Anal sphincter injuries are detected in 25% of women after birth when they are carefully re-examined by a skilled obstetrician; however, these injuries were only found 11% of the time on a routine initial exam. Sphincter injury is the most common cause of fecal incontinence in women and can severely diminish their quality of life leading to substantial personal and financial damage. The vast majority of obstetric anal sphincter injuries can be detected clinically by a careful exam right after delivery. It is standard practice to repair a damaged anal sphincter immediately or within 24 hours of delivery. Delayed diagnosis and repair lead to life long problems with fecal incontinence.
Without an intact external and internal anal sphincter, women suffer involuntary and inappropriate passage of feces or flatus, and also suffer from urgency of defecation. When an anal laceration is promptly recognized, a properly trained obstetrician will suture the two ends of the severed sphincters together and preserve normal bowel control. However, 64% obstetricians and OB/GYN residents reported no training or unsatisfactory training in the management of obstetric anal injury. Ninety four (94%) of physicians reported feeling inadequately prepared when they had to do their first independent repair.
Although sphincter injury can occur even with optimal obstetrical management, women can reduce the risk of sphincter injury by making informed decisions. Any form of instrument delivery increases this risk. If an instrument delivery is required, choose vacuum delivery before forceps. The risk of third degree tears with vacuum extractor is 7%, while the risk with forceps is 16%. If an episiotomy is necessary, a mediolateral episiotomy has 2% risk of sphincter injury compared with 12% for a midline cut. Lastly, women need to ask their obstetrician to carefully examine them in the delivery room after birth to look for anal sphincter injuries.
Britcher Leone & Roth has assisted many women with anal sphincter injuries caused by obstetricians who failed to properly promptly diagnose and repair them after birth and who now suffer from permanent and disabling incontinence. While not every woman with postpartum fecal incontinence was injured as a result of negligence, many times such injuries could have been avoided with proper medical care.