Supporting evidence

Supporting research evidence underpinning repair methods:

A Cochrane systematic review exploring suturing of first and second degree tears versus no suturing reported that there was no difference in pain up to eight weeks postpartum between surgical or non-surgical repair for first or second degree perineal trauma (2 trials, 154 women, no pooling of data). However, one trial showed a significant difference in wound closure and poor wound approximation at 6 weeks postpartum in the non-sutured group (16/36 (44%) vs 26/31 (86%), p = 0.001).

1. Elharmeel SMA, Chaudhary Y, Tan S, Scheermeyer E, Hanafy A, van Driel ML. Surgical repair of spontaneous perineal tears that occur during childbirth versus no intervention. Cochrane Database of Systematic Reviews 2011, Issue 8. Art. No.: CD008534. DOI: 10.1002/14651858.CD008534.pub2.

Cochrane systematic reviews have consistently reported that the use of a subcutaneous continuous suture for skin closure was associated with less short-term pain than interrupted repair method. This benefit was greater when the continuous technique was used for all layers (RR 0.76; 95 CI 0.66 to 0.88, nine trials, 8184 women).

2. Kettle C, Dowswell T, Ismail K. Continuous and interrupted suturing techniques for repair of episiotomy or second degree tears. Cochrane Database of Systematic Reviews. 2012(11).

Systematic reviews, of RCTs investigating suture materials used for repair, demonstrated that rapidly absorbable polyglactin sutures (such as Vicryl Rapide®) significantly reduce the need for postnatal suture removal (RR 0.24, 95% CI 0.15 to 0.36, 2 trails, 1847 women), and was associated with less short-term pain and need for analgesia within the first 10 days post-partum (RR 0.57, 95% CI 0.43 to 0.77, 1 trail, 1539 women)

3. Kettle C, Hills R, Ismail K. Absorbable suture materials for primary repair of episiotomy and second degreee tears. Cochrane Database of Systematic Reviews. 2010.

How long does perineal trauma take to heal?

4. Glazener C, Abdalla M, Stroud P, Naji S, Templeton A, Russell I. Postnatal maternal morbidity: extent, causes, prevention and treatment. British Journal of Obstetrics and Gynaecology 1995;102(4):282-7.

5. East C, Sherburn M, Nagle C, Said J, Forster D. Perineal pain following childbirth: Prevalence, effects on postnatal recovery and analgesia usage. Midwifery. 2012; 28: 93–97

6. East CE, Begg L, Henshall NE, Marchant P, Wallace K. Local cooling for relieving pain from perineal trauma sustained during childbirth. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD006304. DOI: 10.1002/14651858.CD006304.pub2.

What are the complications of childbirth related perineal trauma?

Fear of wound infection

7. Al-Mufti R, McCarthy A, Fisk N. Survey of obstetricians' personal preference and discretionary practice. European Journal of Obstetrics Gynecology and Reproductive Biology. 1997;73(1):1-4.

8. Dudley L, Kettle C, Ismail K. Prevalence, pathophysiology and current management of dehisced perineal wounds following childbirth. British Journal of Midwifery. 2013;21(3):160-71

Incidence of wound infection

9. Johnson A, Thakar R, Sultan AH. Obstetric perineal wound infection: is there underreporting? British journal of nursing (Mark Allen Publishing). 2012;21(5):S28-5.

Wound dehiscence(breakdown)

10. Dudley L, Kettle C, Ismail K. Prevalence, pathophysiology and current management of dehisced perineal wounds following childbirth. British Journal of Midwifery. 2013;21(3):160-71.

Excessive granulation tissue formation

11. Chandru S, Nafee T, Ismail K, Kettle C. Evaluation of Modified Fenton procedure for persistent superficial dyspareunia following childbirth. Gynaecological Surgery. 2010;7(3):245-8.

What is the impact of childbirth related perineal trauma on sexual function?

12. Sleep J, Grant A. West Berkshire perineal management trial: three year follow up. British Medical Journal. 1987;295(6601):749-51.

13. Olson A, Lundquist M, Faxelid E, Nissen E. Women's thoughts about sexual life after childbirth. Scand J Caring Sci. 2005;19:381-7.

14. Rogers RG, Borders N, Leeman LM, Albers LL. Does Spontaneous Genital Tract Trauma Impact Postpartum Sexual Function? Journal of Midwifery and Women's Health. 2009;54(2):98-103.

15. Radestad I, Olsson A, Nissen E, Rubertsson C. Tears in the vagina, perineum, sphincter ani, and rectum and first sexual intercourse after childbirth: a nationwide follow-up. Birth. 2008;35(2):98-106.

Incidence of OASIS

16. Baghestan E IL, Bordahl PE, Rasmussen S. Trends in risk factors for obstetric anal sphincter injuries in Norway. Obstet Gynecol. 2010;116:25-35.

17. Laine K, Gissler M, Pirhonen J. Changing incidence of anal sphincter tears in four Nordic countries through the last decades. European Journal of Obstetrics Gynecology and Reproductive Biology. 2009;146:71-5.

18. Sultan AH, Kamm M, Hudson C, Thomas J, Bartram C. Anal-sphincter disruption during vaginal delivery. New England Journal of Medicine. 1993;329(26):1905-11.

19. Fretheim A, Odgaard-Jensen J, Rottingen J, Reiner L, Vangan S, Tanbo T. The impact of an intervention programme employing a hands-on technique to reduce the incidence of anal sphincter tears: interrupted time-series reanalysis. BMJ Open. 2013(3:e003355).

20. Thiagamoorthy G, Johnson A, Thakar R, Sultan AH. National survey of perineal trauma and its subsequent management in the United Kingdom. International Urogynecology Journal and Pelvic Floor Dysfunction. 2014;25(12):1621-7.

OASIS repair method

For a full thickness EAS tear either an ‘end-to-end’ or ‘overlap’ technique can be used as a Cochrane review of six randomized controlled trials involving 588 women showed no difference in outcomes between these two repair methods.

21. Fernando RJ, Sultan AHH, Kettle C, Thakar R. Methods of repair for obstetric anal sphincter injury. Cochrane Database of Systematic Reviews. 2013(12).

For a partial thickness EAS tear, such as 3A OASIS or a 3B that does not extend through 100% of the EAS, an ‘end-to-end’ repair technique should be used as, in a small study of 32 women, Sultan et al (1999) demonstrated that overlap technique when used to repair a partial EAS tear exerted undue tension on the repair.

22. Sultan AH, Monga AK, Kumar D, Stanton SL. Primary repair for obstetric anal sphincter injury using the overlap technique. BJOG : an international journal of obstetrics and gynaecology. 1999;106:318-23.

Possible complications of OASIS

23. Marsh F, Lynne R, Christine L, Alison W. Obstetric anal sphincter injury in the UK and its effect on bowel, bladder and sexual function. European Journal of Obstetrics Gynecology and Reproductive Biology. 2011;154(2):223-7

24. Keighley MRB, Perston Y, Bradshaw E, Hayes J, Keighley DM, Webb S. The social, psychological, emotional morbidity and adjustment techniques for women with anal incontinence following Obstetric Anal Sphincter Injury: use of a word picture to identify a hidden syndrome. . BMC Pregnancy & Childbirth. 2016;16.

25. Boreham M, Richter H, Kenton K, Nager C, Gregory W, Aronson M. Anal incontinence in women presenting for gynecologic care: prevalence, risk factors and impact upon quality of life. American Journal of Obstetrics & Gynecology. 2005;192:1637-42.

26. Leigh R, Turnberg L. Faecal incontinence: the unvoiced symptom. Lancet. 1982;1(8285):1349-51.

27. Lo J, Osterweil P, Li H, Mori T, Eden K, Guise J. Quality of life in women with postpartum anal incontinence. Obstet Gynecol. 2010;115(4):809-14.

28. Mous M, Mullar S, de Leeuw JW. Long-term effects of anal sphincter rupture during vaginal delivery: faecal incontinence and sexual complaints. BJOG : an international journal of obstetrics and gynaecology. 2008;115:234-8.

29. Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ. 1994;308(6933):887-91.

30. Nichols CM, Nam M, Ramakrishnan V, Lamb EH, Currie N. Anal sphincter defects and bowel symptoms in women with and without recognized anal sphincter trauma. American Journal of Obstetrics & Gynecology. 2006;194(5):1450-5.

Postnatal follow-up for women with OASIS

31. RCOG. Third- and Fourth-degree Perineal Tears, Management (Green-top 29). RCOG Greentop Guidleines. 2015(2).