Tips on obstetric anal sphincter laceration repair. (Evidence-Based Approach).

NEW ORLEANS -- About a third of all women who experience anal sphincter injury at the time of childbirth will develop anal incontinence. Short of prevention, the best approach to this problem is proper repair of the injury, speakers said at the annual meeting of the American College of Obstetricians and Gynecologists.

Proper repair requires good visualization, good analgesia, appropriate suture choice, use of prophylactic antibiotics, and good post repair care, said Dr. Dorothy N. Kammerer-Doak of the University of New Mexico, Albuquerque.

For closure of the rectal mucosa, fine (3-0 or 4-0) polyglycolic acid (PGA) interrupted sutures with a second imbricating layer work well, and for closure of the internal anal sphincter, which is often retracted laterally, fine PGA interrupted and running sutures are appropriate, she noted.

For the external anal sphincter, use 2-0 prolonged delayed sutures (such as PDS II or Maxon), she advised, noting that second-degree repair and perineorrhaphy may be necessary to reattach the rectovaginal septum to the perineal body, thus restoring normal anatomy.

There are no data supporting the use of prophylactic antibiotic treatment before or after laceration repair, but because of the 25% infection rate associated with the secondary repair, Dr. Kammerer-Doak recommended giving one antibiotic dose perioperatively to all patients and prescribing a course of antibiotics in any patient with stool in the wound. She also recommends the use of sitz baths and heat compresses, stool softeners, and pelvic rest.

The technique for repairing obstetrical anal sphincter lacerations has traditionally been the end-to-end repair technique, but this is associated with up to a 50% rate of disrupted external anal sphincter and/or fecal incontinence. The overlapping technique, which has commonly been used for the surgical treatment of fecal incontinence remote from delivery, may be a better approach; it has been associated with an 80% rate of fecal continence in at least one case-control study, Dr. ...