Obstetric anal sphincter injuries: a survey on clinical practices and knowledge amongst midwives and residents
IUGA Academy. Ng K. Jun 30, 2018; 212834
Topic: Anal Incont - Fecal Urgency
Dr. Kai Lyn Ng
Dr. Kai Lyn Ng

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Obstetric anal sphincter injuries: a survey on clinical practices and knowledge amongst midwives and residents

Ng, KL1; Ng, KW1

1: National University Hospital of Singapore

Introduction: Obstetrics anal sphincter injuries (OASIS) remain an ever-increasing medicolegal trend. Despite that, understanding of knowledge, clinical practices and management strategies amongst first-line healthcare professionals remain suboptimal.

Objective: The aim of this survey was to understand the knowledge, clinical practices and management strategies for OASIS amongst the first-line healthcare professionals performing vaginal deliveries and repair of perineal tears - midwives, house officers and residents – within a tertiary obstetrics unit.

Methods: A cross sectional, anonymous 22-question survey was administered to midwives and all house officers and residents in the unit. Results were analyzed descriptively.

Results:31 responses were obtained – 10 midwives, 10 house officers and 11 residents. All had attended episiotomy workshops; 82% of residents reported attending anal sphincter workshops. Half of respondents routinely performed prophylactic episiotomies for nulliparous women; none did so for multiparous women. 22 out of 31 (71%) performed mediolateral episiotomies; the rest identified lateral episiotomy as their routine cut. 68% of them performed a cut at an angle of 60 degrees on crowning; the rest performed it at a 45-degree angle or less. None of the midwives and house officers could identify any muscles cut during episiotomies - slightly over half the residents (6 out of 11) could identify at least 1 of the cut muscle. Confidence in identifying an OASIS varied, with 0% house officers, 50% midwives and 100% residents expressing confidence in doing so. As per the unit’s protocol, all OASIS were repaired by residents and above under supervision. Confidence amongst the residents in repairing one corresponded with their numbers – all with less than 5 OASIS repairs done reported low confidence. 70% of residents correctly identified suture material used. In terms of repair technique, 6 out of 11 residents correctly identified end-to-end technique for internal anal sphincter (IAS); preferences for end-to-end versus overlapping technique for external anal sphincter (EAS) were split. All of them performed vaginal and rectal examinations pre- and post-repair. 7 out of 11 residents correctly counseled patients that 60-80% of women remained asymptomatic 12 months following OASIS repair, with the rest over- or under-estimating the prevalence. 50% of midwives and house officers, as well as 100% of residents prescribed post-procedural antibiotics. All respondents routinely gave lactulose. 23% did not refer their patients for pelvic floor exercises. 68% routinely performed prophylactic episiotomies in patients with previous OASIS attempting vaginal births.

Conclusions: Despite the unit’s guideline on episiotomies and OASIS, knowledge, clinical practices and management strategies amongst first line healthcare professionals within it differed significantly. Knowledge about the basics – anatomy, types and angle of performing an episiotomy, its role in prophylaxis – remains heterogeneous. Anal sphincter workshops contributed to a greater confidence in identifying OASIS and boosted knowledge of repair materials, techniques and post procedural management, whereas clinical experience remained imperative in building confidence for repairing one. This survey revealed an urgent need for increased awareness and educational update on the existing guideline within the unit, as well as more hands-on residents training – we propose this to be done in a controlled, model-based setting.


Work supported by industry: no.

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