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Obstetric Anal Sphincter Injuries (OASIs) in Israel: A Review of the Incidence and Risk Factors

, M.D. * , , M.D., , M.D., , M.D., , M.D.

Rambam Maimonides Medical Journal

Rambam Health Care Campus

Israel, OASIs, workshop

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      Abstract

      Obstetric anal sphincter injuries (OASIs) following vaginal deliveries are the main reason for subsequent development of anal incontinence in women. The diagnosis of such tears is crucial for treating and preventing such a grave sequela. The reported rate of OASIs in Israel was between 0.1% and 0.6%, out of all vaginal births, which is 10-fold lower than that reported in Europe and the United States. Structured hands-on training in repair of OASIs in seven medical centers in Israel significantly increased the detection rate of third-degree perineal tears. The implementation of such programs is crucial for increasing awareness and detection rates of OASIs following vaginal deliveries.

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      Most cited references 24

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      Obstetric anal sphincter injury: incidence, risk factors, and management.

      Obstetric sphincter damage is the most common cause of fecal incontinence in women. This review aimed to survey the literature, and reach a consensus, on its incidence, risk factors, and management. This systematic review identified relevant studies from the following sources: Medline, Cochrane database, cross referencing from identified articles, conference abstracts and proceedings, and guidelines published by the National Institute of Clinical Excellence (United Kingdom), Royal College of Obstetricians and Gynaecologists (United Kingdom), and American College of Obstetricians and Gynecologists. A total of 451 articles and abstracts were reviewed. There was a wide variation in the reported incidence of anal sphincter muscle injury from childbirth, with the true incidence likely to be approximately 11% of postpartum women. Risk factors for injury included instrumental delivery, prolonged second stage of labor, birth weight greater than 4 kg, fetal occipitoposterior presentation, and episiotomy. First vaginal delivery, induction of labor, epidural anesthesia, early pushing, and active restraint of the fetal head during delivery may be associated with an increased risk of sphincter trauma. The majority of sphincter tears can be identified clinically by a suitably trained clinician. In those with recognized tears at the time of delivery repair should be performed using long-term absorbable sutures. Patients presenting later with fecal incontinence may be managed successfully using antidiarrheal drugs and biofeedback. In those who fail conservative treatment, and who have a substantial sphincter disruption, elective repair may be attempted. The results of primary and elective repair may deteriorate with time. Sacral nerve stimulation may be an appropriate alternative treatment modality. Obstetric anal sphincter damage, and related fecal incontinence, are common. Risk factors for such trauma are well recognized, and should allow for reduction of injury by proactive management. Improved classification, recognition, and follow-up of at-risk patients should facilitate improved outcome. Further studies are required to determine optimal long-term management.
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        Third- and fourth-degree perineal tears among primiparous women in England between 2000 and 2012: time trends and risk factors.

        To describe the trends of severe perineal tears in England and to investigate to what extent the changes in related risk factors could explain the observed trends.
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          Frequency of anal sphincter rupture at delivery in Sweden and Finland--result of difference in manual help to the baby's head.

          Anal sphincter rupture is a serious complication of vaginal delivery and almost half the affected women have persistent defecatory symptoms despite adequate primary repair. During the past decade, the incidence of anal sphincter ruptures has been increasing in Sweden and is currently estimated to occur in 2.5% of vaginal deliveries. The aim of the study was to report the frequency of anal sphincter ruptures in two university hospitals in two Scandinavian countries, Malmö in Sweden and Turku in Finland, and analyze the potential determinants. Retrospective analysis of a population of 30,933 deliveries (26,541 vaginal) during the years 1990 to 1994. The incidence of anal sphincter ruptures in Malmö, Sweden was 2.69%, and in Turku, Finland 0.36%. There were no significant population differences for the known risk factors (fetal weight, nulliparity or fetal head circumference). However, there is a difference in manual support given to the perineum and to the baby's head when crowning through the vaginal introitus between Malmö and Turku. The proportion of operative vaginal deliveries and abnormal presentations was significantly higher in Turku reflected in the lower Apgar score at 5 minutes and longer duration of second phase of labor. When high risk deliveries (operative vaginal delivery, abnormal presentation and newborns over 4,000 g) were excluded, the risk for anal sphincter ruptures was estimated to be 13 times higher in Malmö than in Turku. The difference in the incidence of anal sphincter rupture between Malmö, Sweden and Turku, Finland may be due to the difference in manual control of the baby's head when crowning.
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            Author and article information

            Affiliations
            Department of Obstetrics and Gynecology, the Edith Wolfson Medical Center, Holon, Israel, affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
            Author notes
            [* ]To whom correspondence should be addressed. E-mail: ginath@ 123456gmail.com
            Journal
            Rambam Maimonides Med J
            Rambam Maimonides Med J
            RMMJ
            Rambam Maimonides Medical Journal
            Rambam Health Care Campus
            2076-9172
            April 2017
            28 April 2017
            : 8
            : 2
            28467760
            5415364
            10.5041/RMMJ.10295
            rmmj-8-2-e0018
            , M.D., M.S., M.H.A. (Editor), , M.D. (Editor), , M.D. (Editor),
            © 2017 Ginath et al.

            This is an open-access article. All its content, except where otherwise noted, is distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

            Categories
            Special Issue on Gynecology, Fertility, and Obstetrics
            Gynecology: Review

            workshop, israel, oasis

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