Pelvic Floor, Perineal, and Anal Sphincter Trauma During Childbirth: Diagnosis, Management and Prevention

Foreword
Preface
Contents
1: Anatomy of the Pelvic Floor, Perineum and Anal Sphincter
	1.1	 Introduction
	1.2	 Embryology
	1.3	 Muscles of the Perineum
		1.3.1	 The Urogenital Triangle
			1.3.1.1	 Superficial Transverse Perineal Muscle
			1.3.1.2	 Bulbospongiosus Muscle
			1.3.1.3	 Ischiocavernosus Muscle
		1.3.2	 The Anal Triangle
			1.3.2.1	 Anal Canal
			1.3.2.2	 Anal Sphincter Complex
				External Anal Sphincter
				Internal Anal Sphincter
				The Longitudinal Layer and the Conjoint Longitudinal Coat
			1.3.2.3	 Innervation of the Anal Sphincter Complex
			1.3.2.4	 Vascular Supply
			1.3.2.5	 Lymphatic Drainage
			1.3.2.6	 Ischioanal Fossa
	1.4	 Perineal Body
	1.5	 The Pelvic Floor
		1.5.1	 Innervation of the Levator Ani
		1.5.2	 Vascular Supply
	1.6	 The Pudendal Nerve
	1.7	 Conclusion
	Appendix: MCQ
		Questions
		Answers
	References
2: Pathophysiology and Effects of Pregnancy on the Pelvic Floor
	2.1	 Introduction
	2.2	 Pelvic Floor Anatomy
	2.3	 Pelvic Floor Changes
		2.3.1	 Pelvic Floor Changes in Preparation for Birth
		2.3.2	 Pelvic Floor Injury During Birth
			2.3.2.1	 Levator Ani Muscle Injury
				Incidence, Risk Factors, and which Muscle Is Injured
				Mechanism of Injury and Concept of Injury Spectrum
				What Is the Cause of Levator Ani Injury?
				Stretching and Tearing Is the Cause of Injury
		2.3.3	 Recovery After Vaginal Birth
			2.3.3.1	 How Do the Hiatuses Recover?
	2.4	 The Hiatus and Pelvic Floor Disorders
		2.4.1	 How Does High Pressure Zone Contribute to Providing Support?
		2.4.2	 An Enlarged Hiatus Is One Cause of Pelvic Organ Prolapse
		2.4.3	 Factors Affecting Hiatus Size
		2.4.4	 The Perineal Complex
	2.5	 Pelvic Floor Dysfunctions in Relation to Birth Injuries
		2.5.1	 Pelvic Organ Prolapse
			2.5.1.1	 Levator Ani Injury at Birth and Prolapse
			2.5.1.2	 Load Sharing Between Levator Ani and Connective Tissue
		2.5.2	 Urinary Incontinence
			2.5.2.1	 Urethral Support and Birth
			2.5.2.2	 Levator Ani Injury Associated Urethral Sphincter Dysfunction
		2.5.3	 Anal Incontinence
			2.5.3.1	 Ultrasound Studies and Anal Incontinence
	2.6	 Summation
	Appendix: MCQ
		Questions
		Answers
	References
3: Diagnosis of Obstetric Anal Sphincter Injuries (OASIs)
	3.1	 Introduction
	3.2	 Classification of Perineal Trauma
		3.2.1	 Steps to Making an Accurate Clinical Diagnosis of OASIS
	3.3	 Undiagnosed OASIs
	3.4	 Can Routine Anal Sonography Immediately After Delivery Improve Accuracy of Detection of OASIs?
	3.5	 Conclusions
	Appendix: MCQ
		Questions
		Answers
	References
4: Episiotomy, First and Second Degree Tears
	4.1	 Introduction
	4.2	 Definition
	4.3	 Prevalence
	4.4	 Episiotomy Rates: Is There an ‘Ideal’?
	4.5	 Classification of Perineal Trauma
	4.6	 Indications for Episiotomy
	4.7	 Non-suturing of First and Second Degree Tears
	4.8	 Suturing Methods
	4.9	 Suture Materials
	4.10	 Management of Perineal Trauma
		4.10.1	 Basic Surgical Principles
		4.10.2	 First Degree Tears and Labial Lacerations
		4.10.3	 Repair of Episiotomy and Second Degree Tears
		4.10.4	 The Continuous Suturing Technique
			4.10.4.1	 Suturing the Vagina
			4.10.4.2	 Suturing the Muscle Layer
			4.10.4.3	 Suturing the Perineal Skin
		4.10.5	 Training
	4.11	 Conclusion
	Appendix: MCQ
		Questions
		Answers
	References
5: Management of Acute Obstetric Anal Sphincter Injuries (OASIs)
	5.1	 Introduction
	5.2	 Historical Perspective
	5.3	 Prevalence
	5.4	 Repair Techniques
		5.4.1	 Principles and Technique of Repair
	5.5	 Rectal Buttonhole Tears
	5.6	 Outcome of Primary Repair of OASIs
	5.7	 Post-Operative Management
		5.7.1	 Antibiotics
		5.7.2	 Bladder Catheterisation
		5.7.3	 Post-Operative Analgesia
		5.7.4	 Dietary Advice and Stool Softeners
		5.7.5	 Patient Information
		5.7.6	 Follow-Up
	5.8	 Management of Subsequent Pregnancies After OASIs
		5.8.1	 What Is the Risk of Sustaining a Recurrent OASIs (rOASIs)?
		5.8.2	 What Is the Risk of Anal Incontinence After Another Vaginal Birth?
		5.8.3	 What Is Recommended Practice?
			5.8.3.1	 Asymptomatic Women Post OASIs
			5.8.3.2	 Symptomatic Women Post OASI
		5.8.4	 What Is the Risk of Worsening anal Incontinence Symptoms After Recurrent OASIs?
		5.8.5	 How Safe Is Caesarean Birth?
		5.8.6	 Can Objective Assessments Predict Who Will Develop Incontinence?
	5.9	 Who Should Be Performing Acute Primary Obstetric Sphincter Repairs?
	5.10	 Education and Training
	5.11	 Conclusions
	Appendix: MCQ
		Questions
		Answers
	References
6: Short and Long-term Maternal and Neonatal Outcomes of Caesarean Section
	6.1	 Introduction
	6.2	 Short-term Implications of CB
		6.2.1	 Bleeding
		6.2.2	 Surgical Site Infection and Wound Complications
		6.2.3	 Return to Theatre
		6.2.4	 Venous Thromboembolism (VTE)
		6.2.5	 Visceral Injury
		6.2.6	 Maternal Mortality
		6.2.7	 Neonatal Implications
		6.2.8	 Recovery Time
	6.3	 Long Term Implications of CB
		6.3.1	 Future Pregnancies
			6.3.1.1	 Birth Complications
			6.3.1.2	 Uterine Rupture
			6.3.1.3	 Placenta Praevia
			6.3.1.4	 Placenta Accreta Spectrum (PAS)
			6.3.1.5	 Preterm Labour (PTL)
			6.3.1.6	 Spontaneous Abortion and Ectopic Pregnancy
			6.3.1.7	 Caesarean Scar Ectopic Pregnancy (CSEP)
			6.3.1.8	 Fetal Demise
		6.3.2	 Gynaecological Issues
			6.3.2.1	 Fertility
			6.3.2.2	 Chronic Pelvic or Abdominal Pain
			6.3.2.3	 Development of Endometriosis
	6.4	 Emotional and Psychological Wellbeing and Birth Satisfaction
	6.5	 Childhood Wellbeing Implications
		6.5.1	 Cerebral Palsy and Neuropsychological Development
		6.5.2	 Development of Physical Health Conditions
	6.6	 Implications to Perineal Problems, Prolapse and Incontinence
		6.6.1	 Perineal and Anal Sphincter Injury
		6.6.2	 Pelvic Organ Prolapse (POP) and Incontinence
	6.7	 Conclusion
	Appendix: MCQ
		Questions
		Answers
	References
7: Sexual Dysfunction After Childbirth
	7.1	 Introduction
	7.2	 Sexual Function and Dysfunction in Women
	7.3	 Risk Factors
		7.3.1	 Mode of Childbirth
		7.3.2	 Perineal Trauma and Episiotomy
			7.3.2.1	 Obstetric Anal Sphincter Injuries
			7.3.2.2	 Episiotomy
		7.3.3	 Breast Feeding
		7.3.4	 Postpartum Depression
		7.3.5	 Other Contributing Factors
			7.3.5.1	 Fatigue
			7.3.5.2	 Body Image
			7.3.5.3	 Interpersonal Relationships
			7.3.5.4	 Obstetric Trauma/Post-Traumatic Stress Disorder
			7.3.5.5	 Pelvic Floor Disorders
	7.4	 Natural History of Sexual Dysfunction Postpartum
	7.5	 Screening for Sexual Dysfunction
	7.6	 Clinical Evaluation of Sexual Dysfunction
	7.7	 Screening and Diagnostic Questionnaires
	7.8	 Physical Exam
	7.9	 Clinical Counseling and Addressing Patient Goals
	7.10	 Therapeutic Strategies
	7.11	 Conclusions
	Appendix: MCQ
		Questions
		Answers
	References
8: Impact of Pregnancy and Childbirth on Pre-existing Bowel Conditions
	8.1	 Introduction
		8.1.1	 The Changing Physiology of Pregnancy and the Consequences for the Gastrointestinal Tract
	8.2	 The Gastrointestinal Microbiome and Pregnancy
	8.3	 Inflammatory Bowel Disease (IBD)
	8.4	 IBD and Pregnancy
		8.4.1	 Pre-conception Planning (and Fertility)
		8.4.2	 Biologic Medications
		8.4.3	 Managing IBD Flares During Pregnancy
		8.4.4	 The Post-surgical Abdomen and Pregnancy in IBD
		8.4.5	 Managing Stomas in Pregnancy
		8.4.6	 Birth Modality
	8.5	 Other Gastrointestinal Disorders and Pregnancy
		8.5.1	 Irritable Bowel Syndrome
		8.5.2	 Constipation
		8.5.3	 Haemorrhoids
		8.5.4	 Acid Reflux and Peptic Ulcer Disease
		8.5.5	 Coeliac Disease
		8.5.6	 Gallstone Disease
	8.6	 Conclusions
	Appendix: MCQ
		Questions
		Answers
	References
9: Perineal and Anal Sphincter Wound Healing Complications
	9.1	 Introduction
	9.2	 Normal Wound Healing
	9.3	 Perineal Wound Infection
		9.3.1	 Definition
		9.3.2	 Pathophysiology
		9.3.3	 Microbiology
		9.3.4	 Incidence
		9.3.5	 Risk Factors
	9.4	 Perineal Wound Dehiscence
		9.4.1	 Definition
		9.4.2	 Pathophysiology
		9.4.3	 Incidence
		9.4.4	 Risk Factors
	9.5	 Objective Assessment of Wound Healing Complications
		9.5.1	 Advanced Wound Assessment
	9.6	 Management
		9.6.1	 Principles and Technique of Repair
			9.6.1.1	 Perineal Repair
			9.6.1.2	 Anal Sphincter Repair
	9.7	 Common Complications of Disrupted Perineal Healing
		9.7.1	 Granulation Tissue
		9.7.2	 Perineal Pain/Dyspareunia
		9.7.3	 Fistula
		9.7.4	 Psychological Impact
	9.8	 Prevention of Wound Complications
		9.8.1	 Other Treatments
	9.9	 Conclusions
	Appendix: MCQ
		Questions
		Answers
	References
10: Post-partum Problems and the Perineal Clinic
	10.1	 Introduction
	10.2	 Perineal Concerns
		10.2.1	 Perineal Pain
			10.2.1.1	 Treatment of Perineal Pain
				Local Treatment
				Systemic Treatment
					Oral Analgesics
					Suppositories
		10.2.2	 Perineal Haematoma
		10.2.3	 Perineal Wound Healing Complications
	10.3	 Bowel Concerns
		10.3.1	 Anal Fissures
		10.3.2	 Haemorrhoids
		10.3.3	 Anal Incontinence
		10.3.4	 Constipation
	10.4	 Bladder Concerns
		10.4.1	 Postpartum Urinary Retention
		10.4.2	 Urinary Incontinence
	10.5	 Sexual Problems
	10.6	 Pelvic Organ Prolapse
	10.7	 Maternal Recovery Clinics
	10.8	 Conclusion
	Appendix: MCQ
		Questions
		Answers
	References
11: Management of Subsequent Pregnancy After Incontinence and Prolapse Surgery
	11.1	 Introduction
	11.2	 Safety Concerns During Pregnancy
		11.2.1	 Previous Surgery for SUI
		11.2.2	 Previous Sacral Neuromodulation
		11.2.3	 Previous Surgery for POP
	11.3	 Mode of Delivery
		11.3.1	 Previous Surgery for SUI
		11.3.2	 Previous Sacral Neuromodulation
		11.3.3	 Previous Surgery for POP
	11.4	 Efficacy of Prior Surgical Treatment After Subsequent Birth
		11.4.1	 Surgical Treatment for SUI
		11.4.2	 Previous Sacral Neuromodulation
		11.4.3	 Previous Treatment for POP
	11.5	 Conclusions
	Appendix: MCQ
		Questions
		Answers
	References
12: Prevention of Perineal Trauma
	12.1	 Introduction
	12.2	 Risk Factors
		12.2.1	 Perineal Trauma Including Anal Sphincter Injury
		12.2.2	 Levator Injury
	12.3	 Interventions to Prevent Perineal Trauma (Not Involving the Anal Sphincter)
		12.3.1	 Antenatal
			12.3.1.1	 Perineal Massage
		12.3.2	 Intrapartum
			12.3.2.1	 Maternal Position During Labour and Birth
	12.4	 Interventions to Prevent OASI
		12.4.1	 Antenatal
			12.4.1.1	 Perineal Massage
		12.4.2	 Intrapartum
			12.4.2.1	 Second Stage Perineal Massage
			12.4.2.2	 Second Stage Perineal Warm Compress
			12.4.2.3	 Manual Perineal Protection
			12.4.2.4	 Episiotomy
			12.4.2.5	 Assisted Vaginal Birth
			12.4.2.6	 Prediction Models
	12.5	 Interventions to Prevent Levator Avulsion
		12.5.1	 Intrapartum
			12.5.1.1	 Mode of Birth
			12.5.1.2	 Prediction Models
	12.6	 Conclusions
	Appendix: MCQ
		Questions
		Answers
	References
13: Female Genital Mutilation
	13.1	 Definition
	13.2	 Historical Perspective
	13.3	 Why Is FGM practiced?
	13.4	 Incidence
	13.5	 Classification of FGM Types
	13.6	 Type 3 FGM
	13.7	 FGM Type 4
	13.8	 Classification Challenges
	13.9	 Difficulties Associated with Classification of FGM
	13.10	 Differential Diagnosis
	13.11	 Clinical Presentation, Management and Complications
	13.12	 FGM and Psychological Consequences
	13.13	 Women with FGM Presenting to a Gynaecological Setting
	13.14	 Deinfibulation
	13.15	 Management of Pregnant Women Presenting in a Maternity Setting
	13.16	 Management of Pregnant Women with Type 3 FGM
	13.17	 Safeguarding and Law
	13.18	 Safeguarding
	13.19	 Conclusion
	Appendix: MCQ
		Questions
		Answers
	References
14: Anorectal Pathophysiology and Investigations
	14.1	 Introduction
	14.2	 Physiology of Defaecation and Continence
	14.3	 Pathophysiology of Faecal Incontinence
		14.3.1	 Anal Canal: Impaired ‘Seal’ Function
		14.3.2	 Anus and Pelvic Floor: Impaired ‘Barrier’ Structure/Function
			14.3.2.1	 Structural Damage to the Anal Canal and Pelvic Floor
			14.3.2.2	 Compromised Anal Canal and Pelvic Floor Function
			14.3.2.3	 Neurological Injury
		14.3.3	 Rectum: Impaired ‘Reservoir’ Function
		14.3.4	 Impaired Evacuatory Function
		14.3.5	 Sigmoid: Impaired ‘Brake’ Function
		14.3.6	 Colon: Impaired Motility
	14.4	 Investigations
		14.4.1	 Diagnostic Testing
			14.4.1.1	 Tests of Anorectal Motor and Sensory Function
				Anorectal Manometry
				Anorectal Sensory Testing
				Neurophysiological Tests
					Electromyography (EMG)
					Pudendal Nerve Terminal Motor Latencies (PNTML)
					Contemporary Neurophysiological Investigation
			14.4.1.2	 Imaging of Anal and Pelvic Floor Structure
				Ultrasound
				Magnetic Resonance Imaging (MRI)
			14.4.1.3	 Tests of Evacuatory Function
				Direct Tests
					Balloon Expulsion Test
					Defaecography
				Indirect Tests (Manometry and Transperineal/Pelvic Floor Ultrasound)
					Manometry
					Pelvic Floor Ultrasound
			14.4.1.4	 Other Tests
	14.5	 Conclusion
	Appendix: MCQ
		Questions
		Answers
	References
15: Anal Sphincter Imaging of Obstetric Trauma
	15.1	 Introduction
	15.2	 Three-Dimensional Endoanal Ultrasound (3D EAUS)
	15.3	 Normal Ultrasound Anatomy
	15.4	 Endoanal Ultrasound in OASIs
		15.4.1	 Evaluation of OASIS
		15.4.2	 Missed Tears
		15.4.3	 Evaluation After OASI
		15.4.4	 Management of Subsequent Pregnancy
		15.4.5	 Selection of Patient for Rehabilitation
	15.5	 Transperineal Ultrasonography (TPUS) and Introital Ultrasonography (IUS)
	15.6	 Endovaginal Ultrasonography (EVUS)
	15.7	 Magnetic Resonance Imaging
	15.8	 Conclusions
	Appendix: MCQ
		Questions
		Answers
	References
16: Obstetric Pelvic Floor Trauma
	16.1	 Introduction
	16.2	 Functional Anatomy of the Pelvic Floor
	16.3	 Definition and Prevalence of Obstetric Pelvic Floor Trauma
		16.3.1	 Connective Tissue Injury
		16.3.2	 Nerve Injury
	16.4	 Diagnosis of Levator Trauma
		16.4.1	 Diagnosis at Birth
		16.4.2	 Ultrasound Diagnosis
		16.4.3	 Magnetic Resonance Imaging Diagnosis
	16.5	 Repair of Levator Trauma
	16.6	 Consequences of Levator Trauma
	16.7	 Conservative Treatment of Women with Levator Trauma
		16.7.1	 Pelvic Floor Muscle Exercise
		16.7.2	 Vaginal Pessary Treatment of Pelvic Organ Prolapse
	16.8	 Surgical Treatment of Women with Levator Trauma and Prolapse
	16.9	 Prevention of Levator Trauma
	16.10	 Management of Subsequent Pregnancy and Birth
	16.11	 Conclusions
	Appendix: MCQ
		Questions
		Answers
	References
17: Pelvic Floor and Sphincter Neuropathy After Childbirth
	17.1	 Introduction
	17.2	 Pelvic Floor Neuroanatomy
		17.2.1	 Pudendal Nerve
	17.3	 Incidence of Pudendal Neuropathy
	17.4	 Risk Factors
		17.4.1	 Childbirth Related Pudendal Neuropathy
	17.5	 Mechanism of Pudendal Nerve Injury
	17.6	 Other Nerve Injuries in Pregnancy
		17.6.1	 Levator Ani Syndrome
	17.7	 Clinical Presentation of Pudendal Neuropathy
	17.8	 Historical Evaluation of Pelvic Floor Neuropathy
	17.9	 Non -EDX Diagnosis of Pudendal Neuropathy
		17.9.1	 Nantes Criteria
	17.10	 Under-Utilisation of EDX Medicine in Cases of Pelvic Floor and Sphincter Neuropathy
	17.11	 Normal Physiology or Pathology
	17.12	 Modern EDX Evaluation of Pudendal Neuropathy After Childbirth
	17.13	 Kinesiological EMG of Sphincter Muscles
	17.14	 EDX Test Protocols and Methods for Pudendal Nerve Assessment
		17.14.1	 Needle EMG of EAS
	17.15	 The Clitoral Anal Reflex (CAR)
		17.15.1	 Other EDX Tests for Pelvic Floor Neuropathies
	17.16	 The Diagnostic Accuracy and Interpretation of the EDX Tests
	17.17	 Clinical Utility of EDX Assessment of Pelvic Floor and Sphincter Neuropathy Associated with Childbirth
	17.18	 Emerging Technologies for Pelvic Floor Neuromuscular Medicine
		17.18.1	 Intra-partum Pudendal Nerve Monitoring
	17.19	 Conclusion
	Appendix: MCQ
		Questions
		Answers
	References
18: Physical Therapy After OASIs
	18.1	 Introduction
		18.1.1	 Physical Therapy After OASIS
			18.1.1.1	 The Repair Phase: Early Recovery within 3 Weeks Postpartum
				Management of the Acute Muscular Injury
				Physical Therapy and Pelvic Floor Muscle training in the Acute Phase
			18.1.1.2	 The Subacute Postpartum Recovery Phase: 3–12 Weeks Postpartum
				Management of the Subacute Muscular Injury
				Physical Therapy and Pelvic Floor Muscle Training in the Subacute Phase
			18.1.1.3	 Late Postpartum Recovery: 3–12 Months Postpartum
				Late Management of a Muscular Injury 3–12 Months Postpartum
				Physical Therapy and Pelvic Floor Muscle Training in the Late Postpartum Phase
			18.1.1.4	 Long-Term Postpartum Recovery– Beyond 12 Months after Delivery
				Long-Term Management of a Muscular Injury – From 12 Months Postpartum
				Long-Term Postpartum Period – From 12 Months Postpartum
				The Long-Term Effect of PFMT and Barriers to Physical Therapy
	18.2	 Conclusions
	Appendix: MCQ
		Questions
		Answers
	References
19: Non-surgical Management of Anal Incontinence
	19.1	 Introduction
	19.2	 Prevalence of Anal Incontinence
	19.3	 Impact of Anal Incontinence on Women
	19.4	 Lifestyle Aspects that Can Affect Anal Incontinence
		19.4.1	 Body Mass Index (BMI)
		19.4.2	 Smoking
		19.4.3	 Physical Exercise
		19.4.4	 Assessment
	19.5	 Conservative Treatments
	19.6	 Education and Empowerment
	19.7	 Biofeedback
	19.8	 Diet and Fluids
	19.9	 Pelvic Floor Muscle Training
	19.10	 Defaecatory Dynamics
	19.11	 Femmeze
	19.12	 Suppositories
	19.13	 Low Volume Irrigation
	19.14	 High Volume Irrigation
	19.15	 Medication Management
	19.16	 Posterior Tibial Nerve Stimulation
	19.17	 Living with Anal Incontinence
		19.17.1	 Coping Strategies
	19.18	 Conclusions
	Appendix: MCQ
		Questions
		Answers
	References
20: Surgical Management of Anal Incontinence
	20.1	 Introduction
	20.2	 Evaluation of a Patient Presenting with Fecal or Anal Incontinence
		20.2.1	 History
			20.2.1.1	 Key Points
		20.2.2	 Investigations (See Chap. 14 and 15)
		20.2.3	 Treatment
	20.3	 Sphincteroplasty
	20.4	 Sacral Neuromodulation
	20.5	 Injectable Therapies
	20.6	 Historical Repairs
	20.7	 Regenerative Medicine
	20.8	 Stoma Formation
		20.8.1	 Antegrade Continence Enema
		20.8.2	 End Stoma
	20.9	 Conclusions
	Appendix: MCQ
		Questions
		Answers
	References
21: Obstetric Rectovaginal Fistulas
	21.1	 Introduction
	21.2	 Historical Background
	21.3	 Incidence
	21.4	 Classification
	21.5	 Pathophysiology
		21.5.1	 Obstetrical Fistulas
	21.6	 Evaluation
	21.7	 Surgical Technique
	21.8	 Outcomes
	21.9	 Conclusions
	Appendix: MCQ
		Questions
		Answers
	References
22: Patient Reported Outcomes After Childbirth
	22.1	 Introduction
	22.2	 Patient Reported Outcomes (PRO) and Measures (PROM)
		22.2.1	 Defining PROMs
		22.2.2	 Types of PROMs
		22.2.3	 PROM Validation
		22.2.4	 Evaluation and Selection of a PROM
	22.3	 Domains of Patient Reported Outcomes Associated with Childbirth-Related Pelvic Floor Trauma (CBRPFT)
	22.4	 Commonly Used and Validated PROMs
		22.4.1	 Bowel Function
		22.4.2	 Urinary Function
		22.4.3	 Pelvic Organ Prolapse (POP) and Vaginal Symptoms
		22.4.4	 Sexual Health
		22.4.5	 Global Pelvic Floor Dysfunction PROMs
		22.4.6	 Pain
		22.4.7	 Birth Experience and Perception of Trauma
		22.4.8	 Emotional Functioning and Mental Health
			22.4.8.1	 Post-Traumatic Stress Disorder (PTSD)
	22.5	 Postpartum Recovery
	22.6	 Generic Pregnancy and Childbirth-Specific PROMs
	22.7	 Conclusions
	Appendix: MCQ
		Questions
		Answers
	References
23: Education and Training in OASIS
	23.1	 Introduction
	23.2	 History of Education in OASI
	23.3	 Importance of Classification and Repair
	23.4	 National Guidelines on OASIs
	23.5	 Training for Doctors
	23.6	 Training for Midwives
	23.7	 Training Courses
	23.8	 Training Models and Resources
	23.9	 Online Training Programmes
	23.10	 Colorectal Involvement in the Repair of OASIs
	23.11	 Conclusion
	Appendix: MCQ
		Questions
		Answers
	References
24: Litigation After Pelvic Floor and Anal Sphincter Injuries
	24.1	 Introduction
	24.2	 Why Do Patients Bring a Claim?
	24.3	 What Do Claimants Need to Establish to Obtain Damages?
	24.4	 Burden & Standard of Proof
	24.5	 Breach of Duty in Relation to Treatment
	24.6	 The Montgomery Decision and Informed Consent
	24.7	 Urgent Situations
	24.8	 What About More Junior Staff?
	24.9	 Will a Failure to Identify a Tear Always Establish Breach of Duty?
	24.10	 Causation
	24.11	 Quantum
		24.11.1 First Head of Claim: Pain, Suffering and Loss of Amenity (“PSLA”)
		24.11.2 Second Head of Damages: Special Damages
			24.11.2.1	 Lost Earnings and Pension Claims
	24.12	 OASI Claims in Practice
	24.13	 Midwifery Care and OASI
	24.14	 Avoiding Litigation while Providing Appropriate Treatment
	24.15	 Case Law Update and the Updated Situation in the United States
	24.16	 Conclusions
	Appendix: MCQ
		Questions
		Answers
Index