References

Ali-Masri H, Hassan S, Ismail K, Zimmo K, Zimmo M, Fosse E, Vikanes Å, Laine K. Enhancing recognition of obstetric anal sphincter injuries in six maternity units in Palestine: an interventional quality improvement study. BMJ Open. 2018; 8:(6) https://doi.org/10.1136/bmjopen-2017-020983

The American College of Obstetricians and Gynecologists. Practice bulletin no. 198: prevention and management of obstetric lacerations at vaginal delivery. Obstetrics and Gynecology. 2018; 132:(3)e87-e102 https://doi.org/10.1097/AOG.0000000000002841

Anderson A. Ten years of maternity claims: an analysis of the NHS Litigation Authority data – key findings. Clinical Risk. 2013; 19:(1)24-31 https://doi.org/10.1177/1356262213486434

Andrews V, Thankar R, Sultan AH, Kettle C. Can hands-on perineal repair courses affect clinical practice?. British Journal of Midwifery. 2005; 13:(9)562-566 https://doi.org/10.12968/bjom.2005.13.9.19625

Andrews V, Sultan AH, Thakar R, Jones PW. Occult anal sphincter injuries--myth or reality?. British Journal of Obstetrics and Gynaecology. 2006; 113:(2)195-200 https://doi.org/10.1111/j.1471-0528.2006.00799.x

Andrews V, Shelmeridine S, Sultan AH, Thakar R. Anal and urinary incontinence 4 years after a vaginal delivery. International Urogynecology Journal. 2013; 24:(1)55-60 https://doi.org/10.1007/s00192-012-1835-7

Combs CA, Robertson PA, Laros RK. Risk factors for third-degree and fourth-degree perineal lacerations in forceps and vacuum deliveries. American Journal of Obstetrics and Gynecology. 1990; 163:(1)100-104 https://doi.org/10.1016/S0002-9378(11)90678-4

Cornell K, De Souza A, Tacey M, Long D, Veerasignam M. The effect of implementing a new guideline and operative pro forma on the detection and management of third- and fourth-degree perineal tears. International Journal of Women's Health. 2016; https://doi.org/10.2147/IJWH.S101188

Croydon Urogynaecology and Pelvic Floor Reconstruction Unit. Courses. 2020. https://www.perineum.net/courses (accessed 22 September 2020)

Diko S, Guiahi M, Nacht A, Connell KA, Reeves S, Bailey BA, Hurt KJ. Prevention and management of severe obstetric anal sphincter injuries (OASIs): a national survey of nurse-midwives. International Urogynecology Journal. 2019; 31:591-604 https://doi.org/10.1007/s00192-019-03897-x

Diko S, Sheeder J, Guiahi M, Nacht A, Reeves S, Connell KA, Hurt KJ. Identification of obstetric anal sphincter injuries (OASIs) and other lacerations: a national survey of nurse-midwives. International Urogynecology Journal. 2020; https://doi.org/10.1007/s00192-020-04304-6

Fernando RJ, Sultan AH, Radley S, Jones PW, Johanson RB. Management of obstetric anal sphincter injury: a systematic review and national practice survey. BMC Health Services Research. 2002; 2:(1) https://doi.org/10.1186/1472-6963-2-9

Groom KM, Paterson-Brown S. Can we improve on the diagnosis of third degree tears?. European Journal of Obstetrics and Gynecology and Reproductive Biology. 2002; 101:(1)19-21 https://doi.org/10.1016/s0301-2115(01)00495-x

Harvey M-A, Pierce M, Alter J-EW, Chou Q, Diamond P, Epp A, Geoffrion R, Harvey M-A, Larochelle A, Maslow K Obstetrical anal sphincter injuries (OASIS): prevention, recognition, and repair. Journal of Obstetrics and Gynaecology of Canada. 2015; 37:(12)1131-1148 https://doi.org/10.1016/s1701-2163(16)30081-0

Jordan PA, Naidu M, Thakar R, Sultan AH. Effect of subsequent vaginal delivery on bowel symptoms and anorectal function in women who sustained a previous obstetric anal sphincter injury. International Urogynecology Journal. 2018; 29:(11)1579-1588 https://doi.org/10.1007/s00192-018-3601-y

Kettle C, Raynor MD. Perineal management and repair.: Churchill Livingstone; 2009

Kettle C, Tohill S. Perineal care. BMJ Clinical Evidence. 2008;

McFarlane MJ. The rectal examination, 3rd edn. In: Walker HK, Hall WD, Hurst JW (eds). Boston: Butterworths; 1990

Mutema EK. ‘A tale of two cities’: auditing midwifery practice and perineal trauma. British Journal of Midwifery. 2007; 15:(8)511-513 https://doi.org/10.12968/bjom.2007.15.8.24394

National Institute for Health and Care Excellence (Grande-Bretagne). Intrapartum care for healthy women and babies. 2017. https://www.nice.org.uk/guidance/cg190/resources/intrapartum-care-for-healthy-women-and-babies-pdf-35109866447557 (accessed 19 November 2019)

Norton C, Christensen J, Butler U. Anal incontinence, 2nd edn. Plymouth: Health Publications Ltd; 2002

Nursing and Midwifery Council. Standards of proficiency for midwives. 2019. https://www.nmc.org.uk/globalassets/sitedocuments/standards/standards-of-proficiency-for-midwives.pdf (accessed 28 May 2020)

Priddis H, Schmied V, Dahlen H. Women's experiences following severe perineal trauma: a qualitative study. BMC Women's Health. 2014; 14:(1) https://doi.org/10.1186/1472-6874-14–32

Ramage L, Yen C, Qiu S, Simillis C, Kontovounisios C, Tan E, Tekkis P. Does a missed obstetric anal sphincter injury at time of delivery affect short-term functional outcome?. The Annals of the Royal College of Surgeons of England. 2018; 100:(1)26-32 https://doi.org/10.1308/rcsann.2017.0140

Reid AJ, Beggs AD, Sultan AH, Roos A-M, Thakar R. Outcome of repair of obstetric anal sphincter injuries after three years. International Journal of Gynecology and Obstetrics. 2014; 127:(1)47-50 https://doi.org/10.1016/j.ijgo.2014.04.013

Roos A-M, Thakar R, Sultan AH. Outcome of primary repair of obstetric anal sphincter injuries (OASIS): does the grade of tear matter?. Ultrasound in Obstetrics and Gynecology. 2010; 36:(3)368-374 https://doi.org/10.1002/uog.7512

Royal College of Obstetricians and Gynaecologists. Management of third and fourth degree perineal tears. Green-top guideline number 29. 2015. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-29.pdf (accessed 1 September 2019)

Scheer I, Andrews V, Thakar R, Sultan AH. Urinary incontinence after obstetric anal sphincter injuries (OASIS)—is there a relationship?. International Urogynecology Journal. 2008; 19:(2)179-183 https://doi.org/1007/s00192-007-0431-8

Scheer I, Thakar R, Sultan AH. Mode of delivery after previous obstetric anal sphincter injuries (OASIS)—a reappraisal?. International Urogynecology Journal. 2009; 20:(9)1095-1101 https://doi.org/10.1007/s00192-009-0908-8

Simhan H, Krohn M, Heine RP. Obstetric rectal injury: risk factors and the role of physician experience. Journal of Maternal-Fetal and Neonatal Medicine. 2004; 16:(5)271-274 https://doi.org/10.1080/jmf.16.5.271.274

Sioutis D, Thakar R, Sultan AH. Overdiagnosis and rising rate of obstetric anal sphincter injuries (OASIS): time for reappraisal. Ultrasound in Obstetrics and Gynecology. 2017; 50:(5)642-647 https://doi.org/10.1002/uog.17306

Smith LA, Price N, Simonite V, Burns EE. Incidence of and risk factors for perineal trauma: a prospective observational study. BMC Pregnancy Childbirth. 2013; 13:(1) https://doi.org/10.1186/1471-2393-13-59

Sultan AH. Editorial: obstetrical perineal injury and anal incontinence. AVMA Medical and Legal Journal. 1999; 5:(6)193-196 https://doi.org/10.1177/135626229900500601

Sultan AH, Kamm MA, Hudson CN. Obstetric perineal trauma: an audit of training. Journal of Obstetrics and Gynaecology. 1995; 15:(1)19-23 https://doi.org/10.3109/01443619509007724

Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. New England Journal of Medicine. 1993; 329:(26)1905-1911 https://doi.org/10.1056/NEJM199312233292601

Sultan AH, Kettle C. Diagnosis of perineal trauma.: Springer; 2007

Sultan AH, Thakar R. Third and fourth degree tears.: Springer; 2007

Perineal and anal sphincter trauma: diagnosis and clinical management. In: Sultan AH, Thakar R, Fenner DE (eds). London: Springer; 2007

Symon A. Third degree tears: the three-stage negligence test. British Journal of Midwifery. 2008; 16:(3)192-193 https://doi.org/10.12968/bjom.2008.16.3.28696

Taithongchai A, Veiga SI, Sultan AH, Thakar R. The consequences of undiagnosed obstetric anal sphincter injuries (OASIS) following vaginal delivery. International Urogynecology Journal. 2019; 31:635-641 https://doi.org/10.1007/s00192-019-04033-5

Thakar R, Fenner DE. Anatomy of the perineum and the anal sphincter.London: Springer; 2007

Thiagamoorthy G, Johnson A, Thakar R, Sultan AH. National survey of perineal trauma and its subsequent management in the United Kingdom. International Urogynecology Journal. 2014; 25:(12)1621-1627 https://doi.org/10.1007/s00192-014-2406-x

Tsakiridis I, Mamopoulos A, Athanasiadis A, Dagklis T. Obstetric anal sphincter injuries at vaginal delivery: a review of recently published national guidelines. Obstetrical and Gynecological Survey. 2018; 73:(12)695-702 https://doi.org/10.1097/OGX.0000000000000622

Vergers-Spooren HC, de Leeuw JW. A rare complication of a vaginal breech delivery. Case reports in obstetrics and gynecology. 2011; 1-2 https://doi.org/10.1155/2011/306124

Volløyhaug I, Taithongchai A, Van Gruting I, Sultan A, Thakar R. Levator ani muscle morphology and function in women with obstetric anal sphincter injury: Levator injury, muscle contraction and incontinence. Ultrasound in Obstetrics and Gynecology. 2019; 53:(3)410-416 https://doi.org/10.1002/uog.20115

Wickham A. Management of obstetric anal sphincter injury. British Journal of Midwifery. 2012; 20:(8)540-543 https://doi.org/10.12968/bjom.2012.20.8.540

Diagnosis of perineal trauma: getting it right first time

02 October 2020
13 min read
Volume 28 · Issue 10

Abstract

This narrative literature summarises the evidence to support the need for digital rectal examination after every vaginal delivery. The importance of a digital rectal examination, based on clinical sequalae and consequences of incorrect diagnosis of perineal trauma, is discussed. Digital rectal examination is recommended by many national guidelines as part of a postpartum evaluation of the perineum. Obstetric anal sphincter injuries and isolated rectal tears can be missed if a full examination is not performed. This can lead to serious consequences for women, including anal incontinence. Training is needed to ensure tears are correctly identified. This review provides the evidence base for including digital rectal examination during clinical assessment of the perineum following every vaginal delivery for all healthcare professionals involved in the care of women in the immediate postnatal period.

It is estimated that 85% of women will sustain some degree of perineal trauma during vaginal delivery and 60–70% of these will require suturing (Kettle and Tohill, 2008). Perineal trauma includes not only trauma to the perineal muscles but more extensive tears during vaginal delivery such as obstetric anal sphincter injuries (OASIs), collectively known as third and fourth degree tears, and isolated rectal button hole tears. Perineal tears are classified according to the widely accepted Sultan classification outlined in Table 1. The incidence of perineal tears varies significantly depending on parity, location of delivery and mode of delivery (Smith et al, 2013). The overall incidence of OASI in the UK is 2.9%, with a higher incidence in primiparae (6.1%) compared to multiparae (1.7%) (Thiagamoorthy et al, 2014; Royal College of Obstetrics and Gynaecology [RCOG], 2015). Although the exact incidence of rectal button hole tears is not known, these injuries are rare (Vergers-Spooren and de Leeuw, 2011).

Register now to continue reading

Thank you for visiting British Journal of Midwifery and reading some of our peer-reviewed resources for midwives. To read more, please register today. You’ll enjoy the following great benefits:

What's included

  • Limited access to our clinical or professional articles

  • Unlimited access to the latest news, blogs and video content

  • Monthly email newsletter