What specialist should assess suspected obstetric sphincter tears after childbirth?
Executive summary
For suspected obstetric anal sphincter tears (third- or fourth-degree perineal tears), clinical guidelines and reviews say immediate careful clinical inspection, including a digital rectal exam, is essential and initial assessment is usually by the delivering obstetrician or midwife; women should be reviewed 6–12 weeks postpartum in a dedicated clinic with a clinician with a specialist interest in OASIs (obstetric anal sphincter injuries) such as a urogynaecologist or pelvic floor/colorectal specialist [1] [2] [3]. Multidisciplinary referral pathways are common: specialist pelvic floor surgeons, urogynaecologists, colorectal surgeons and dedicated OASI clinics are recommended when imaging, secondary repair, persistent symptoms, or complex cases arise [4] [5] [6].
1. Who examines first: the delivery team must inspect and do a rectal exam
Immediate post‑delivery detection relies on a systematic physical exam at the bedside: inspection of the perineum and a digital rectal exploration are the most appropriate diagnostic tools for early detection of OASIS, and guidelines advise offering every patient a rectal exam after vaginal birth [1] [3]. Multiple reviews warn that many injuries are missed on the labour ward, so the delivering obstetrician or trained midwife plays the crucial first role in recognising a tear [1] [7].
2. When to involve a specialist: complexity, persistent symptoms, or secondary repair
If the tear is complex, not clearly identified, fails primary repair, or if the patient develops ongoing symptoms (incontinence, pain), referral to specialist pelvic floor services is recommended. Secondary repair and planning for future deliveries typically occur in dedicated peripartum or OASI subspecialty clinics led by clinicians with a special interest in anal sphincter injuries—commonly urogynaecologists, colorectal surgeons or pelvic floor surgeons [8] [4] [2].
3. Which specialists are commonly involved: urogynaecology, colorectal surgery, pelvic floor surgeons
The literature and clinic models describe multidisciplinary teams: urogynaecologists and female pelvic medicine and reconstructive surgeons manage many OASIS cases; colorectal surgeons are consulted particularly for complex or secondary repairs and when anorectal function assessment is needed [4] [5]. National surveys emphasise collaboration between obstetrics, urogynaecology and colorectal specialties to optimise outcomes [6].
4. Role of imaging and diagnostic tests: who orders and interprets them
Endoanal ultrasound (EAUS) and transperineal ultrasound (TPUS) are used in early follow‑up to identify defects and to stratify risk for long‑term problems; these investigations typically occur in specialist clinics and inform whether specialist surgical input or altered birth planning is required [1]. Newer technologies (e.g., impedance spectroscopy) are being studied against EAUS in multicentre trials, but these are adjuncts processed within specialist pathways rather than first‑line bedside tools [9] [1].
5. Timing and follow‑up: the specialist clinic review window
Guidance and reviews recommend routine postpartum review at 6–12 weeks in a dedicated clinic with a clinician who has a special interest in OASIs; that follow‑up is where targeted investigations, physiotherapy referral, and decisions about secondary repair or future mode of delivery are made [2] [3]. Evidence and specialist practice emphasise that early detection and appropriate referral reduce the risk of long‑term faecal incontinence and other sequelae [1] [10].
6. Who actually repairs the tear acute vs. delayed — lack of consensus
There is no universal agreement about which surgeon should perform primary repair: surveys show variation in who is called for acute repairs and that many general surgeons or obstetricians have limited recent experience with primary OASI repairs; several authors argue that surgeon involvement should be reserved for cases where adequate exposure and training are assured or where secondary repair is anticipated [5]. That lack of consensus has driven development of specialist clinics and training initiatives [11] [5].
Limitations and unresolved questions
Available sources document recommended pathways, multidisciplinary roles and timing but do not prescribe a single specialist title universally responsible in every health system; local resources, training, and established OASI pathways determine whether an obstetrician, urogynaecologist, pelvic floor surgeon, or colorectal surgeon leads care [5] [6]. If you want a practical next step for a specific hospital or locality, available sources do not mention local contact names—contact your maternity unit to ask about their OASI clinic or on‑call pelvic floor specialist [6] [2].