One in five operative vaginal deliveries in a large modern cohort ended with a third- or fourth-degree tear. A proportion of those are found only at follow-up, because the perineum looked intact from outside and nobody put a finger in the rectum before starting the repair.
The examination takes under a minute and is the same every time: inspect with good light and adequate analgesia, then a systematic per-rectal examination feeling for the intact sphincter ring, then the pill-rolling test between index finger and thumb before any suture goes in. Anything uncertain is escalated, not repaired optimistically.
A sphincter injury repaired properly at delivery by someone trained to do it has a different long-term outcome from one discovered years later in a continence clinic. The cost of the examination is a minute; the cost of missing it is measured in decades.
- Per-rectal examination after every operative vaginal delivery and every perineal tear, before repair.
- Use the pill-rolling test to assess the external sphincter rather than inspection alone.
- Grade and document the tear explicitly — 3a, 3b, 3c or 4 — not "third degree".
- Escalate rather than repair a sphincter injury you have not been trained and signed off to repair.
- Tell the woman what was found and arrange follow-up; she cannot report a symptom she was never warned about.
Why it matters
The sphincter injuries that do worst are not the ones repaired badly — they are the ones nobody looked for.
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