OBSTETRICAL ANAL SPHINCTER

INJURIES (OASIS): A REPAIR GUIDE

Maria Giroux, BSc (Hons.), MD
Anita Harding, MD, FRCSC

Corrine Jabs, MD, FRCSC

Illustrations by Martinique Downs & Maria Giroux

Last modified March 2020 OASIS REPAIR 1

Disclaimer:
The information presented is designed as an educational resource. It is intended for educational or
information purposes only; it is not intended to be a substitute for independent professional judgement of
the treating clinician. The use of information is voluntary. The information presented should not be
considered a statement of standard of care or all inclusive of proper treatments/care. Variations in practice
exist and it is at the discretion of treating clinical to exercise clinical judgement.

The OBGYN Academy team makes effort to present accurate and reliable information. The information is
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presented.

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Introduction
• In order to maximize the outcomes of sphincter injury repair, the
following is recommended
• Even though there is a lack of evidence for many aspects of repair,
there is international acceptance of expert opinions, as summarized
in the references

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Principles of Repair
• The repair should be performed or supervised by an experienced
obstetrician. Assure that an appropriate assistant is available.
• Surgical skills lab improves learners’ acquisition of skills required for
OASIS repair
• If the provider is not experienced in OASIS repair or not available, repair can
be delayed for 8-12hrs with no impact on anal incontinence and pelvic floor
symptoms

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Where To Perform Repair
• The repair should ideally be performed in the Operating Room or
well-equipped delivery room to assure appropriate lighting,
anesthetic options, an assistant, and access to instrumentation

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Analgesia
• Adequate anesthesia is a must!
• Options
• Local infiltration
• Pudendal nerve block
• Regional (spinal/epidural) anesthesia
• General anesthesia
• No studies have evaluated use of
anesthetics in repair of OASIS
• No RCT has compared using local vs
regional anesthetic for OASIS repair
SOGC recommendations:
• Epidural or general anesthesia are not
always necessary
• Need adequate analgesia à can be
achieved with local infiltration or
pudendal nerve block
Spinal/epidural anesthesia:
• Provides analgesia, sufficient
sphincter muscle relaxation, reduces
muscle tension
• Muscle relaxation improves
evaluation of EAS since it has intrinsic
tone and retracts and assures
appropriate tension-free
approximation during repair
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Need for Repair
Need for repair:
• Optimal light and exposure
• Anesthesia
• Assistant(s)
• Equipment
• Needle driver
• Tissue forceps
• Sutures
• Sponges
• Retractor (e.g. Sim retractor or self-retaining retractor) for optimal exposure
• Allis clamps x2
• Mosquito artery forceps or hemostat
• Scissors for dissection of external anal sphincter (EAS)- Metzenbaum or McIndoe
• Suture scissors
• Glove liners x2 for the rectal examination

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Sutures
• Very little data comparing different
types of sutures
• No studies comparing suture
types and long-term outcomes
(e.g. Anal incontinence)
• Use absorbable or delayed absorbable
sutures
• Avoid non-absorbable sutures
à can cause stitch abscess,
perineal pain requiring removal
• No studies have examined the
benefit of delayed absorbable
suture and long-term outcomes
Comparison of sutures:
• Monofilament sutures are less likely
to harbour organisms for infection
• EAS: no difference in 3-0 PDS vs 2-0
Vicryl in suture-related morbidity at
6 weeks
• Synthetic sutures:↓ pain, ↓ need
for resuturing compared to catgut
• Rapidly absorbable suture: no
difference in long-term
pain/dyspareunia when compared
to regular synthetic suture
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Anatomy of Perineal Laceration

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OASIS Diagnosis

Physical Examination
• Inspection with adequate lighting and analgesia Asking patient to contract anal
• Vaginal examination sphincter
• May not be conclusive if there
• Part labia with middle and index fingers
is partial thickness tear (may
• Inspect perineum and distal posterior vagina contract) or if patient has
• Vaginal examination for the full extent of any vaginal epidural (may be unable to
tears contract)
• Inspect for 3rd degree tear behind “intact” perineum
• Rectovaginal examination for all tears more than superficial
in depth!
• Dominant hand: insert index finger into the anal
canal and ipsilateral thumb into vagina à palpate
thickness with a ”pill-rolling” motion
• Ends of the external anal sphincter can retract à
can feel cavity along the course of sphincter (may be
less evident if epidural is present)
• Examine for buttonhole tears

Repeat rectovaginal examination after the repair!

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Summary

Summary of OASIS Repair

1. Proper physical examination, including a rectovaginal examination
• Rectal exam for all lacerations more than superficial in depth for OASIS and
buttonhole tears prior to suturing
2. Proper lighting, anesthesia, exposure, assistance
3. Identify and grasp external anal sphincter (EAS) ends with 2 Allis clamps
• Torn ends of EAS are under tonic contraction à can retract within the capsule
sheath and can be found latero-posterior to the laceration in a downward
depression
4. Avoid figure-of-eight sutures during repair
5. Repair anorectal mucosa
6. Repair internal anal sphincter (IAS)
7. Repair external anal sphincter (EAS)
8. Reconstruct perineal body and perineal muscles (bulbocavernosus and superficial
transverse perineal muscles) to take off tension from the anal sphincter
9. Repair vaginal mucosa and perineal skin
10. Repeat rectovaginal examination to ensure that repair is adequate and to identify any
sutures connecting vagina to rectum

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Summary

Closure Recommendations
Anorectal mucosa • Continuous nonlocking with 3-0 PDS
• Or simple interrupted with 3-0 Vicryl
Internal anal • End-to-end repair (do not attempt to overlap)
sphincter (IAS) • Delayed absorbable suture à e.g. 3-0 PDS
External anal • End-to-end repair or overlapping repair with 2-3 mattress sutures
sphincter (EAS) • 3-0 or 2-0 PDS or 2-0 Vicryl
• Bury knots in order to avoid migration to skin
Perineal musculature • Reconstruct perineal body
• Running closure, can do interrupted for distorted spaces
• 2-0 or 3-0 Vicryl/Vicryl rapide/Chromic
Vaginal mucosa and • Repair vaginal mucosa and skin
perineal skin • Subcuticular closure or interrupted if uneven edges
• 3-0 Vicryl/Vicryl rapide

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Video Demonstrating Repair
• Dr. Corrine Jabs demonstrates elements of OASIS repair on a Pig
model based on SOGC guidelines

https://www.youtube.com/watch?v=7kQAHpAAlHk&feature=emb_title

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Anorectal Mucosa
• Continuous nonlocking with 3-0 PDS
• Or simple interrupted with 3-0 Vicryl

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Internal Anal Sphincter (IAS)
• Need to repair IAS Complications of isolated IAS defect:
• Repairing IAS defect may improve • Higher risk of anal incontinence
anal incontinence at 1 year • Lower anal pressures
• Shorter anal length
• Most colorectal surgeons would
not attempt to repair an isolated
IAS defect
• End-to-end repair
• Delayed absorbable suture à e.g.
3-0 PDS
• Dr. Sultan’s and Dr. Thakar’s 2018
PROTECT Program: end-to-end,
continuous, nonlocking

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External Anal Sphincter (EAS)
• 2 techniques
• End-to-end
• Overlapping
• SOGC: one technique is not recommended over another
• Some evidence that overlapping repair is superior for full thickness 3b
• Experience of physicians performing repair was not evaluated in
all studies

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External Anal Sphincter (EAS)
End-to-end
• For all partial thickness 3rd degree (3a, some 3b)
• Technique
• Dissect to mobilize ends of EAS using Metzenbaum
scissors
• 2-3 mattress sutures to reapproximate EAS
• Include the fascial sheath into the repair
• Cut sutures short, burry knot under superficial perineal
muscles
• Mattress sutures are preferred (less tissue necrosis)!
• Interrupted sutures can cut through circular muscle
fibers of the anal sphincter
• Less flatal incontinence
Overlapping
• For full thickness 3b, 3c, 4th degree à Only possible
with ≥3b
• Need more dissection of EAS with Metzenbaum
scissors
• Use ischiorectal fat as a lateral landmark!
• Technique
• EAS (including fascial sheath) are
overlapped using horizontal mattress
sutures in 2 rows
• Less fecal urgency, fecal incontinence, less
deterioration from 6 weeks to 6 months
• This difference is not evident at 36 months
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Evidence
Sultan (1999)- 1st study to compare 2 techniques
• Overlapping has less anal incontinence
• End-to-end: 41%
• Overlapping: 8%
• Small study, n=27
Farrell OASIS RCT (2010):
• Study compared 2 techniques in primips with
OASIS
• End-to-end technique had less flatal
incontinence at 6 months post-repair
• End-to-end: 39%
• Overlapping 61%
• No difference in fecal incontinence between
2 techniques
2013 Cochrane review:
• Overlapping has less fecal urgency and fecal
incontinence, less deterioration of incontinence from
6 weeks to 12 months
• One trial showed that this difference is no
longer present at 36m
• Issues with current literature: heterogeneity in
outcome measures, time points, and reported results;
included both primips and multips with partial and
complete tears; did not evaluate surgical experience
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MANAGEMENT AFTER REPAIR

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Documentation
• Type and extent of perineal injury
• Method of repair (end-to-end vs overlapping)
• Sutures used
• Antibiotics
• Counselling

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Counselling post-OASIS

Counselling
• Discuss
• Events that took place
• Degree of perineal laceration
• How to care for an obstetrical tear
• When to follow-up with a healthcare provider
• Possible short-term and long-term complications
• When to see a pelvic floor physiotherapist
• Patient educational resource makes a lot of difference to patients!
• Patients may be traumatized by the experience
• Follow-up
• Further debriefing and explanation of events that took place, plans for
subsequent pregnancy

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Patient Educational Resource

https://obgynacademy.com/obstetri
cal-lacerations/

Content:
• Overview of obstetrical tears
• How to care for an obstetrical tear
• When to resume sex
• When to follow-up with a healthcare provider
• Possible short-term and long-term
complications
• When to see a pelvic floor physiotherapist
• Kegel exercises
• Future deliveries

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Summary

Summary of Post-Op Management

Orders:
• Antibiotics: prophylactic single dose intravenous antibiotics (2nd generation
cephalosporin e.g. cefoxitin or cefotetan)
• Foley catheter for a minimum of 12hrs postpartum
• Analgesia: NSAIDs +/- acetaminophen
• Avoid NSAIDs per rectum (e.g. Diclofenac) for 4th degree tear (reports of wound
breakdown)
• Use opioids with caution, if using then add laxative
• Bowel regimen: laxative to reduce risk of wound dehiscence
• Pelvic floor physiotherapy postpartum
• Follow-up with obstetrician

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Prophylactic Antibiotics
SOGC 2015 Clinical practice Guidelines:
• Prophylactic single dose intravenous antibiotics (2nd generation
cephalosporin e.g. cefoxitin or cefotetan) administered for the
reduction of wound complications
• E.g. Cefoxitin 2g IV x1 at the time of perineal laceration repair.
If allergy to penicillin, then administer clindamycin 900mg
IVx1
Evidence:
• Only 1 RCT compared placebo vs 1 dose of 2nd generation cephalosporin IV (cefotetan, cefoxitin) given
at the time of repair on postpartum perineal wound complications 2 weeks post-OASIS
• Wound complications= purulent discharge, abscess, breakdown of repair
• Significant reduction in perineal wound complications: 24.1% placebo vs 8.2% antibiotics; RR=
0.34
• Issue was high drop-out rate (27.2%)
• No studies have evaluated the value of additional doses of antibiotics

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Foley Catheter
• Place and leave a Foley catheter for a Pathophysiology of postpartum
minimum of 12hrs postpartum urinary retention:
• Place the patient on a bladder protocol • Unclear
• May be due to
after removal of Foley catheter to • Perineal discomfort
assure proper bladder emptying • Urethral and perineal
• Patients with OASIS are at increased risk for trauma
postpartum urinary retention • Neurologic damage
• 33% of pts with PP urinary retention • Discomfort and edema
of perineal tissues may
had OASIS
inhibit voiding à urinary
• Patients with epidural are at increased risk retention à bladder
• Bladder sensation can take up to distension injury
12hrs to return post-epidural

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Analgesia
SOGC 2015 Clinical practice Guidelines:
• 1st line- NSAIDs +/- acetaminophen
• Avoid NSAIDs per rectum (e.g. Diclofenac) for 4th degree tear
(can impair wound healing, reports of wound breakdown)
• Use opioids with caution due to risk of constipation
• Add laxative to avoid constipation

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Bowel Regimen
SOGC 2015 Clinical practice Guidelines:
• The use of postoperative laxatives is recommended to reduce the risk of
wound dehiscence
• E.g. PEG 3350 17g PO dissolved in 8oz of water daily for 7-10 days
• Laxatives result in earlier and less painful 1st BM, earlier discharge from
hospital
• Constipating regimen and bulking agents are not recommended

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Follow-Up
• Follow-up with obstetrician in 6 weeks
• Follow-up sooner if necessary or if problems arise
• Prescription
• Analgesia (NSAIDs +/- acetaminophen)
• Laxative (e.g. PEG 3350 17g PO dissolved in 8oz of water daily
prn for 2 weeks)
• Referral for pelvic floor physiotherapy

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Pelvic Floor Physiotherapy
• All patients should be advised to pursue pelvic floor physiotherapy
following repair
• The ideal time to commence is uncertain, but most experts agree
that the 6-8 week mark is appropriate for evaluation

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References
Harding, A., & Prollius, A. (2017, April 27). OASIS: Obstetrical Anal Sphincter Injuries. Lecture presented at Academic Half Day in
University of Saskatchewan, Saskatoon.
Harvey, M., Pierce, M., Walter, J., Chou, Q., Diamond, P., Epp, A., Geoffrion, R., Larochelle, A., Maslow, K., Neustaedter, G.,
Pascali, D., Schulz, J., Wilkie, D., Sultan, A., Thakar, R. (2015). Obstetrical Anal Sphincter Injuries (OASIS): Prevention,
Recognition, and Repair. SOGC Clinical Practice Guideline. J Obstet Gynaecol Can, 37(12), 1131-1148.
Lone, F., Sultan, A., Thakar, R. Obstetric Pelvic Floor and Anal Sphincter Injuries. The Obstetrician & Gynaecologist,
2012;14:257-66.
Sultan, A., Kamm, M., Hudson, C., Bartram, C. Third Degree Obstetric Anal Sphincter Tears: Risk Factors and Outcome of
Primary Repair. BMJ. 1994 Apr 2,308(6933):887-91.
Sultan, A., & Thakar, R. (2017, June 21). Hands-On Workshop on Diagnosis and Repair of 3rd/4th Degree Obstetric Tears.
Workshop presented at International Urogynecological Association (IUGA) 42nd Annual Meeting, Vancouver, Canada.
Sultan, A., & Thakar, R. (2018, June 26). Prevention and Repair Of perineal Trauma Episiotomy through Coordinated Training
(PROTECT)- Train the Trainer Program. Workshop presented at International Urogynecological Association (IUGA) 43rd Annual
Meeting, Vienna, Austria.
Sultan, A. H., Thakar, R., & Fenner, D. E. (2008). Perineal and Anal Sphincter Trauma: Diagnosis and Clinical Management (2nd
ed.). New York: Springer.
The Management of Third- and Fourth-Degree Perineal Tears. RCOG Green-Top Guideline No.29. June 2015.

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