Obstetric anal sphincter injuries (OASIs) are associated with significant long-term physical, psychological, and quality-of-life morbidity. They are among the most severe forms of perineal trauma associated with vaginal delivery, leading to significant short and long-term morbidities (1).   These injuries, which involve disruption of the anal sphincter muscles, are associated with complications such as fecal incontinence, severe urinary incontinence, sexual dysfunction and persisting pelvic pain (2,3).  The intrapartum management of OASIs is well established governed by many international clinical practice guidelines.  Postpartum follow-up however, is less well-defined, with limited established guidance.  We developed the first clinical practice guideline dedicated to the scope of long term follow-up care after OASI, which is a very much needed area of guidance given the current variability in care provision and associated outcomes.  Importantly, this guideline aimed to address the current practice gap related to counselling clients after previous OASI.

A literature review was conducted using MEDLINE, Embase, SCOPUS, and Cochrane databases (2014–2025).  Multidisciplinary expert consensus including pelvic health physiotherapy and a range of relevant medical specialties informed guideline development, with consideration of diverse clinical settings and resource availability.  Results were restricted to systematic reviews, metanalyses, randomized controlled trials/controlled clinical trials, observational studies, and clinical practice guidelines. The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

From the systematic literature review, 11 summary statements and 16 recommendations were developed.  Ten of the 16 recommendations were categorized as strong recommendations meaning the guideline panel is highly confident that the desirable effects of the intervention (benefits, quality of life, cost-effectiveness) clearly outweighs the undesirable effects (harms, burden, costs), or vice-versa.

The guideline strongly recommends structured follow-up for all women with OASI, ideally within dedicated multidisciplinary clinics. Endoanal ultrasound and anorectal manometry are preferred investigations where available. Universal enactment of birth debriding and assessment of emotional recovery as well as referral to pelvic health physiotherapy is advised. Algorithms were developed to support individualized counselling for subsequent mode of delivery, acknowledging limited and heterogeneous evidence (Figures 1 & 2).  Importantly, obstetrical care providers should counsel all women with history of OASIs regarding subsequent mode of delivery using a collaborative approach.

OASI and its associated pelvic floor disorders can have a profound impact on women’s quality of life. Standardized, multidisciplinary long-term surveillance and counselling after OASI may improve informed decision-making and recovery.  Flexible application of evidence-based recommendations and decision-support algorithms allows adaptation across resource settings.

Lallemant M, Ferdinando Ruffolo A, Kerbage Y, Garadebian C, Ghesquiere L, Rubod C, Cosson M. Clinical practices in the management and follow-up of obstetric anal sphincter injuries: a comprehensive review. Eur J Obstet Gynecol Reprod Biol. 2024 Nov;302:362-369. doi: 10.1016/j.ejogrb.2024.09.042. Epub 2024 Oct 1. PMID: 39388912.
Diko S, Guiahi M, Nacht A, Connell KA, Reeves S, Bailey BA, Hurt KJ. Prevention and Management of Severe Obstetric Anal Sphincter Injuries (OASIs): a National Survey of Nurse- Midwives. Int Urogynecol J. 2020 Mar;31(3):591-604. doi: 10.1007/s00192-019-03897-x. Epub 2019 Mar 15. PMID: 30877353.
Sideris M, McCaughey T, Hanrahan JG, Arroyo-Manzano D, Zamora J, Jha S, Knowles CH, Thakar R, Chaliha C, Thangaratinam S. Risk of obstetric anal sphincter injuries (OASIS) and anal incontinence: A meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2020 Sep;252:303-312. doi: 10.1016/j.ejogrb.2020.06.048. Epub 2020 Jun 27. PMID: 32653603.