Standardizing the Repair of Obstetric Anal Sphincter Injuries: A Quality Improvement Initiative

Objectives: Obstetric anal sphincter injuries (OASI) increase the risk of developing wound infection, accidental bowel leakage, and rectovaginal fistula. Timely identification and treatment of OASI can help prevent these sequelae. The aim of this quality initiative was to improve the immediate and long-term treatment of obstetric anal sphincter injuries through the development of a standardized protocol and provider education at a single quaternary care center.

Methods: An evidence-based standardized protocol for OASI treatment was developed, including suture material and repair technique, antibiotic prophylaxis, homegoing medications, and postpartum urogynecology follow up. This protocol was presented to the Department of Obstetrics and Gynecology during institutional grand rounds in June 2022. The recommendations for repair methods were posted in work areas on labor and delivery and printed on badge backer cards, which were distributed to the department. Patients who had an OASI between January 2021 to December 2021 (pre-intervention, n=41) and July 2022 to February 2023 (post-intervention, n=22) were included in the analysis. The outcomes of interest were rates of operative report documentation, antibiotic prophylaxis, discharge with recommended homegoing medications, specialist referral, and wound complications. The pre-intervention and post-intervention outcomes were compared using Chi-square tests.

Results: 63 total patients with OASI were identified. Mean age was 29.2 years, mean gestational age was 39 weeks 0 days, and mean BMI was 33.4. 22% of patients were Black, and 73% were White. Compared to patients with OASI repaired pre-intervention, there was significantly greater adherence to antibiotic administration (54% vs 90%, p=0.003), prescribing the recommended homegoing medication regimen (29% vs 86%, p< 0.000), and specialist referral (27% vs 81%, p< 0.000) in the post-intervention group. Adherence to the recommended repair technique in the post-intervention group was 63%. The rates of wound infection (9.7% vs 0%), repair revision (14.6% vs 0%), fistula formation (4.8% vs 0%), and perineal pain at time of postpartum visit (34.1% vs 13.6%) were higher in the pre-intervention ground compared to post-intervention, though none of these findings were significantly different. There were higher rates of reported urinary incontinence (0% vs 13.6%, p=0.015) and accidental bowel leakage (7.3% vs 18.1%, p=0.191) in the post-intervention group.

Conclusions: This quality improvement initiative resulted in significantly increased rates of antibiotic administration, prescription of homegoing laxative, and postpartum specialist referrals in patients who had an OASI repair. This evidence-based standardized repair technique shows promising trends toward decreasing rates of perineal pain and wound infection, OASI repair revision, and fistula formation. The increased rates of urinary incontinence and accidental bowel leakage in the post-intervention group may be related to increased detection and closer follow up in a specialty clinic for high risk patients.