Obstetric anal sphincter injuries are missed when the perineum is inspected but not examined. A rectal examination before suturing any second-degree tear or episiotomy, with the finger pressed gently up against the perineal body, shows whether the external sphincter is intact and whether the anal mucosa is breached. Classify the injury before repairing it, document the classification, and repeat the rectal examination after repair to make sure no suture has gone through the anal mucosa.
- Do a rectal examination before repairing any perineal tear or episiotomy.
- Classify the tear (first to fourth degree) before suturing and record it.
- Escalate any sphincter involvement to an experienced operator for repair in theatre with good light and analgesia.
- Repeat the rectal examination after repair to check no suture has passed through the anal mucosa.
Why it matters
Sphincter injury was the main driver of lasting perineal pain in today's research, and a missed one cannot be repaired early.
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