Effect of a new guideline on outcome following third-degree perineal tears: results of a 3-year audit

Abstract

The aim of this study was to assess the impact of a new guideline on the outcome of repair of obstetric anal sphincter tears by examining adherence to the guideline and the effect upon the incidence of symptoms of anal incontinence. An audit of third-degree perineal tears was conducted in 1997. A reaudit was completed in 1998 and 1999 after the introduction of a new guideline. The audits were conducted in a tertiary obstetric unit with 5000 deliveries per annum. Over the 3-year period between 1997 and 1999 124 women with a third-degree tear were identified; 14 381 women who had delivered vaginally without third-degree tears were used as controls. The main outcome measure was the number of cases with adherence to the protocol, and the number of patients with ongoing symptoms. Cases were identified from the hospital database, and case notes were reviewed to obtain clinical data. The incidence of third-degree perineal tears was 0.81% over the 3-year period. Following the introduction of a new guideline there was a significant increase in the number of repairs performed in theatre (70% vs 82% vs 97%, P<0.05), using Prolene (64% vs 76% vs 93%, P< 0.05), with adequate anesthesia (70% vs 82% vs 97%, P<0.05). At follow-up there was a transient improvement in defecatory symptoms in the first year of the protocol only (45% vs 32% vs 50%, P<0.01). More patients had complete follow-up data after introduction of the protocol: 66% vs 86% vs 80% (P<0.001). There were more cases of Prolene suture migration (7% vs 34% vs 16%, P<0.01). We concluded that the introduction of a new guideline was followed by improved performance of appropriate repair. There was no sustained improvement in fecal symptoms at follow-up.