Obstetric anal sphincter injury is easy to miss and much harder to repair late. After any instrumental delivery, or any second-degree tear, a systematic examination that includes a rectal examination is established practice. It identifies third-degree tears that look like second-degree ones from the outside, and buttonhole tears of the rectal mucosa with an intact sphincter.
Document the grade using the standard 3a, 3b, 3c and fourth-degree classification. Repairs of third- and fourth-degree tears belong with an experienced operator in a theatre with good light and adequate analgesia. Afterwards, broad-spectrum antibiotics, laxatives and a follow-up plan for continence symptoms are standard.
- Do a rectal examination after every instrumental birth and every second-degree tear before suturing.
- Grade third-degree injuries as 3a, 3b or 3c and record it.
- Repair third- and fourth-degree tears in theatre with good light and analgesia, by an experienced operator.
- Prescribe laxatives and give antibiotics after sphincter repair, and arrange follow-up for continence.
Why it matters
An injury missed at delivery becomes faecal incontinence that is far harder to fix months later.
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