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Calendar Dates

8/28/2018 » 8/31/2018

9/26/2018 » 9/28/2018
ESCP 2018 Scientific and Annual Meeting

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Prevention and Repair Of perineal Trauma Episiotomy through Coordinated Training "PROTECT"

Chairs: Dr. Ranee Thakar and Dr. Abdul Sultan

Steering Group:
Jan Willem De Leeuw (Netherlands)
Natarajan Rajmaheshwari (India)
Module contributors:
Catherine Matthews
Jan Willem De Leeuw
Zeelha Abdool
Abdul Sultan
Ranee Thakar

To promote knowledge of obstetricians and midwives worldwide in the management of perineal trauma and episiotomy through structured training with a view to minimising pelvic floor and perineal morbidity associated with childbirth.


To minimise pelvic floor and perineal morbidity associated with childbirth.

  • NOTE: Participation in this program is open to IUGA members and non-members.

Perineal repair after childbirth affects millions of women worldwide. In the United Kingdom approximately 85% of women sustain some form of perineal trauma during vaginal delivery and of these 69% will require suturing [1]. The prevalence of perineal trauma varies as it is dependent on obstetric practice including rates and types of episiotomy [2].

Obstetric anal sphincter injuries (OASIS) occur in 1.7% (2.9% in primiparae) [3] of woman in centers where mediolateral episiotomies are practised compared to 12% [4] to 19% [5] (19% in primiparae) in centers practising midline episiotomy. Unfortunately it has been shown previously that up to half of OASIS are not recognised by the accoucher [6,7]. Inadequate training of doctors and midwives in perineal and anal sphincter anatomy [8] is believed to be a major contributing factor. In a survey of 75 doctors and 75 midwives in the United Kingdom, Sultan et al demonstrated inconsistencies in the classification of perineal trauma, as one third of doctors were classifying third degree tears as second degree tears [8]. Most trainee doctors admitted that their training in recognising (84%) and repairing (94%) OASIS was poor. Furthermore in another study 64% of consultants reported unsatisfactory or no training in the management of OASIS [9]. McLennan et al also raised concern about training in the USA. They surveyed 1,177 fourth year residents and found that the majority of residents had received no formal training in pelvic floor anatomy, episiotomy or perineal repair, and supervision during perineal repair was limited [10].

However despite recognition and primary repair of acute OASIS, 39 to 61% [11,12,13] have symptoms of anal incontinence and 92% have persistent anal sphincter defects on ultrasound [14] within 3 months of delivery. The morbidity associated with perineal trauma depends on the extent of perineal damage, technique and materials used for suturing and the skill of the person performing the procedure. It is therefore important that practitioners ensure that procedures such as perineal repair, are evidence-based in order to provide care that is effective, appropriate and cost-efficient [15]. Unfortunately, there is no standardised approach to prevention and repair of perineal trauma and episiotomy.

Based on this background, in 2000, Sultan and Thakar developed the first international hands-on course for repair and diagnosis of perineal and obstetric anal sphincter trauma (16,17). Two surveys of midwives and doctors conducted a few months after attending the course have indicated that there was an improvement in diagnosis and repair of perineal and anal sphincter trauma [16,17], Based on this experience we would like to develop a worldwide program to improve knowledge in this area.


1. Complete and pass theoretical Test Modules on the IUGA website.
2. Attend the OASIS hands-on repair workshop at the IUGA Annual Meeting or one conducted by a PROTECT trained trainer within 2 years of step 1.
3. Attend the IUGA sponsored PROTECT Train the Trainers session within 2 years of step 2. (Training also includes teaching of episiotomy repair
*4. Upload personal videos or photographs to IUGA Website (PROTECT area) within 2 years of Step 3. Important steps that need to be included can be found in the chart below. (Demonstrate live surgical technique)
5. Following successful completion of these 4 steps, participants will be awarded a certificate of successful completion of the PROTECT train the trainer program.
*NOTE: Those submitting videos or photography must secure consent forms from the subject patients and should use the forms that are typically used within their own institution.



Demonstration of per rectal examination before repair to exclude OASIS or button hole tear

Demonstrating classification of tear

Identifying apex of vaginal laceration

Demonstration of per rectal examination before repair

Technique of repair i.e Continuous technique for all 3 layers

Identification of EAS and IAS (if torn)

Suture material - Vicryl rapide (explanation if not used)

Suturing mucosa if 4th degree tear (interrupted or continuous)

Good apposition of muscle and skin

Repair of IAS* (end-to-end)

Demonstration of per rectal examination after repair

Repair of EAS** – End-to-end (Overlap only acceptable if complete 3b or greater)

Quality of video for teaching purposes

Demonstration of per rectal examination after repair

Appropriate suture material (PDS 3-0 or Vicryl 2-0 for sphincters)

Quality of video for teaching purposes

*IAS = internal anal sphincter
**EAS = External anal sphincter

Members who have successfuly completed the program

  • Dr. Suvit Bunyavejchevin
    Bangkok, Thailand - November 2014
  • Dr. Emmanuel Karantanis, FRANZCOG PhD CU
    Sydney, Australia - July 2014
  • Dr. Natarajan Rajamaheswari, M,D., DGO., MCh.
    Chennai, India - June 2013
  • Dr. Roger Capmartin Salinas, M.D.
    Bogota, Colombia - September 2013
  • Dr. Rachid Alfred El Haddad, M.D.
    Prague, Czech Republic - September 2013
  • Dr. Louise Jane Tomlinson, MBCHB FRANZCOG
    Auckland, New Zealand - September 2013
  • Dr. Jacqueline Smalldridge, MBBS, FRCOG, FRANZCOG
    Auckland, New Zealand - May 2014
  • Farah Lone Consultant and Lead Subspecialist Urogynaecologist, Royal Cornwall Hospital
    United Kingdom - March 2016
  • Lucas Schreiner, MD, PhD
    Porto Alegre, Brazil - April 2016
  • Dr. Ng Kwok Wen Roy
    Singapore – June 2016
  • Ng Kai Lyn, MBBS (Spore), MMed O&G (Spore), MRCOG (UK)
    Singapore – June 2016
  • Mrs. Nadia Bhal, MBChB, MRCOG, PGDip.MedEd,PGCert.USS, FHEA
    United Kingdom – July 2016

  • Dr. Edna Cortes
    Mexico - August 2016
  • Dr Jeslyn Wong
    Singapore – November 2016

PROTECT Disclaimer:
I understand that completion of this IUGA sponsored educational activity in no way implies that IUGA has endorsed, certified, qualified or licensed me, or other health care professionals I will teach or supervise. The IUGA logo and the PROTECT name may not be used in the promotion of educational activities organized outside the framework of IUGA's annual meetings, regional symposia, exchange programs, online courses and other IUGA sponsored educational activities. I may, after completing all PROTECT modules, signify myself as a 'PROTECT trained trainer'. All courses I organize, supervise or teach using this signifier should be offered without profit, and be reported to the IUGA office. I agree to audit change in practice by ensuring delegates complete a PROTECT pre-course questionnaire which will be repeated after 3 months.

View References

1. McCandlish R, Bowler U, van Asten H, Berridge G, Winter C, Sames L, et al. A randomised controlled trial of care of the perineum during second stage of normal labour. BJOG 1998;105:1262-72.

2. Royal College of Obstetricians and Gynaecologists. Methods and materials used in perineal repair. Guideline No. 23. London: RCOG press 2004.

3. Harkin R, Fitzpatrick M, O’Connell PR, O’Herlihy C. Anal sphincter disruption at vaginal delivery: Is recurrence predictable? Eur J Obstet Gynaecol 1999;106:318-23.

4. Coats PM, Chan KK, Wilkins M, Beard RJ. A comparison between midline and mediolateral episiotomies. BJOG 1980;87:408-12.

5. Peleg D, Kennedy CM, Merril D, Zlatnik FJ. Risk of repetition of a severe perineal laceration. Obstet Gynecol 1999;93:1021-4.

6. Groom KM, Paterson-Brown S. Can we improve on the diagnosis of third degree tears? Eur J Obstet Gynecol Reprod Biol 2002;101:19-21.

7. Andrews V, Sultan AH, Thakar R, Jones PW. Occult anal sphincter injuries – myth or reality? BJOG 2006;113:195-200.

8. Sultan AH, Kamm MA, Hudson CN. Obstetric perineal trauma: an audit of training. J Obstet Gynaecol 1995;15:19-23.

9. Fernando R, Sultan AH, Radley S, Jones PW, Johanson RB. Management of obstetric anal sphincter injury: A systematic review and national practice survey. BMC Health Services Research 2002;2:9.

10. Mc Lennan MT, Melick CF, Clancy SL, Artal R. Episiotomy and perineal repair. J Reprod Med 2002;47:1025 –1030.

11. Sultan AH, Thakar R. Third and fourth degree tears. In: Sultan AH, Thakar R, Fenner DE, eds. Perineal and anal sphincter trauma. Springer, London. 2007. pp 33-51.

12. Sultan AH, Thakar R. Lower genital tract and anal sphincter trauma. Best Pract Res Clin Obstet Gynaecol 2002;16:99-115.

13. Pinta TM, Kylanpaa M, Salmi TK, Teramo KAW, Luukkonen PS. Primary sphincter repair: Are the results of the operation good enough? Dis Colon Rectum 2004;47:18-23.

14. Fitzpatrick M, Cassidy M, O’Connell R, O’Herlihy C. Experience with an obstetric perineal clinic. Eur J Obstet Gynecol Reprod Biol 2002;100:199-203.

15. Sultan AH, Kettle C. Diagnosis of perineal trauma. In: Sultan AH, Thakar R, Fenner DE, eds. Perineal and anal sphincter trauma. Springer, London. 2007. pp 13-19.

16. Andrews V, Thakar R, Sultan AH, Kettle C. Can hands-on perineal repair workshops change clinical practice? Br J Midwifery 2004;13: 562-565.
Andrews V, Thakar R, Sultan AH. Structured hands-on training in repair of obstetric anal sphincter injuries (OASIS): an audit of clinical practice. Int Urogynecol J 2009;20:193-199

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