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104 Maternity and Obstetrics 2020 | NMH Annual Rep t 2016 2017 2018 2019 2020 Appointments offered 433 440 391 375 310 Attendances 333 343 301 282 241 New referrals 236 (71%) 238 (69%) 213 (71%) 198 (70%) 175 (73%) Follow-ups 97 (29%) 105 (31%) 88 (29%) 84 (30%) 66 (27%) Did Not Attend 100 (23%) 97 (28%) 90 (23%) 93 (25%) 69 (22%) NMH OASIS Total 86 3a 28 (33%) 3b 30 (35%) 3c 4 (5%) 4th 3 (3%) Ungraded 21 (24%) SVD 54 (63%) Forceps 9 (10%) Ventouse 11 (13%) Forceps/Ventouse 12 (14%) Nulliparous 62 (72%) Episiotomy 35 (41%) Birthweight > 4gs 23 (27%) incidence of 1.7% of vaginal deliveries. Of the 86, an episiotomy had been performed in 41%, which is higher than the overall episiotomy rate of 31%. This suggests that episiotomy is over- represented within this population and may lend weight towards a school of thought that episiotomy is not protective for these tears and if anything may contribute to them. The majority of tears recorded were graded as 3a and 3b tears. Of note 21/86 (24%) were ungraded and this is unhelpful in terms of future management and prognosis. The grading of tears reflects the extent of damage to the sphincter. When this is not recorded, it may lead to underestimation of the difficulties the patient may experience. 62/86 (72%) were nulliparous, reinforcing all published data that shows first vaginal delivery holds the greatest risk. While such tears are not overly common, neither are they a rare event. We strongly advocate that the possibility of such tears should be explained to all women attending for antenatal care. Indeed, this is likely to become a legal imperative in the future and better that we include it in our routine information provision than it be thrust upon us unprepared. 27% of babies delivered in this group of women weighed greater than 4 kgs compared with the general hospital population of 18%. 39% were associated with instrumental delivery compared with 18% in the general hospital population. These figures confirm that the risk factors associated with anal sphincter tears are nulliparity, large birthweight and instrumental delivery. This combination should heighten our suspicion for the occurrence of such a tear and careful inspection of the perineum performed to outrule it. The management of these tears and the documentation of the management of these tears are extremely important for doctors and midwives alike. Clear recording of the grade of tear and the performance of a rectal examination after delivery and after the repair are essential and standards of recording must be adhered to in the electronic chart, where proformas and diagrams are less available than previously. Reassuringly the vast majority of patients attending the Perineal Clinic for assessment are asymptomatic or have mild symptoms of faecal incontinence. This is a yearly finding and it is evidence that the quality of repairs being undertaken is good. Those women who have significant symptoms are referred for physiotherapy or, in severe cases, for a colorectal review. The documented numbers referred to physiotherapy, in particular, belies the huge amount of work our Physiotherapy colleagues put into these patients in the months before they arrive to our clinic. The small numbers, who require further physiotherapy, after seeing us, is a testament to their hard work and that of the women themselves. a smooth referral pathway from the postnatal wards to the Postnatal (Poppy) clinic to the Perineal clinic is essential.