Authors: Ghadeer Alenezi , Meshaal Alenezi , Omar Yousef , Ahmed Osman , Nabil Riyad , Mohammad AlJasmi

Abstract

Background: 
Episiotomy, a perineal incision during labor to facilitate vaginal delivery, is now selectively used in instrumental births like vacuum-assisted procedures to lessen severe perineal trauma, though it risks rare extensions into the rectal wall. Such full-thickness rectal tears, classified as fourth-degree injuries, occur more commonly with midline incisions and can lead to fecal incontinence, pain, or sepsis if not addressed swiftly. 
Case Presentation:
A 32-year-old woman with an unremarkable prenatal history underwent vacuum-assisted vaginal delivery complicated by a mediolateral episiotomy extending to a full-thickness anterior rectal tear 10 cm from the anal verge. She presented hemodynamically stable with perineal pain, bleeding, and stool spillage; digital exam confirmed the injury without soiling. Under anesthesia, a triple-layer closure was used with absorbable sutures for mucosa, muscularis, and serosa, avoiding colostomy. Broad-spectrum antibiotics continued for two weeks, with nil per os for 48 hours followed by enteral feeding. Postoperative monitoring showed no infection or incontinence; discharge occurred on day 10. Follow-up MRIs at six weeks and six months revealed intact rectal integrity and normal sphincter function, with pelvic exercises aiding recovery.
Conclusion:
This case demonstrates that timely recognition and layered repair of rectal tears after episiotomy can achieve excellent functional outcomes without the need for diversion colostomy.

Keywords: Episiotomy, rectal tear, fourth-degree perineal injury, vacuum-assisted delivery, triple-layer repair, case report.