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Anovaginal distance and obstetric anal sphincter injury: a prospective observational study
Linköping University, Department of Clinical and Experimental Medicine, Division of Children's and Women's health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center of Paediatrics and Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics in Linköping.
Linköping University, Department of Clinical and Experimental Medicine, Division of Children's and Women's health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center of Paediatrics and Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics in Linköping.
Linköping University, Department of Clinical and Experimental Medicine, Division of Children's and Women's health. Linköping University, Faculty of Medicine and Health Sciences. Region Östergötland, Center of Paediatrics and Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics in Linköping.
2019 (English)In: International Urogynecology Journal, ISSN 0937-3462, E-ISSN 1433-3023, Vol. 30, no 6, p. 939-944Article in journal (Refereed) Published
Abstract [en]

Introduction and Hypothesis

No measurements are available for diagnosing the extent of obstetric lacerations. The primary aim of this study was to evaluate the relation between the anovaginal distance (AVD) measured with transperineal ultrasound immediately after delivery and external anal sphincter injury. A secondary aim was to assess whether the palpated perineal thickness was associated with the AVD.

Methods

A prospective observational study of 150 primiparous women at the University Hospital, Linköping, Sweden. After vaginal delivery, initial inspection and palpation of the perineal thickness were performed by the midwife. The women were then divided into subgroups depending on the degree of the suspected perineal laceration. Transperineal ultrasound of the AVD was performed by a physician. Diagnostics of the perineal laceration were done according to standard care.

Results

Women with an external sphincter injury had a shorter AVD and shorter palpatory perineal thickness compared with women without anal sphincter injury. No external sphincter injuries were diagnosed when the AVD and/or palpation height was > 20 mm. The mean AVD in the group with probable second-degree laceration (n = 85) was 18.8 mm (95% CI 17.8–19.8), in suspected third-degree laceration (n = 33) 15.7 mm (95% CI 13.7–17.7) and in probable third-degree laceration (n = 32) 11.8 mm (95% CI 9.7–13.9) (p < 0.001).

Conclusions

A short AVD could be a warning sign postpartum and should increase the awareness of possible external sphincter injury before suturing. An AVD of 20 mm seems to indicate a cutoff level of the occurrence of external sphincter injury, but this needs further evaluation.

Place, publisher, year, edition, pages
Springer London, 2019. Vol. 30, no 6, p. 939-944
Keywords [en]
Anovaginal distance; Obstetrical anal sphincter injury; Perineal laceration; Transperineal ultrasound
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
URN: urn:nbn:se:liu:diva-157515DOI: 10.1007/s00192-018-3838-5ISI: 000467656700011PubMedID: 30535980Scopus ID: 2-s2.0-85058189785OAI: oai:DiVA.org:liu-157515DiVA, id: diva2:1328794
Note

Funding Agencies|Ostergotland Region

Available from: 2019-06-23 Created: 2019-06-23 Last updated: 2019-12-09Bibliographically approved
In thesis
1. Clinical and methodological aspects on perineal laceration diagnostics at childbirth
Open this publication in new window or tab >>Clinical and methodological aspects on perineal laceration diagnostics at childbirth
2019 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background: Obstetric perineal lacerations are common after vaginal birth. The degree of obstetric perineal laceration is defined by the extent of tissue involved in the laceration. When a perineal laceration has occurred after vaginal delivery, the examination for correct diagnostics is essential before primary suturing. Standard immediate postpartum care is an inspection and palpation of the obstetric perineal laceration. The aim of this thesis was to explore the diagnostics of obstetric perineal lacerations, and to examine how the methods of bidigital perineal palpation and transperineal ultrasound postpartum can contribute to the clinical diagnostic decisions before primary repair.

Material and Methods: Study I is a methodological study of transperineal ultrasound of the anovaginal distance. The learning curve and inter-observer agreement of the method is studied between three examiners in an outpatient gynaecological setting. Study II is a prospective observational study of 150 primiparous women with suspected perineal laceration of degree 2-3 immediately after childbirth and the association between bidigital palpation of the perineal height, the anovaginal distance and the final diagnosis of the perineal laceration. Study III is a retrospective observational study with data from the Swedish national Perineal Laceration Registry, studying maternal and obstetric risk factors for internal anal sphincter injury in 3,333 women with external sphincter injury. Study IV is a follow-up study focusing on the implementation strategies and outcome when introducing a new method, (the Diagnostics After DELivery – DADEL concept) for examining perineal lacerations at a maternity ward. The DADEL concept consists of a combination of bidigital palpation of the perineal tissues and transperineal ultrasound in order to determine the degree of perineal lacerations.

Results and conclusions: In study I, the method of transperineal ultrasound measurement of anovaginal distance revealed a short learning period and high interobserver agreement. This indicated that the method can be taught and reliably used in further research and clinical practice. In study II, women with external sphincter injury had a shorter anovaginal distance compared to women without this injury. The palpatory perineal thickness was associated with the anovaginal distance. Study III showed that 33% of primiparous women with an external anal sphincter injury also had an internal anal sphincter injury diagnosed immediately after delivery. When the infant was born with a hand or arm beside the head, there was an increased risk for internal anal sphincter injury. Perineal palpatory thickness of less than 10 mm was significantly associated with an internal anal sphincter injury. In the follow-up study of diagnostic methods showed a significantly higher use of bidigital palpation five years after introduction of the DADEL concept. The use of transperineal ultrasound showed no significant change during the same period.

Place, publisher, year, edition, pages
Linköping: Linköping University Electronic Press, 2019. p. 68
Series
Linköping University Medical Dissertations, ISSN 0345-0082 ; 1715
National Category
Obstetrics, Gynecology and Reproductive Medicine
Identifiers
urn:nbn:se:liu:diva-162580 (URN)10.3384/diss.diva-162580 (DOI)9789179299620 (ISBN)
Public defence
2020-01-17, Belladonna, University Hospital Campus, Linköping, 09:00 (Swedish)
Opponent
Supervisors
Available from: 2019-12-09 Created: 2019-12-09 Last updated: 2020-01-08Bibliographically approved

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Pihl, SofiaUustal Fornell, Eva

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Division of Children's and Women's healthFaculty of Medicine and Health SciencesDepartment of Gynaecology and Obstetrics in Linköping
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International Urogynecology Journal
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