Pelvic floor after childbirth — structured oral station (12 minutes)

Opening prompt — "Tell me what you do with this woman."

Model response — say it in this order: ^[1][2]

• "New faecal urgency six weeks after a forceps birth, with a documented second-degree tear, is an occult obstetric anal sphincter injury until proven otherwise. Sultan found that 35% of primiparae had a sonographic sphincter defect after vaginal delivery, most of which were not recognised at delivery."
• "I would take a focused continence, bladder and sexual-function history, examine the perineum and perform a digital rectal examination, and arrange an endoanal ultrasound to look for an external or internal anal sphincter defect."
• "I would refer her to a perineal trauma clinic and start supervised pelvic floor muscle training, and screen for postnatal mood disorder and birth-trauma distress."^[1][2]

Examiner is listening for: the occult-injury reflex, the endoanal ultrasound, and the perineal clinic referral — not reassurance and discharge.

Probe 1 — "The endoanal ultrasound shows a 3c injury. What does that mean?"

• "A 3c tear means involvement of the internal anal sphincter. The Sultan grading runs 3a — under half the external sphincter; 3b — over half; 3c — internal sphincter involvement; and fourth degree — through to the anorectal mucosa."^[1][2]
• "The grade matters for prognosis: the Okeahialam network meta-analysis found anal incontinence incidence of about 22.4% for 3a rising to about 28.6% for fourth degree, with 3c and fourth degree significantly worse than 3a."^[2]

Probe 2 — "She asks whether her tear should have been repaired differently at the time."

• "For the external anal sphincter, the overlap technique is favoured over end-to-end where feasible. The Cochrane review found overlap was associated with less faecal urgency at 12 months (RR 0.12, 95% CI 0.02 to 0.86), but at 36 months there was no difference in flatus or faecal incontinence, and the evidence rests on small trials."^[3]
• "The honest answer is that technique matters less than recognition and follow-up — and in her case the injury was not recognised at all, which is the real problem."^[1][3]

Probe 3 — "Will pelvic floor muscle training fix her symptoms?"

• "PFMT is recommended as first-line therapy for women with urinary incontinence on the strength of the Cochrane evidence and the International Consultation on Incontinence. But I would be honest: postpartum trial evidence is mixed. Sigurdardottir's trial found PFMT reduced urinary incontinence at 6 months but not anal incontinence, and the urinary benefit was not sustained at 12 months; Hilde's trial found no significant reduction in urinary incontinence."^[6]
• "So I would prescribe it supervised and individualised, and follow her response — I would not promise a cure for the anal symptoms, and I would keep the perineal and colorectal pathway open for persistent anal incontinence."^[2]

Probe 4 — "She is anxious about future births. How do you counsel her?"

• "I would individualise the advice using her current continence, the size of any residual defect on imaging, and her symptoms. Many women can safely attempt a vaginal birth next time; persistent anal incontinence symptoms or a large residual defect would tilt toward elective caesarean."^[2][3]
• "I would also acknowledge the nerve component: Allen's study found 80% of first-time mothers show EMG evidence of denervation, driven by a long second stage — so counselling is about cumulative risk, not just the sphincter."^[4]

Probe 5 — "She is distressed and tearful during the consultation."

This is a scored domain, not a courtesy. Demonstrate it out loud: ^[2]

• Move to her eye level, use her name, acknowledge her distress: "It is completely understandable to feel this way. What happened to you is real, and we are going to investigate it properly and look after you."
• Offer a debrief of the birth, screen for postnatal mood disorder with a validated tool, and refer to psychological support and a perineal trauma service.
• Avoid minimising language ("it's just a small tear") and avoid conducting the conversation with your back turned while writing notes.^[2]