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O76 Two spontaneous deliveries in a woman with congenital indifference to pain due to SNC9A channelopathy
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Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S93–S396
O73 Vertical transmission of HCV in middle and low socio economic population of Karachi S. Aziz1 , N. Hossain1 , S. Aziz Karim3 , J. Rajper1 , N. Soomroo4 , R. Qamar1 . 1 Sarwar Zuberi Liver Centre, Dow University of Health Science, 2 Gynae Unit III, Civil Hospital Karachi, Dow University of Health Sciences, 3 Gynae & Obstetrics Abbasi Shaheed Hospital, Karachi Medical and Dental College Karachi, 4 Gynae Unit II, Civil Hospital Karachi, Dow University of Health Sciences Objective: To determine the rate of HCV vertical transmission in middle and low socio-economic population of Karachi. Place and Duration of study: This study was conducted for 42 months from September, 2005 to March2009. The study was jointly done at Sarwar Zuberi liver centre and department of Obstetrics and Gynecology, Dow University of Health Sciences, Civil Hospital Karachi and Karachi Medical and Dental College, Abbasi Shaheed hospital. Patient and Method: All the pregnant women seeking antenatal care were screened for Hepatitis C antibodies (Anti HCV) using fourth generation ELIZA technique. Those found positive were further investigated HCV RNA by PCR (qualitative) and ALT. Spouse of all patients were also screened for viral hepatitis. Those who were PCR positive were treated postnatally by interferon therapy after completion of six months lactation of babies. All new borns were advised Anti HCV at the age of 18 months and followed upto the age of 3 years and those who were affording were offered HCV RNA PCR. Past history of intravenous drug used, surgical and dental procedures, blood transfusions were obtained. Labour details were collected. Results: 829 mothers were Anti HCV positive out of which PCR result of 490 were available where as 397 (81%) were PCR positive. Out of 551 delivered patients, majority [384 (69.7%)] had delivered by spontaneous vaginal delivery (SVD), only 39 (7.1%) by forceps delivery, 72 (13.1%) had elective and 56 (10.2%) had emergency caesarian section. 51 had pre labour rupture of membrane. Data of 539 babies presented at different ages shows female gender 270 (51.1%) mean birth weight (kg) 2.95±0.56, height (cm) 54.1±7.9, OFC, 37±4 respectively Apgar score median at 1 and 5 min was 7 (range 2–10), 8 (range 4–10) respectively. 63 newborns/babies had low birth weight, 38 H/o NICU admission due to various reasons. Data of 100 babies is available to date only 2 babies were HCV-antibody positive. Subsequent HCV-RNA-PCR was negative. Conclusion: None of the babies of HCV-RNA-PCR positive mothers were infected to date.
and newborns with congenital anomalies. Details are recorded on a proforma, maternal blood is drawn for 25(OH) Vit D and at delivery, cord blood is analyzed for 25 (OH) Vit D. Sampling technique is non probability purposive, Women with normal levels of Vit D are taken as controls and those having below normal levels as cases. Dietary counseling and Vit D supplementation is offered to all Vit. D deficient mothers and babies. 2 months later, Vit D levels in mothers and infants will be re-measured. Data is being entered on SPSS 2 and analysis will be done using independent ’t’test and chi square test. Results: Out of 15 mother infant pairs enrolled so far, 14 mothers have Vit D deficiency (level <20 ng/ml) and all cord bloods show Vit D deficiency (<30 ng/ml). The remaining 85 samples will be collected in the next 3 months and detailed results will be presented. Conclusion: So far, Vit D deficiency predominates in the study population. Further results will highlight the magnitude of the maternal/neonatal problem and the relationship of predisposing factors, thus helping in the formulation of supplementation guidelines. O75 Effect of zone regimen on weight loss in polycystic ovarian syndrome women M. Azizpoor1 , F. Jamshidi, F. Golboni. 1 Islamic Azad University Sanandaj Branch Background: Abdominal obesity and hyperinsulinemia play a key role in the development of PCOs complication. Noninvasive method like weight loss and dietary regimen can be useful in decreasing of serum insulin and androgen to improve PCOs complication. Methods and Materials: This is an interventional study and we used simple sampling method to collect data. We designed our study with 24 PCOs women who were oligomenorohea, overweight, obese and didn’t have another hormonal disorder, then we advised zone diet with 1500 kcal/day and aerobics exercise (twice a week) and after each week nutrition 24 hour recall and after each month weight was recorded. Data was analyzed using the SPSS software version 14. Result: Average quality of weight in first month (1/45 kg), in second month (3/221) and third month (5/046) showed decreasing. The Wilcoxone test showed significant difference in weight loss at the third month compared the study began. (p = 0/004). Conclusion: zone diet is alternative medicine, non invasive, cheap and a safe method to improve weighty loss rate in women affected by polycystic ovarian syndrome.
O74 Vitamin D deficiency in pregnant women and their newborns as seen at a major tertiary care hospital of Karachi
O76 Two spontaneous deliveries in a woman with congenital indifference to pain due to SNC9A channelopathy
S. Aziz Karim1 , U. Nusrat2 , S. Aziz3 . 1 Karachi Medical and Dental College & Abbasi Shaheed Hospital, Karachi, 2 Abbasi Shaheed Hospital, Karachi, 3 Dow University of Health Sciences
B. Backe1 , J. Aasly2 . 1 Department of Laboratory medicine, Children’s and Women’s Health, Norwegian University of Science and Technology, and Department of Obstetrics and Gynaecology, St Olav University Hospital, Trondheim, Norway, 2 Department of Neuroscience, Norwegian University of Science and Technology, and Department of Neurology, St Olav University Hospital, Trondheim, Norway
Objectives: 1. To estimate frequency of vit. D deficiency amongst pregnant women. 2. To correlate maternal Vit. D deficiency with that of newborns (cord blood) at birth. 3. To assess the relationship of Vit. D deficiency with education, parity socioeconomic status, exposure to sunlight and diet. 4. To see effect of counselling and Vit. D supplementation on deficient mothers and babies at 2 months. Material and Methods: This is an observational analytical cohort study in which 100 consecutive women delivering at Abbasi Shaheed Hospital are being enrolled after informed consent. All age and socioeconomic groups, any gravidity, term and singleton pregnancies are included. Exclusions are preterm and twin pregnancy, women with systemic diseases, those taking Vit D
Sodium channel 9 alpha channelopathy is an extremely rare autosomal-recessive trait causing complete inability to sense pain, due to loss of function of a protein that is essential for the normal function of nociceptive sodium channels. The disorder was genetically mapped and described in 2006. Affected individuals have complete normal motor and sensory functions, but inability to sense pain. So far, only a handful of individuals have been described. To our knowledge, no deliveries have previously been reported in women with this disorder. In early childhood, our patient was diagnosed with indifference to pain but the nature of her disorder was unclear. These patients are susceptible to injuries, and our patient has sequelae from fractures
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S93–S396
and reduced vision due to corneal lesions, but is otherwise healthy. Following genetic testing her condition was diagnosed in 2007. Our patient had normal spontaneous term deliveries in 2002 and 2008. Both pregnancies were normal with spontaneous onset of labour at expected term. The primary problem was to recognise the onset of labour, as uterine contractions may pass unrecognised. During the second stage of labour, she feels a continuous strong urge to push and does not recognise the contractions. Patients with rare disorders are frequently misunderstood and distrusted. Our patient’s experiences from her encounters with the health services system confirm this. This disorder is a natural experiment pointing out a very interesting future direction for development of the perfect analgesic drug. O77 Effect of inseminated oocytes’ number and male and female ages in ICSI’s results comparing testicular sperm extraction and ejaculated sperm M. Da Broi, C. Teloken, ¨ A. Petracco, A. Arent, R. Azambuja, M. Badalotti Introduction: The intracytoplasmic sperm injection (ICSI) is the only alternative of biological paternity for men with nonobstructive azoospermia (NOA) submitted to TESA/TESE. Factors such female and male ages and inseminated oocytes’ number could have high negative effect on these cycles, which possibly have the sperm’s source influencing ICSI outcomes. Objective: the aim of the present study was to compare the effect of female age, male age and inseminated oocytes’ number between cycles with testicular sperm and ejaculate sperm. Methods and Results: We analyzed 142 ICSI cycles from couples with NOA who underwent to TESA/TESE. For the control group, ICSI cycles from severe oligospermic patients were matched. The fertilization rate was higher in the ejaculate group (EG: 72.2% ±21.6 e TG: 60.4±22.9; p < 0.001) than in the testis group. The female age just had significant difference in implantation rates in TESA/TESE cases (p < 0.05). The male age influenced negatively fertilization rate in ejaculate group (r = −0.268; p = 0.001). Increased pregnancy rate was associated with higher inseminated oocytes’ number (p < 0.05). Conclusion: We concluded that ICSI cycles of advanced age women, whose partners have NOA and need to be submitted to TESA/TESE, the only factor able to be altered is the inseminated oocytes’ number, which must be greater than three. O78 Improving the quality of care and satisfaction of obstetrical patients and their families at North York General Hospital C. Badeau Purpose: North York General Hospital (NYGH) located in Toronto CANADA. We are an advanced level II facility situated in a multicultural city with 6,000 deliveries per year. At NYGH we have reviewed overall patient/family satisfaction by developing multilingual satisfaction surveys, collecting the data, analyzing the data and sharing the results with staff. As a result of the data collected, specific improvements are being made and will be monitored on an ongoing basis. Results are displayed in patient care areas and discussed at a variety of council meetings. Innovations: Our multilingual survey to evaluate the perception of patients/families in the Labour and Delivery Unit utilizes specific indicators including; involvement in care, communication with healthcare providers, pain management, family centered care and overall safety. Survey questions were selected based on alignment with our organizational strategic themes and linkages to recent or current unit-based projects. Results: We have set a target goal of overall satisfaction with care at 95% (including good and excellent). To date we are pleased with our results however we have not reached or maintained these results.
S115
Nursing care-results vary from 82–88% related to understanding, respectful, communication and provision of education. Physician care-results vary from 71–79% related to communication, provision of education and respectful care. Lessons learned: 1. Communicate, Communicate! Get the word out to everyone 2. Important to have an effective process to ensure reflective response rate to surveys 3. Importance of a ‘non-critical’ approach to sharing the results with members of the health care team 4. Identify key areas of focus and ensure ‘profession specific’ buy in. O79 The long term outcome of third and fourth degree perineal tears P. Bagade, S. Mackenzie. Wansbeck General Hospital, Ashington, Northumberland, UK Introduction: Third and fourth-degree tears are associated with a risk of anal incontinence, an increasing rate of litigation but can be repaired with good outcome. To date, figures quoted reveal the prevalence of anal incontinence following primary repair to vary between 15% and 61%. We followed up one such cohort of patients prospectively to determine the long term outcome and quality of life. Aim: To study the long term outcome of third and fourth degree perineal tears in terms of symptoms, endoanal ultrasound and manometry findings, need for secondary repair and physiotherapy and any future obstetric event. Methods: It was a prospective study of 79 patients who had had third or fourth degree perineal tear during the index pregnancy and were repaired and followed-up with strict adherence to the RCOG guideline. All patients were offered a colorectal appointment with endoanal ultrasound and anal manometry at six months. The mean follow-up period was 24 months. Those patients who did not undergo colorectal evaluation were telephoned and enquiry was made regarding symptoms, reason for not keeping colorectal appointment and wish to remake an appointment with the colorectal surgeon. Results: The overall incidence of third and fourth degree perineal tear was found to be 2.41% with primiparity as the commonest risk factor (80.4%). The incidence of patients with symptoms was 12.6% (10/79), with 40% being noted to have grade IIIa tear. Anterior defects were seen in 13% and scarring in 52.7%. Four patients were found to have disrupted internal anal sphincters, but were completely asymptomatic. Poor squeeze and resting pressures on anal manometry were noted in five of the symptomatic patients, with the rest having normal pressures. Two patients required physiotherapy and one needed a secondary sphincter repair. Six patients had normal deliveries in their next pregnancy, with three having repeat third degree perineal tear. Four patients opted for caesarean section. Majority of the patients (96%) who failed to follow-up were asymptomatic, with three patients refusing to see the surgeon it was a male doctor. Four patients requested a colorectal appointment. Conclusion: Majority of women, after having a third/fourth degree perineal tear, are asymptomatic if the protocol for repair and followup is strictly adhered to. The need for appropriate assessment of grade of injury and repair by a trained obstetrician cannot be overemphasized. Failure to attend colorectal appointment at six months is often due to patients being asymptomatic. It is good practice to offer endoanal ultrasound/anal manometry to all patients, though it is not routinely recommended by thr RCOG. However, it needs a dedicated colorectal service and the costbenefit analysis in the long-term should be evaluated.
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S93–S396
O73 Vertical transmission of HCV in middle and low socio economic population of Karachi S. Aziz1 , N. Hossain1 , S. Aziz Karim3 , J. Rajper1 , N. Soomroo4 , R. Qamar1 . 1 Sarwar Zuberi Liver Centre, Dow University of Health Science, 2 Gynae Unit III, Civil Hospital Karachi, Dow University of Health Sciences, 3 Gynae & Obstetrics Abbasi Shaheed Hospital, Karachi Medical and Dental College Karachi, 4 Gynae Unit II, Civil Hospital Karachi, Dow University of Health Sciences Objective: To determine the rate of HCV vertical transmission in middle and low socio-economic population of Karachi. Place and Duration of study: This study was conducted for 42 months from September, 2005 to March2009. The study was jointly done at Sarwar Zuberi liver centre and department of Obstetrics and Gynecology, Dow University of Health Sciences, Civil Hospital Karachi and Karachi Medical and Dental College, Abbasi Shaheed hospital. Patient and Method: All the pregnant women seeking antenatal care were screened for Hepatitis C antibodies (Anti HCV) using fourth generation ELIZA technique. Those found positive were further investigated HCV RNA by PCR (qualitative) and ALT. Spouse of all patients were also screened for viral hepatitis. Those who were PCR positive were treated postnatally by interferon therapy after completion of six months lactation of babies. All new borns were advised Anti HCV at the age of 18 months and followed upto the age of 3 years and those who were affording were offered HCV RNA PCR. Past history of intravenous drug used, surgical and dental procedures, blood transfusions were obtained. Labour details were collected. Results: 829 mothers were Anti HCV positive out of which PCR result of 490 were available where as 397 (81%) were PCR positive. Out of 551 delivered patients, majority [384 (69.7%)] had delivered by spontaneous vaginal delivery (SVD), only 39 (7.1%) by forceps delivery, 72 (13.1%) had elective and 56 (10.2%) had emergency caesarian section. 51 had pre labour rupture of membrane. Data of 539 babies presented at different ages shows female gender 270 (51.1%) mean birth weight (kg) 2.95±0.56, height (cm) 54.1±7.9, OFC, 37±4 respectively Apgar score median at 1 and 5 min was 7 (range 2–10), 8 (range 4–10) respectively. 63 newborns/babies had low birth weight, 38 H/o NICU admission due to various reasons. Data of 100 babies is available to date only 2 babies were HCV-antibody positive. Subsequent HCV-RNA-PCR was negative. Conclusion: None of the babies of HCV-RNA-PCR positive mothers were infected to date.
and newborns with congenital anomalies. Details are recorded on a proforma, maternal blood is drawn for 25(OH) Vit D and at delivery, cord blood is analyzed for 25 (OH) Vit D. Sampling technique is non probability purposive, Women with normal levels of Vit D are taken as controls and those having below normal levels as cases. Dietary counseling and Vit D supplementation is offered to all Vit. D deficient mothers and babies. 2 months later, Vit D levels in mothers and infants will be re-measured. Data is being entered on SPSS 2 and analysis will be done using independent ’t’test and chi square test. Results: Out of 15 mother infant pairs enrolled so far, 14 mothers have Vit D deficiency (level <20 ng/ml) and all cord bloods show Vit D deficiency (<30 ng/ml). The remaining 85 samples will be collected in the next 3 months and detailed results will be presented. Conclusion: So far, Vit D deficiency predominates in the study population. Further results will highlight the magnitude of the maternal/neonatal problem and the relationship of predisposing factors, thus helping in the formulation of supplementation guidelines. O75 Effect of zone regimen on weight loss in polycystic ovarian syndrome women M. Azizpoor1 , F. Jamshidi, F. Golboni. 1 Islamic Azad University Sanandaj Branch Background: Abdominal obesity and hyperinsulinemia play a key role in the development of PCOs complication. Noninvasive method like weight loss and dietary regimen can be useful in decreasing of serum insulin and androgen to improve PCOs complication. Methods and Materials: This is an interventional study and we used simple sampling method to collect data. We designed our study with 24 PCOs women who were oligomenorohea, overweight, obese and didn’t have another hormonal disorder, then we advised zone diet with 1500 kcal/day and aerobics exercise (twice a week) and after each week nutrition 24 hour recall and after each month weight was recorded. Data was analyzed using the SPSS software version 14. Result: Average quality of weight in first month (1/45 kg), in second month (3/221) and third month (5/046) showed decreasing. The Wilcoxone test showed significant difference in weight loss at the third month compared the study began. (p = 0/004). Conclusion: zone diet is alternative medicine, non invasive, cheap and a safe method to improve weighty loss rate in women affected by polycystic ovarian syndrome.
O74 Vitamin D deficiency in pregnant women and their newborns as seen at a major tertiary care hospital of Karachi
O76 Two spontaneous deliveries in a woman with congenital indifference to pain due to SNC9A channelopathy
S. Aziz Karim1 , U. Nusrat2 , S. Aziz3 . 1 Karachi Medical and Dental College & Abbasi Shaheed Hospital, Karachi, 2 Abbasi Shaheed Hospital, Karachi, 3 Dow University of Health Sciences
B. Backe1 , J. Aasly2 . 1 Department of Laboratory medicine, Children’s and Women’s Health, Norwegian University of Science and Technology, and Department of Obstetrics and Gynaecology, St Olav University Hospital, Trondheim, Norway, 2 Department of Neuroscience, Norwegian University of Science and Technology, and Department of Neurology, St Olav University Hospital, Trondheim, Norway
Objectives: 1. To estimate frequency of vit. D deficiency amongst pregnant women. 2. To correlate maternal Vit. D deficiency with that of newborns (cord blood) at birth. 3. To assess the relationship of Vit. D deficiency with education, parity socioeconomic status, exposure to sunlight and diet. 4. To see effect of counselling and Vit. D supplementation on deficient mothers and babies at 2 months. Material and Methods: This is an observational analytical cohort study in which 100 consecutive women delivering at Abbasi Shaheed Hospital are being enrolled after informed consent. All age and socioeconomic groups, any gravidity, term and singleton pregnancies are included. Exclusions are preterm and twin pregnancy, women with systemic diseases, those taking Vit D
Sodium channel 9 alpha channelopathy is an extremely rare autosomal-recessive trait causing complete inability to sense pain, due to loss of function of a protein that is essential for the normal function of nociceptive sodium channels. The disorder was genetically mapped and described in 2006. Affected individuals have complete normal motor and sensory functions, but inability to sense pain. So far, only a handful of individuals have been described. To our knowledge, no deliveries have previously been reported in women with this disorder. In early childhood, our patient was diagnosed with indifference to pain but the nature of her disorder was unclear. These patients are susceptible to injuries, and our patient has sequelae from fractures
Free communication (oral) presentations / International Journal of Gynecology & Obstetrics 107S2 (2009) S93–S396
and reduced vision due to corneal lesions, but is otherwise healthy. Following genetic testing her condition was diagnosed in 2007. Our patient had normal spontaneous term deliveries in 2002 and 2008. Both pregnancies were normal with spontaneous onset of labour at expected term. The primary problem was to recognise the onset of labour, as uterine contractions may pass unrecognised. During the second stage of labour, she feels a continuous strong urge to push and does not recognise the contractions. Patients with rare disorders are frequently misunderstood and distrusted. Our patient’s experiences from her encounters with the health services system confirm this. This disorder is a natural experiment pointing out a very interesting future direction for development of the perfect analgesic drug. O77 Effect of inseminated oocytes’ number and male and female ages in ICSI’s results comparing testicular sperm extraction and ejaculated sperm M. Da Broi, C. Teloken, ¨ A. Petracco, A. Arent, R. Azambuja, M. Badalotti Introduction: The intracytoplasmic sperm injection (ICSI) is the only alternative of biological paternity for men with nonobstructive azoospermia (NOA) submitted to TESA/TESE. Factors such female and male ages and inseminated oocytes’ number could have high negative effect on these cycles, which possibly have the sperm’s source influencing ICSI outcomes. Objective: the aim of the present study was to compare the effect of female age, male age and inseminated oocytes’ number between cycles with testicular sperm and ejaculate sperm. Methods and Results: We analyzed 142 ICSI cycles from couples with NOA who underwent to TESA/TESE. For the control group, ICSI cycles from severe oligospermic patients were matched. The fertilization rate was higher in the ejaculate group (EG: 72.2% ±21.6 e TG: 60.4±22.9; p < 0.001) than in the testis group. The female age just had significant difference in implantation rates in TESA/TESE cases (p < 0.05). The male age influenced negatively fertilization rate in ejaculate group (r = −0.268; p = 0.001). Increased pregnancy rate was associated with higher inseminated oocytes’ number (p < 0.05). Conclusion: We concluded that ICSI cycles of advanced age women, whose partners have NOA and need to be submitted to TESA/TESE, the only factor able to be altered is the inseminated oocytes’ number, which must be greater than three. O78 Improving the quality of care and satisfaction of obstetrical patients and their families at North York General Hospital C. Badeau Purpose: North York General Hospital (NYGH) located in Toronto CANADA. We are an advanced level II facility situated in a multicultural city with 6,000 deliveries per year. At NYGH we have reviewed overall patient/family satisfaction by developing multilingual satisfaction surveys, collecting the data, analyzing the data and sharing the results with staff. As a result of the data collected, specific improvements are being made and will be monitored on an ongoing basis. Results are displayed in patient care areas and discussed at a variety of council meetings. Innovations: Our multilingual survey to evaluate the perception of patients/families in the Labour and Delivery Unit utilizes specific indicators including; involvement in care, communication with healthcare providers, pain management, family centered care and overall safety. Survey questions were selected based on alignment with our organizational strategic themes and linkages to recent or current unit-based projects. Results: We have set a target goal of overall satisfaction with care at 95% (including good and excellent). To date we are pleased with our results however we have not reached or maintained these results.
S115
Nursing care-results vary from 82–88% related to understanding, respectful, communication and provision of education. Physician care-results vary from 71–79% related to communication, provision of education and respectful care. Lessons learned: 1. Communicate, Communicate! Get the word out to everyone 2. Important to have an effective process to ensure reflective response rate to surveys 3. Importance of a ‘non-critical’ approach to sharing the results with members of the health care team 4. Identify key areas of focus and ensure ‘profession specific’ buy in. O79 The long term outcome of third and fourth degree perineal tears P. Bagade, S. Mackenzie. Wansbeck General Hospital, Ashington, Northumberland, UK Introduction: Third and fourth-degree tears are associated with a risk of anal incontinence, an increasing rate of litigation but can be repaired with good outcome. To date, figures quoted reveal the prevalence of anal incontinence following primary repair to vary between 15% and 61%. We followed up one such cohort of patients prospectively to determine the long term outcome and quality of life. Aim: To study the long term outcome of third and fourth degree perineal tears in terms of symptoms, endoanal ultrasound and manometry findings, need for secondary repair and physiotherapy and any future obstetric event. Methods: It was a prospective study of 79 patients who had had third or fourth degree perineal tear during the index pregnancy and were repaired and followed-up with strict adherence to the RCOG guideline. All patients were offered a colorectal appointment with endoanal ultrasound and anal manometry at six months. The mean follow-up period was 24 months. Those patients who did not undergo colorectal evaluation were telephoned and enquiry was made regarding symptoms, reason for not keeping colorectal appointment and wish to remake an appointment with the colorectal surgeon. Results: The overall incidence of third and fourth degree perineal tear was found to be 2.41% with primiparity as the commonest risk factor (80.4%). The incidence of patients with symptoms was 12.6% (10/79), with 40% being noted to have grade IIIa tear. Anterior defects were seen in 13% and scarring in 52.7%. Four patients were found to have disrupted internal anal sphincters, but were completely asymptomatic. Poor squeeze and resting pressures on anal manometry were noted in five of the symptomatic patients, with the rest having normal pressures. Two patients required physiotherapy and one needed a secondary sphincter repair. Six patients had normal deliveries in their next pregnancy, with three having repeat third degree perineal tear. Four patients opted for caesarean section. Majority of the patients (96%) who failed to follow-up were asymptomatic, with three patients refusing to see the surgeon it was a male doctor. Four patients requested a colorectal appointment. Conclusion: Majority of women, after having a third/fourth degree perineal tear, are asymptomatic if the protocol for repair and followup is strictly adhered to. The need for appropriate assessment of grade of injury and repair by a trained obstetrician cannot be overemphasized. Failure to attend colorectal appointment at six months is often due to patients being asymptomatic. It is good practice to offer endoanal ultrasound/anal manometry to all patients, though it is not routinely recommended by thr RCOG. However, it needs a dedicated colorectal service and the costbenefit analysis in the long-term should be evaluated.