Intended for healthcare professionals


Midline episiotomy and anal incontinence

BMJ 2000; 320 doi: (Published 10 June 2000) Cite this as: BMJ 2000;320:1601

Training is needed in the recognition and repair of perineal trauma

  1. Charlotte Chaliha, specialist registrar,
  2. Abdul H Sultan, consultant obstetrician and gynaecologist
  1. Department of Obstetrics and Gynaecology, Kingston Hospital, Kingston upon Thames, Surrey KT2 7QB
  2. Department of Obstetrics and Gynaecology, Mayday University Hospital, Croydon, Surrey CR7 7YE
  3. Academic Medical Centre, Department of Obstetrics and Gynaecology, University of Amsterdam, 1100 DE Amsterdam, Netherlands
  4. Division of Obstetrics and Gynaecology, St Michael's Hospital, Bristol BS2 8EG
  5. Department of Obstetrics and Gynecology, Georgetown University Medical Center, Washington, DC 20007, USA

    EDITOR—The finding by Signorello et al that midline episiotomy may impair anal continence is valuable and highlights the effect of perineal trauma on the anal continence mechanism.1 The authors acknowledge the limitations of the study, which was retrospective, non-randomised, and may have included misclassifications of perineal trauma.

    We investigated 161 nulliparous women in the third trimester and 12 weeks post partum. A symptom questionnaire and anorectal investigations were performed at both visits and anal endosonography was performed post partum.2

    Women with an intact perineum had a mean squeeze pressure of 105.8±26.4 mmHg, those who sustained second and third degree perineal tears had a mean squeeze pressure of 92.3±30.3 mmHg (P=0.022), and those who had mediolateral episiotomies had a mean squeeze pressure of 92.2±29.7 mmHg (P=0.032).

    Sphincter trauma was associated with perineal trauma at delivery: of 59 women with second or third degree tears, 41 (69%) had sphincter trauma versus 39 out of 97 women (40%) with an intact perineum (P=0.001). Sphincter trauma was also significantly more common in women who underwent vaginal delivery: 58 out of 130 (45%) women had sphincter defects in the vaginal delivery group versus 1 out of 26 women (4%) women who underwent a caesarean section (P=0.0005). However, the difference between our study and that of Signorello et al is that the patients in our study had a mediolateral and not a midline episiotomy, and it …

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