaginal tear and will then repeat PR exam to ensure that sutures are not palpable or exposed per rectum. I will then ensure my needles and swabs are correct with safe disposal. I will catheterise the patient as she will not be mobile for a few hours. I will document operation procedure and post up plan.
Post operatively, the patient will be placed on antibiotics e.g augmentin 375mg tds for 7 days, and lactulose 10mls b.d for 7 days. This is prophylaxis against infection and ensure soft stool to allow healing. I will fill an clinical incident form and debrief patient on the procedure and subsequent management plan which will include arrangement of clinic in 6 weeks and 3 months to assess for fetal incontinence.

B)The information i will obtain will include any symptom of incontinence of flatus, fluid of feaces. I will inquire for any signs of urgency or difficulty with emptying bowels. I will ask for any symptom of on going anal pain which may signify ongoing infection. I will ask her if she understands what had happened and how she feels about it all.

C)I will inform her that 3rd degree tear usually has a good prognosis but there can be delayed manifestation of symptoms. If reported this can be treated initially with physiotherapy. A small number of patients will require corrective surgery by colorectal surgeons. I will explain that it is her choice to the mode of delivery in her next pregnancy. Usually, if there are residual symptoms, ceasarean section is offered. If she choses vaginal delivery, prophylactic episiotomy is not recommended and vaginal delivery has the potential of worsening a mild anal symptom or making a covert symptom overt. I will tell her the risk factors associated with 3rd degree tear which include instrumental delivery, macrosomic babies, proplonged 2nd stage of labour, induction/augumentation and this we will try to avoid as much as possible should she want a vaginal delivery. I will give information leaflet.



a)
Third degree tear is injury to perineum involving the anal sphincter complex.Repair of 3rd gegree tear should be conducted in an operating theatre,under local or regional anaestesia in good lighting by an appropriately trained person or under supervision.Examination under anaesthesia to identify nature and extent of injury.Rectal examination also performed to find out extent of injury.Internal anal sphincter is identified and repaired by 3.0 PDS or Vicrylby interrupted stich.External anal spincter should be repaired by 3-0 PDS or vicryl.There is no difference in outcome either end-to-end or overlapping techique used.Knots should be baried under superficial perinal muscles to reduce risk of knot migration and perinal irritation.Apex of vaginal tear idenfied and repair done by continuous non-locking absorbable suture.After repair finished rectal examination performed to make sure that rectal mucosa is not taken by suture.Swab and instrument count checked.Intrapartum broad-spectrum antibiotics as cepalosporins given to prevent infection and fistula formation. Metronidazole advised to prevent anaerobic infection from faecal matter.All anatomic structures involved,suture materials and techniques should be documented.Postoperatively laxatives as Lactulose and bulk-forming agents such as Fibogel are recommended for about 10 days after repair to decrease risk of wound disruption.Foley's catheter inserted and left for 24 hours.Unit protocols should be followed regarding use antibiotics,laxatives,examination and follow-up of women with anal sphincter repair.Risk management form should be filled-up.Woman and partner debriefed and all questions answered.
b)Woman should be asked about faecal/flatus incontinence/soiling.Per rectum examination performed to check integrity of anal sphincter.
c)Woman should be advised that prognosis following repair is usually good.60-80% asymptomatic at 12 month.If woman had an anal sphincter injury in a previous pregnancy she should be warned about risk of developing anal incontinence and worsening of symptoms with subsequent vaginal delivery.She should be told that prophylactic episiotomy has no role in preventing anal sphincter injury.If woman has a sustained anal sphincter injury and symptomatic or she has abnormal endoanal ultrasonography and/or monometry should have opinion of elective caesarean birth.In all cases woman's choice should be respected.Written inforamation should be provided
.

She should have her third perinea tear repaired to avoid or reduce her risk of developing incontinence to flatus and stools.This should be done by an experienced person at the operating theatre with good light. Antibiotic prophylaxis is started and continued post operatively. Anesthesia ,either general or regional is given to relax the anal sphincter and allow its easy picking. After antiseptic cleaning of the area, the extent and degree of the third degree tear is detected by vaginal and rectal examination ( 3 A <50% of ext anal sph EAS-- 3B >50% of EAS -- 3C EAS + internal anal sphincter IAS).
The IAS tear is corrected by interrupted delayed absorbable stitches like 3-0 PDS. The EAS is corrected using end to end or overlaping techniques via 3-0 PDS sutures also. Both techinques give the same results.
The vaginal skin and perinea muscles are closed using continuous non locked rapidly absorbed vicryl sutures. ( Anal sphincter sutures are buried under the perinea muscles to avoid their migration and stitch sinus). The skin is closed with subcuticular or interrupted ,rapidly absorbable vicryl stitches, both giving same results .
Swab count is done and a self retaining urinary catheter is put to avoid retention which is commonly seen in these patients post operatively and removed when mobile.
Laxatives are given for 2 weeks post operatively. Patient debriefed about what she had and the correction done. Incident report is filled for the risk management team to inestigate and lessons learnt disseminated. GP is informed. Arrange for physiotherapy and give a follow up appointement in 6wk after discharge.



Will ask her if she is cotinent to stools and flatus. She might be continent to hard stools but not to fluid stools or flatus or incontinent to all which is a severe degree. Will ask how this is affecting her quality of life. Will ask if the repair has healed well and there is no area that has not . Will ask if she has started intercourse and if there is any dyspareunia. Will ask if she is using contraception and what type so as to counsell her regarding this.



Seventy percent of women who under gone a repair for 3rd or 4th degree tear are continent at 12 months of having a repair. Those who are incontinent will need to have futher tests including endo anal ultrasound and manometry and might need either physiotherapy or 2ry repair. Some will need a colo rectal surgeon to correct.
Patients who are symptom free after a successful 1ry repair are given the choice of having a vaginal delivery after explaing the risks and benfits of a vaginal delivery including the risk of recurrence and that episiotomy will not protect against its occurrence.Some women will opt for an elective cesarean.
Women who have symptoms after repair are told that their symptoms can become worse with vaginal delivery and advised to have a planned cesarean.
Women who had a successful 2ry repair should not repeat their bad experience again and are allowed to have a planned cesarean section
.


A
healthy 25 year old woman is found to have suffered a third degree perineal tear following a normal vaginal delivery. She has been assessed and consented for repair. (a) Discuss and justify your intra-operative and post-operative management [12 marks]. (b) She attends for follow-up 6 weeks post-partum. Discuss the information you will obtain from the history [3 marks]. (c) Discuss the prognosis of third degree tears and what you will tell the woman about planned mode of delivery in a future pregnancy [5 marks]



a)Third degree perineal tears have a good outcome if indentified and managed optimally.I will repair the tear in theatre, under good light and regional anesthesia, by a senior anesthetist, with a good assistant to provide adequate exposure.I will identify and categorise the tear (into 3a,b or c), after careful inspection, per vaginal and per rectal examination.Categorisation is based upon degree of external(EAS) and internal sphincter(IAS) involvement and helps to repair the tear appropriately.I will start with repair of the internal sphincter, if involved,with fine sutures(PDS 2/0 or 3/0) by interrupted technique and bury the knots to avoid irritaion and knot migration.EAS will be sutured by fine sutures (PDS 3/0),either by overlap or end to end anastomosis, as both methods are effective in reducing complications.I will identify the vaginal apex and suture the mucosa and muscle with continuous,loose, non locking technique, using vicrl rapide 2/0; as this technique is associated with less suture requirement,short operating time and less post operative analgesia requirement.I will approximate the skin edges by continuous, sub cuticular technique as it improves healing, is cosmetic and less post operative analgesia required.I will check and suture any other lacerations and perform a PV and PR examination to detect any sutures in the anal canal.I will insert an indwelling cathether at the end, for at least 12 hours,to avoid urinary overflow retention.I will count the needles, swabs and instruments and dispose the sharps into sharps bin and measure estimated blood loss.I will clearly document the extent of injury, method of repair, technique and sutures used and preferrably draw a diagram and complete an incident form for risk management.
I will discuss the events of delivery and advise about diet, hygeine and perineal care to her and prescribe her regular analgesia, antibiotics and laxatives for at least 7 days; to reduce post operative pain, risk of infection and avoid constipation.I will arrange a GOPD appointment in 6-8 weeks for follow up.


b)I will ask about history of fecal or flatus incontinence and urgency.I will enquire about general health and perineal healing and associated pain or bleeding;whether sexually active and discuss contraception.
I will obtain her views about the events around delivery and her ideas about next pregnancy and delivery.


c)Prognosis is generally good if tears identified and managed optimally. Unrecognised tears can have poor prognosis,especially if large defects.
I will inform her that she will be booked under consultant led care in the next pregnancy and reviewed in joint clinic with colorectal surgeons and that she may need an endo anal uss to identify any defects.If she is asymptomatic, vaginal delivery is possible.Risk of recurrence is low and there is no role for routine episiotomy.If symptomatic, caesarean section is an option.However, the mode of delivery will be individualised based upon presence of symptoms,other pregnancy complications and her wishes.


a)
The repair must be done by an experienced obstetrician, preferably someone who has had formal training in anal sphincter repair. All repairs should be done in the operation theater, under general or regional anaesthesia, so that the muscles are more relaxed and identification of the damaged can be done easily. The patient has to be put in lithotomy position for better visualization of the perineum and the examination of the tears done systemically so that other associated vaginal tears can also be identified for repairs.
Repair of the external anal sphincter can be done either by overlapping the muscle or by end to end anastomosis, using fine, absorbable monofilament sutures, such as polydiaxanone ( PDS) 3/0 or modern braided sutures, such as polyglactin (Vicryl) 2/0. Repair of the internal anal sphincter is done separately using interrupted sutures. Fine sutures cause less irritation and discomfort. Burying the knots underneath the superficial perineal muscle prevents knot migration, which can cause pain and impairment of the wound integrity. Using non absorbable sutures would also increase the risk of knot migration, thus it is not recommended.
She requires broad spectrum antibiotics to reduce the risk of wound infection, and metronidazole is added on to cover for anaerobes that could originate from the anal cavity. Development of infection can predispose her for future anal incontinence and fistula formation if her wound breaksdown. Adequate pain relief should be given post repair. She has to be prescribed stool softeners, such as Lactulose, to prevent pain and wound dehiscence caused by passing out hard stools. She should be referred to the physiotherapist for pelvic floor exercises for 6 to 12 weeks postpartum to strengthen her pelvic floor muscles, and reduce the risk of flatus and faecal incontinence postpartum.
She should be followed up in the postpartum clinic 6 to 12 weeks post repair to be reviewed by the consultant obstetrician and gynaecologist.
Details of the repair, which includes anatomical structures involved, method of repair and suture materials has to be clearly documented for future referance.

b)
She should be asked regarding if she has flatus or faecal incontinence, how severe is her symptoms, and if it has affected her quality of life. If she has the abovementioned complains, she should be referred for endoanal ultrasound and anorectal manometry. She may also require a referral to the colorectal surgeon for further evaluation.

c)
She should be counselled that prognosis is good after external anal sphincter repair, with 60 to 80% of patients will remain asymptomatic at 12 months. She should also be counselled she may be 17 to 24% at risk of developing worsening symptoms or anal incontinence with subsequent vaginal delivery, and that an episiotomy does not prevent the occurence of a sphincter tear. If she is found to have worsening symptoms of anal incontinence, and an abnormal endoanal ultrasound and/or manometry, she should be given the option of an elective caesarean section. Written information should be given to the patient where possible
.



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Re: Essay ( 3rd degree perineal tear) m

Post by mandible on Mon Jul 05, 2010 3:46 am

a
) This repair should be done by a trained operator or consultant to optimize a good outcome. The repair should be done in the operating theater, with adequate lighting and assistance. She would be placed in a lithotomy position under regional or general anesthesia for proper assessment and repair. After the bladder is emptied a thorough inspection of the extent of the 3rd degree tear should be examined and noted. PDS sutures or vicryl sutures should be used to approximate the internal anal sphincters and end to end approximation of the external anal sphincters done separately. The knot should be buried underneath the perineal muscle to prevent knot migration or irritation. The remaining perineal repair is done via continuous non interlocking of the vaginal mucosa and perineal muscles. The skin and the fourchette closed with subcuticular suturing with vicryl rapid. A perineal examination must be done before concluding the operation to assess the anal tone and to assess the presence of any sutures in the anal canal. Proper swab, sutures and instrument count must be done to prevent any unwanted retainment of foreign body. She should be given lactulose to prevent her from passing hard stool which could interrupt the perineal and sphincter repair. She should be given broad spectrum antibiotics and metronidazole for anaerobic organism cover. Proper documentation in regards to the type of repair and sutures used is important for her debriefing during her follow up. She should be offered physiotherapy and pelvic floor exercise after 6-12 weeks of delivery. She should be also informed of the possibilities of the complication such as rectovaginal fistula and infection and to come for urgent follow up when this occurs.

b) She should be asked in regards to her general well being and in regards to her quality of life. Her contraception plan and her plan for her next pregnancy also must be asked as to reduce poor spacing of her next pregnancy. Her bowel function is assessed to such as any fecal urgencies, any fecal or flatus incontinence is present. Presence of this symptoms require urgent referral to the the colorectal surgeon.

c) She should be reassured that 60-80% will be asymptomatic by a 1 year period. If she is symptomatic she could ungergo anal manomatry testing or endoanal ultrasound as to assess the anal sphincters. She could be referred to a colorectal surgeon for secondary repair of the sphincter if required. If she remains asymptomatic she could be allowed vaginal delivery but bearing in mind that this could cause increase in the symptoms of incontinence as well. She should be informed that there is no role for prophylactic episiotomy as well. She can be given the option for a elective caesarean section as well. Her wishes and written information in regards to her subsequent pregnancy should be given to the patient for the benefit of her future care givers
.



A
)Repair should be performed in the operating theatre as it will allow the procedure to be performed under aseptic conditions with appropriate instruments, adequate light and assistant.Regional or general anaesthesia will allow the anal sphincter to relax,which is essential to retrieve the retracted torn ends of the anal sphincter .This will also allow the ends of the sphincter to be brought together without any tension.Assessment and repair should be undertaken by trained operator or trainee under supervision.Internal anal sphincter should be identified and repaired separately using 3/0 polydiaxanon(PDS) or polygalactin by interrupted sutures.External anal sphincter should be identified and repaired using end -to- end or overlapping technique with 3/0 polydiaxanon or polyglactin.Knots should be buried under superficial perineal muscles to reduce the risk of knot migration and perineal irritation.Apex of the vaginal tear should be clearly visualized and repair should be done with continuous non locking,rapidly absorbable sutures.Perineal skin should be repaired using subcuticular rapidly absorbable sutures.Rectal examination should be performed to ensure sutures have not been placed through the mucosa.Ensure all swabs and instruments should be accounted for and sharps should be disposed off. Intraoperative prophylactic antibiotics should be administered.Finally an indwelling bladder catheter should be inserted.
Postoperatively ,the use of broad –spectrum antibiotics is recommended to reduce the incidence of postoperative infection and wound dehiscence.The use of postoperative laxatives to reduce the incidence of wound dehiscence.Woman should be offered physiotherapy and pelvic floor exercises for 6 to 12 after the repair .woman should be warned about the possibility of knot migration to the perineal surface with long acting non absorbable suture material.Woman should be reviewed 6-12 weeks postpartum by a consultant obstetrician and gynaecologist.If woman is experiencing incontinence or pain at follow up,she should be referred to specialist colorectal surgeon for endoanal ultrasonography and anorectal manometery.
B)Woman should be asked about the pain and discomfort or knot migration.She should be asked about any incontinence of flatus or faecal urgency.Information should be taken for any offensive vaginal discharge and lochia.
C)Woman should be advised that the prognosis following the EAS repair is good,with 60 -80% asymptomatic at 12 months.Most women who remain symptomatic describe incontinence of of flatus or faecal urgency.Woman should be counseled about the risk of developing anal incontinence or worsening symptoms with subsequent vaginal delivery.She should be advised that there is no evidence to support the role of prophylactic episiotomy in subsequent pregnancies.She should be informed that if she is symptomatic or have abnormal endoanal ultrasonography/or manometery,she should have the option of elective caesarean birth
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hird degree perineal tear is partial or complete disruption of anal sphincter muscles.Repair should be done in operation theatre under good exposure and light and good asepsis.In operation theatre all instruments are available.it should be done by a person who has had trainning for repair of perineal tears as it will lead to good repair with less failure rate .Repair should be done under regional or general anaesthesia as it will relax the muscles and suturing of torn ends can be done without any tension.suture materials which can be used are vicryl or polydiaxanone as they are late absorbable.fine suture materials should be used like 3-0 pds or 2-0 vicryl as it is associated with less post op pain and discomfort.methods which can be used are end to end anastomoses or overlapping method ,studies have shown that both have equivalent outcomes.interrupted sutures for internal anl sphincter and external anal sphincters are advised as less risk of wound dehiscence and failure of repair.knots should be buried as it reduces the risk of knot migration and pain.
Intraoperatively antibiotics should be given to reduce risk of infection.DOCUMENTATION OF the anatomical repair,suture materials used and method of repair is important.documentation of swabs and sharps should be done.
POSToperative management is very important to reduce the risk of infection.personal hygeine is important .post operaltive analgesia to reduce the pain,nonsteroidal analgesics can be given
use of antibiotics to reduce the chances of infection as infection can lead to disruption of wound and wound dehiscence.broad spectrum antibiotics should be given and metronidazole should be added for cover of anaerobic organisms as soiling of wound is common.laxatives in the form of stool softener and bulking agents should be given for 10 days as hard stools can disrupt the repair.pelivic floor exercises and physioterapy is advised for 6 -12 weeks.
post natal appointment should be given after 6 weeks preferably in specialised perineal clinic or to be seen by consultant.warning symptoms like fever,perineal pain and incontinence should be explained and to report to hospital if any such problem arises.
b] at 6 weeks postpartum we should ask for perinealpain,and incontinence of flatus or liquid stools and also about urgency incontinence of stools .
c]prognosis of repair of external anal sphincter if repaired correctly is good,60%success at 12 months.studies have shown that external anal sphincter injury alone has better prognosis than damage to both external and internal anal sphincter.some women who still have incontinence have to be referred to colorectal surgeon for further repair.woman has to be explained that in subsequent pregnancy vaginal delivery may lead to worsening of symptoms.there is no role of prophylactic episiotomy to prevent further damage.if she has incontinence syptoms or abnormal endoanal sonography or analmanaometric findings she will be offered elective caesarean section.DURING booking her mode of delivery should be discussed and written in hand held notes
.


A
healthy 25 year old woman is found to have suffered a third degree perineal tear following a normal vaginal delivery. She has been assessed and consented for repair. (a) Discuss and justify your intra-operative and post-operative management [12 marks]. (b) She attends for follow-up 6 weeks post-partum. Discuss the information you will obtain from the history [3 marks]. (c) Discuss the prognosis of third degree tears and what you will tell the woman about planned mode of delivery in a future pregnancy [5 marks]

a) Third degree perineal repair need to be undertaken in an aseptic manner in the operating theatre under regional / general anaesthesia, with the help of an assistant to improve the outcome of the repair. The anaesthesia will help relaxation of the sphincter muscles which makes it easier to identify the torn ends and repair them appropriately. Intra-operative antibiotics will be given [co-amoxiclauv 1.2g i.v (gentamycin 120 mg and metronidazole 500 mg i.v if allergic to penicillin)] to minimise the post-op infection.The legs will be put in the lithotomy and the perineal area will be cleaned using an antiseptic solution and the area draped. The internal anal sphincter, if torn (3C), is sutured using 3/0 PDS (delayed reabsorbable) with interrupted sutures. The external anal sphincter tear (3A or 3B) will be sutured using end-end technique (overlap technique can also be used) using 3/0 PDS. The knots will be buried under superficial muscles to prevent knot migration. The vaginal is sutured using 2/0 vicry rapide, the vaginal skin in a continuous non-interlocking manner, the same technique be continued to the superficial perineal muscles and continuing the same suture subcuticularly for the perineal skin to decrease the post-procedure pain/discomfort.
A vaginal examination and a per rectal examination will be undertaken at the end to make sure there are no more tears in the vagina or bleeding and to make sure that the suturing has not gone through the rectum/anus respectively. The swabs, needles and the instruments will be counted to correct and the total blood loss estmated. An indwelling bladder catheter will be inserted. A thorough documentation of the extent of the tear, suture materials used and the blood loss will be made. Oral antibiotics (augmentin 375mg tds) will be given for 5 days to minimise the post-op infection and wound breakdown and laxatives (lactulose 10 ml BD and fybogel 1 sachet BD) for 2 weeks to avoid constipation. Sufficient analgesics will be written up avoiding opiates. Thromboprophylaxis (TEDS +/- LMWH) given and appropriate bladder care taken.
A thorough de-briefing regarding the tear, repair, implications for future life and pregnancy will be given to the patient before discharge and an out-patient appointment will be made in 6-8 weeks time to see a consultant gynaecologist/urogynaecologist for review of symptoms and further management.

b) Any complications during the post-op period such as perineal infections and constipation will be useful and the post natal notes will be reviewed. I would ask her about the incontinence bowel symptoms such as unable to hold the flatus and/or faeces and fecal urgency and persisting pain and painful intercourse (if she has already started) which will be useful in further management. Further referral to colo-rectal surgeons for endoanal ultrasound and/or anal manometry if any of these symptoms.

c) Third degree perineal tears have a good pronosis if the repair is undertaken in suitable manner by an appropriately trained surgeon. About 60-80% of the women are asymptomatic at the end of 12 months and some may need secondary repair for persisting symptoms and abnormal endoanal ultrasound findings and / or anal manometry.
With regards to future mode of delivery, I would counsel her that there is a risk of developing anal incontinence or worsening of symptoms with subsequent vaginal delivery. I would inform her that there is no evidence to support the role of prophylactic episiotomy to prevent further third degree tears during a vaginal delivery. I would also tell her that she will be offered elective caesarean section, if she is symptomatic or has abnormal endoanal ultrasonography and/or manometry. She will be booked under a consultant care in her subsequent pregnancy and decision regarding the mode of delivery will be made depending on her symptoms and her wishes



a
) Repair of a third degree tear should be performed by an obstetrician who is trained in anal sphicter repair. Repair should be performed in the operating theatre under aseptic condition. The patient should be adequately relaxed so as to enable approximation of the ends of the external and internal anal sphincter muscle. Preferably repair is done under general or epidural anesthesia. Patient is place in lithotomy position. The area is cleaned and the extent of the tear is identified.
Internal anal sphincter muscle is repaired with polydiaxanone (PDS) 3-0 with interupted sutures. The knots are burried within the muscle to prevent knot migration. The external anal sphincter is repaired with PDS 2-0 with end to end or overlapping sutures. The vaginal mucosa and muscle is repaired with Vicryl 3-0 sutures, continuous non locking technique. The skin is repaired with absorpable vicryl 3-0 subcuticular stiches. Once the repair is complete a vaginal examination is performed to check for any tampons left behind. A rectal examination is done to check the sphincter tone.
The patient is prescribed broad spectrum antibiotics to prevent secondary infection like cephalosporin and metronidazole for 2 weeks. She is also prescrible laxatives and stool softening agents and is given appointment for physiotherapy. An incident reporting is done.

b) At 6 weeks follow up the patient is assessed for complications as a consequence of the third degree tear. In majority of patients they recover well with no long term effects. She is asked if she has fecal or flatulent incontinence which could indicate improper healing of the anal sphincter. She is also enquired if she has any presistant vaginal discharge which may indicate possibility of a fistula.

c) The prognosis is usually good and at least 60 -80% of patients are asymptomatic at 12 months. If she is symptom free, there is no contraindication for a vaginal delivery in her next pregnancy and there is no role for an episiotomy during the delivery as it does not reduce the incidence of third and fourth degree tear. If the patient does complain of fecal incontinence, she may need a endoanal scan to check the spincter integrity and assessment by a colorectal surgeon. She would be advised for a caesarean section in her next pregnancy. Written information is given and the patient will need to be reassesed during her next pregnancy. The patients wishes will need to be respected regarding the mode of delivery
.


a
. Perineal repair need to be done in theatre with a good lighting. Appropriate anaesthesia should be given as patient need to be relaxed in order to assess and repair appropriately. It should be done by skilled and experience surgeon or trainee under supervision. Presence of a good assistant needed as this provide good exposure to identify the structure. Aseptic technique need to be practiced throughout the procedure to reduce risk of infection along with antibiotic cover. Approximation of the sphincter needs to be done first with long term suture e.g. PDS. Then followed by muscle layer with absorbable suture such as vicryl. Both overlapped or end to end approximation technique can be used.
Post operatively, she can be observed in post natal ward if haemodynamically stable and well. Adequate analgesia need to be given. Indwelling urinary catheter need to be left insitu. She can be allowed soft diet and laxative such as Fybogel can be prescribed to avoid constipation. Perineal care need to be explained to the patient. Debriefing should be done. Breast feeding is not contraindicated. Patient information sheet and contact number should be given. Advice of perineal care and need of attention should be given on discharge.

b. I will ask her regarding her wound healing. Swollen and painful perineum may suggest poor healing due to infection. Her faeces and flatus continence need to be reviewed as faecal incontinence may suggest sphicteric dysfunction. Symptom of dyspareunia need to be asked if she has resumed her sexual intercourse a this is not uncommon.

c. There is increase risk of another third degree tear for her next delivery. If there are no symptoms of faecal incontinence, she can be allowed vaginal delivery. However need to anticipate recurrence and prophylaxis episiotomy on next delivery is not proven to reduce the incidence of recurrent third degree tear. If she is symptomatic of faecal incontinence, manometry of the anal pressure should be measured. If proven sphincteric dysfunction, surgical referral needed. She then need to be offered caesarean section on next pregnancy.

:
a
) Repair should be done in theatre (1) by trained personnel. Adequate lighting, equipment and analgesia is required. It can be done under regional or general anaesthesia .This allows identification of the type of tear,approximation of the torn sphincteric ends and adequate analgesia . The torn ends are approximated using Allis tissue forceps and sutured with 3-0 PDS USING END TO END OR OVERLAP TECHNIQUE (1) . cOLORECTAL SURGEONS PREFER OVERLAP TECHNIQUE. ? obs & gynae exam!
3-0 PDS has long T1/2 ??? and has reduced risk of infection. Knots should be buried how? to prevent knot migration Rest of the tear can be repaired using vicryl rapide how? Should the examiner assume that you know how to repair the tear? . .Intrapartum broad spectrum antibiotics (1) such as augmentin/cephalosporin + metronidazole should be give. Sharps, swabs and needles should be accounted for .P/R should be done at the start and end (1) to assess repair . Indwelling catheter (1) for 24 hrs is advised .
.Postoperatively, she should be advised laxatives, oral antibiotics and adequate analgeia (1) . Debriefing should be done (1) . Advice regarding perineal hygiene and diet should be given .Proper documentation with pictorial representation is best .Risk management form should be filled. Follow up at antenatal clinic at 6weeks/ 12 weeks should be arrang ed. She should have physiotherapy for 6-12 weeks (1) .

b)She should be asked about flatus/faecal urgency .Bowel function questionnaire is helpful (1) . Faecal urgency is defined as inabililty to defer defeacation for more than 5 min .Local examination may reveal absence of anal reflex, soiling .P/R may reveal loss of integrity of sphincter and perineal body were you asked about examination?? Urinary symptoms, perineal pain, dyspareunia .
c)Prognosis for external anal sphincter tears are good . 60-80 % are asymptomatic at 12 weeks following proper repair (1) . There is a risk of developing anal incontinence or worsening symptoms with subsequent vaginal delivery (1) . No role of prophylatic episiotomy (1) . If symptomatic, woman should be counselled about caesarian section (1)



Y
A healthy 25 year old woman is found to have suffered a third degree perineal tear following a normal vaginal delivery. She has been assessed and consented for repair. (a) Discuss and justify your intra-operative and post-operative management [12 marks].
A third degree perineal tear is partial or complete disruption of the anal sphincter muscles which may involve either can internal be involved without external? or both the external or internal sphincter muscles.
Repair should be conducted in the theater under regional or general anaesthesia (1) . This will allow to be performed under aseptic conditions with appropriate instruments, agequate light and assisstant.Either overlapping or end to end technique can be used with equivalent outcome. Where internal anal sphincter(IAS) can be identified, it should be repaired separetely with interrupted sutures (1) ? suture type . For external anal sphincter either PDS or Vicryl can be used with equivalent outcome (1) . For IAS fine sutures as 3,0 PDS or 2,0 Vicryl may cause less irritation.Burying of surgical knots beneaththe superficial perineal muscles (1) is recommended to prevent knot migration, but woman should be warnedof possibility of knot migration with non-absorbable suture. is that all you will repair in a woman with a third degree tear??? Rectal examination, catheter, antibiotics
The method of repair, structures involved suture materials should be clearly documented and the the instruments, swaps, sharps count is correct. The patient should be informed of the nature of her injuryand the benefits of follow up. Written information should be given.
Repair should be performed by appropriately trained doctor, formal training is recommended.
The use of broad spectrum antibiotic intra-op or post-op? is redcommended to reduce postoperative wound dehiscence and infection. Use of postoperative laxatives for about 10 days postpartum associated with reduced incidence of wound dehiscence analgesia . Patient should be offered phisiotherapy and pelvic floor exercises for 6-12 weeks. Local protocols should be implemented regarding antibiotics, laxatives and follow up. Follow up appointment with consultant obstetrician should be arranged 6-12 weeks postpartum (1) .
(b) She attends for follow-up 6 weeks post-partum. Discuss the information you will obtain from the history [3 marks].
The information if any incontinence at follow up referral should be made to specialist gynaecologist or colorectal surgeon for endoanal ultrasonography and anorectal manometry, sometimes secondary repair is necessary.
HISTORY – fecal symptoms, urinary symptoms, perineal pain / dyspareunia
(c) Discuss the prognosis of third degree tears and what you will tell the woman about planned mode of delivery in a future pregnancy [5 marks]
Prognosis is good with 60-80% asymptomatic at 12 months (1) . If symptomatic it is usually flatus or fecal urgency (1) .
The patient should be counselled that the risk increased of developing anal incontinence or worsening symptoms with subsequent vaginal delivery (1) . There is no role of prophylactic episiotomy in subsequent pregnancies (1) . If patient is symptomatic she can have the option of elective caesarean section (1) .


T
he patient should be transferred to the theatre for repair as diagnosis has already been made. She must have adequate analgesia or anaesthesia (1) what would you consider adequate?.The repair should be done under aseptic condition with appropriate assistant , instruments & good source of light for optimum visualisation.. Thorough examination under anaesthesia to be done to assess the extent & nature of injury (1) ( 3a, 3b or 3c according to Sultan’s classification ).Rectal examination should be done .The use of regional or general anaesthesia helps sphincter to relax & permits retrieval of retracted ends of the torn muscle.It also allows to bring the ends together without tension. This repair should be done by a trained operator or a trainee under direct supervision Your management – you are not writing a guideline . Identification & repair of internal anal sphincter (1) should be done separately using 3-0 Polydiaxanon or polyglactine interrupted stitches .Identification & repair of external anal sphincter will be done using same suture materials like external anal sphincter.These fine suture materials cause less irritation & discomfort. The repair of external anal sphincter can be done in two methods, overlapping & end to end with equivalent outcome (1) .The knots in anal sphincter should be buried under superficial perineal muscle (1) to avoid knot migration.Identification of apex of vaginal tear & repair of vaginal wall should be done with continuous non locking stitches using rapidly absorbable suture.Perineal muscle should be repaired with continuous non-locking stitches using same suture ( rapidly absorbable suture ).Perineal skin should be repaired with subcuticular stitches using same suture material (1) .Rectal examination should be done to check that sutures have not been placed through rectal mucosa (1) .Ensure all swabs & instruments are correct.Indwelling cather should be inserted (1) & also prophylactic antibiotic should be given intraoperatively (1) .
Postoperatively, broad spectrum antibiotics (1) should be used to reduce postoperative wound infection & dehiscence.Also postoperative laxative is recommended to reduce wound analgesia dehiscence. Local protocol should be followed regarding antibiotic , laxative, examination & follow up of women with third degree perineal tear.Physiotherapy & pelvic floor exercise should be offered to this lady for 6-12 wks after repair.Finally, she should be given an follow up appointment in 6-12 wks postpartum with consultant obstetrician (1) .

b. Information regarding wound healing, any problem like pain or incontinence of faeces or flatus, fecal urgency should be obtained (1) .If the lady complains of pain or incontinence at follow up visit, she should be referred to specialist gynaecologist or colorectal surgeon for endoanal ultrasonography or manometry & if required secondary sphincter repair may be considered.
you were simply asked about the Hx, not what should be done
c. Prognosis following external anal sphincter repair is very good & 60-80% of patient being asymptomatic in 12 months time (1) . Where women are symptomatic, the symptoms tend to be flatal incontinence or fecal urgency (1) .
I would counsel her that there is a risk of developing anal incontinence or worsening of symptom in her subsequent vaginal delivery (1) .I would also tell her that there is no evidence to support the role of prophylactic episiotomy (1) in her subsequent pregnancies. I would also tell her that she might be offered elective caesarean section during her next pregnancies, if she is symptomatic or had abnormal endoanal ultrasonography and/or manometry (1) . She should be counselled at booking visit during her subsequent pregnancy regarding the mode of delivery & it should be documented clearly in her notes.
Excellent answer


(a
) Discuss and justify your intra-operative and post-operative management [12 marks].

I will repair in operating theatre for getting aseptic environment with good light with proper instruments and good assistant. I will ensure proper analgesia or anaesthesia (1) what is proper?. It will give adequate relaxation of anal sphincters which is essential to retrieve torn ends of anal sphincters and to repair without tension. Through examination under anaesthesia (1) including PR would be done again before repair to identify nature and extent of injury. I will identify and repair internal anal sphincters(IAS) and external anal sphincters separately. Fine sutures (delayed absorbable polydiaxanone,3-0 or 2-0 polyglactin) are used which will cause less irritation and discomfort. IAS is repaired by interrupted stiches (1) and EAS by end-to-end or by overlapping sutures (1) . I will bury the knots in anal sphincters under perineal muscles (1) to prevent knot migration / perineal irritation. I will identify the apex of vaginal wall injury and repair by continuous non-locking technique with rapidly absorbable suture ( polyglactin vicryl rapide). I will then repair the perineal muscles by same methods(continuous non-locking with rapidly absorbable sutures). After that I will repair perineal skin by sub-cuticular with rapidly absorbable sutures which will lower perineal pain (1) . I will then perform rectal examination to see whether rectal mucosa were involved in sutures (1) or not and to see sphincteric integrity . Instruments , sharps, swabs will be accounted for. Indweling bladder catheter (1) to avoid urinary retention and prophylactic anbiotiocs (1) to prevent infection.
Postopratively, I will prescribe broad-spectrum antibiotics (1) (including metronidazole for anaerobes)to prevent post-oprative infection and dehiscence. Adequate laxatives like lactulose will be given for softening stool to prevent wound dehiscence. I will follow the unit protocol. I will discuss nature of injury with woman (1) and her partner or family members and benefits of further follow-up visits( including physiotherapy , pelvic floor exercise, further managements). Clear documentation including structures involved , methods of repair, sutures materials. I will provide her written information

(b) She attends for follow-up 6 weeks post-partum. Discuss the information you will obtain from the history [3 marks].
I will ask about her incontinence of flatus or leakage of soft or hard stools suggestive of anal incontinence and severity of somptoms (1) , impacts on quality of life. I will enquire about her perineal discomfort or pain. Also I will try to disclose about any problems of conjugal life such as dyspareunia(superficial) (1) .

(c) Discuss the prognosis of third degree tears and what you will tell the woman about planned mode of delivery in a future pregnancy [5 marks]
Prognosis is good, about 60-80% willl be asymptomatic at 12 months (1) . Those who remain symptomatic, usually complain about incontinence of flatus or faecal urgency (1) .
I will tell her that there will be risk of developing anal incontinence or worsening symptoms with subsequent vaginal delivery (1) . I will inform her that no evidence to support prophylactic episiotomy in future pregnancy (1) . If she has any symptoms of perineal dysfunctions or abnormal endo-anal untrasonogram and / or manometry I will give her option for elective casarean section delivery in future pregnancy (1) . Her informed choice in future delivery plan must also be considered and respected.

Excellent answer


A)
I will undertake the repair in an operating theatre under regional or general anesthesia (1) . This will allow the repair to be performed under aseptic conditions with appropriate instruments, adequate light and an assistant.Regional or general anesthesia will allow the anal sphincter to relax,which is essential to retrieve the torn ends of the anal sphincter.This also allows the ends of the sphincter to be brought together without tension.
The External anal sphinter would be repaired ,either by end to end or overlapping method (1) ,using either monofilament sutures such as PDS or braided sutures i.eVicryl.Both have been found to be equally effective.Internal anal sphincter repair is best performed by interrupted sutures,using fine suture size ,3-0 PDS or 2-0 vicryl (1) ,as this causes less irritation and discomfort.I would take care to bury the surgical knots beneath the superficial perineal muscles (1) to prevent knot migration to the skin.Long acting and non absorbable suture material is avoided as there is possibility of knot migration to the perineal surface. will you repair the rest of the tear? Catheter, antibiotics, PR…
Postoperative care is crucial following the repair.Intraoperative and postoperative broad spectrum antibiotis (1) and laxatives are given according to unit protocol to reduce the incidence of postoperative infections and wound dehiscence.This would also reduce the risk of anal incontinence and fistula formation.She should be offered physiotherapy for 6-12 weeks and reviewed by consultant obstetrician and gynaecologist (1) .
Incident report is done.I would ensure that anatomical structures involved,method of repair and suture materials are clearly documented and instruments sharps and swabs are accounted .She should be fully informed of the nature of her injury (1) and the benefits to her of follow-up.Written information will be given.
b)At follow-up,if facilities are available ,she should be seen in a dedicated perineal clinic.She should be enquired about incontinence of flatus or fecal urgency or pain (1) do you expect to get 3 marks for a single sentence?.
c) Woman should be advised that the prognosis following EAS repair is good,with 60-80%asymptomatic at 12months (1) .
She should be counselled at the booking,about the risk of developing anal incontinence or worsening symptoms with vaginal delivery in next pregnancy (1) why wait till the booking visit??.and prophylactic episiotomy has not been found to be very useful is it a bit useful? .
If she is symptomatic and complains of anal incontinence,she should be referred to colorectal surgeon for endoanal ultrasound and anorectal manometry.In case of abnormal results,she should be given option of caesarean section (1) .This information regarding mode of delivery should be clearly documented in her records ,
See excellent answers above

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(a[size=18]
) Third degree perineal tear should be sutured in operating theater and under regional or general anaesthesia (1) .Appropriat instruments,adequate light and an assistant are required . Inespection of the rest of genital tract for any other injury PV / PR to identify extent of injury .Repair will be either by overlapping or end to end method which sphincter? .No evidence to support of use of one method over the other. Internal anal sphincter (IAS) is identified and sutured separatly by fine suture how? (3-0) PDS or (2-0) vicryl to reduce irritation and discomfort. .External anal sphincter(EAS) repair is done by monofilament suture as (PDS) or braided suture as (vicryl) with equivilant outcome (1) . Burying of surgical knots beneath the superficial muscle of perineam (1) is recommended to prevent knot migration .Identification of apex of vaginal tear is repaired by continuous non locking suture . Suturing of perineal muscle in two layers which 2 layers?? and closure of skin by subcuticular suture to reduce pain is performed. Post operative intra-op antibiotics?? managment include use of broad spectrum antibiotic + metronidazol for anaerobic bacteria to reduce risk of infection and wound dehiscence . Laxative use is recommended to reduce risk of wound dehiscence. Post operative analgesia as non steroidal anti inflammatory drugs are effective to control pain (1) . I will provide post operative information about perineal care to reduce infection . I will offer physiotherapy and pelvic floor exercise for 6-12 weeks after repair (1) . Incident form should be filled and documentation of procedures performed .

(b) I would ask her about any symptoms regarding incotinence of flatus or urgency of faeces (1) .Also, i would ask her about perineal pain and pain during intercourse (1) (dysparonia).

(c) Woman should be informed that the prognosis following EAS repair is good. 60-80% are asymptomatic at 12m (1) . I would advice her that no evidence to support use of prophylactic episiotomy in subsequent pregnancy (1) . Iwould inform her that she has the risk of developing anal incontinence or worsening of symptoms in subsequent vaginal delivery (1) . I would inform her that if she have symptoms or abnormal endoanal ultrasound and/or manometry , she should have elective c/s in next pregnancy (1) .
See excellent answers above



(a
)Adequate analgesia in the form of either spinal or general anaesthesia is indicated as it will help relax the anal sphincter, thereby helpful in retrieving the torn end of the sphincter.
Repair should be done in theatre (1) with adequate lighting and assistance to enable a good repair thereby helping in good recovery and less post operative complication.
A systematic assessment including a vaginal as well as rectal examination (1) prior to commencement of repair, to identify the anatomical structures involved is done. This helps in the correct documentation of the same helping in audit and risk management as well as assist in choosing the appropriate suture materials.
Internal anal sphincter is sutured separately (1) with 3-o pds or 2-o vicryl if injured. The external anal sphincter is sutured either by end to end anastamosis or by overlapping technique using either 3-o pds or 2-o vicryl (1) . The finer suture materials reduce the discomfort and irritation. There has been no difference in the long term complication or results with either technique. The knot is buried under the perineal muscles and overlapped to prevent knot migration (1) . The rest of the tear is repaired with vicryl rapide in a continuous method with sub cutaneous to skin.
Rectal examination (1) and clear documentation of instrument, swab and needle count helps in audit and risk management.
Intra and post operative broad spectrum antibiotics (1) help to reduce the risk of infection as sepsis can lead to breakdown of the repair leading to increased incidence of incontinence as well as development of fistulae formation. Addition of metronidazole what do you understand by broad spectrum antibiotics if it does not include anaerobic cover??? need to be considered ,to cover anaerobes present in the faeces.
Laxatives including stool softerners like lactulose and bulking agents like fybogel help to reduce the strain and pressure associated with straining and are prescribed for 10 days (1) analgesia .
Risk managent form need to be filled as it a nofifyable incident . Written information in the form of patient leaflet help with counselling.
Post natal appointment with the consultant at 6-12 weeks helps in de briefing as well as to elicit symptoms which might need referral to a colorectal surgeon. Physiotherapy and pelvic floor exercise for 6-12 weeks (1) help to improve the results.
(b)I will inquire about any history of incontinence of faeces or flatus ,as well as any urgency or urge incontinence of faeces or flatus (1) . Any history of pain need to be enquired urinary symptoms, dyspareunia .
Any of the above symptoms prompts a referral to colorectal surgeon with a special interest in 3rd degree tears for further investigations in the form of anal ultrasound and/or anorectal manometry. you were only asked about Hx, not what you will do with it
(c) Women need to informed that the prognosis after surgery for external anal sphincter is good. 60-80% of women are asymptomatic after 12 months (1) . In the symptomatic group of women the predominant symptoms are incontinence of flatus and fecal urgency (1) .
Secondary surgery with a colorectal surgeon may be necessary if she remains symptomatic or there is abnormal anal ultrasound or anorectal manometry.
She needs to be informed that she can develop incontinence or worsening of symptoms after subsequent pregnancy and delivery (1) .
Prophylactic episiotomy is not recommended (1) as they have not been any documented benefit.
Mode of delivery need to be discussed and documented at booking and an elective ceaserean offered if she is symptomatic or there is abnormal anal ultrasound or anorectal manometry (1
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