IUGA International Guidelines on Obstetric Anal Sphincter Injuries

Obstetric health care providers should have a basic understanding of the anatomy and physiology of anal continence in order to perform surgical repair, optimize nonsurgical management, and adequately counsel patients on the risks and outcomes of obstetric anal sphincter injuries (OASIs) (Grade Good Practice Point [GPP]).• Patients should be fully informed of the potential for pelvic floor and anal sphincter injury with vaginal birth during the antenatal period, prior to experiencing labor.This counseling should include individual factors that can increase or reduce risks of injuries, including the risks and benefits of operative vaginal birth (OVB), episiotomy, and cesarean section (CS) (Grade GPP).• Perineal protection strategies (e.g., perineal massage, warm compresses, perineal support at crowning) can be used during the second stage of labor to reduce OASI risk (Grades A-C).• Clinicians should consider seeking support from a second clinician to assist with perineal trauma prevention techniques (Grade B).• Mediolateral/lateral episiotomy during operative vaginal births in nulliparous women is associated with a lower risk of OASIs; the association in forceps-assisted births is stronger than in vacuum-assisted births (Grade A).Clinicians should ensure that the angle is 60° from the midline at crowning.• Every woman should be offered a rectal examination after every vaginal birth to avoid missing OASIs or rectal buttonhole tears (Grade GPP).• The Sultan classification should be used when describing any OASI to ensure that all injuries, especially internal sphincter injuries, are excluded (Grade A).• Repair settings