Imperforated Anus/Anorectal Malformations – Health of the children has been considered as the vital importance to all societies because children are the basic resource for the future of humankind. Nursing care of children is concerned for both the health of the children and for the illnesses that affect their growth and development. The increasing complexity of medical and nursing science has created a need for special area of child care, i.e. pediatric- nursing.

Pediatric nursing is the specialized area of nursing practice concerning the care of children during wellness and illness. It includes preventive, promotive, curative and rehabilitative care of children. It emphasizes on all round development of body, mind and spirit of the growing individual. Thus, pediatric nursing involves in giving assistance, care and support to the growing and developing children to achieve their individual potential for functioning with fullest capacity.

Table of Contents

Imperforated Anus/Anorectal Malformations

Anorectal malformation:

Anorectal malformations (ARMs) are developmental deformities of the lower end of the alimentary tract, i.e. the anorectal canal.

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Anorectal malformations are birth defects, or problems that happen as an unborn baby is developing during pregnancy.

Anorectal malformations, also known as imperforate anus, are defects that occur during the fifth to seventh weeks of fetal development.

[Ref-www.cincinnatichildrens.org]

Imperforated Anus:

The term imperforate anus is used to describe all congenital abnormalities of the anorectal canal or in location of the anus within the perineum.

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A birth defect in which the rectum is a blind alley and there is no anus. Imperforate anus occurs in about 1 in 5,000 births, and it can be corrected by surgery.

[Ref-www.medicinenet.com]

Causes of Imperforate Anus:

1. The exact cause of these malformations is not known.

2. It occurs due to arrest in embryonic development of the anus, lower rectum and urogenital tract at the 5th week of embryonic life.

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Associated Anomalies Of Imperforated Anus:

Anal fissure: It is the most frequent cause of fresh rectal bleeding and usually follows a tear or small laceration of the mucocutaneous junction of the anus during passage of a hard fecal matter in a severely constipated child.
Perianal abscess and fistula

[Ref-Suraj Gupta/11/701]

Classification Of Ano-Rectal Malformations:

A. Classification of ARMs can be done into three groups in the infants without a normal anus.

1. With a visible abnormal opening of the bowel:

Anal stenosis
Anoperineal fistula.
Anovestibular fistula in female.

2. With an invisible but manifested opening of the bowel:

Rectovaginal fistula in female.
Rectourethral fistula in male.
Rectovesicular fistula.

3. No manifested opening of the bowel:

Persistent anal membrane.
Rectal atresia.

B. Anorectal malformations can be classified into two groups on the basis of levator ani muscle, which is the main muscle of fecal control-

1. Supralevator or high ahorectal malformations: When rectum terminates above the levator ani muscle, which is found as rectal atresia, rectoprostatic fistula and rectovaginal fistula. About 30 percent of children with high ARMs or associated genito-urinary fistula achieve bowel continence.

2. Transleuator or low anorectal malformations: When rectum terminates below the levator ani muscle, e.g. in anocutaneous fistula and anovestibular fistula. About 90 percent of children with low ARMs achieve bowel continence.

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Clinical Features of Anorectal Malformation:

1. No anal opening.

2. Absence of meconium.

3. Presence of fistula with passage of stool through the fistula.

4. In female baby the fistula may present between rectum and vagina or perineum.

5. In male baby the fistula is commonly found between rectum and urinary tract or perineum.

6. Presence of meconium in urine may be found in some children. 7. Progressive abdominal distension and vomiting may present.

8. Rectal tube cannot be inserted into the rectum during examination.

[Ref-Paediatric Nursing, Parul Datta/3/292)

Management of ARM:

The reconstructive surgery is done to correct or repair the congenital malformations. It depends upon the type of anomalies and sex of the infant’
In case of low ARM; rectal cutback anoplasty or Y-V plasty is done for male infants and dilatation of fistula with definitive repair or perineal anoplasty is performed for female infant.
In case of high ARMs, initial colostomy is done in the neonatal period followed by definitive reconstructive surgery.
Colostomy closure is done after 10-12 weeks of surgery.

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Nursing Management Of ARMS:

Neonatal conditions requiring surgery fall into two main categories –

Those which are life-threatening & need immediate surgery.
Those which may be postpone until the baby is in the optimum condition for surgery.

Much of the preoperative care will be specific to the condition, but the general principles are as follows-

Preoperative care:

1. Stabilize temperature: Maintenance of warm, prevention of hypothermia & hyperthermia & prevention of heat loss.

2. Stabilize respiratory state: Correct acidosis or electrolytes imbalance & Oz therapy.

3. Ensure good hydration with the administration of IV fluid.

4. Screen for infections & begin antibiotics

5. Check consent forms are signed & contact telephone number obtained from the Parents

6. Encourage the parents to touch or cuddle their baby before surgery.

Postoperative care:

1. Promote a good recovery.

2. Identify & treat complications early

3. Prevent infections

4. Prevention of skin breakdown around colostomy wound

5. Routine postoperative care to be provided after colostomy & definitive surgery.

6. Established adequate nutrition

7. Ensure the baby is free from pain & discomfort

8. Promote parental involvement & interaction

9. Emotional support for family copying & demonstrate colostomy care

10. Health education to be given about continuation of care at home, diet modification, bowel habit & need for medical help.

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Complications of ARMs:

The common complications of ARMs are –

1. Urinary tract infection (UTI).

2. Intestinal obstruction.

3. Fecal impaction.

4. Colostomy related problems.

5. Recurrence of fistula.

6. Anal stenosis and

7. Postoperative complications.