OT notes · Obstetrics

Episiotomy and perineal tear (including OASIS) repair

Usual anaesthesia
Local infiltration with lignocaine 1% for episiotomy and first or second degree tears; spinal or general anaesthesia in OT for third and fourth degree tears
Position
Lithotomy
Setting
emergency

Operative note template for episiotomy and perineal tear repair, including third and fourth degree (OASIS) tears, with a filled example for a 3b tear extending from a mediolateral episiotomy repaired in OT under spinal anaesthesia.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • bleeding and perineal haematoma
  • wound infection and breakdown
  • perineal pain and pain during intercourse
  • anal incontinence to flatus or stool, and faecal urgency
  • rectovaginal fistula
  • urinary retention needing a catheter
  • suture migration or need to remove stitches
  • need for further repair

Pre-operative details for this operation

  1. Delivery detailsmode (spontaneous / vacuum / forceps), time of birth, baby weight, parity
  2. Episiotomy givenNoRight mediolateralLeft mediolateralMidlineLateralindication, and whether given at crowning
  3. Examination done before repairVaginal and rectal examination doneapex of vaginal tear identified; sphincter palpated between finger in anus and thumb in vagina
  4. Degree of tear1st2nd3a3b3c4thRectal buttonhole3a < 50% EAS thickness, 3b > 50% EAS, 3c IAS torn, 4th anal epithelium torn
  5. Other tearslabial, periurethral, vaginal sulcus, cervical
  6. Repair byname and grade; for OASIS the supervising senior
  7. Consent for repair in OT (OASIS)

Anaesthesia and position

  1. AnaesthesiaLocal infiltrationEpidural top-upSpinalGeneralfor local: drug, strength, volume
  2. Place of repairLabour roomOperation theatre
  3. PositionLithotomy
  4. BladderCatheterised, Foley left inEmptied with plain catheterNot catheterised

Operative findings

  1. Episiotomy / tear extentlength, apex level in vagina, extension (side)
  2. External anal sphincterIntactPartly torn (< 50%)Partly torn (> 50%)Completely tornposition of torn ends
  3. Internal anal sphincterIntactTorn
  4. Anal / rectal mucosaIntactTornlength of mucosal tear
  5. Bleeding points / haematoma

Procedure (steps)

  1. Episiotomy incision (if given)site (7 o'clock for right MLE), angle at crowning (about 60 degrees), length, scissors
  2. Cleaning and draping, swabs and needles countedantiseptic used
  3. Anal / rectal mucosa repair (4th degree)suture, size, continuous or interrupted, where the knots lie
  4. Internal anal sphincter repair (3c / 4th)ends held with Allis, suture, technique (interrupted / mattress / continuous), repaired separately from EAS
  5. External anal sphincter repairEnd-to-endOverlappingends grasped with Allis, fascial sheath included, suture (e.g. PDS 2-0 / 3-0), number of sutures
  6. Vaginal mucosaanchoring stitch above the apex, continuous to hymenal ring, suture used
  7. Perineal musclescontinuous or interrupted, one or two layers, crown stitch to bulbospongiosus
  8. Perineal skinContinuous subcuticularInterruptedLeft unsutured (edges well apposed, with consent)suture used
  9. Labial / other tears repairedsuture used
  10. Wound irrigation (OASIS)

Closure, drains and dressing

  1. Rectal examination after repairDone: no suture through rectal mucosa
  2. Vaginal examination after repairno pack or swab left, vagina not narrowed
  3. Vaginal packNonePack left: remove at (time)
  4. Haemostasis and uterine tone at end
  5. Swab and needle count after repairCorrect

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Analgesiadrug, dose, frequency; regular, not only as needed
  2. Antibiotics (OASIS)IV dose at repair and oral course, drugs and duration
  3. Stool softener (OASIS)e.g. lactulose, dose, for 10 days
  4. Urinary catheterkeep for 24 h after OASIS repair or regional block; check voiding after removal
  5. Perineal caresitz bath / washing, pad changes, look for swelling or discharge
  6. Watch forperineal haematoma, excessive pain, retention of urine, fever
  7. Pelvic floor exercisesstart when comfortable
  8. Explain to the womandegree of tear, what was repaired, signs to report
  9. Follow-upOASIS: review by senior obstetrician at 6 to 12 weeks

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mrs. P.D., 23 years, primigravida at 39+1 weeks, spontaneous vaginal delivery of a 3.4 kg baby with right mediolateral episiotomy, found on rectal examination to have a 3b tear extending from the episiotomy.

Case details

Date: 18/07/2026. Repair of right mediolateral episiotomy with extension to a 3b perineal tear. OT 3.

Baby born 10:42. Tear diagnosed 10:55. In OT 11:25. Spinal given 11:30. Repair started 11:40, completed 12:30.

Surgeon: Dr A. (2nd-year resident, OBGY) under direct supervision of Dr C. (consultant). Assistant: Dr B.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Right mediolateral episiotomy given at crowning for a rigid perineum with fetal bradycardia in the second stage. Cut from 7 o'clock at about 60 degrees, about 3 cm long, with straight scissors.

After delivery of placenta, vaginal and rectal examination done. Episiotomy had extended. External anal sphincter felt torn on pill-rolling, more than half its thickness. Anal mucosa intact on PR. Classified as 3b.

Uterus well contracted. Blood loss at delivery 300 ml.

Patient and husband told about the tear and need for repair in OT. Consent taken in Marathi. WHO checklist done. Inj cefazolin 1 g IV at 11:35.

Anaesthesia and position

Spinal anaesthesia. Lithotomy. Parts cleaned with povidone-iodine and draped. Foley catheter inserted, urine clear. Swabs and needles counted.

Findings

Episiotomy wound 4 cm, extended through perineal body. Vaginal apex 4 cm inside the introitus.

External anal sphincter torn through about 70% of its thickness, remaining fibres intact. Internal anal sphincter pale and intact. Anal mucosa intact. No haematoma.

Procedure

Wound irrigated with normal saline. Internal sphincter checked again and found intact.

Torn ends of external anal sphincter grasped with Allis forceps with their fascial sheath. End-to-end repair with three mattress sutures of polydioxanone (PDS) 3-0. Suture ends cut short and buried under the superficial perineal muscles.

Vaginal mucosa: first stitch placed above the apex, then continuous non-locking polyglactin 910 rapid (Vicryl Rapide) 2-0 to the hymenal ring.

Perineal muscles closed in two continuous layers with Vicryl Rapide 2-0. Crown stitch taken to bring together the bulbospongiosus.

Perineal skin closed with continuous subcuticular Vicryl Rapide 2-0, knot tied inside the vagina behind the hymen.

Closure

Rectal examination after repair: sphincter tone felt, no suture through anal mucosa. Vaginal examination: no swab left, vagina not narrowed. No vaginal pack.

Uterus well contracted. Minimal bleeding.

End of procedure

Estimated blood loss during repair 100 ml.

Swab and needle count correct before and after repair, confirmed by scrub nurse.

No intra-operative complications. Specimens: none.

Shifted to postnatal ward in stable condition. Pulse 86/min, BP 112/70 mmHg.

Post-op orders

Pulse, BP, uterine tone and perineal bleeding every 30 min for 2 hours.

Foley catheter for 24 hours, then check voiding.

Oral amoxicillin-clavulanate and metronidazole for 5 days, dose as per unit policy.

Tab diclofenac 75 mg slow release 12-hourly regularly, with paracetamol as needed.

Syrup lactulose 15 ml twice daily for 10 days. Normal diet with plenty of fluids.

Perineal hygiene and sitz bath twice daily. Pelvic floor exercises when comfortable.

Degree of tear and repair explained to patient. Review in OASIS follow-up with Dr C. at 6 weeks.

Signature

Dr A., JR-2, OBGY. Reg. no. ________. 18/07/2026, 12:45. Countersigned Dr C.

Must document for this operation

  • That a rectal examination was done before the repair, and the result. Missing an anal sphincter tear is treated as negligence, and a documented PR examination is the proof that it was looked for.
  • The degree of tear using the 1st to 4th classification with 3a / 3b / 3c. The grade decides follow-up and the advice about mode of delivery in the next pregnancy.
  • Which sphincter was repaired, the method (end-to-end or overlap) and the suture. A surgeon doing a later secondary sphincter repair needs to know what was done first.
  • Rectal examination after repair. It shows that no stitch went through the anal mucosa, which could cause a fistula.
  • Swab and needle counts before and after, and whether a vaginal pack was left. A retained vaginal swab is a common cause of complaint and must be traceable.
  • Who repaired the tear and who supervised. OASIS repair by a trainee should be under supervision, and audits check this.
  • What was explained to the woman. She needs to know the degree of tear for follow-up and for her next pregnancy.

Common mistakes in these notes

  • Writing 'episiotomy sutured' with no degree of tear and no PR (per rectal) finding.
  • Calling a partial sphincter tear a 2nd degree tear.
  • Not recording whether the internal anal sphincter was seen.
  • Leaving out the swab count or a vaginal pack left in place.
  • Not writing the episiotomy side and the indication for it.

Sources

  • Arulkumaran S, ed. Best Practice in Labour and Delivery. 3rd ed. Cambridge University Press, Ch 19, Episiotomy and obstetric perineal trauma (Thakar R, Okeahialam NA, Sultan AH), pp. 230-241.
  • Handa VL, Van Le L, eds. Te Linde's Operative Gynecology. 13th ed. Wolters Kluwer; 2024, Ch 36, Repair of episiotomy and complex perineal lacerations, e-book PDF pp. 1915-1931.
  • Apuzzio JJ, Vintzileos AM, Berghella V, Alvarez-Perez JR, eds. Operative Obstetrics. 4th ed. CRC Press; 2017, Ch 27, Maternal birth injuries (Ginath S, Golan A): perineal tears, principles of repair, pp. 358-360.
  • Arulkumaran, Best Practice in Labour and Delivery, Ch 19, p. 236 (lidocaine 1% 20 ml for perineal infiltration) and p. 239 (diclofenac 75 mg slow release 12-hourly; lactulose 15 ml twice daily for 10 days; follow-up at 6-12 weeks).
  • Te Linde's Operative Gynecology 13e, Ch 36 (IV cephalosporin at OASIS repair; oral metronidazole and amoxicillin-clavulanate 5-7 days). Operative Obstetrics 4e, Ch 31, p. 423 (cefazolin 1 g).

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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