Diagnosis of perineal trauma: getting it right first time
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).
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