Perineal wound complications and breakdown — structured oral station (12 minutes)

Opening prompt — "Take me through your assessment."

Model response — say it in this order: ^[3]

• "This is a perineal wound complication after OASIS repair at day 5 — pain worsening, offensive discharge, and a known 3b tear. Pain that is not settling or is getting worse after day 3 is a perineal wound complication until I have examined her."^[3]
• "I would examine her now with a chaperone, in lithotomy with good light and adequate analgesia, and I would perform and document a digital rectal examination to look for sphincter involvement in the breakdown."
• "I would ask the four NICE NG194 questions: pain that is not settling or is getting worse; any offensive discharge or bleeding; any difficulty or pain passing urine or stool; any feeling that something is not right."

Examiner is listening for: recognition, the rectal examination obligation, the four NG194 questions, and the same-day disposition.^[3]

Probe 1 — "On examination there is a 1 cm separation of the skin and perineal muscle with slough at the base and a small amount of purulent discharge. Rectal examination confirms an intact anal sphincter. Her observations are normal. What do you do?"

• "This is an infected perineal wound dehiscement without sphincter involvement, in a systemically well woman. NICE NG194 is explicit: perineal wound breakdown is a same-day specialist referral. I would manage conservatively."^[3]
• "Wound swab for culture and sensitivity; broad-spectrum oral antibiotics guided by the swab — amoxicillin-clavulanate 875/125 mg PO bd plus metronidazole 400 mg PO tds for 7 days; scheduled analgesia with paracetamol 1 g qid plus diclofenac 50 mg tds plus tramadol 50 mg every 4 h prn (avoiding codeine because she is breastfeeding); lactulose 15 to 30 mL bd plus senna 7.5 to 15 mg nocte to keep the stool soft; and pelvic-floor physiotherapy referral."
• "Daily review for the first 48 hours; clear safety-net advice to return immediately if pain escalates, fever develops, or urinary retention recurs."

Probe 2 — "She asks whether the wound should be re-sutured. What is the evidence?"

• "The honest evidence is PREVIEW — a pilot and feasibility randomised trial by Dudley and colleagues, published in BMJ Open in 2017. Thirty-four women with dehisced perineal wounds were randomised to resuture or expectant management. Wound healing at 2 weeks favoured resuture (OR 20.00, 95 percent CI 2.04 to 196.37, p=0.004). However, by 6 to 8 weeks all but one wound in both arms had healed. Women reported higher satisfaction with resuturing at 3 months."^[1]
• "But the trial was a feasibility study — strong patient and clinician preference limited recruitment, and no definitive large trial has been completed. The Cochrane review of 2013 found insufficient evidence to recommend one approach over the other."^[2]
• "The counselling message: resuture heals faster at 2 weeks but almost every wound heals by 6 to 8 weeks either way. Crucially, I would not resuture this wound now — it is sloughy and infected. Resuturing an infected wound produces a worse breakdown or a fistula. Debride, treat, granulate, then decide."

Probe 3 — "She is upset and asks if she will leak again."

Communication probe — demonstrate it out loud: ^[4]

• "I would sit at her eye level, use her name, and acknowledge her distress: 'This is not what you needed after a difficult birth, and I am sorry. The good news is that the breakdown has not involved the sphincter muscle, which is the part that controls continence.'"^[4]
• "I would explain that approximately 60 to 80 percent of women are asymptomatic at 12 months after primary OASIS repair. The breakdown does increase her risk of being in the symptomatic group, and we will follow her closely with a perineal clinic, endoanal ultrasound at 6 months, and pelvic-floor physiotherapy throughout."
• "I would commit to a debrief afterwards and to a structured follow-up plan."

Probe 4 — "She asks about her next pregnancy."

• "I would defer the mode-of-birth decision until the perineal clinic review at 6 weeks and the endoanal ultrasound at 6 months. The decision is individualised — informed by her symptoms, the imaging findings, and her preferences. The Mørch and Carter systematic reviews inform this discussion."^[4]
• "I would not promise a caesarean now, and I would not promise a vaginal birth either. The right answer at this stage is structured follow-up and a deferred, individualised decision."

Probe 5 — "What is the role of antibiotics at the original OASIS repair? Did she get what she should have?"

• "Yes — she received co-amoxiclav at repair, which is appropriate. The Duggal randomised trial showed that a single dose of prophylactic antibiotics at OASIS repair reduced wound complications from 14.6 percent to 4.9 percent per-protocol. The Buppasiri Cochrane review of 2014 rests on the Duggal trial and concludes that routine broad-spectrum prophylaxis at OASIS repair is standard, endorsed by RCOG Green-top Guideline 29."^[5][6]
• "Antibiotics do not prevent every breakdown — the Gommesen cohort showed BMI over 35 and episiotomy as additional risk factors that operate independently. But they reduce the rate, and she got them."