Clinical and Experimental Health Sciences 3rd and 4th Degree Perineal Tears that Occurs During Vaginal Delivery Mustafa Senturk1 , Yusuf Yavuz2 1 2 Necmettin Erbakan University, Meram School of Medicine, Department of General Surgery, Konya, Türkiye. Sanliurfa Training and Research Hospital, Clinic of General Surgery, Sanliurfa, Türkiye. Correspondence Author: Mustafa Senturk E-mail: m-sntrk@hotmail.com Received: 29.04.2021 Accepted: 04.04.2022 ABSTRACT Objective: Perineal injuries are common in vaginal delivery. In this study, we aimed to investigate the factors affecting the degree of perineal injury and the effect of injury degree on incontinence. Methods: Fifteen patients, underwent sphincter repair by the general surgery unit, who had perineal tear during normal vaginal delivery between January 2018 and March 2019 in our hospital and were retrospectively evaluated. Those with grade 3a and 3b perineal tears were divided into 2 groups as group-1, and those with grade 3c and grade 4 perineal tears as group-2. Episiotomy type, fetal characteristics [head circumference and birth weight], early postoperative continence findings were compared in between groups. Results: The average age of the patients was 30 ± 8.7 years. When the groups were compared, there was no significant superiority of episiotomy in terms of perineal injury (p=0.07). 4 patients had 3a, 3 patients had 3b, 6 patients had 3c and 2 patients had fourth-degree perineal injuries. F-florbetaben The average birth weight of the newborns was 3438 ± 492 g, and the head circumference was 34.33 ± 1.23 cm. There was no significant difference in incontinence between the groups (p=0.55). Conclusion: The treatment of anorectal injuries is surgery. The method of treatment varies according to the time elapsed between injury and intervention, fecal contamination, degree of injury, general condition of the patient, presence of accompanying injury, experience and preference of surgeon. We think that sphincter damage during delivery can be looked after successfully with early diagnosis and intervention before tissue edema develops. Keywords: Perineal Tears, Fecal incontinence, Sugical treatment Our findings of positive association of plasma transthyretin levels with global and regional 1. INTRODUCTION Perineal injury is one of the major complications during vaginal delivery. Perineal injury can develop during urological, gynecological and coloproctological interventions. [1,2]. and has 2 definitive are Classification of perineal pathological injury is usedfeatures, for gradingwhich perineal neurofibrillary tangles (NFTs) of intracellular aggregation injury. Obstetric anal sphincter injury, including third and fourth degree perineal tears, occurs in approximately 3% of women after their first birth and 0.8% of women who have had at least one previous birth [3]. It has also been reported that the true incidence can be as high as 11% in some series [4]. There are publications in England and Norway showing that the incidence has increased in recent years [5,6]. It is unclear whether these changes are due to an actual uplift or greater awareness. A perineal tear during delivery is an important cause of short and long term maternal morbidity. Urinary incontinence, anal incontinence, perineal pain, sexual dysfunction may cause many problems after perineal injury. Anal incontinence has been reported by 4.3% of women aged 15 to 60 years with Clin Exp Health Sci 2022; 12: 396-400 ISSN:2459-1459 or without injury to the perineum. [7]. Intestinal symptoms have a significantly greater progression to in women with perineal injuries risk vary of between 7.6% and 61% depending on parity and injury type. [8]. Risk factors for perineal injuries involving anal sphincter include gestational age, nulliparity, duration of delivery, occipitoparietal diameter and birth weight. Episiotomy is controversial some studies have shown that the risk is reduced with a mediolateral incision, while in others it is increased or unchanged [9]. In this study, we aimed to investigate the factors affecting the degree of perineal injury and the effect of injury degree on incontinence. 2. METHODS We retrospectively evaluated patients who have perineal injuries during normal vaginal delivery and underwent fibrillation. In anbyingeneral vivo AD transgenic mouse model, sphincter repair surgery unit in our hospital between January 2018 and March 2019. The study was conducted according to the Declaration of Helsinki. The patients identified Copyright © 2022 Marmara University Press DOI: 10.33808/clinexphealthsci.929691 Content of this journal is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. Original Article Anal Sphincter Injury for this series were retrieved from the surgical department records. Ethics committee approval was received for this study (E2-22-1623). During this period, the total number of 35.614 deliveries takes place in our hospital, including 23.816 spontaneous vaginal delivery and 11.798 cesarean delivery. Patients with first degree and second-degree perineal injury were not included in the study. Only perineal injury of 3rd degree and above was included [Table-1] [10]. The perineal injury classification was used to determine treatment and the degree of rectal injury. The degree of injury was determined by intraoperative physical examination. We used the Cleveland Clinic Florida Fecal Incontinence Score (CCFIS) system [Table-2] [11]. Scoring was done according to the follow-up data in the system. Patients whose follow-up did not come were called for control. There was no anorectal manometry in our hospital; Therefore, patients were referred to comprehensive centers. Table 2. Cleveland Clinic Florida Fecal Incontinence Score (CCFIS) Frequency Never Table 1. Classification of perineal injury Grade 1 Grade 2 Grade 3 3A 3B 3C Grade 4 Laceration of the vaginal mucosa or perineal skin only Laceration involving the perineal muscles Laceration involving the anal sphincter muscles, being further subdivided into 3A, 3B, 3C: Where <50% of the external anal sphincter is torn Where >50% of the external anal sphincter is torn Where the external and internal anal sphincters are torn Laceration extending through the anal epithelium (resulting with a communication of the vagina epithelium and anal epithelium) Solid stool leakege 0 1 2 3 4 Liquid stool leakege Gas leakege Pad use (for stool) Lifestyle restriction 0 0 0 0 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 Never = 0; Rarely = <1/month; Sometimes = <1/week but >1/month; Usually = <1/day but >1/week; Always = >1/day. 2.2. Statistical Analysis Social Science Statistical Package 22.0 (SPSS Inc., Chicago, IL, USA) software was used for biostatistical analysis. Kolmogorov-Simirmov and Shapiro-Wilk tests were used to check the distribution of parameters. Mann Whitney U test was used for comparison of independent groups and Fisher’s exact chi-square tests in cross tables were used for categorical data. In the interpretation of the statistical hypothesis tests, a type 1 error was accepted as 0.05. Those with grade 3a and 3b perineal tears were divided into 2 groups as group-1, and those with grade 3c and grade 4 perineal tears as group-2. Age, parity, episiotomy type, fetal characteristics [head circumference and birth weight], anesthesia type, first intervention time, instrumentation during delivery, perineal injury classification, surgical intervention, and early postoperative continence findings were compared in between groups. Data of 18 patients were collected. Fifteen patients with complete data were included. Written consent was obtained from all patients for surgical procedures. 3. RESULTS The average age of the patients was 30 ± 8.7 years. The mean number of delivery was 3 (min-max: 1-7). 14 patients underwent spinal anesthesia and 1 received general anesthesia during normal vaginal delivery and underwent surgery due to third and fourth-grade perineal tears. The mean duration of the first intervention was 70 minutes (min-max: 30-90 minutes). Episiotomy was performed in 11 patients (73.3%). When the groups were compared, there was no significant superiority of episiotomy in terms of perineal injury (p = 0.07). 4 patients had 3a, 3 patients had 3b, 6 patients had 3c and 2 patients had fourth-degree perineal injuries [Figure 1]. In 3 of the cases, birth weight was over 4000 g. The average birth weight of the newborns was 3438 ± 492 g, and the head circumference was 34.33 ± 1.23 cm . On the postoperative first day, rectal examination of the patients it was showed that sphincter tone decreased. On the 7th day, rectal examination showed that sphincter tones were more active than the first day examination but decreased compared to normal. Colostomy was not performed in any patient. 2 patients (13.4%) had less than one gas incontinence per month, 1 patient (6.7%) had less than one gas and stool incontinence per month. There was no significant difference in incontinence between the groups (p=0.50) [Table-3]. The average follow-up period was 9.8 ± 4 months. None of the patients developed surgical complications. 2.1. Surgical Technique End-to-end repair was performed in all our cases. The ends of the torn muscle were grasped with Allis forceps and endto-end repair was performed with 3/0 or 2/0 polyglactin sutures. Because overlap can be technically difficult, a torn internal sphincter mattress or single interrupted sutures should be approximated. In addition to preoperative antibiotic prophylaxis, all patients were administered with post-operative broad-spectrum antibiotics. Medical constipation was achieved with the drug containing diphenoxylate + atropine sulfate active ingredients, preventing the wound from contacting with stool. Medical constipation was achieved for three days postoperatively. Oral food intake was started on the third postoperative day. Perineal examination and digital rectal examination was done at the postoperative follow-up and regular policlinic examination. They were advised to avoid vaginal delivery. In all patients, treatment with laxatives was started to promote bowel. Clin Exp Health Sci 2022; 12: 396-400 Rarely Sometimes Usually Always 397 DOI: 10.33808/clinexphealthsci.929691 Original Article Anal Sphincter Injury Table 3. Properties of the groups and comparison results Yes No Episiotomy Done No Head circumference(cm) (mean±SD) Birth weight (g) (mean±SD) SD: Standart Deviation Incontinens Group-1 (Grade 3a-3b) 1 (14.2%) 6(85.8%) 7(100%) 0(0%) 34.1 ± 1.4 Group-2 P (Grade 3c-4) 2(25%) 0.55 6(75%) 4(50 %) 0.07 4(50%) 34.5 ± 1 0.69 3335 ± 424 3527 ± 558 0.53 Figure 2. Post-repair image Figure 2. Post-repair image Figure 1. A patient with type 3b injury 4. DISCUSSION Table 4. Demographic characteristics of patients (n=15) n Age (Years) Number of delivery Anesthesia type General Spinal Time to first intervention (Minute) Grade of injury Grade 3A Grade 3B Grade 3C Grade 4 Episiotomy Done None Birth weight of the newborns (gr) Head circumference (cm) İncontinens Gas Gas+stool None Average follow-up (month) Clin Exp Health Sci 2022; 12: 396-400 % The morbidity rate is high in perineal tears during delivery. Fecal incontinence is one of the most important of these. Obstetric trauma or sphincter defects after perianal field surgery are the main causes of stool incontinence. During vaginal delivery, 53% to 79% of patients have varying degrees of perineal injury. [8,12]. Rectal examination should be performed in vaginal deliveries so that perineal tears are not overlooked. Maternal or fetal features may cause perineal injuries. Fetal factors include abnormal presentation, birth weight, and head circumference, while maternal factors include rapid presentation, pelvic length, and tissue characteristics. [13]. A large volume study reported an association between shoulder dystocia and perineal injury [8]. Every 100 grams increase in birth weight caused a 10% increase in the rate of perineal injury. There were 3 children with shoulder dystocia. Their weight was over 4000 grams. One of the patients had a fetus over 4000 g, the other had a fetus transverse position and althought the last one had a low fetus weight, a perineum injury occurred for the pelvic incompatibility groove [Table-4]. Mean±SD 30±8.7 3(1-7) 1 14 70±24 5 3 5 2 33.3% 20% 33.3% 13.4% 11 4 73.3% 26.7% 3438±492 34.33 ± 1.23 2 1 12 13.4% 6.7% 80% The rate of anal sphincter injury in vaginal deliveries is approximately 18% [14]. In patients with sphincter injury at birth, the rate of fecal incontinence is 7.7% [15]. The incontinence rate is 6.3% in nulliparous women, 8.8% in 9.8 ± 4 398 DOI: 10.33808/clinexphealthsci.929691 Original Article Anal Sphincter Injury uniparous women and 8.4% in secundiparous women and 11.5% in triparous women and women with more than 3 deliveries [16]. In a study of patients with normal vaginal delivery, it was reported that complaints about incontinence ranged from 13% to 25% [17]. Two patients (13.4%) had less than 1 gas incontinence per month, 1 patient (6.7%) had less than 1 gas and stool incontinence per month. 3 patients (20%) were nulliparous and 12 patients (80%) were multipara. 5. CONCLUSION Sphincter repair should be done in experienced centers to obtain better results. Surgical repairs should be made in the early stages of injuries. It is known that the sphincter ends torn in the late intervention will separate more with time and repair in the late period may be more difficult. We think that sphincter damage during delivery can be looked after successfully with early diagnosis and intervention before tissue edema develops. It is reported in the literature that early intervention is a key factor in recovery [13]. The mean duration of the first intervention was 70 minutes (min-max: 30-90 minutes). Authors’ contributions (Authors initials) There are publications stating that episiotomy increases or decreases the risk of perineal injury [8]. In our study, 73.3% of our patients underwent episiotomy. When the groups were compared, there was no significant superiority of episiotomy in terms of perineal injury (p = 0.07). We found that episiotomy did not affect the risk of 3rd or 4th degree perineal injury. The low number of patients is also a factor in this result. Design of the study: MS There is insufficient data to determine whether the next delivery of a patient with perineal injury after vaginal delivery is vaginal or caesarean section delivery. A vaginal delivery performed in a patient with perineal injury has been reported to have a 3% risk of re-anal sphincter injury [8]. We do not recommend vaginal delivery to prevent possible injury. Conflicts of interest Acquisition of data for the study: YY Analysis of data for the study: MS, YY Interpretation of data for the study: Drafting the manuscript: MS Revising it critically for important intellectual content: MS, YY All authors have disclosed no conflicts of interest. Funding The authors received no financial support for the research, authorship, and/or publication of this article. The first option in anal sphincter defect is sphincter repair. Perioperative second-generation cephalosporin antibiotic prophylaxis has been shown to reduce the rate of postoperative infection [19]. In sphincter repair performed after vaginal delivery injury, the infection rate can reach up to 20% [20]. None of our patients had surgical site infections. We use metronidazole and third generation cephalosporin for prophylaxis in our patients and we complete this treatment for 5 days. We think that the susceptibility to infection increases in the surgical area if vaginal discharge is high after delivery. For this reason, we pay attention to vaginal dryness. REFERENCES [1] [2] [3] All layers must be repaired separately. The internal and external sphincter should be repaired separately. The posterior anal canal mucosa and the anterior vaginal wall should be repaired separately. In the literature, there was no difference between overlapping and end-to – end suturing as a repair technique [21]. We performed end-to-end repairs in all our cases [Figure 2]. [4] [5] Although there is no significant difference between pelvic floor muscle training and biofeedback treatment, studies are suggesting early postnatal biofeedback treatment in symptomatic women with perineal injuries [18]. During follow-up up to 1 year, one of our cases had stool and two had gas incontinence. We have directed our patients with gas or stool incontinence to the centers where biofeedback treatment is applied. However, because of the low socioeconomic and sociocultural levels of our patients, none of our patients received this treatment. All of our results consisted only of patients who had performed pelvic floor exercises at home. This is one of the limitations of our study. Clin Exp Health Sci 2022; 12: 396-400 [6] [7] [8] 399 Tin R.Y.T., Schulz J., Gunn B., Flood C. & Rosychuk R.J. The prevalence of anal incontinence in post-partum women following obstetrical anal sphinter injury. International Urogynecology Journal 2010;21, 927– 932. Kavic SM, Basson MD. Complications of endoscopy. Am J Surg 2001;181:319-332. Harkin R, Fitzpatrick M, O’Connell PR, O’Herlihy C. Anal sphincter disruption at vaginal delivery: is recurrence predictable? Eur J Obstet Gynecol Reprod Biol 2003, 109:149– 152. Dudding TC, Vaizey CJ, Kamm MA. Obstetric anal sphincter injury: incidence, risk factors, and management. Ann Surg 2008, 247:224–237. Revicky V, Nirmal D, Mukhopadhyay S, Morris EP, Nieto JJ. Could a mediolateral episiotomy prevent obstetric anal sphincter injury?. Eur J Obstet Gynecol Reprod Biol 2010, 150:142–146. Hals E, Øian P, Pirhonen T, Gissler M, Hjelle S, Nilsen EB, Severinsen AM, Solsletten C, Hartgill T, Pirhonen J. A multicenter interventional program to reduce the incidence of anal sphincter tears. Obstet Gynecol 2010, 116:901–908. Pretlove SJ, Thompson PJ, Toozs-Hobson PM, Radley S, Khan KS. Does the mode of delivery predispose women to anal incontinence in the first year postpartum? A comparative systematic review. BJOG 2008, 115:421–434. Smith LA, Price N, Simonite V, Burns EE. Incidence of and risk factors for perineal trauma: a prospective observational study. BMC Pregnancy Childbirth 2013;13:59. DOI: 10.33808/clinexphealthsci.929691 Original Article Anal Sphincter Injury [9] [10] [11] [12] [13] [14] [15] Andrews V, Sultan AH, Thakar R, Jones PW: Risk factors for obstetric anal sphincter injury: a prospective study. Birth 2006, 33:117–122. Ducarme G, Pizzoferrato AC, de Tayrac R, Schantz C, Thubert T, Le Ray C, D.Riethmuller, E.Verspyck, B.Gachon, F.Pierre, F.Artzner, B.Jacquetin,X.Fritel. Perineal prevention and protection in obstetrics: CNGOF clinical practice guidelines. J Gynecol Obstet Hum Reprod 2019, 48.7: 455-460. Wang, JY, Abbas, MA. Current management of fecal incontinence. Perm. J. 2013, 17(3): 65–73. Rogers RG, Leeman LM, Borders N, Qualls C, Fullilove AM, Teaf D. Contribution of the second stage of labour to pelvic floor dysfunction: a prospective cohort comparison of nulliparous women. BJOG 2014;121: 1145-53. Patmano M, Çetin D, Gümüş T, Yavuz Y, Yıldırım S: EpisiotomyRelated Perineal Injury During Spontaneous Vaginal Delivery. Turk J Colorectal Dis 2018;28:95-98. Lowder JL, Burrows LJ, Krohn MA, Weber AM. Risk factors for primary and subsequent anal sphincter lacerations: a comparison of cohorts by parity and prior mode of delivery. Am J Obstet Gynecol 2007; 196:344.e1-5. Melville JL, Fan MY, Newton K, Fenner D. Fecal incontinence in US women: a population-based study. Am J Obstet Gynecol 2005; 193:2071. [16] Nygaard I, Barber MD, Burgio KL, Kenton K, Meikle S, Schaffer J, Spino C, Whitehead WE, Wu J, Brody DJ. Pelvic Floor Disorders Network. Prevalence of symptomatic pelvic floor disorders in US women. JAMA 2008; 300: 1311. [17] Guise JM, Morris C, Osterweil P, Li H, Rosenberg D, Greenlick M. Incidence of fecal incontinence after childbirth. Obstet Gynecol 2007; 109:281-8. [18] C Peirce, C Murphy, M Fitzpatrick, M Cassidy, L Daly, PR O’Connell, C O’Herlihy. Randomised controlled trial comparing early home biofeedback physiotherapy with pelvic floor exercises for the treatment of thirddegreetears (EBAPT Trial). BJOG 2013; 120: 1240-7. [19] Duggal N, Mercado C, Daniels K, Bujor A, Caughey AB, ElSayed YY. Antibiotic prophylaxis for prevention of postpartum perineal wound complications: a randomized controlled trial. Obstet Gynecol 2008;111: 1268-73. [20] Lewicky-Gaupp C, Leader-Cramer A, Johnson LL, Kenton K, Gossett DR. Wound complication safter obstetric anal sphincter injuries. Obstet Gynecol 2015; 125: 1088-93. [21] Fernando RJ, Sultan AH, Kettle C, Thakar R. Methods of repair for obstetric anal sphincter injury. Cochrane Database Syst Rev 2013;CD002866 How to cite this article: Senturk M, Yavuz Y. 3rd and 4th Degree Perineal Tears that Occurs During Vaginal Delivery. Clin Exp Health Sci 2022; 12: 396-400. DOI: 10.33808/clinexphealthsci.929691 Clin Exp Health Sci 2022; 12: 396-400 400 DOI: 10.33808/clinexphealthsci.929691