2015 29 3rd & 4th Degree Tears

Question 1

** At what angle should episiotomy be cut? **

Answer 1

60° from the midline

Question 2

** What suturing technique should be avoided in OASI? **

Answer 2

Figure of 8 as can cause tissue iscahemia

Question 3

** What suturing technique should be used for anorectal mucosa? **

Answer 3

Continuous or interrupted

Question 4

** What suturing technique should be used for the internal anal sphincter? **

Answer 4

Separately with interrupted or mattress sutures
Do not attempt to overlap

Question 5

** What suturing technique should be used for the external anal sphincter? **

Answer 5

Full thickness: overlapping or end to end
Partial thickness (all 3a & some 3b): end to end

Question 6

** Which suture material should be used to repair anotectal mucosa? **

Answer 6

3-0 polyglactin (braided) eg Vicryl
Because more comfortable than PDS

Question 7

** What suture material should be used to repair IAS & EAS? **

Answer 7

Monofilament eg 3-0 PDS
Or modern braided eg 2-0 polyglactin

Question 8

** How should OASI be managed postoperatively? **

Answer 8

1. Broad-spectrum antibiotics
2. Postoperative laxatives eg lactulose (not bulking agents)
3. Advice re: benefits of physiotherapy
4. Special interest review 6-12 weeks
5. Gynae/colorectal review if incontinence or pain at follow-up

Question 9

** What proportion of women are asymptomatic 12 months following OASI repair? **

Answer 9

60-80%

Question 10

** How should future pregnancies be managed following OASI? **

Answer 10

1. Counselling about mode of birth
2. Episiotomy only if clinically indicated
3. ElCS as option, particularly if symptomatic or abnormal endoanal US or manometry

Question 11

What are the incidence rates of OASI?

Answer 11

2.9% overall
6.1% primips
1.7% multips

Question 12

How are perineal tears classified?

Answer 12

1st ° Skin &/or vaginal mucosa
2nd ° Perineal muscles but not sphincter
3rd ° Anal sphincter complex
3a: EAS < 50% thickness
3b: EAS > 50% thickness
3c: EAS & IAS
4th ° Anorectal mucosa as well as 3rd °

Question 13

What is a buttonhole tear?

Answer 13

Tear to rectal mucosa with intact anal sphincter complex
NOT a 4th degree tear

Question 14

What are the risk factors for OASI?

Answer 14

1. Asian ethnicity
2. Nulliparity
3. Birthweight >4kg
4. Shoulder dystocia
5. OP position
6. Prolonged 2nd stage of labour
7. Instrumental delivery

Question 15

What are the OASI rates for instrumental birth?

Answer 15

22.7% forceps without epis
6% forceps with epis
6% Ventouse without epis
2% Ventouse with epis

Question 16

What are the 4 aspects of perineal protection?

Answer 16

1. Left hand slows delivery of head
2. Right hand protects perineum
3. Mother stops pushing at crowning
4. Episiotomy if at risk