Table 2.

Summary of recommendations for examination, diagnosis, repair and follow-up of perineal injuries, in particular for obstetric anal sphincter injuries

Diagnosis	Delivering midwife or obstetrician examines perineum, identifying perineal injury. If complex or extensive injury, second opinion from senior obstetrician should be sought.
Examination	A thorough vaginal and perineal examination should be conducted, followed by careful rectovaginal examination of the anal sphincter complex and rectal mucosa.
Environment	Complex, atypical or extensive perineal injuries should be repaired in the operating theatre with adequate lighting and effective analgesia (regional).
Antibiotics	Prophylactic antibiotics should be administered as per local antimicrobial guidelines.
Suture type	Absorbable synthetic suture material is preferrable, such as polyglycolic acid suture or polyglactin suture material.
Visualisation	If there is clinical suspicion for an obscured perineal injury, the perineal skin and subcutaneous tissues should be dissected down to fully visualise the anal sphincter complex.
Rectal mucosa repair	The torn rectal mucosa should be repaired using continuous non-locking 3/0 or 4/0 braided polyglactin suture material.
IAS repair	The IAS should be carefully identified after dissection of the perirectal fascia and repaired with 3/0 polyglactin.
EAS repair	The EAS should be carefully identified and repaired with 3/0 polyglactin in either end-to-end or overlapping technique.
Follow-up	Follow-up includes adequate analgesia, antibiotics, regular laxatives, physiotherapy review and specialist perineal clinic review.

EAS, external anal sphincter; IAS, internal anal sphincter.