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Episiotomy and Second Degree Perineal Tears : Hands-on Workshop

Sultan AH, Thakar R, Fenner D. Perineal and anal sphincter trauma. London: Springer. 2007 (This comprehensive textbook covering all topics listed below)

Repair of Episiotomy and Second Degree Tear


  • Intrapartum Care. NICE Clinical Guideline. Guideline 55 2007 Available from: URL: www.nice.org.uk/CG055
  • Kettle C, Hills RK, Jones P, Darby L, Gray R, Johanson R. Continuous versus interrupted perineal repair with standard or rapidly absorbed sutures after spontaneous vaginal birth: a randomised controlled trial. Lancet 2002: 359: 2217-23
  • Kettle C, Hills RK, Ismail KMK. Continuous versus interrupted sutures for repairof episiotomy or second degree tears. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD000947. DOI:10.1002/14651858.CD000947.
  • Kettle C, Johanson RB. Absorbable synthetic versus catgut suture material for perineal repair. The Cochrane Database of Systematic Reviews 1999, Issue 4. Art. No.: CD000006. DOI: 10.1002/14651858.CD000006.


  • Andrews V, Thakar R, Sultan AH, Jones PW. Are mediolateral episiotomies actually mediolateral? BJOG 2005;112:1156-8
  • Carroli G, Mignini L. Episiotomy for vaginal birth. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD000081. DOI: 10.1002/14651858.CD000081.pub2.
  • Eogan M, Daly L, O'Connell PR, O'Herlihy C. Does the angle of episiotomy affect the incidence of anal sphincter injury? BJOG 2006; 103:190-4.
  • Henriksen TB, Bek KM, Hedegaard M, Secher NJ Methods and consequences of changes in use of episiotomy. BMJ 1994;309: 1255-8
  • Henriksen TB, Bek KM, Hedegaard M, Secher NJ. Episiotomy and perineal lesions in spontaneous vaginal deliveries. B J Obstet Gynaecol 1992;99: 950-4
  • Sleep J, Grant A. West Berkshire perineal management trial. BMJ 1987;295:749-51
  • Woolley RJ. Benefits and risks of episiotomy: A review of the English language literature since 1980. Obstet Gynecol Surv 1995;50:806-35

Prevention of perineal trauma

  • Cluett E R, Nikodem VC, McCandlish RE, Burns EE. Immersion in water in pregnancy, labour and birth. The Cochrane Database of Systematic Reviews 2002, Issue 2. Art. No.: CD000111. DOI: 10.1002/14651858.CD000111.pub2.
  • Beckmann MM, Garrett AJ. Antenatal perineal massage for reducing perineal trauma. Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD005123. DOI: 10.1002/14651858.CD005123.pub2.
  • Gupta JK, Hofmeyr GJ, Smyth R. Position in the second stage of labour for women without epidural anaesthesia. The Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD002006. DOI:10.1002/14651858.CD002006.pub2.
  • Johanson RB, Menon V. Vacuum extraction versus forceps for assisted vaginal delivery. The Cochrane Database of Systematic Reviews 1999, Issue 2. Art. No.: CD000224. DOI: 10.1002/14651858.CD000224.
  • Labrecque M, Marcoux S, Pinault JJ, Laroche C, Martin S. Prevention of perineal trauma by perineal massage during pregnancy: a pilot study. Birth 1994; 21:20-5
  • Labrecque M, Eason E, Marcoux S et al. Randomized controlled trial of prevention of perineal trauma by perineal massage during pregnancy. Am J Obstet Gynecol 1999; 180(3 Pt 1):593-600.
  • Labrecque M, Eason E, Marcoux S. Randomized trial of perineal massage during pregnancy: perineal symptoms three months after delivery. Am J Obstet Gynecol 2000; 182(1 Pt 1):76-80.
  • Labrecque M, Eason E, Marcoux S. Women's views on the practice of prenatal perineal massage. BJOG 2001;108:499-504
  • Shipman MK, Boniface DR, Tefft ME, McGlohry F. Antenatal perineal massage and subsequent perineal outcomes: a randomised controlled trial. BJOG 1997;104:787-91.

Instrumental delivery

  • Bofill JA, Rust OA, Schorr SJ et al. A randomized prospective trial of the obstetric forceps versus the M-cup vacuum extractor. Am J Obstet Gynecol 1996;175:1325-30
  • Johanson RB, Rice C, Doyle M et al. A randomised prospective study comparing the new vacuum extractor policy with forceps delivery. BJOG 1993;100: 524- 30.
  • Johanson RB, Heycock E, Carter J, Sultan AH, Walklate K, Jones PW. Maternal and child health after assisted vaginal delivery: five-year follow up of a randomised controlled study comparing forceps and ventouse. BJOG1999;106:5444-49.
  • Sultan AH, Johanson RB, Carter JE. Occult anal sphincter trauma following randomized forceps and vacuum delivery. Int J Gynecol Obstet 1998;61:113-9.
  • Royal College of Obstetricians and Gynaecologists. Operative vaginal delivery. Guideline No 26 London: RCOG Press, 2005.

Occult anal sphincter injury

  • Andrews V, Thakar R, Sultan AH, Jones PW. Occult anal sphincter injuries -- myth or reality? BJOG 2006;113:195-200.
  • Chaliha C, Sultan AH, Kalia V, Monga AK, Stanton SL. Anal function: effect of pregnancy and delivery. Am J Obstet Gynecol 2001;185:427-32
  • Donnelly V, Fynes M, Campbell D, Johnson H, O'Connell R, O'Herlihy C. Obstetric events leading to anal sphincter damage. Obstet Gynecol 1998;92: 955-61.
  • Faltin DL, Boulvain M, Floris LA, Irion O. Diagnosis of anal sphincter tears to prevent fecal incontinence. A randomised controlled trial. Obstet Gynecol 2005;106:6-13
  • Fynes M, Donnelly V, Behan M, O'connell PR, O'Herlihy C. Effect of second vaginal delivery on anorectal physiology and faecal incontinence: a prospective study. Lancet 1999;354:983-86.
  • Norton C, Christiansen J, Butler U, Harari D, Nelson RL, Pemberton J, Price K, Rovnor E, Sultan A. Anal Incontinence. In Abrams P, Cardozo L, Khoury, Wein A (eds). Incontinence 2nd ed. Plymouth: Health Publication Ltd 2002:985-1044
  • Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal sphincter disruption during vaginal delivery. New Engl J Med 1993;329:1905-11.
  • Sultan AH, Thakar R. Diagnosis of anal sphincter tears to prevent fecal incontinence. A randomised controlled trial. Obstet Gynecol [letter] 2005;106:1108-9

Obstetric anal sphincter Injuries (OASIS)

  • DeLeeuw JW, Struijk PC, Vierhout ME, Wallenburg HCS. Risk factors for third degree perineal ruptures during delivery. BJOG 2001;108:383-7
  • DeLeeuw JW, Vierhout ME, Struijk PC, Wim WCJ, Wallenburg HCS. Anal sphincter injury after vaginal delivery: functional outcome and risk factors for fecal incontinence. Acta Obstet Gynecol Scand 2001:80:830-4.
  • Duggal N, Mercado C, Daniels K, Bujor A, Caughey AB, El-Sayed YY. Antibiotic prophylaxis for prevention of postpartum perineal wound complications: a randomized controlled trial. Obstet Gynecol 2008;111:1268-73.
  • Eogan M, Daly L, Behan M, O'Connell PR, O'Herlihy C. Randomised clinical trial of a laxative alone versus a laxative and a bulking agent after primary repair of obstetric anal sphincter injury. BJOG 2007;114:736-40.
  • Fenner DE, Becky-Genberg MPH, Brahma P, Marek L, DeLancey JOL. Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States. Am J Obstet Gynecol 2003;189:1543-50.
  • Fernando RJ, Sultan AH, Kettle C, Radley S, Jones P, O'Brien PMS. Repair techniques for obstetric anal sphincter injuries. A randomized controlled trial. Obstet Gynecol 2006;107:1261-8.
  • Fitzpatrick M, Behan M, O'Connell R, O'Herlihy C. A randomized clinical trial comparing primary overlap with approximation repair of third degree obstetric tears. Am J Obstet Gynecol 2000;183:1220-4.
  • Mahony R, Behan M, O'Herlihy C, O'Connell PR. Randomized, clinical trial of bowel confinement vs. laxative use after primary repair of a third-degree obstetric anal sphincter tear. Dis Colon Rectum 2004;47:12-7
  • Mahony R, Behan M, Daly L, Kirwan C, O'Herlihy C, O'Connell PR. Internal anal sphincter defect influences continence outcome following obstetric anal sphincter injury. Am J Obstet Gynecol 2007;196:217-5
  • Nordenstam J, Mellgren A, Altman D, Lopez A, Johansson C, Anzen B, et al. Immediate or delayed repair of obstetric anal sphincter tears-a randomised controlled trial. BJOG 2008;5:857-65
  • Poen AC, Felt-Bersma RJF, Strijers RLM, Dekkers GA, Cuesta MA, Meuwissen SGM. Third-degree obstetric perineal tear: long-term clinical and functional results after primary repair. Br J Surg 1998;85:1433-38
  • Pirhonen JP, Grenman SE, Haadem K, Gudmundsson S, Lindqvist P, Sihola S, Erkkola RU, Marsal K. Frequency of anal sphincter rupture at delivery in Sweden and Finland - result of difference in manual help to the baby's head. Acta Obstet Gynecol Scand 1998;77:974-77
  • Royal College of Obstetricians and Gynaecologists. Management of Third and Fourth Degree Perineal Tears Following Vaginal Delivery. London: RCOG Press: 2007. RCOG Guideline No. 29.
  • Sangali MR, Floris L, Faltin D, Weil A. Anal incontinence in women with third or fourth degree perineal tears and subsequent vaginal deliveries. Aust N Z J Obstet Gynaecol 2000;40:244-8
  • Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third degree obstetric anal sphincter tears: risk factors and outcome of primary repair. BMJ 1994;308:887-91
  • Sultan AH, Monga AK, Kumar D, Stanton SL. Primary repair of obstetric anal sphincter rupture using the overlap technique. BJOG1999;106:318-23.
  • Sultan AH, Thakar R. Lower genital tract and anal sphincter trauma. Best Practice & Research - Clin Obstet Gynaecol 2002;16:99-116
  • Thakar R, Sultan AH. Management of obstetric anal sphincter injury. The Obstetrician and Gynaecologist. 2003; 5:31-9
  • Thakar R, Sultan AH. Episiotomy and obstetric perineal trauma. In: Warren R and Arulkumaran S. Best Practice in Labour and Delivery, Cambridge University Press 2009: 182-94
  • Williams Adams EJ, Tincello DG, Alfirevic Z, Walkinshaw SA, Richmond DH. How to repair an anal sphincter injury after vaginal delivery: results of a randomized controlled trial. BJOG 2006;201-7


  • Eddy A. Litigating and quantifying maternal damage following childbirth. Clin Risk 1999;5 :178-180.
  • Jaiyesimi RAK. Pitfalls in the management of perineal trauma. Clin Risk 2007;13:89-91
  • Sultan AH. Editorial: Obstetric perineal injury and anal incontinence. Clin Risk 1999;5:193-6


  • Andrews V, Thakar R, Sultan AH, Kettle C. Can hands-on perineal repair courses affect clinical practice. Br J Midwifery 2005;13:562-5
  • Andrews V, Thakar R, Sultan AH. Structured hands-on training in repair of obstetric anal sphincter injuries (OASIS): an audit of clinical practice. Int Urogynecol J Pelvic Floor Dysfunct. 2009; 20:193-9.
  • Groom KM, Paterson-Brown S. Can we improve on the diagnosis of third degree tears? Europ J Obstet Gynecol Rep Biol 2002;101:19-21
  • McLennan MT, Melick CF, Clancy SL, Artal R. Episiotomy and perineal repair. An evaluation of resident education and experience. J Reprod Med 2002;47(12):1025-30
  • Sultan AH, Kamm MA, Hudson CN. Obstetric perineal tears: an audit of training. J Obstet Gynaecol 1995;15:19-23