Course review

Third and fourth degree perineal tears hands-on repair course

Authors: Ganesh Thiagamoorthy 

Publication date:  14 Feb 2012

What is it?

Obstetric anal sphincter injuries are a major cause of anal incontinence and can have a devastating effect on a woman’s physical, social, and emotional wellbeing. When undiagnosed they are a frequent source of complaint and litigation. This one day hands-on course gave me the knowledge and practical skills to identify the risk factors and diagnose, classify, and manage obstetric anal sphincter injuries.

Why did you do it?

I attended the course as a junior registrar in obstetrics and gynaecology because I wanted to understand the basic anatomy and physiology and, most importantly, how to identify obstetric anal sphincter injuries before being taught repair techniques. During postnatal ward rounds I realised how little is taught and known about the consequences of such injuries and how women should be managed in subsequent pregnancies. I chose this course after positive reviews from colleagues who had done it.

Who is it for?

Obstetricians, gynaecologists, colorectal surgeons, midwives, nurse specialists, general practitioners practising obstetrics, and anybody who is involved at any point in the care pathway to diagnose and manage a woman with obstetric anal sphincter injuries.

What are the benefits of the course?

The course enables a clear understanding of the importance of recognising obstetric anal sphincter injuries. Surgical options are combined with a holistic approach, and the consequences of missed diagnosis and poor repair techniques are demonstrated. Anatomy lessons are reinforced with videos and models, and complex repairs are simplified into basic surgical steps. There is plenty of opportunity to practise the steps under supervision by the faculty, who are clearly experienced and approachable.

What is the course structure?

The full day course is run by Abdul Sultan and Ranee Thakar, who are internationally renowned and passionately devoted to the subject. They introduced the first course 10 years ago and have trained thousands of doctors and midwives. This is a comprehensive A to Z course on the anal sphincter. Introductions, anatomy, physiology, investigations, and tips and pitfalls on making a diagnosis are covered in the morning. Before lunch, repair techniques are discussed and reinforced with video demonstrations.

After a three course feast, the dilemma lecture follows as an interactive session with evidence based discussion on the management of subsequent pregnancies, the perineal clinic, risk factors, and prevention of obstetric anal sphincter injuries. The correct indications and technique for episiotomy are also covered. The lecture on the management of women who develop faecal incontinence leads on nicely to the medicolegal casebook in a courtroom drama. Hands-on training with the Sultan anal sphincter trainer model helps clarify the steps. The grand finale is the porcine anal sphincter. This allowed for real life differentiation between the internal and external sphincters and was the highlight of this course.

Is there an exam?

There is no exam, but a pre-course questionnaire highlights deficiencies in knowledge. The course ends with a certificate of successful completion.

How do you prepare for the course?

Before attending the course you are given access to password protected online course material at [Link] . On the day, the information is drip fed to ensure that the salient points are absorbed.

What is the cost?

The course costs £270, which includes a comprehensive textbook on perineal trauma, along with an excellent lunch and the usual supply of coffee and biscuits. I bought the extra DVD for £30.

Was it worth it?

Definitely. No one should be allowed to deliver obstetric care without attending such a course. Initially I became despondent as it dawned on me and the other delegates how many obstetric anal sphincter injuries we have probably missed during our practice, but by the end of the day we were fuelled with enthusiasm to put what we learnt into practice. The tips and emphasis on basic clinical skills such as proper digital rectal examination were invaluable. This is the best course I have attended, and I gained the confidence that every obstetric trainee needs to practise and to train others. It was a true master class.

Further information

The course is run at Croydon University Hospital, London Road, Croydon CR7 7YE, UK. Contact Michelle Lawrence: tel: +44(0)20 8401 3000, extension 4768;

Competing interests: None declared.

Ganesh Thiagamoorthy year 4 specialist trainee, obstetrics and gynaecology, London Deanery, London, UK

Cite this as BMJ Careers ; doi: