Traumatic injury to the anal sphincter sustained in a thirdor

Transcription

1 Obstetric Anal Sphincter Injuries: A Survey of Clinical Practice Among Canadian Obstetricians Carolyn Best, BSc, MD, FRCSC, Harold P. Drutz, MD, FRCSC, May Alarab, MBChB, MRCOG, MRCPI, MSc Division of Urogynaecology and Reconstructive Pelvic Surgery, Department of Obstetrics and Gynaecology, Mount Sinai Hospital, University of Toronto, Toronto ON Abstract Objective: To describe the current practice, experience, and confidence of Canadian obstetricians in the management of obstetric anal sphincter injuries (OASIS) and to explore the need for national practice guidelines on this topic. Methods: We conducted a cross-sectional, Internet-based survey between December 2010 and March The survey was initially tested among a sample population and then distributed electronically to 665 Canadian obstetricians. Data were analyzed descriptively. The main outcome measures were the self-reported confidence and experience of Canadian obstetricians in OASIS management and the frequency of performing specific OASIS management steps. Results: The survey response rate was 28.7%. The majority of the respondents (95%) reported confidence in performing OASIS repairs. In the event of a perineal laceration, 47.9% of respondents routinely performed a rectal examination. Most OASIS repairs were performed in the delivery room (89.4%) under local anaesthesia (60.6%) when regional anaesthesia was not already present. If lacerated, the internal anal sphincter was repaired separately by 63.4% of respondents, and intraoperative antibiotics were ordered by 51.1% of respondents. Most (92%) reported the absence of a local protocol to guide OASIS repair. Conclusion: The confidence of Canadian obstetricians who participated in this survey in performing OASIS repairs was high. However, their experience in performing repairs and their use of management steps varied. The need for national guidelines and an increase in awareness is suggested. Résumé Objectif : Décrire les pratiques actuelles, l expérience et le degré de confiance des obstétriciens canadiens en ce qui a trait à la prise en charge des lésions obstétricales affectant le sphincter anal (OASIS), ainsi qu explorer la nécessité d élaborer des lignes directrices nationales à ce sujet. Key Words: Third-/fourth-degree tear, obstetric anal sphincter injury, practice survey Competing Interests: None declared. Received on December 6, 2011 Accepted on February 17, 2012 Méthodes : Nous avons mené un sondage transversal par Internet entre décembre 2010 et mars Le sondage a d abord été mis à l essai auprès d un échantillon populationnel, pour ensuite être distribué par voie électronique à 665 obstétriciens canadiens. Les données ont été analysées de façon descriptive. Les principaux critères d évaluation ont été la confiance et l expérience autosignalées par les obstétriciens canadiens en matière de prise en charge des OASIS, ainsi que la fréquence avec laquelle ils procédaient à des étapes particulières de la prise en charge des OASIS. Résultats : Le taux de réponse au sondage a été de 28,7 %. La majorité des répondants (95 %) ont signalé être confiants au moment de mener des interventions visant à réparer des OASIS. En présence d une lacération périnéale, 47,9 % des répondants procédaient systématiquement à la tenue d un examen rectal. La plupart des réparations d OASIS étaient menées dans la salle d accouchement (89,4 %) sous anesthésie locale (60,6 %), lorsqu une anesthésie régionale n avait pas déjà été mise en œuvre. Lorsqu il était lacéré, le sphincter anal interne a été réparé séparément par 63,4 % des répondants et l administration peropératoire d antibiotiques a été mise en œuvre par 51,1 % des répondants. La plupart des répondants (92 %) ont signalé l absence d un protocole local orientant la réparation des OASIS. Conclusion : La confiance des obstétriciens canadiens qui ont participé à ce sondage était élevée, en ce qui a trait à la tenue de réparations d OASIS. Toutefois, leur expérience en matière d exécution de ces réparations et leur utilisation des étapes de la prise en charge variaient. Nous suggérons la rédaction de lignes directrices nationales sur la prise en charge des OASIS et l intensification des efforts de sensibilisation à cette problématique. J Obstet Gynaecol Can 2012;34(8): INTRODUCTION Traumatic injury to the anal sphincter sustained in a thirdor fourth-degree laceration during vaginal delivery is the most common cause of anal incontinence in women of reproductive age. The main risk factors for obstetric anal sphincter injuries are primiparity, fetal macrosomia, midline episiotomy, prolonged second stage of labour, and forceps assisted delivery. 1 3 OASIS are recognized to occur in approximately 1% of vaginal deliveries, 4 with a reported incidence of 0.5% to 20%. 5 7 AUGUST JOGC AOÛT

2 Following conventional primary repair, the rate of persistent anal symptoms including incontinence has been reported to be as high as 59%, 7 12 with incontinence of flatus and fecal urgency being most common. The spectrum of distressing OASIS sequelae can also include incontinence of liquid or solid stool, passive soiling, perineal pain, dyspareunia, or leakage due to rectovaginal fistulae. Even though anal incontinence can severely compromise quality of life, social stigma and embarrassment may prevent many women from reporting symptoms to their physicians. Therefore, the true prevalence of anal symptoms following OASIS is unknown and is likely underestimated. Litigation related to OASIS and related consequences has increased worldwide over the last 10 years. 13 Missed diagnosis, lack of expertise, insufficient training, and inadequate surgical technique have all been suggested as possible reasons for the high rate of persistent symptoms after primary repair. 14 In an attempt to reduce morbidity and litigation, the Royal College of Obstetricians and Gynaecologists in the United Kingdom published clinical practice guidelines on the repair of third- and fourthdegree lacerations in Based on the available evidence at the time, the guidelines described the specific location, type of anaesthesia, method of repairing the sphincter, type of suture to be used, and perioperative medications that should be prescribed to provide optimal clinical results. The authors of the guidelines suggested that local protocols should be developed and implemented, both to aid in the complete documentation of the repair methods and to provide consistent care to women with sphincter injury. It has been suggested that primary sphincter repair immediately after delivery is more likely to be successful in the long term than a secondary repair performed remote from delivery. 15,16 Not only do obstetricians perform the majority of deliveries in Canada, but they are also the surgeons consulted when a significant laceration has occurred under the care of a midwife or family physician. The current practice among obstetricians in Canada in the repair of OASIS is unknown. It is suspected that without national guidelines or an established standard of care, the methods used across the country vary widely. Therefore, the specific aims of this study were threefold: ABBREVIATIONS EAS external anal sphincter IAS OASIS RCOG internal anal sphincter obstetric anal sphincter injuries Royal College of Obstetricians and Gynaecologists 1. to describe the current practice, experience, and confidence of Canadian obstetricians in the management of OASIS; 2. to determine whether local protocols on the repair of OASIS exist within Canada; and 3. to explore whether Canadian obstetricians would benefit from national practice guidelines on this topic. It is the intention of the authors to investigate Canadian practice, and also to stimulate discussion and heighten awareness of this important and under-recognized women s health issue. METHODS A cross-sectional survey designed to investigate OASIS management was distributed electronically to Canadian obstetrician gynaecologists in December The main outcomes were the self-reported confidence and experience of respondents who practised obstetrics in performing OASIS repairs and their frequency of performing specific management steps. Following an extensive review of the literature, a 25-item questionnaire was developed to encompass the important aspects of OASIS repair in evidence reported in current research and in the guidelines published by the RCOG in the United Kingdom. 4 The content validity of the questionnaire was reviewed by two experts on OASIS repair from the Division of Urogynaecology at Mount Sinai Hospital, Toronto, to confirm that the questions covered all relevant aspects of the topic. The questions were organized into four sections: 1. demographic data, 2. experience and training in OASIS repair, 3. management of OASIS repair, and 4. postoperative and postpartum care. The survey content and flow was then assessed by five practising obstetrician gynaecologists, and modifications were made according to their suggestions. The electronic format of the questionnaire was created with the use of FluidSurveys, an Internet-based survey vehicle. The online software allowed instant analysis and filtering of data as soon as the surveys were completed, and all data were stored within Canada. Reliability testing was then performed by administering the online version of the questionnaire to 40 staff physicians in the Department of Obstetrics and Gynaecology at Mount Sinai Hospital on two occasions, 748 AUGUST JOGC AOÛT 2012

3 Obstetric Anal Sphincter Injuries: A Survey of Clinical Practice Among Canadian Obstetricians two months apart. The survey results were found to be similar and reproducible based on the responses collected from the two time points. After approval of the survey validation process was obtained from the Council of the SOGC, a cover letter describing the nature and purpose of the study and a link to the online survey was sent via to the 665 SOGC members who had previously given permission to receive electronic research surveys. Consent was implied by completion of the survey. A reminder to complete the survey was ed in January 2011, and responses were accepted until the end of March All responses were confidential. The data were analyzed descriptively. Ethics approval for the study was obtained from the Research Ethics Board at Mount Sinai Hospital in Toronto, Ontario. RESULTS A total of 191 responses were received, a response rate of 28.7%. The first question of the survey identified those currently practising obstetrics versus those currently practising only gynaecology. The remaining questions on OASIS practice were answered only by the 142 (73.9%) who currently practise obstetrics. The demographic data collected from the respondents is summarized in Table 1. When asked to estimate the number of repairs performed in the preceding year, 60.5% of respondents indicated that they had repaired fewer than 10 third-degree lacerations, and 76.8% repaired fewer than five fourth-degree lacerations (Table 2). Confidence in the identification of OASIS following delivery was reported to be high, with 78.2% indicating that they were very confident and the remainder confident. Rates of confidence in performing laceration repairs were slightly lower but still high, with 95% reporting that they were either very confident or confident, and just 4.9% choosing either not very confident or not at all confident (Table 3). There was no statistically significant correlation between years in practice and confidence in performing OASIS repairs. When asked about training, 11.9% felt that their residency training had not adequately prepared them to perform OASIS repairs in practice. In the event of an apparent second-degree perineal laceration after a vaginal delivery, 52.1% of obstetricians completing the survey did not routinely perform a rectal examination to assess the integrity of the anal sphincter. The majority of OASIS repairs were performed in the delivery room (89.4%) as opposed to the operating room. Table 1. Characteristics of survey respondents currently practising obstetrics Respondents Characteristic n/n (%) Year residency training completed 2001 to /142 (42.9) 1991 to /142 (26.1) 1981 to /142 (19.0) 1980 or earlier 17/142 (12.0) Location of residency training Within Canada 131/140 (93.6) Outside Canada 9/140 (6.4) Type of practice University teaching hospital 65/138 (47.1) Community hospital 73/138 (52.9) Level of obstetrical/neonatal unit Level 1 13/141 (9.2) Level 2 76/141 (53.9) Level 3 52/141 (36.9) Province of current practice Alberta 16/142 (11.3) British Columbia 15/142 (10.6) Manitoba 3/142 (2.1) New Brunswick 1/142 (0.7) Newfoundland 3/142 (2.1) Nova Scotia 11/142 (7.7) Ontario 57/142 (40.1) Quebec 31/142 (21.8) Saskatchewan 5/142 (3.5) For a patient who did not receive regional anaesthesia during delivery, 60.6% of respondents indicated that they would perform a third- or fourth-degree laceration repair under local anaesthetic. If laceration was complete, 69.5% of respondents performed an end-to-end repair of the EAS, and 63.4% responded that they would repair the internal anal sphincter separately. Most reported using delayed-absorbable (braided or monofilament) suture to repair the EAS (90.1%); chromic or plain catgut was used by 7.0%, and permanent suture was used by 0.7%. Ninety-two percent of respondents were not aware of a protocol to guide OASIS repair at their hospital, and 51.1% routinely ordered intraoperative prophylactic antibiotics during repair. The responses on OASIS management are summarized in Table 4. During postpartum care for a woman who has sustained OASIS, 97.2% of the survey respondents routinely ordered laxatives or stool softeners, and 28.9% ordered a AUGUST JOGC AOÛT

4 Table 2. Self-estimated number of third- and fourth-degree laceration repairs performed by survey respondents in the last year Number of repairs performed (N = 142), n (%) Type of laceration < 5 5 to to 15 > 15 Third-degree 29 (20.4) 57 (40.1) 29 (20.4) 28 (19.0) Fourth-degree 109 (76.8) 27 (18.3) 7 (4.9) 0 (0) Table 3. Self-reported degree of confidence among survey respondents in identifying and repairing OASIS Degree of confidence (N = 142), n (%) Task Very confident Confident Not so confident Not at all confident Identifying OASIS 111 (78.2) 31 (21.8) 0 (0) 0 (0) Repairing OASIS 78 (54.9) 57 (40.1) 6 (4.2) 1 (0.7) course of postoperative antibiotics. Eighty-four percent of respondents indicated that they routinely arranged followup for women after OASIS, with 91.4 % suggesting they see an obstetrician. When asked to whom they would refer a patient who presented with fecal incontinence at six months postpartum after OASIS, the responses were variable, with 20.4% choosing a general surgeon, 42.9% a colorectal surgeon, 29.6% a urogynaecologist, and 7.0% other. The majority of those choosing other for referral for fecal incontinence postpartum suggested that they would send the patient to a physiotherapist. The majority (95.7%) of Canadian obstetricians who completed the survey felt that evidence-based guidelines on the repair of obstetrical anal sphincter injuries would be helpful in their practice. DISCUSSION Following vaginal delivery, women are at risk of developing anal symptoms, particularly if there is an anatomic disruption of the external or internal anal sphincters. Despite recognition and repair of such disruption, the reported incidence of anal incontinence and related symptoms after sphincter laceration is high. 3,7 12 Primary repair after delivery is the repair most likely to preserve long-term continence. 15,16 Therefore, as the surgeons attending delivery and those responsible for the majority of repairs, obstetricians play a pivotal role in providing the best clinical results when an anal sphincter injury has occurred. The goal of this study was to investigate and describe the current practice in OASIS management among obstetricians in Canada and to explore whether national guidelines are needed to establish a standard of care. A critical step in the repair of OASIS is recognition of the injury when it has occurred. It is obviously impossible to provide a high-quality repair to an undetected laceration, and an undiagnosed injury is almost certain to result in some degree of incontinence. Studies indicate that heightened awareness of OASIS and training in its identification may be associated with an increase in OASIS detection; in one centre, when an experienced research fellow attended all deliveries with an apparent second-degree perineal laceration, the reported incidence of OASIS doubled from 7.5% to 15% because many tears were upstaged to third- or fourth-degree lacerations. 17 In another study, 87% of midwives and 28% of obstetricians failed to correctly identify the extent of sphincter injury after careful independent examination, and endoanal ultrasound performed immediately after delivery was not more likely to detect OASIS than a thorough physical examination alone. 18 As a result of these findings, the RCOG guidelines state that all women having a vaginal delivery with evidence of genital tract trauma should be systematically examined to assess the severity of the damage prior to suturing. 4 Canadian obstetricians reported confidence in identifying OASIS, but only 47.9% routinely performed a rectal examination in the event of an apparent seconddegree laceration. This response may be one of the most important findings in this study, because it suggests the possibility of under-detection of OASIS without complete anal sphincter assessment in many cases. Further study involving standardized clinical examination with digital rectal examination following perineal laceration is required in order to quantify the incidence and detection rate of OASIS in Canada. 750 AUGUST JOGC AOÛT 2012

5 Obstetric Anal Sphincter Injuries: A Survey of Clinical Practice Among Canadian Obstetricians Table 4. Survey responses on intraoperative and postoperative OASIS management Number of responses Survey question n/n (%) Local protocol to guide OASIS management? No 130/141 (92.2) Yes 11/141 (7.8) Routine rectal examination after perineal laceration? Yes 68/142 (47.9) No 74/142 (52.1) Location of repair? Delivery room 127/142 (89.4) Operating room 15/142 (10.6) Anaesthesia for repair after no regional anaesthesia for delivery? Local 86/142 (60.6) Regional 48/142 (33.8) General 8/142 (5.6) Type of repair of external anal sphincter? End-to-end 98/141 (69.5) Overlapping 43/141 (30.5) Routine repair of internal anal sphincter? Yes 90/142 (63.4) No 52/142 (36.6) Routine intraoperative antibiotic prophylaxis? Yes 72/141 (51.1) No 69/141 (48.9) Routine postoperative antibiotics? Yes 41/142 (28.9) No 101/142 (71.1) Routine postoperative laxative/stool softener? Yes 138/142 (97.2) No 4/142 (2.8) Routine postoperative follow-up arranged? Yes 119/141 (84.4) No 22/141 (15.6) Only a few elements of OASIS care have been investigated in randomized trials. Based on expert opinion, the RCOG recommends that third- and fourth-degree tears be repaired in the operating room under regional anaesthesia to provide complete visualization of retracted sphincter muscles and to allow approximation with minimal tension. 4 The majority of OASIS repairs in Canada appear to be performed in the delivery room (89.4%), with local anaesthesia provided (60.6% of the time) only to women who delivered without regional anaesthesia. This result likely represents a practical element of care on a busy unit, with the operating room reserved for operative deliveries and complications other than perineal lacerations. Without further study, it is difficult to quantify the potential impact of additional anaesthesia, lighting, and instruments on the quality of OASIS repair. It makes intuitive sense for centres to consider such operative conditions in the event of a higher degree or more complex tear in which tissue identification can be challenging. Complete lacerations of the EAS have traditionally been repaired in an end-to end (approximation) fashion by obstetricians, while colorectal surgeons often perform an overlapping sphincteroplasty. Sultan et al. demonstrated that anal incontinence following OASIS was significantly AUGUST JOGC AOÛT

6 associated with an EAS defect on endoanal ultrasound in the postpartum period. Such a defect was found in significantly more women following OASIS repair (85%) than in those who had not sustained a sphincter injury (33%). 3 In 1999, this group was the first to suggest the use of an overlapping technique for OASIS repair along with separate careful suturing of the IAS, aimed to improve postpartum outcomes. In a small retrospective study of 32 women receiving overlapping sphincteroplasty with delayed absorbable suture, only two had incontinence of flatus and none had fecal incontinence five months after delivery. 19 Six randomized trials have since been conducted comparing end-to-end and overlapping sphincter repairs following OASIS A Cochrane Review and meta-analysis of three of these trials found no statistically significant difference between the two techniques in overall perineal pain, dyspareunia, incontinence of flatus, fecal incontinence, or quality of life at 12 months postpartum. 26 There was, however, a significantly lower risk of fecal urgency and deterioration of anal symptoms over 12 months with the overlapping technique. The significant findings in favour of overlapping repair came mostly from the study by Fernando et al., 22 in which all repairs were conducted by two surgeons equally experienced in both methods. Because of the limitations and heterogeneity of the studies, one technique could not ultimately be recommended over the other. A recently published randomized trial by Farrell et al. 25 strove to overcome the limitations of the previous trials by including only primiparous women with complete EAS injury, with a more common primary outcome of incontinence of flatus. At six months, the rates of incontinence of flatus (61% vs. 39%) and fecal incontinence (15% vs. 8%) were higher among those who underwent overlapping repair than those who had endto-end repair. The authors proposed that the additional dissection required to perform the overlapping repair may cause enough denervation and scarring to compromise EAS function. In contrast to the study of Fernando et al., 22 79% of the surgeons in the study by Farrell et al. 25 had performed fewer than 10 overlapping repairs prior to the study, but the experience of the surgeon was not found to correlate with clinical outcomes. In the current Canadian survey, 69.5% of respondents indicated that they routinely perform an end-to-end approximation of the EAS following laceration. Although those experienced in the overlapping technique may not change their practice from the results of this recent trial alone, obstetricians who are mainly proficient in the end-to-end technique can be assured that they are likely providing patients a good quality repair. Surgeons repairing OASIS should choose the method of repair with which they are most comfortable and in which they are most experienced. The IAS plays an important role in anal continence by providing resting anal sphincter tone. 27 Disruption of the IAS can lead to passive soiling with liquid stool. The IAS often retracts and can be difficult to find following laceration, but a persistent IAS defect following OASIS repair has been found to be associated with higher rates of fecal incontinence. 9,11,28,29 Farrell et al. found higher rates of anal incontinence (of both flatus and feces) when defects in both the EAS and IAS were found on ultrasound than when there was a defect in the EAS alone. 25 Only 36.6% of Canadian obstetricians who participated in the survey repaired a lacerated IAS separately. This may indicate the need for additional training in IAS laceration identification and repair. The majority of survey respondents indicated that they use delayed absorbable suture to repair the EAS, in the form of either a monofilament such as polydiaxanone or a braided suture such as polyglactin. All of the randomized trials comparing sphincter repair techniques used these delayed absorbable suture materials A randomized trial comparing 3 0 polydiaxanone and 2 0 polyglactin for EAS repair reported no significant difference in perineal pain, anal incontinence, or suture migration at 12 months, 21 and thus the RCOG recommends the use of either suture type. 4 Only 7.0% of Canadian obstetricians reported using chromic or plain catgut suture for sphincter laceration repair. Because of its considerably shorter halflife, catgut is less likely to provide a repair strong enough to allow for optimal healing of the sphincter. Data from randomized trials have favoured the use of more delayed absorbable suture over chromic or plain catgut for seconddegree laceration and episiotomy repairs, with less perineal pain postpartum. 30 To reduce the likelihood of wound and sphincter repair dehiscence, it has been recommended that laxatives be prescribed to women following OASIS. 4 A single randomized trial comparing the use of laxatives with the use of a constipating agent after OASIS repair found that patients who took laxatives had a significantly earlier and less painful first bowel movement and earlier discharge from hospital, but no difference in sphincter continence or anal symptoms was found. 31 Consistent with the intuitive sense of this recommendation and the evidence, 97.2% of Canadian obstetricians routinely prescribe laxatives after OASIS repair. A course of broadspectrum antibiotic prophylaxis during and after OASIS repair has been recommended to reduce the risk of wound breakdown due to infection. 4 A randomized trial comparing a single prophylactic intravenous dose of a 752 AUGUST JOGC AOÛT 2012

7 Obstetric Anal Sphincter Injuries: A Survey of Clinical Practice Among Canadian Obstetricians second-generation cephalosporin during repair of OASIS with placebo showed a significantly lower rate of perineal complication at two weeks postpartum for the women who received the antibiotics. 32 We found that only one half of responding Canadian obstetricians provide antibiotics during OASIS repair, and just 28.9% routinely prescribe them postoperatively. Adequate surgical training, competence, and experience are critical elements in providing high quality outcomes following any type of surgical procedure. Perineal laceration repairs are one of the most basic and common surgical procedures performed by obstetricians. When an anal sphincter laceration has occurred along with a perineal tear, an attempt at sphincter repair by an inexperienced clinician can increase the risk of persistent anal symptoms and incontinence. A survey of clinical practice and experience in OASIS in the United Kingdom found that 64% of both obstetricians and trainees reported either a lack of or unsatisfactory training in performing OASIS repairs. 14 In our study, just 11.9% of Canadian obstetricians completing the survey felt that their residency training was inadequate in preparing them to manage OASIS in practice. Obstetricians also reported high rates of confidence in actually performing the repairs, with 95% claiming to be either very confident or confident. Although these figures may be reassuring in light of the previous United Kingdom survey results, it is unclear whether or not such responses are over-confident without knowing the true incidence of OASIS or the Canadian-specific risk of postoperative anal symptoms. Regardless of their surgical confidence, obstetricians perform few OASIS repairs each year, and this may provide even fewer opportunities for hands-on experience for residents in teaching centres. The majority of respondents (60.5%) estimated that they perform fewer than 10 third-degree repairs, and 76.8% perform fewer than five fourth-degree laceration repairs per year. Medico-legal action related to OASIS has declined in the United Kingdom since the publication of clinical practice guidelines and the creation of specialized multidisciplinary perineal clinics designed to provide standardized followup and care to women after sphincter repair. 4 The RCOG recommends that centres develop protocols in OASIS management, documentation, and follow-up, specifying that all women should be offered physiotherapy and evaluation by an obstetrician gynaecologist at six to 12 weeks postpartum. 4 Ninety-two percent of Canadian obstetricians responded that they currently do not have a protocol on OASIS management at their hospital. Although the majority (91.4%) felt that patients should be seen by an obstetrician following OASIS, 8.6% felt that follow-up with the patient s family doctor was adequate. When asked to whom they would refer a patient with fecal incontinence six months after OASIS, responses varied and included a colorectal or general surgeon, a urogynaecologist, and a physiotherapist. The frequency of litigation related to OASIS in Canada is not clear, as this information is not publicly available. However, because of national differences in medical education, health care systems, resource allocation, and medico-legal cultures, it is conceivable that guidelines and protocols specific to Canadian practice may be necessary. Indeed, 95.7% of survey respondents indicated that national guidelines on OASIS would be useful in their practice. Clear and graded recommendations based on the available evidence would help to ensure consistent care and follow-up for patients who sustain a sphincter injury; especially since women who are symptomatic postpartum may not feel comfortable volunteering their distress. Limitations of this study include the response rate of 28.7%, with the responses possibly not being representative of the opinions of Canadian obstetricians as a whole. A higher rate of response (56%) was obtained in a similar survey conducted by mail in the United Kingdom. The electronic format limited distribution to SOGC members with access. Although all Canadian provinces were represented in the sample of respondents, the survey was provided in English only and was not translated into French. Surveys were distributed only to SOGC members who had previously consented to receive research surveys. This population could have provided an inherent selection bias, because those willing to participate in surveys may have more interest in research and more knowledge of clinical evidence in obstetrics. Criticisms from respondents included the fact that third- and fourth-degree lacerations were grouped together for most questions on management, but that they managed repair of these two types of lacerations differently. Previously published reports and guidelines, however, do not separate third- and fourthdegree lacerations, as both are considered significant risk factors for anal incontinence and it has been assumed they should be managed in a similar fashion. CONCLUSION Although they do not perform many repairs of OASIS per year, Canadian obstetricians who responded to the current survey reported that they were confident in identifying and repairing sphincter lacerations. Overall, many aspects of the management of OASIS by Canadian obstetricians are consistent with what is suggested by the available evidence, AUGUST JOGC AOÛT

8 but numerous recommendation made by the RCOG in the United Kingdom are not being followed. Further study of the incidence of OASIS and the prevalence of long-term anal symptoms in Canada is needed to provide context for the findings of this study. A need for Canadian clinical practice guidelines and protocols in OASIS management is suggested. ACKNOWLEDGEMENTS The authors would like to thank the obstetricians and gynaecologists at Mount Sinai Hospital in Toronto for their assistance in the testing and validation of the survey, and the Society of Obstetricians and Gynaecologists of Canada for providing the opportunity to distribute the survey electronically. REFERENCES 1. Dahl C, Kjolhede P. Obstetric anal sphincter rupture in older primiparous women: a case control study. Acta Obstet Gynecol Scand 2006;85: Raisanen S, Vehvilainen-Julkunen K, Gissler M, Heinonen S. The increased incidence of obstetrical anal sphincter rupture an emerging trend in Finland. Prev Med 2009;49: Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ 1994;308: Fernando RJ, Williams AA, Adams EJ. The management of third and fourth degree perineal tears. Green Top Guideline No. 29. London: Royal College of Obstetricians and Gynaecologists; March Crawford LA, Quint EH, Pearl M, DeLancey JOL. Incontinence following rupture of the anal sphincter during delivery. Obstet Gynecol 1993;82: Handa VL, Danielsen BH, Gilbert WM. Obstetric anal sphincter lacerations. Obstet Gynecol 2001;98: Walsh CJ, Mooney EF, Upton GJ, Motson RW. Incidence of third-degree perineal tears in labour and outcome after primary repair. Br J Surg 1996;83: Sultan AH, Thakar R. Lower genital tract and anal sphincter trauma. Best Pract Res Clin Obstet Gynaecol 2002;16: Goeffeng AR, Andersch B, Andersson M, Berndtsson I. Objective methods cannot predict anal incontinence after primary repair of extensive anal tears. Acta Obstet Gynecol Scand 1998;77: Haadem K, Dahlstrom JA, Lingman G. Anal sphincter function after delivery: a prospective study in women with sphincter rupture and controls. Eur J Obstet Gynecol Reprod Biol 1990;35: Poen AC, Felt-Bersma RJF, Strijers RL, Dekker GA, Cuesta MA, Meuwissen SG. Third degree obstetric perineal tear: long term clinical and functional results after primary repair. Br J Surg 1998;85: Nazir M, Carlsen E, Jacobsen AF, Nesheim BI. Is there any correlation between objective anal testing, rupture grade and bowel symptoms after primary repair of obstetric anal sphincter injury? Dis Colon Rectum 2002;45: Sultan AH. Obstetric perineal injury and anal incontinence. Clin Risk 1999;5(5): Fernando RJ, Sultan AH, Radley S, Jones PW, Johanson RB. Management of obstetric anal sphincter injury: a systematic review & national practice survey. BMC Health Serv Res 2002;2: Dudding TC, Vaizey CJ, Kamm MA. Obstetric anal sphincter injury. Incidence, risk factors and management. Ann Surg 2008:247; Johnson E, Carlsen E, Steen TB, Backer Hjorthaug JO, Tandberg Eriksen M, Johannessen H. Short and long term results of secondary anterior sphincteroplasty in 33 patients with obstetric injury. Acta Obstet Gynecol Scand 2010;89: Groom KM, Paterson-Brown S. Can we improve on the diagnosis of third degree tears? Eur J Obstet Gynecol Reprod Biol 2002;101: Andrews V, Thakar R, Sultan AH, Jones PW. Occult anal sphincter injuries myth or reality? BJOG 2006;113: Sultan AH, Monga AK, Kumar D, Stanton SL. Primary repair of obstetrical anal sphincter rupture using the overlap technique. Br J Obstet Gynaecol 1999;106: Fitzpatrick M, Behan M, O Connell PR, O Herlihy C. A randomized clinical trial comparing primary overlap with approximation repair of third degree obstetric tears. Am J Obstet Gynecol 2000;183: Williams A, Adams EJ, Tincello DG, Alfirevic Z, Walkinshaw SA, Richmond DH. How to repair an anal sphincter injury after vaginal delivery: results of a randomised controlled trial. BJOG 2006;113: Fernando RJ, Sultan AH, Kettle C, Radley S, Jones P, O Brien PMS. Repair techniques for obstetric anal sphincter injuries. A randomized controlled trial. Obstet Gynecol 2006;107: Garcia V, Rogers RG, Kim SS, Hall RJ, Kammerer-Doak DN. Primary repair of obstetric anal sphincter laceration: a randomized trial of two surgical techniques. Am J Obstet Gynecol 2005;192: Rygh AB, Korner H. The overlap technique versus end-to-end approximation technique for the primary repair of obstetric anal sphincter rupture: a randomized controlled study. Acta Obstet Gynecol Scand 2010;89: Farrell SA, Gilmour D, Turnbull GK, Schmidt MH, Baskett TF, Flowerdew G, et al. Overlapping compared with end-to-end repair of third and fourth degree obstetric anal sphincter tears. A randomized controlled trial. Obstet Gynecol 2010;116: Fernando R, Sultan AH, Kettle C, Thakar R, Radley S. Methods of repair of obstetric anal sphincter injury. Cochrane Database Syst Rev 2006, Issue 3. Art. No.:CD Sangwan YP, Solla JA. Internal anal sphincter: advances and insights. Dis Colon Rectum 1998; 41: de Leeuw JW, Srujik PC, Vierhout ME, Wallenburg HC. Risk factors for third degree perineal ruptures during delivery. BJOG 2001;108: Mahoney R, Behan M, Daly L, Kirwan C, O Herlihy C, O Connell R. Internal anal sphincter defect influences continence outcome following obstetric anal sphincter injury. Am J Obstet Gynecol 2007:196(3):217.e1 e Kettle C, Dowswell T, Ismail KMK. Absorbable suture materials for primary repair of episiotomy and second degree tears. Cochrane Database Syst Rev 2010, Issue 6. Art. No.:CD Mahony R, Behan M, O Herlihy C, O Connell PR. Randomized clinical trial of bowel confinement vs. laxative use after primary repair of a third degree obstetric anal sphincter tear. Dis Colon Rectum 2004;47: Duggal N, Mercado C, Daniels K, Bujor A, Caugey AB, El-Sayed YY. Antibiotic prophylaxis for prevention of postpartum perineal wound complications. Obstet Gynecol 2008;111: AUGUST JOGC AOÛT 2012