Repair of the 3rd and 4th degree obstetric perineal tear

Authors: V. Kališ 1;  B. Bednářová 1;  J. Štěpán jr. 2;  Z. Rokyta 1
Authors‘ workplace: Gynekologicko-porodnická klinika LF UK a FN Plzeň, přednosta doc. MUDr. Z. Rokyta, CSc. 1;  Sanatorium Sanus, Hradec Králové 2
Published in: Čes. Gynek.2010, 75, č. 4 s. 284-291


Summary of the current knowledge of repair of obstetric anal sphincter trauma.


Department of Gynecology and Obstetrics, Charles University and University Hospital Pilsen.

Review of the current international literature covering the given problem. RCOG classification of obstetrics perineal trauma should always be used as it respects the anatomic structures together with the physiological functions of tissue involved in ano-rectal continence.

Two types of procedure:
end-to-end approximation and overlapping of torn ends of the anal sphincter are both referred to and they are discussed with regards to the functional outcome of the repair.

Operating conditions:
experience of the surgeon, operating theatre and its equipment, asepsis, lighting, operating instruments, anesthesia, material and type of suture, medication is described to increase the effectiveness of the repair. A delay in primary repair of up to 8-12 hours does not seem to be detrimental to the functional outcome of the procedure.

Uncommon types of injury mentioned:
segmented tear of internal anal sphincter, lateral tear of external anal sphincter.

Key words:
perineal tear, third and fourth degree tear, perineal trauma, ano-rectal incontinence, classification, repair.


1. Joint Commission on Accreditation of Healthcare Organizations. Specification manual for national hospital quality measures (2005). Available at http://www.jointcommission. org/pms/core+measures/aligned_manual.htm Retrieved December 7, 2004.

2. RCOG Guideline No 29. Management of third and fourth degree perineal tears following vaginal delivery. March 2007.

3. World Health Organization. International classification od diseases, 9th revision, clinical modification (ICD-9-CM), Geneva, Switzerland, 1996.

4. Andrews, V., Thakar, R., Sultan, AH. Outcome of obstetric anal sphincter injuries (OASIS) - role of structured management. Int Urogynecol J Pelvic Floor Dysfunct 2009, 20(8), p. 973-978.

5. Bannister, JJ., Gibbons, C., Read, NW. Preservation of faecal continence during rises in intra-abdominal pressure: is there a role for the flap valve? Gut 1987, 28(10), p. 1242-1245.

6. Bek, KM., Laurberg, S. Intervention during labour: risk factors associated with complete tear of anal sphincter. Acta Obstet Gynecol Scand 1992, 71, p. 520-524.

7. Cook, TA., Mortensen, NJ. Management of faecal incontinence following obstetric injury. Br J Surg 1998, 85, p. 293-299.

8. Cunningham, FG., McDonald, PC., Gant, NF., et al. Williams Obstetrics. Newark: Prentice-Hall 1993, p. 388-393.

9. Čech, E., Hájek, Z., Maršál, K., a kol. Porodnictví. Praha: Grada Publishing 1999, 266 s.

10. Damon, H., Bretones, S., Henry, L., et al. Long-term consequences of first vaginal delivery-induced anal sphincter defect. Dis Colon Rectum 2005, 48(9), p. 1772-1776.

11. De Lancey, JOL. Childbirth, continence, and the pelvic floor (editorial:comment). N Engl J Med, 1993, 329, p. 1956-1957.

12. De Leeuw, JW., Vierhout, ME., Struijk, PC., et al. Anal sphincter damage after vaginal delivery: functional outcome and risk factors for fecal incontinence. Acta Obstet Gynecol Scand 2001, 80, p. 830-834.

13. Duthie, HL. Progress report. Anal continence. Gut 1971, 12(10), p. 844-852.

14. Engel, AF., Kamm, MA., Sultan, AH., et al. Anterior anal sphincter repair in patients with obstetric trauma. Br J Surg, 1994, 81, p. 1231-1234.

15. Faltin, DL., Otero, M., Petignat, P., et al. Women’s health 18 years after rupture of the anal sphincter during childbirth: I. Fecal incontinence. Am J Obstet Gynecol 2006, 194(5), p. 1255-1259.

16. Fernando, RJ., Sultan, AH., Kettle, C., et al. Repair techniques for obstetric anal sphincter injuries: a randomized controlled trial. Obstet Gynecol 2006, 107(6), p. 1261-1268.

17. Fernando, R., Sultan, AH., Kettle, C., et al. Methods of repair for obstetric anal sphincter injury. Cochrane Database Syst Rev. 2006 Jul 19;3:CD002866.

18. Fitzpatrick, M., Behan, M., O’Connell, PR., O’Herlihy, C. A randomized clinical trial comparing primary overlap with approximation repair of third-degree obstetric tears. Am J Obstet Gynecol 2000, 183, p. 1220-1224.

19. Floyd, WF., Walls, EW. Electromyography of the sphincter ani externus in man. J Physiol. 1953, 29, 122(3), p. 599-609.

20. Fornell, EU., Matthiesen, L., Sjodahl, R., Berg, G. Obstetric anal sphincter injury ten years after: subjective and objective long term effects. BJOG 2005, 112(3), p. 312-316.

21. Go, P., Dunselman, G. Anat omic and functional results of surgical repair after total perineal rupture at delivery. Surg Gynecol Obstet 1988, 166, p. 121-124.

22. Johnson, MA., Polgar, J., Weightman, D., Appleton, D. Data on the distribution of fibre types in thirty-six human muscles. An autopsy study. J Neurol Sci 1973, 18(1), p. 111-129.

23. Jorge, JMN., Wexner, SD. Etiology and management of fecal incontinence. Dis Colon Rectum 1993, 36, p. 77-97.

24. Jorge, JMN., Wexner, SD. Anatomy and Physiology of the Rectum and Anus. Eur J Surg 1997, 163, p. 723-731.

25. Kališ, V., Chaloupka, P., Turek, J., et al. Vaginální porod u primipar a anální inkontinence. [Vaginal delivery in primiparas and anal incontinence] Ces Gynek 2003, 68(5), p. 312-320.

26. Kuijpers, HC., Strijk, SP. Diagnosis of disturbances of continence and defecation. Dis Colon Rectum 1984, 27(10), p. 658-662.

27. Lestar, B., Penninckx, F., Kerrimans, R. The composition of the anal basal pressure. An in vivo and in vitro study in man. Int J Colorect Dis 1989, 4, p. 118–122.

28. Main, EK., Bloomfield, L., Hunt, G.; Sutter Health, First Pregnancy and Delivery Clinical Initiative Committee. Development of a large-scale obstetric quality-improvement program that focused on the nulliparous patient at term. Am J Obstet Gynecol 2004, 190(6), p. 1747-1756; discussion 1756-1758.

29. Nordenstam, J., Mellgren, A., Altman, D., et al. Immediate or delayed repair of obstetric anal sphincter tears-a randomised controlled trial. BJOG 2008, 115(7), p. 857-865.

30. Nygaard, IE., Rao, SS., Dawson, JD. Anal incontinence after anal sphincter disruption: a 30-year retrospective cohort study. Obstet Gynecol, 1997, 89, p. 896-901.

31. Parks, AG., McParthlin, JF. Late repairs of injuries of the anal sphincter. Proc R Soc Med 1971, 64, p. 1187-1189.

32. Peschers, UM., De Lancey, JOL., Schaer, GN., Schuessler, B. Exoanal ultrasound of the anal sphincter: normal anatomy and sphincter defects. Br J Obstet Gynaecol 1997, 104, p. 999-1003.

33. Poen, AC., Felt-Bersma, RJ., Dekker, GA., et al. Third degree obstetric perineal tears: risk factors and the preventive role of mediolateral episiotomy. Br J Obstet Gynaecol 1997, 104, p. 563-536.

34. Röckner, G., Fianu-Jonasson, A. Changed pattern in the use of episiotomy in Sweden. Br J Obstet Gynaecol 1999, 106, p. 95-101.

35. Roos, AM., Sultan, AH., Thakar, R. 33rd Annual Meeting of IUGA, Taipei, Taiwan.

36. Sainz, LE. Episiotomie a její komplikace. Gyn po prom 2001, 1, p. 50-58.

37. Samarasekera, DN., Bekhit, MT., Wright, Y., et al. Long-term anal continence and quality of life following postpartum anal sphincter injury. Colorectal Dis 2008, 10(8), p. 793-799.

38. Schuster, MM., Hookman, P., Hendrix, TR., Mendeloff, AI. Simultaneous manometric recording of interval and external anal sphincteric reflexes. Bull Johns Hopkins Hosp 1965, 116, p. 79-88.

39. Sultan, AH., Kamm, MA. Faecal incontinence after childbirth. Br J Obstet Gynaecol 1997, 104, p. 979-982.

40. Sultan, AH., Kamm, MA., Bartram, CI., Hudson, CN. Third degree obstetric anal sphincter tears: Risk factors and outcome of primary repair. BMJ 1994, 308, p. 887-891.

41. Sultan, AH., Kamm, MA., Hudson, CN., et al. Anal sphincter disruption during vaginal delivery. N Engl J Med 1993, 329, p. 1905-1911.

42. Sultan, AH., Monga, AK., Kumar, D., Stanton, SL. Primary repair of obstetric anal sphincter rupture using the overlap technique. Br J Obstet Gynaecol 1999, 106, p. 318-323.

43. Sultan, AH. Mayday University Hospital Labour Ward Protocol: Management of Obstetric Anal Sphincter Rupture 2001.

44. Sultan, AH. Obstetrical perineal injury and anal incontinence. Clin Risk 1999:5, p. 193-196.

45. Sultan, AH., Thakar, R., Monga, A., Stanton, S. Repair of Third Degree Tears. Hands-on Workshop. St. George’s Hospital, London, 10th November 2001.

46. Štěpán, J. Jr., Bednářová, B., Kališ, V. Řešení a výsledky porodního poranění análního sfinkteru. Mělník. Praktická urogynekologie. 2007, 16.

47. Thacker, SB., Banta, DH. Benefits and risks of episiotomy: an interpretative review of the English language literature, 1860-1980. Obstet Gynecol Surv 1983, 38, p. 322-338.

48. Walsh, CJ., Mooney, EF., Upton, GJ., Motson, RW. Incidence of third degree perineal tears in labour and outcome after primary repair. Br J Surg 1996, 83, p. 218-221.

49. Zetterström, J., López, A., Anzén, B., et al. Anal sphincter tears at vaginal delivery: risk factors and clinical outcome of primary repair. Obstet Gynecol 1999, 94, p. 21-28.

Paediatric gynaecology Gynaecology and obstetrics Reproduction medicine
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