Layered primary closure of a fourth-degree obstetric laceration

(A) The anal mucosa is first closed with a running or interrupted layer of a 4-0 delayed absorbable suture.
(B) The retracted ends of the internal anal sphincter are reunited with a running layer of a 3-0 delayed absorbable suture.
(C) An end-to-end anastomosis of the EAS is accomplished using four or five interrupted 2-0 delayed absorbable sutures placed through the capsule of the EAS.
(D) The rectovaginal fascia and puborectalis fibers are approximated with a running 2-0 delayed absorbable suture.