FREE ONLINE CME

To earn CME credit for this article, participants

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activity is May 1, 2006. The expiration date is
May 1,2007.

CME Learning objectives

Upon completion of this article, participants will
be ^ l e to:
Restate the risks for repeat sphincter
laceration and/or anal incontinence in women
with overt versus occult perineal lacerations,
based on the latest research cited.
Using currently available evidence, document
anal incontinence symptoms and ultrasound
assessment of anal sphincters during
prenatal counseling of women with previous
extensive perineal tears.
After evaluating the authors' risk assessment
algorithm, formulate a practical,
evidence-based approach to counseling
women about their risk for repeat lacerations
with vaginal versus cesarean delivery.
Accreditation

This activity has been planned and implemented

in accordance witfi the Essential Areas and
Policies of the Accreditation Council for
Continuing Medical Education through the joint
sponsorship of Tfiomson American Health
Consultants (AHC) and Contemporary OB/GYN.
Thomson American Health Consultants is
accredited by the ACCME to provide continuing
medical education for physicians.
Thomson American Health Consultants
designates this educational activity for a
maximum of 1 AMA PRA Category 1 Credit(sf".
Physicians should only claim credit
commensurate with the extent of their
participation in the activity.
Target audience

Obstetrician/gynecologists and women's health

practitioners.
Disclosures

The authors of this article (Husam Abed, MD.

and Rebecca Rogers, MD) report no
relationships with companies having lies to this
field of study. Judith M. Orvos and Elizabeth A.
Nissen disclose that they do not have any
financial relationships with any manufacturer in
this therapeutic category.

3 4 CONTEMPORARY OB/GYN MAY 2006

Managing future
pregnancies after a
severe perineal
laceration
By Husam Abed, MD, and Rebecca Rogers, MD

Whal do you tell a pregnant patient with a

previous third- or fourth-degree tear, for
whom another vaginal delivery raises the
risk of further injury? Can some women
even safely have a trial of labor? Diagnose
occult tears with ultrasound, advise these
expertsand use it to assess the anal
sphincters of all incontinent women.

he advice you give a

pregnant palienl who has
suffered an anal sphincter laceration during a previous
delivery can have a critical impact
on her quality of life. With
another vaginal birth, she's more
likely to suffer a repeat anal
sphincter tear and worsening
symptoms of anal incontinence.
Sexual dysfunction may also he

at stake. Despite all this, there are

no easy answers, because the hest
way to manage a subsequent pregnancy of a woman with a previous
tear is controversial.
Sphincter tears resulting from
vaginal delivery occur in 0.7% to
19.3% of births, mostly during a
first pregnancy.' '' How do you
advise the many patients who
become pregnant again? Our goal

DR. ABED is Clinical Faculty, and DR. ROGERS is Director, Division of Female Pelvic Medicine and
Reconstructive Surgery, University of New Mexico. Albuquerque, N.M.

Grand Rounds

PERINEAL LACERATION

FIGURE 1. Third-degree perineal laceration

FIGURE 2. Fourth-degree perineal laceration

Bulbocavemosus
muscles
Transverse
perineal muscles

External anal
sphincter

here is to review the classification

and complications of anal sphincter
lacerations, as well as outcomes following subsequent vaginal delivery.
We'll also present management
strategies for future pregnancies.
Anatomical knowledge of the
anorectal canal is essential. The
canal is surrounded by a complex
tube of muscle fibers composed of
the external and internal sphincters.
The striated muscles of the external
sphincter are under voluntary control, and are responsible for the
squeeze tone of the rectal canal.
The smooth muscle of the intemal
sphincter, on the other hand, maintains resting tone and is responsible
for minute-to-minute fecal continence. Both muscle groups overlap
for a distance of 2 cm and extend
4 cm up the canal. The external
sphincter is attached to the perineal

3 6 CONTEMPORARY OB/GYN MAY 2006

Internal anal
sphincter

Rectal
mucosa

body and is surrounded by the ter lacerations remain continent. ]

Anal sphincter lacerations are
puborectalis muscle.
Although both sphincters are further classified into "overt" or
important in maintaining conti- "occult" lacerations. Overt laceranence, laceration classification is tions are identified and repaired at
based only on the extent of injury the time of delivery, while occult
to the external anal sphincter. lacerations can only be diagnosed
Third-degree lacerations include by ultrasound or magnetic resocomplete or partial laceration of nance imaging. Occult lacerations,
the external sphincterwith or which are most commonly diagwithout internal sphincter lacera- nosed by U/S, can occur beneath
tion (Figure 1), whereas fourth- an intact perineum or in the presdegree lacerations include com- ence of less severe second- or firstplete laceration of both sphincters degree tears in up to 35% of firstwith extension into the rectal time deliveries.^ (Figure 3 shows a
mucosa (Figure 2). [Anal conti- normal finding on translabial U/S,
nence doesn't completely depend while Figures 4 and 5 show occult
on intact sphincters; also impor- lacerations using translabial and
tant are intact neuromuscular transanal U/S respectively.)
function, including a functioning
[Five key risk factors of severe
puborectalis muscle and pudendal lacerations are: (1) Midline epinerve. This is supported by the siotomy, (2) Forceps or vacuum
fact that some women with sphinc- delivery (vacuum being less trau-

matic than forceps), (3) Asian

ancestry, (4) High birthweight, and
Watch for these complications

Complications of anal sphincter laceration

include anal incontinence, fecal urgency,
perineal pain, and sexual dysfunction.

Complications of anal sphincter tinence rates reported by women

laceration include anal inconti- with and without lacerations may
nence, fecal urgency, perineal pain, fade with advancing age. For examand sexual dysfunction. The statis- ple, a 30-year retrospective cohort
tics are disturbing. Anal inconti- showed equivalent rates of anal
nence, defined as "the involuntary incontinence among women who
loss of flatus, liquid or solid stool delivered vaginally with sphincter
that is a social or hygienic prob- rupture, episiotomy without
lem," occurs in 15% to 59% of sphincter rupture, or C/S delivery'^
women after anal sphincter laceraAlthough sexual function followtion with repair at the time of ing sphincter disruption is less well
delivery.* Anal urgency plagues an studied, women with third- and
additional 6% to 28% of women. fourth-degree lacerations were
Fecal incontinence, the loss of found to be nearly three times
loose or formed stool, is less com- more hkely than those who delivmon, occurring in 2% to 23%.'^ ered intact to complain of dyspareThese symptoms may occur after unea at 3 months postpartum.'"^
either overt or occult laceration.^
Longer term follow-up to 5 years
confirms the persistence of anal
incontinence symptoms following
obstetric sphincter laceration.^"-^ In
addition, despite documented primary repair at the time of delivery,
up to 90% of women have persistent defects on U/S follow-up.^
[ Moreover, primary cesarean
dehvery doesn't provide complete
protection from anal incontinence.
Symptoms can even occur after
planned cesarean delivery J despite
absence of sphincter laceration," In
fact, the Breech Trial, which randomized women to C/S versus vaginal delivery, found no differences
between delivery groups in the incidence of fecal (RR 1.10; 95% CI;
0.47-2.58) or flatal incontinence
(RR 1.14; 95% Cl; 0.80-1.61)."
Likewise, differences in anal incon- IASInternal anal sphincter; EASE>;temal anal sphlfictet

Effect of suhsequent vaglnal

delivery

Although women with lacerations

report more incontinence than
women without tears, incontinence symptoms increase in both
groups with subsequent deliveries.
A prospective cohort study of 242
women 5 years after vaginal delivery found that age, prior sphincter
laceration, as well as subsequent
vaginal delivery predicted anal
incontinence symptoms.'
Overt lacerations

[ The risk of laceration during a second delivery in women who have

MAY 2006 CONTEMPORARY OB/GYN 3 7

PERINEAL IACERATION

EASExternal anal spfilficter; IASIntemal anai sphincter

had a previous tear is increased two

to five times over women who had
no history of overt laceration.''"''^
Recurrence risk is highest when the
second dehvery is operative vaginal
(OR 6.5; 93% CI; 1.5-9.4) or when
episiotomy (OR 17.4; 95% CI;
7.5-51) is performed."'] A population-based study found a 4.4%
recurrence risk of sphincter laceration with subsequent delivery and
concluded that 23 C/S deliveries
would be needed to prevent a single repeat laceration.'''
Subsequent vaginal delivery also
affects the severity of incontinence
symptoms. A study of 117 wotnen
with third- or fourth-degree lacerations found that 43 women who
underwent another vaginal delivery
had an increased risk (RR 1.6; 95%
Cl; 1.1-2.5) of anal incontinence
when compared to 74 women who

38

CONTEMPORARY OB/GYN MAY 2006

EASExternal anai sptilncter: IASinterna) anal spnincter

did not have another delivery up to

10 years after primary repair.'^ A
primary fourth-degree laceration
probably causes more severe anal
incontinence symptoms than thirddegree lacerations.'" !n a series of
177 women with anal sphincter
laceration, severe anal incontinence
was reported more often after a second delivery in those who had sustained a fourth-degree laceration in
their first delivery than for women
with only third-degree lacerations
(P=0.043).-''
Another factor influencing the
risk of anal incontinence with subsequent delivery is the severity of
symptoms following the incident
delivery. Of 56 women with complete external anal sphincter tear,
23 (41%) had transient incontinence and 4 (7%) had permanent
incontinence following their first

delivery. Among the 23 with transient incontinence, symptoms

recurred in nine (39%) of the
women with a subsequent delivery,
and in four of them (17%), these
symptoms became permanent.'^'
Not all studies support the conclusion that subsequent delivery
contributes to anal incontinence.
A study that compared 125 women
with third- and fourth-degree lacerations to 125 controls 14 years after
their first delivery did identify
sphincter laceration as an independent risk factor for fecal incontinence
(RR 2.54; 95% CI; 1.45-4.45).
However, subsequent vaginal deliveries were not associated with an
increased risk of fecal incontinence
(RR 2.32; 95% Cl; 0.85-6.33).^^
Researchers did another retrospective analysis via phone interviews
about continence with 234 women

who had sustained a complete thirddegree laceration. In this cohort, no

differences were found between
women with zero, one, or two subsequent deliveries, nor were there
any differences between women
who sustained additional thirddegree lacerations and those without any subsequent deliveries.^^
These studies question whether
increases in anal incontinence are
due to subsequent vaginal delivery
or to other influences, such as age.

Ultrasound assessment of the anal

sphincters may be indicated in all women
who are incontinent.

women with occult sphincter lacera- delivery method for a subsequent

tions found anal incontinence symp- pregnancy by discussing it with the
toms increased in those who under- patient. It's essential to document
went subsequent vaginal delivery transient or permanent anal inconcomparKi to women with no history tinence symptoms following the
of sphincter laceration or second previous delivery J The appearance
deiivery (RR 11.2,95% Cl, 1.4-86.2).'^ of the anal opening, as well as a
rectal exam, should be documented
Strategies for managing
and the presence of a rectovaginal
Occult lacerations
subsequent pregnancies
fistula (which occurs in up to 3%
[ Although occult lacerations are asso- [ After sphincter laceration, clini- of women after anal sphincter lacciated with postpartum anal inconti- cians can only determine the best eration) should be excluded." U/S
nence, appropriate management of
subsequent pregnancies remains
FIGURE 6. Algorithm for deciding on route of delivery
controversial. ] Does immediate verin subsequent pregnancy
sus subsequent repair of occult
lacerations make a difference?
Investigators randomized 752
women with second-degree laceraHistc ty of third- or foi rth-degree laceration
tion to either clinical examination
cr
anal incontine ice symptoms
and repair of the second-degree laceration or U/S. If a sphincter laceration was suspected on U/S, all these
women underwent surgical exploration for repair of the sphincter lacHistory of secondaiv m^
Asymptomatic
Symptomatic
eration. Of 21 suspected sphincter
ref air
H
and
or
lacerations on U/S, 16 were identiSphincter defect on anal
No defects on anal
fied by surgical exploration and
endosonography
endosonography
repaired. At 1 year follow-up, the
group that underwent U/S postpartum and immediate repair of^ an
Reasonable to attempt
Offer C/S
Offer C/S
occult sphincter laceration were less
vaginal delivery
Level
B/C
Level
C/D
likely to develop severe anal incontiLevel B/C
recommendation
recommendation
nence than the group without U/S
recommendation
(3.3% vs. 8.7%, P= 0.03)." The
authors concluded that U/S was
indicated to diagnose occult laceraLevel B recommendations = Based on limited or Inconsistenl sdenlillc evidence
tion and that immediate repair
Level C recommendations = Based chiefly on consensus and expert opinion
resulted in less anal incontinence.
Level D recommendations = Based on evidence inadequate or conflicting
Another prospective cohort study of

MAY 2006 CONTEMPORARY OB/GYN 3 9

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assessment of the anal sphincters

may be indicated in all women who
are incontinent. It is also useful in
counseling women who have a history of a prior laceration, but
remain continent.
At the time of counseling,
inform women of an increased
risk of repeat laceration with
another vaginal delivery. [Continent women are less likely to
develop anal incontinence ] than
women who previously had
symptoms of either transient or
persistent anal incontinence.
[Patients with transient incontinence are at significant risk of
developing permanent symptoms
and these symptoms may be
worse than those experienced
with their first delivery.] Nearly
all women with anal incontinence
will experience deterioration of
their symptoms. All of these
outcomes are compounded by
episiotomy and operative delivery,
which increase the risk of repeat
laceration and subsequent anal
incontinence. These views are
echoed by a recent ACOG Practice Bulletin that states, "The best
available data do not support the
liberal or routine use of episiotomy.^^ It's unclear whether
long-term symptoms following a
repeat vaginal delivery in women
with prior sphincter laceration are
different than those without a history of laceration. Thus, this issue
deserves further investigation.
Risks of C/S delivery must also be
discussed. Although it hasn't been
studied, women with a history of
sphincter repair remote from
delivery for anal incontinence are

almost universally offered C/S

delivery for a subsequent pregnancy Figure 6 is a decision tree
that addresses route of delivery
for these patients.

4 0 CONTEMPORARY OB/GYN MAY 2006

Conclusions

Women with a history of anal

sphincter laceration are more
likely to develop another laceration and worsening anal incontinence symptoms with another
vaginal birth. Trial of labor in
women with a histor)' of sphincter
laceration who are asymptomatic,
show no defects on U/S, and have
not undergone a secondary' repair
of the anal sphincter, may not
affect anal incontinence symptoms. Avoid operative delivery
and episiotomy, because they
compound the risk for further
damage in al! these women. After
a thorough consultation about the
risks and benefits of attempting a
repeat vaginal delivery, elective
C/S delivery is appropriate for
symptomatic women. D
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