Unusual rectal trauma due to compound fetal presentation

Obstetric rectal laceration in the absence of an anal sphincter injury

Rectal laceration in the absence of concurrent anal sphincter injury at the time of parturition is not a frequently reported finding. This rarely encountered injury is also referred to as a buttonhole injury. It is a disruption of the vaginal and rectal tissue with resultant disruption of the anal epithelium in the setting of an intact external anal sphincter. A 30-year-old gravida 1 para 0 at 39 weeks presented for induction of labour due to chronic hypertension. During her labour course, she developed with superimposed preeclampsia with severe features and magnesium sulfate was initiated. She underwent a spontaneous vaginal delivery of an infant weighing 3840 g. Following delivery, stool was visualised in the vagina. A rectal examination revealed a rectovaginal defect separate from the second-degree perineal laceration, which extended proximally to the cervix. The anal sphincter was noted to be intact with good tone. Both defects were repaired, and she had an uncomplicated recovery.

Isolated rectal buttonhole tears in obstetrics: case series and review of the literature

INTRODUCTION AND HYPOTHESIS

The management of isolated rectal buttonhole tears is not standardised and can be challenging in an acute obstetric setting. Our aim was to review the published literature and describe management and repair techniques in a case series.

METHODS

A literature search was carried out. All results were screened and reviewed. Rectal buttonhole tears following vaginal delivery between April 2012 and January 2020 in our institution were identified. Repair technique and post-operative management were recorded.

RESULTS

There were nine published case reports (four instrumental deliveries, two vaginal breech and three normal vaginal deliveries). Four case reports described a two-layer closure and five described a three-layer closure. Two cases were repaired in collaboration with colorectal surgeons. All nine cases made an uneventful recovery. We identified three patients with buttonhole tears all of whom had instrumental deliveries. A colorectal surgeon repaired the tear in two layers in one case, and an obstetrician performed the repair in the other two cases, one in three layers and the other in two layers. One patient had a de-functioning stoma at a later date due to a second breakdown of the recto-vaginal fistula repair.

CONCLUSION

Buttonhole tears are rare but techniques of repair vary. Most cases reviewed had an uneventful recovery after repair. We provide standardised steps for repair and management of isolated rectal buttonhole tears along with a video demonstrating the repair technique in an animal tissue (pig) model.

A rare case of isolated rectal laceration during parturition: consideration of the controversial role of the episiotomy and literature review

BACKGROUND

Rectal laceration without sphincter lesion during childbirth is an unusual presentation. Like all the other severe lacerations during parturition, if left undiagnosed and untreated could hesitate in serious short and long term complications. Episiotomy once considered a routine procedure in nulliparous and a safeguard against severe tissue trauma nowadays is undergoing criticism and his effectiveness reconsidered. Currently, a policy of "selective" use of episiotomy is recommended only when an impending risk of lacerations is identified. When, according to this proposal, in the absence of risk factors episiotomy is not performed and complications occur, the medicolegal implication could arise.

CASE

A 29-year-old primigravida was admitted with spontaneous onset of labor at 41 weeks after an uncomplicated pregnancy. During the second stage of labor a spurt of siero- hemorrhagic fluid was noted trough the anus. In absence of recognized risk factor episiotomy was not performed. A healthy 3650 grams female was born in a fair condition. Rectal examination immediately after delivery revealed a longitudinal laceration with un undamaged sphincter. The rectal tear was repaired and recovery was uneventful.

CONCLUSIONS

In our as in the other cases here reviewed a severe laceration occurred unexpectedly and unpreventably in patients where, according to a selective regime, episiotomy was not performed. In this setting, if severe short and long term complications ensued, especially in nulliparous, the decision to withhold episiotomy could be a source of medicolegal issues. Therefore a detailed informed consent is necessary to offer to patients a full disclosure on the role of episiotomy, its recent indications as well as the possible complications stemming from both executing or withholding this procedure.

A rare complication of a vaginal breech delivery

Rectal lesions without anal sphincter trauma in childbirth are only sporadically described in literature. We describe the case of a 29-year-old primigravida who delivered a child in frank breech presentation. During the second stage of labour a foot presented transanally through a rectal laceration with intact anal sphincters. The laceration was repaired immediately after delivery in theatre. Follow-up visits showed a properly cured laceration and no complaints of incontinence or foul discharge.