The First Global IUGA Guideline on Acute Obstetric Anal Sphincter Injuries

The First Global IUGA Guideline on Acute Obstetric Anal Sphincter Injuries

Leon N. Plowright, MD, FACOG, FACS, URPS

Assistant Professor, University of Florida College of Medicine – Jacksonville

Moderators: Jorge Milhem Haddad (Brazil), Donald Ostergard (United States), Anna Rosamilia (Australia)

Speaker: Abdul Sultan (United Kingdom)

Dr. Abdul Sultan (United Kingdom) presented the first global IUGA guideline on the management of acute obstetric anal sphincter injuries (OASIS), the culmination of a multi-year initiative he chaired through the OASIS Special Interest Group. The guideline has now been endorsed by the International Continence Society (ICS), FIGO, and multiple international societies, marking an important milestone toward standardizing care worldwide.

Dr. Sultan opened by defining the problem: despite the significant long-term morbidity associated with OASIS, there has never been a universally applicable, evidence-based guideline for its management. An AGREE-II appraisal of existing national guidelines revealed inconsistent methodology, variable evidence grading, and limited applicability across different healthcare settings. He highlighted a critical structural blind spot in obstetrics—patients with fecal incontinence often return years later to colorectal surgeons or urogynecologists, not to the obstetricians who managed the delivery, making the true burden of injury largely invisible to those best positioned to prevent it.

The guideline itself was developed by 16 lead authors and two women’s health physiotherapists, with a 23-member international consensus panel reviewing its recommendations for global applicability. Each recommendation is paired with an explicit level of evidence and grade of recommendation. A defining strength of the document is its dual framework: distinguishing what is ideal in well-resourced settings from what is essential in any setting, ensuring practical use worldwide.

Several recommendations stood out as immediately practice-changing. Every woman should be offered a rectal examination after vaginal delivery—particularly before suturing—with documented consent. A refined three-part classification system (3A, 3B, and 3C) improves prognostication and counseling. The “lift test” is recommended to confirm correct identification of the external anal sphincter before repair, a critical step illustrated by examples of missed injuries inadvertently repaired through superficial perineal musculature. When operative vaginal delivery is necessary, vacuum should be preferred over forceps when clinically appropriate, and mediolateral episiotomy should be placed at a 60-degree angle from midline.

Importantly, the guideline extends beyond intrapartum management. Dr. Sultan emphasized that informed delivery counseling should begin antenatally—not in the urgency of second stage labor.

The dissemination strategy is integral to its success. The guideline will publish open-access in the International Urogynecology Journal and is being translated into multiple languages. It is designed to function alongside the PROTECT training program, which has already certified 21 trainers across 16 countries and trained more than 20,000 obstetricians worldwide.

Dr. Sultan closed with a statement that captured the essence of the work: a guideline that does not change practice and improve quality of life is not worth the paper it is printed on. For the first time, obstetricians, urogynecologists, midwives, and patients across diverse resource settings now share a common reference point—and a standard against which care can be measured.