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Obstetrical Trauma

This is the first dedicated clinic in Canada with a longitudinal care model for patients with obstetrical trauma that includes
1. Postpartum patients: a comprehensive 12-months dedicated care pathway for patients with obstetric anal sphincter injuries (OASIS) (3rd and 4th degree perineal lacerations); management of postpartum pelvic floor disorders and postpartum pain
2. Subsequent pregnancy post-OASIS: counselling regarding mode of subsequent delivery and postpartum follow-up
3. Long-term complications of obstetrical trauma for pre- and postmenopausal women with dedicated pelvic floor disorders clinic and anorectal clinics.

Endoanal ultrasound (EAUS) is performed and interpreted in-clinic by a urogynecologist to provide consistent patient counselling and management.

Assessments are performed at the Centre for OASIS. Anorectal manometry and surgeries are performed at St. Paul's Hospital and BC Women's Hospital.

Centre for OASIS collaborates with the OBGYN Academy to present recurrent multidisciplinary virtual patient educational sessions across Canada and recurrent hands-on OASIS repair training courses for providers.

Conditions Treated

  • Obstetric anal sphincter injury (OASI)

    • Currently postpartum (preferably referred immediately postpartum to enter the pathway, but may be referred at any point in time)

    • Currently pregnant, history of previous OASI (for appointment at 28-32 weeks)

    • Not currently pregnant, presence of anorectal symptoms, remote history of OASI

  • Pelvic floor dysfunction postpartum

    • Urinary incontinence​

    • Anorectal symptoms

      • Fecal urgency

      • Fecal incontinence

      • Flatal incontinence

    • Pelvic organ prolapse

    • Voiding dysfunction

  • Levator avulsion

  • Pain within 12 months postpartum

    • Pelvic floor pain​

    • Perineal wound complication

    • Dyspareunia

    • Pudendal neuralgia

    • Cesarean section scar pain

  • Rectovaginal fistula

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Obstetrical tears are common and 85% of women sustain some degree of perineal laceration during vaginal delivery (Frohlich et al 2015). Obstetric anal sphincter injuries (OASIS) are severe perineal lacerations that occur in 5% of all vaginal deliveries in the province of British Columbia (Muraca et al 2018). The incidence of OASIS has been increasing in Canada and worldwide (Jha et al 2016). 

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The role of this dedicated clinic for patients with OASIS:

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Postpartum patients after OASIS:

This clinic is used to:

  • Debrief and discuss the delivery complicated by OASI

  • Assess postpartum physical and emotional recovery

  • Provide consistent multidisciplinary patient education about obstetrical trauma and postpartum recovery

  • Provide early identification and management of complications related to obstetrical trauma such as anorectal symptoms, postpartum pain, postpartum pelvic floor dysfunction, levator avulsions, and rectovaginal fistula

  • Identify and provide counselling regarding prevention of pelvic floor disorders in the future

  • Counsel and empower women to make an informed decision regarding mode of subsequent delivery

  • Provide management strategies to decrease risk of recurrence of OASIS with subsequent delivery

  • Provide with multidisciplinary community referrals 

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Currently pregnant patients with previous OASIS:

This clinic is used to:

  • Provide consistent multidisciplinary patient education about obstetrical trauma and postpartum recovery

  • Provide management of complications related to obstetrical trauma

  • Identify and provide counselling regarding prevention of pelvic floor disorders in the future

  • Counsel and empower women to make an informed decision regarding mode of subsequent delivery

  • Provide management strategies to decrease the risk of recurrence of OASIS with subsequent delivery

  • Provide multidisciplinary community referrals 

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OASIS Care Pathway

Centre for OASIS has a dedicated pathway for patients with OASIS. Patients are preferably referred immediately postpartum to enter the pathway, but may be referred at any point in time. This pathway consists of history, physical examination, endoanal ultrasound, anorectal manometry, and patient counselling. Assessments are virtual and in-person.

Patients continue to be under the care of their current healthcare provider for the 6-8 week postpartum appointment (for postpartum patients) or antenatal appointments (for antepartum patients). This pathway is in addition to the usual care.

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The Role of Endoanal Ultrasound and Anorectal Manometry

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Endoanal ultrasound is used together with anorectal manometry to create individualized recommendations regarding mode of subsequent delivery in patients with OASIS. The Centre for OASIS uses the newest bkSpecto high-resolution 3D endoanal ultrasound imaging. 

The Role of Endoanal Ultrasound in Patients with OASIS:
Endoanal ultrasound is the gold standard for assessment of the structure of anal sphincter complex that has sensitivity of 100% (Sultan et al 1994). It is used to confirm accuracy of clinical diagnosis of the degree of perineal tear and provides information that is used for counselling regarding mode of subsequent delivery after OASIS. A recent Canadian study revealed that 36.8% of women with clinical diagnosis of OASIS at the time of vaginal delivery have normal endoanal ultrasound. These women do not have OASIS (they are overdiagnosed) and do not require an elective Cesarean section for the sole indication of OASIS for deliveries in the future (Giroux et al 2023). In women with correct diagnosis of OASIS, endoanal ultrasound is used to assess for presence of a scar versus a significant residual defect. A significant residual defect is found in 69.2% of women with OASIS, which affects counselling regarding mode of subsequent delivery (Giroux et al 2023). Since there is a weak positive correlation between anorectal symptoms and the findings of endoanal ultrasound, this highlights the importance of endoanal ultrasound regardless presence of anorectal symptoms to assist with selecting the most appropriate mode of delivery in future pregnancies (Giroux et al 2023).

The Role of Anorectal Manometry in Patients with OASIS:
Anorectal manometry assesses the function of the anal sphincter complex, which is used for counselling regarding mode of subsequent delivery after OASIS. Presence of abnormal anorectal manometry findings is associated with anorectal symptoms. Nonetheless, 30.6% of women after OASIS have abnormal anorectal manometry findings, no anorectal symptoms, and normal endoanal ultrasound, which can influence counselling regarding mode of subsequent delivery (Badri et al 2023).

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Procedures Performed

  • Anal sphincteroplasty

  • Rectovaginal fistula repair

  • Trigger point injections for hypertonic pelvic floor and rectus myalgia

  • Pudendal nerve block

References

Badri H, Fowler G, Lane S. The role of anal manometry in the follow-up of women with obstetric anal sphincter injuries (OASI). Int Urogynecol J. 2023;34:399-404. 

Edwards M, Kobernik E, Suresh S, Swenson C. Do women with prior obstetrical anal sphincter injury regret having a subsequent vaginal delivery? BMC Pregnancy and Childbirth. 2019;19:225. 

Frohlich J, Kettle C. Perineal care. BMJ Clin Evid 2015;3:1-22.

Giroux M, Naqvi N, Alarab M. Correlation of anorectal symptoms and endoanal ultrasound findings after obstetric anal sphincter injuries (OASIS). Int Urogynecol J. 2023. Online ahead of print.  https://doi.org/10.1007/s00192-023-05491-8

Jha, Swati, and Victoria Parker. “Risk Factors for Recurrent Obstetric Anal Sphincter Injury (ROASI).” Obstetrical & Gynecological Survey, vol. 71, no. 9, 2016, pp. 523–524. doi:10.1097/ogx.0000000000000359.

Muraca G, Lisonkova S, Skoll A, Brant R, Cundiff G, Sabr Y, Joseph K. Ecological association between operative vaginal delivery and obstetric and birth trauma. CMAJ 2018;190(24):E734-E741

Sultan A, Kamm M, Talbot I, Nicholls R, Bartram C. Anal endosonography for identifying external sphincter defects confirmed histologically. J Surg. 1994;81(3):463-465. 

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