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Anal Sphincter Tears During Vaginal Delivery: A New Challenging Problem for the Health System in Iran


1 Department of Surgery, Colorectal and Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
2 Student Research Committee, Shiraz University of Medical Sciences, Shiraz, IR Iran
*Corresponding author: Mohammad Yasin Karami, Department of Surgery, Colorectal and Laparoscopy Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran. Tel: +98-9171800710, Fax: +98-7132330724, E-mail: karamiy@sums.ac.ir.
Annals of Colorectal Research. 4(4): e39490 , DOI: 10.17795/acr-39490
Article Type: Letter; Received: Sep 4, 2016; Accepted: Sep 10, 2016; epub: Sep 19, 2016; collection: Dec 2016

Keywords: Anal Cancal Laceration; Normal Vaginal Delivery


Dear Editor,


Anal sphincter injury is a severe complication in vaginal delivery and is the leading cause of anal incontinence. The association between third and fourth degree anal sphincter tears and fecal incontinence has been reported for many years (1). Sphincter tears occur in up to 18% of deliveries (2). Recently, the new health system program recommended obstetrics surgeons to perform vaginal delivery instead of caesarian section in Iran. Third and fourth anal sphincter tears in vaginal delivery caused by Obstetrics residents have increased in educational hospitals. Certain recommendations may decrease this complication. Training must secure obstetrics residents can identify indications and contra-indications, choose the appropriate object, use the tools correctly, and know the rules of quality control applied to vaginal delivery. The training program must take place simultaneously with training on the use of traditional instruments, such as vacuum extractors and spatulas. Excellent knowledge of the mechanics of obstetrics and pelvic anatomy is demanded. Furthermore, traditional training should be accompanied by test runs. The use of test runs in training also helps resolve problems that long experience in a large number of procedures is desirable but very hard to reach in real life. Training should be designed for each person and unlimited for some students. The danger of instrumental deliveries depends more on the operator’s skills than on the tools itself. The evaluation of training should focus on both teachers and trainees. Sessions should be held to understand the worth of department-wide professional practices and should cover quality-judging requirements associated with vaginal deliveries.


The obstetricians and residents should repair grade 3 anal sphincter tears and must also refer those with grade 4 to a colorectal surgeon for better approach and evaluation. The involvement of obstetricians may improve practices. The authors hope for a decrease in usual vaginal delivery complication rate during this program by training methods.

Footnotes

Authors’ Contribution: Alimohammad Bananzadeh, supervisor, conception and design, and revision of the manuscript; Mohammad Yasin Karami, drafting of the manuscript and final approval.

References


  • 1. Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med. 1993;329(26):1905-11. [DOI] [PubMed]
  • 2. Fenner DE, Genberg B, Brahma P, Marek L, DeLancey JO. Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States. Am J Obstet Gynecol. 2003;189(6):1543-9. discussion 1549-50 [DOI] [PubMed]