Severe tears get missed
The most consequential unrecognized injury in obstetrics.
In a study of 241 first vaginal births, a single examination by the clinician who attended the birth found sphincter injury in 11%. An independent re-examination immediately afterward raised detection to 24.5%. Ultrasound found only 3 additional truly hidden injuries, 1.2%.
In other words, most missed injuries were not hidden. They were simply not found by the first examination. Midwives missed 87% of the injuries they had not recognised on first examination; doctors missed 28%.
Important caveat on that numberThe 24.5% figure comes from an intensive research protocol in first births. It is a measure of how much better careful examination detects, not the rate at which women in general sustain sphincter injury. The population rate is around 4% to 6%.
What to ask for after a vaginal birth"Has anyone examined me for a sphincter injury, including a rectal examination?" A rectal examination after birth is the standard way to find these, and it is not always done.
Where this comes from:
210. Andrews V, Sultan AH, Thakar R, Jones PW. Occult anal sphincter injuries: myth or reality? BJOG. 2006;113(2):195-200.
211. Sultan AH, Kamm MA, Hudson CN, Thomas JM, Bartram CI. Anal-sphincter disruption during vaginal delivery. N Engl J Med. 1993;329(26):1905-1911.
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