Dr. Warner Huh (Host): Hello, everyone. This is Dr. Warner Huh, again, the Chair of the Department of OB-GYN here at the University of Alabama at Birmingham, and I'd like to welcome you to this monthly episode of Women's Health with Dr. Huh.

Host: Today, we're going to talk about something very specific but important. We're going to talk about the topic of obstetrical injuries, specifically anal sphincter injuries and something known as the OASIS Project. And with me today are Dr. Holly Richter, who is a professor in the Departments of OB-GYN, Urology and Geriatrics. She's also the Medical and Quality Officer for our Ambulatory OB-GYN Clinics and the Associate Director for Gynecologic Research in the Center for Women's Reproductive Health and then, lastly, the Research Director for the Division of Urogynecology and Pelvic Reconstructive Surgery. And with me also today is Dr. Clark Powell, who is an Assistant Professor also in the Division of Urogynecology and Pelvic Reconstructive Surgery. So welcome, Dr. Richter and Dr. Powell.

Holly Richter, MD: Thank you. Good morning.

Thomas Clark Powell, MD: Thanks so much for having us.

Host: So, I'm excited about this because you all are really the first individuals in the department where we talk about the topic of quality care. And I'll get into more of that in a second. But I thought maybe you all could just comment on these obstetrical injuries, particularly anal sphincter injuries that are really something that most OB-GYNs and also patients don't like to discuss and, I would argue, are probably underrecognized and underappreciated. I thought maybe one of you could just comment on it for our listeners about how these sphincter injuries occur and are they preventable.

Holly Richter, MD: I'm happy to take that, Dr. Huh. And thank you for this important question. Despite our best efforts as well-trained evidence-based OB-GYNs, obstetric lacerations or tears around the opening of the vagina and the vaginal walls overall occur in approximately 75% of vaginal deliveries. Typically, they are repaired and heal well with minimal side effects. However, another type of injury associated with vaginal delivery can result in damage to the anal sphincter muscles which surround the anal opening. And this occurs in approximately 6-7% of women undergoing vaginal deliveries. These are called obstetric anal sphincter injuries or OASIs. It is important to highlight these types of tears as they are more complex to repair, and are at risk for infection, breakdown, associated loss of bowel control and a lot of mental stress for a patient. There are some known risk factors for these tears, including the use of forceps delivery, episiotomy, large babies, first babies, having a labor induction and, interestingly, the position of the fetal head. Despite knowing these risk factors and trying to work around them, and in cases where these risk factors do not exist, these tears may occur.

Host: So, I think that, you know, this is really important. And I think I heard you say 75%, is that correct, the injury rate, and then about 67% for anal sphincter rates. I personally didn't realize the rate was that high. And I suspect that most of our listeners don't realize it's that high as well. And this is the exact reason why we're bringing this topic to this monthly podcast. And one of the things I mentioned earlier was what I'm really proud of in this department is how we address quality and quality of care. And I often consider that to be the fourth mission pillar of the department, you know, alongside with clinical care, research and education. I see this department as a true national leader in the area of delivering evidence-based quality care. I thought maybe one of you, maybe Dr. Powell, you could comment on what the OASIS Care Bundle is and how this project fits into our quality program.

Thomas Clark Powell, MD: Thanks, Dr. Huh. I really appreciate that perspective of quality as a key pillar of our mission in the department. As Dr. Richter said, OASI represent a small percentage of the total number of obstetric tears and lacerations, but they're not rare and implications and outcomes for an individual can be really significant.

Our approach to ensuring high quality care for our patients has been to optimize and standardize treatment, so that everyone has the best opportunity for a full recovery. We really believe that to achieve this, surgical repair, medical management and followup should be standardized and be completely in line with internationally recognized best practices that are based on extensive research. To make sure that we were achieving this, we did a thorough review of the literature. And we created a system to make sure each OASI is appropriately managed so that any negative outcome can be prevented as much as possible or addressed in a timely manner. We created a care bundle that starts with provider education so that OASI are accurately identified and surgically corrected with the utmost attention to detail. We've also included a pathway that ensures appropriate antibiotics, patient education and followup in a specialized clinic are all provided. So, our patients get individualized care during a critical period for healing.

Host: I love this because this is, I mean, so important. And I'm going to say it again, this is the reason why it's the focus of this month's podcast. Could you also just comment for me what are the key findings of the study? I think our listeners would be very interested in knowing that and really just what's important to share with them.

Thomas Clark Powell, MD: Yeah, I think that's great. I really want people to hear that in putting together this care bundle, we importantly confirmed that our institutional rates of OASI are quite low and stable and, most importantly, it showed us that our standardized care bundle works. Our patients are getting the right care, including antibiotics and followup, that we know based on other studies are key to getting the best outcomes after an OASI.

Host: And I know both of you know this, but I'll state this for our audiences. What's neat about this is that you are looking at the sort of the expanse and longitudinal care of obstetrics beyond the obstetrical period. So, it's like really the perfect merger between the gynecology space and the obstetrical space. And for me, it speaks to why that continuity of care is really important, particularly for a department like ours. So, it's amazing. I applaud you. And my understanding is that you are in the process of trying to get these findings published. So hopefully, we'll see that in the literature.

So, what are the next steps, Dr. Richter? I'm just kind of curious, where do you go forward from here now? Let's assume, let's say you get it published, you understand the value, you understand the rates here at UAB, where do we go forward from here?

Holly Richter, MD: We believe that a key component of high quality care is continuing to adapt to provide the best possible outcomes. One thing we did find is approximately one half of patients that were scheduled to come to clinic came, so we want to improve on that proportion. Another thing is where these sphincter tears are performed. It's recommended in an evidence-based manner that they should be done in the operating room. Most are still performed in the labor and delivery room. So, we have a few things that I think we can improve on, and this is to provide the best possible outcomes. Further to that end, we collect a lot of information from our OASI patients to continue to improve our process and better understand the implications of OASI on pelvic floor symptoms during the immediate postpartum period and in the long term.

I'd also like to finish by saying we also think that it is important for any individual dealing with a difficult obstetric laceration to know that they are not alone. SOLACE, Severe Obstetric Laceration Awareness and Community Engagement, for Women.org is a non-profit organization started in Birmingham by a woman who did sustain an anal sphincter tear. And SOLACE seeks to raise awareness, advocate, provide resources and education for individuals dealing with OASI.

Host: One more time, what's the name of the website one more time, Dr. Richter?

Holly Richter, MD: SOLACE, spelled S-O-L-A-C-E for women, all no spaces, dot org.

Host: Right. And let's see if we can try to include that in the show notes as well if we can. You know, I don't know if you have any further comments or thoughts. One thing I'll just share with the audience is, you know, I think this is a general statement for all medical care, but I think as women seek care, I think it's important that they seek care at a place where they're actively assessing the quality of their care. And I think that this is becoming more mainstream, definitely in the United States, but I think this is an expected standard. I think every provider should know what their outcome should be and look at it systematically in an evidence-based way, which is why I really applaud the both of you for doing this because you probably had a sense of what the data was going to be, but you looked at it systematically and you're working to improve it.

I mean, that's how we all get better. So, I think sometimes our audience doesn't realize that self-correction and how important that self-correction is. But closing out, I don't know if you all have any additional thoughts or comments about this project.

Thomas Clark Powell, MD: I just want to thank you for giving voice to this as an important topic in women's health, certainly something that's underdiscussed and an area where we want to be good advocates for our patients. And just to highlight what you said earlier, it has implications not just for the immediate postpartum period, but really for the life course in general and quality of life in the long term. So, just want to thank you for letting us tell you about our project and we just want to keep improving and striving to do the best we can for all of the women we serve.

Holly Richter, MD: I echo those sentiments, and I think we can only do better if we understand the ramifications of this type of injury, discuss it in a transparent manner between provider and patient and treat it in an evidence-based manner, looking toward long-term quality of life.

Host: Awesome. Well, thank you to both of you. I look forward to your publishing the data and sharing that more broadly. But again, I want to thank both Drs. Richter and Powell for discussing this important quality project and really looking at mechanisms to identify, manage and prevent anal sphincter injuries related to obstetrics.

As always, please rate this podcast and we welcome any comments, particularly on topics that you all are interested in learning more about. And so for more information on our urogynecology, incontinence and pelvic reconstructive surgery care and other clinical services that UAB provides, please check out uabmedicine.org. Until next time, thank you. And I hope you guys have a great day. Peace out. Bye-bye.