Perineal wound complications and breakdown — structured SAQ (15 marks)

(a) NICE NG194 questions and the essential examination (3 marks)

One mark for the four questions; two for the rectal examination and why. [3]

• The four NICE NG194 perineal questions asked at every postnatal contact: (1) is there pain that is not settling or is getting worse; (2) any offensive discharge or bleeding; (3) any difficulty or pain passing urine or stool; (4) any feeling that something is not right down below.[3]
• The single most important examination is a digital rectal examination. This woman had a 3b OASIS repaired and now has a gaping infected wound — sphincter involvement in the breakdown must be excluded before any decision about conservative versus surgical management. The absence of a documented rectal examination is the commonest medicolegal pitfall in perineal trauma and the breakdown that follows it.[7]

(b) Investigations and the theatre-versus-conservative decision (4 marks)

One mark for investigations; three for the disposition criteria. [3]

Investigations:

• Wound swab for culture and sensitivity.
• Full blood count and C-reactive protein (she is at risk of systemic infection).
• Midstream urine culture if urinary symptoms.
• Observations: temp, HR, BP, RR — and lactate if any systemic upset.

Theatre (immediate) if: necrotising infection suspected (pain out of proportion, dusky or crepitant tissue, systemic toxicity); expanding haematoma with haemodynamic compromise; deep abscess; breakdown involving the sphincter complex; suspected rectovaginal fistula.[3]

Conservative (with daily review) if: the woman is systemically well; the wound is superficial or limited to skin and subcutaneous tissue; the sphincter is intact on rectal examination; the wound base is sloughy or purulent but not necrotic. Conservative package: wound hygiene, broad-spectrum antibiotics guided by swab (amoxicillin-clavulanate 875/125 mg PO bd plus metronidazole 400 mg PO tds), scheduled analgesia (paracetamol 1 g qid, diclofenac 50 mg tds, tramadol 50 mg every 4 h prn; avoid codeine in breastfeeding), and lactulose plus senna.[3]

(c) PREVIEW honestly stated (4 marks)

Two marks for the 2-week and 6-to-8-week outcomes; one for the design limitations; one for the counselling message. [1]

• PREVIEW (Dudley and colleagues, BMJ Open 2017) was a multicentre pilot and feasibility randomised controlled trial in the UK.
• 34 women randomised (17 in each arm) — small by design.
• Wound healing at 2 weeks favoured resuturing (OR 20.00, 95 percent CI 2.04 to 196.37, p=0.004).
• By 6 to 8 weeks, all but one wound in both groups had healed.
• Women reported higher satisfaction with resuturing at 3 months.
• Design limitations: strong patient and clinician preference limited recruitment; the trial was a feasibility study, not a definitive trial; no definitive large randomised trial has been completed; the Cochrane review of 2013 (Dudley) found insufficient evidence to recommend one approach over the other.[2]
• Counselling message: resuture heals faster at 2 weeks and may be preferred by women, but almost every wound heals by 6 to 8 weeks either way. Choose resuture for a clean, granulating, deep or OASIS-involving breakdown; never resuture a sloughy or infected wound.

(d) The post-OASIS bundle (2 marks)

One mark for what was given (and the rationale); one for what should be added now. [8]

• At repair (Green-top 29): broad-spectrum antibiotics (a single IV dose at repair, continued orally — amoxicillin-clavulanate plus metronidazole is standard); a laxative (lactulose 15 to 30 mL bd) without a routine bulking agent (Eogan RCT showed bulking agents add bloating without benefit); structured pelvic-floor physiotherapy; and a documented plan for perineal clinic follow-up.[8][9]
• What should be added now: a wound swab and broad-spectrum antibiotic cover guided by the result; an escalation of analgesia if her current regimen is insufficient; and a same-day specialist review per NICE NG194 — perineal wound breakdown is a same-day referral, not a next-clinic problem.[3]

(e) Follow-up over the next 12 months (2 marks)

One mark for the perineal clinic structure; one for the mode-of-birth counselling. [4][7]

• Perineal clinic at 6 weeks with a structured review of pain, continence (flatus and faecal), sexual function, and wound healing.
• Endoanal ultrasound and anal manometry at 6 months to assess sphincter integrity and inform future mode of birth.
• Pelvic-floor physiotherapy throughout, with scar mobilisation and a structured return to sexual function.
• Sexual function counselling — dyspareunia is common at 3 months and persists in a minority at 12 months; lubricants, scar mobilisation, and referral to a sexual function clinic if persistent.
• Mode of birth next pregnancy — individualised conversation informed by her symptoms, the endoanal ultrasound findings, and her preferences; the Carter and Mørch systematic reviews inform the caesarean-versus-vaginal discussion.[4]
• Approximately 60 to 80 percent of women are asymptomatic at 12 months after primary OASIS repair — quote the number and address the remainder.[4]