Repair of perineal and other lacerations

associated with childbirth

Author: Marc R Toglia, MD
Section Editor: Vincenzo Berghella, MD
Deputy Editor: Kristen Eckler, MD, FACOG

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.

Literature review current through: Aug 2019. | This topic last updated: Jun 05, 2019.

INTRODUCTION

After vaginal delivery, the vagina, perineum, and anorectum are examined to
identify and repair significant injuries. In particular, occult injury to the anal
sphincter complex may occur at the time of an otherwise uncomplicated delivery
and, if neglected, can contribute to anal and fecal incontinence [1]. Even when
recognized and repaired, persistent sphincter dysfunction is considered to be the
most common cause of postpartum anal incontinence [2,3].

Evaluation and repair of perineal and other obstetric lacerations, such as labial,
sulcal, and periurethral lacerations, will be reviewed here. Repair of episiotomy,
although relative uncommonly performed, is also discussed. Postpartum perineal
care, management of complications, and the evaluation and management of
traumatic vaginal lacerations are discussed separately.

● (See "Postpartum perineal care and management of complications".)

● (See "Evaluation and management of female lower genital tract trauma",

section on 'Vagina'.)
ANATOMY

The muscles of the female pelvic floor and perineum are shown in the following
figures (figure 1 and figure 2). The perineal body is the central point of the
perineum and separates the urogenital triangle from the anal triangle. Within the
perineal body are the interlacing fibers of the superficial transverse perineal
muscles, bulbocavernosus, and fibers of the external anal sphincter (EAS). The
anorectal sphincter complex is comprised of two structures with different, but
overlapping, roles for maintaining continence (figure 3). The EAS is a thick, circular,
predominantly striated muscle that surrounds the anal orifice, and is responsible
for continence of solid and liquid stool, as well as flatus, both at rest and at times
of rectal distension. The internal anal sphincter (IAS) lies between the external
sphincter and the anal canal and represents a thin condensation of the
longitudinal smooth muscle fibers of the colon submucosa (figure 3). The IAS
extends more than a centimeter above the cephalad margin of the external
sphincter [4]. It is entirely under involuntary control and contributes to maintaining
anal continence at rest [4]. The puborectalis portion of the levator ani complex
also plays an important role in continence of solid stool. The EAS is innervated by
the pudendal nerve, which may be susceptible to injury during delivery.

CLASSIFICATION

In 1999, Sultan proposed refining the traditional classification system for obstetric
perineal lacerations [5]. The revised system provided a subclassification for third-
degree lacerations [6]:

● First-degree lacerations involve injury to the skin and subcutaneous tissue of

the perineum and vaginal epithelium only. The perineal muscles remain intact.

● Second-degree lacerations extend into the fascia and musculature of the

perineal body, which includes the deep and superficial transverse perineal
 muscles and fibers of the pubococcygeus and bulbocavernosus muscles. The
anal sphincter muscles remain intact.

● Third-degree lacerations extend through the fascia and musculature of the

perineal body and involve some or all of the fibers of the external anal
sphincter (EAS) and/or the internal anal sphincter (IAS).

Third-degree lacerations are subclassified as follows:

• 3a – <50 percent of EAS thickness is torn

• 3b – >50 percent of EAS thickness is torn

• 3c – Both EAS and IAS are torn

● Fourth-degree lacerations involve the perineal structures, EAS, IAS, and the
rectal mucosa.

The above classification system represents a significant improvement over older

systems, as it takes the IAS into account. The new classification has been adopted
by the Royal College of Obstetricians and Gynaecologists as well as the American
College of Obstetricians and Gynecologists [6,7]. It has also been acknowledged
by the Agency of Healthcare Research and Quality.

PREOPERATIVE PREPARATION

The key initial task is to assess both the extent of bleeding and injury to the
perineum, vagina, and anorectum [4]. This assessment should include both visual
inspection and palpation. Adequate exposure, lighting, and analgesia are essential
for a thorough examination. Some studies have suggested that a significant
number of sphincter injuries go undetected at the time of delivery [8].

A thorough visual inspection of the distal vagina, perineum and anorectum should
be performed following a vaginal delivery to identify and evaluate the extent of a
vaginal tear. The apex of the vaginal laceration should always be identified. The
clinician can place four fingers into the perineal laceration, and then spread the
fingers to increase visualization of the laceration apex. After inspecting the vagina,
a rectal examination is performed to exclude injury to the anorectal mucosa and
anal sphincter. Palpation is important to determine whether the rectal mucosa and
anal sphincter are intact. The rectovaginal examination is accomplished by placing
an index finger in the rectum and the thumb over the anal sphincter and using a
pill-rolling motion to assess the sphincter. Of note, the anal sphincter may be
disrupted by shearing forces produced by descent of the fetal head, and this can
occur in women with an otherwise intact perineum [2,9].

The surgeon should also make sure that the uterus is properly contracted
following the delivery of the placenta. Although delivery of the placenta is not
mandatory before beginning the repair, sutures can be disrupted by manual
removal of the placenta and other intrauterine manipulations if such interventions
become necessary after the perineum has been reapproximated. In general, we
suggest placental delivery before repair of the laceration unless the tear needs
immediate attention because of profuse bleeding.

Lacerations can usually be repaired in the delivery room with the patient in the
lithotomy position; however, third- and fourth-degree lacerations may require an
operating room for ready access to appropriate equipment and lighting,
anesthesia support, and maintenance of aseptic conditions.

If feces are obviously present, it should be removed and the tissues irrigated
thoroughly. We perform a gentle scrub with chlorhexidine under such conditions
[10].

Perineal shaving is unnecessary [11].

Antibiotics — Antibiotics are unnecessary for repair of first- and second-degree

lacerations. While a trial in the United Kingdom reported a reduction in episiotomy
infections following a single dose of intravenous antibiotics in the setting of
operative vaginal delivery, major study limitations prevent universal adoption of
this approach [12]. This trial is reviewed in detail in a related topic. (See "Operative
vaginal delivery", section on 'Antibiotics'.)

For repair of a third- or fourth-degree obstetric laceration, we suggest a single

dose of a broad spectrum antibiotic (second generation cephalosporin [eg,
cefotetan or cefoxitin; clindamycin if beta lactam allergy] (table 1)), given prior to
the repair, based upon results of a single trial demonstrating that antibiotic
administration resulted in a marked reduction in wound complications (eg,
dehiscence) [13-15]. Although this trial had a high rate of loss to follow-up, it is the
best available data on which to base a recommendation, and antibiotic prophylaxis
is a low-cost/low-risk intervention that could prevent complications with
significant morbidity. The Royal College of Obstetricians and Gynaecologists and
the American College of Obstetricians and Gynecologists support the use of broad
spectrum antibiotics to reduce the incidence of postoperative infection for third-
and fourth-degree lacerations [7,15].

Independent from antibiotic use, if the wound is contaminated by gross fecal

spillage, then local cleansing and irrigation should also be performed.

Anesthesia — The level of anesthesia should be adequate for the surgical repair. If

the patient had an epidural catheter placed for labor and delivery
analgesia/anesthesia, it can be used to provide anesthesia for the repair.

For repair of third- or fourth-degree lacerations, re-dosing may be needed prior to

beginning the surgical repair as additional muscle relaxation is often necessary to
relax the contracted anal sphincter, retrieve the retracted ends, and bring them
back together without tension. A bilateral pudendal block with or without a local
field block, a saddle block, or general anesthesia are alternatives if there is no
preexisting analgesia.
For repair of first- and second-degree lacerations, pudendal nerve block or local
field block is generally adequate if there is no preexisting anesthesia. In patients
with adequate epidural anesthesia, local anesthesia has been used to reduce
postpartum analgesia requirements, but a randomized trial found neither
ropivacaine nor lidocaine was more effective than saline in the first 24 hours after
delivery [16]. (See "Pudendal and paracervical block".)

CHOICE OF SUTURE

The choice of sutures for repair of perineal lacerations is largely one of personal
preference. In most institutions, chromic catgut has been largely replaced by
synthetic, delayed-absorbable materials, such as polyglactin 910 and polyglycolic
acid, as use of chromic catgut appears to be associated with more postpartum
discomfort [17-19]. A 2010 systematic review of randomized trials concluded that,
compared with catgut (plain, chromic, glycerol impregnated), standard absorbable
synthetic suture for perineal repair following childbirth was associated with less
pain in the first three days postpartum (odds ratio [OR] 0.83, 95% CI 0.76-0.90),
less need for analgesia in the first 10 days postpartum (OR 0.71, 95% CI 0.59-
0.87), and less resuturing for dehiscence (OR 0.25, 95% CI 0.08-0.74), but no
difference in long-term pain or dyspareunia [19]. However, the need for removal of
unabsorbed synthetic suture material was almost twice as common; this problem
is significantly diminished by using rapidly-absorbable synthetic sutures [19].
When catgut and glycerol-impregnated catgut were compared, results were similar
for most outcomes, although the latter was associated with more short-term pain.

Rapid absorption (average 42 days) or standard absorption (average 63 days)

braided polyglactin 910 sutures and monofilament sutures (eg, poliglecaprone 25,
glycomer 631) in a variety of sizes are usually readily available on most Labor and
Delivery Units. In general, one should use the smallest diameter suture that has
adequate tensile and knot strength for the task; 2/0 and 3/0 sutures are suitable
for soft tissue repair. Monofilament sutures may cause less tissue reaction than
braided sutures, and thus may minimize discomfort and infection risk. However,
this must be balanced against the significantly longer absorption time, and quicker
loss of tensile strength that is characteristic of monofilament sutures. In general,
the use of polyglactin 910 suture sizes 2/0 and 3/0 is a reasonable choice for
most routine repair of perineal and vaginal lacerations. Rapid absorption
polyglactin 910 appears to be associated with reduced perineal pain, including a
reduction in superficial dyspareunia, at three months postpartum, as well as a
significant reduction in the need for suture removal up to three months
postpartum [20].

SURGICAL TECHNIQUE

The sutures described in the text represent the author's preferences.

Third- and fourth-degree tears — Third- or fourth-degree tears, if present, should

be repaired first. To help with exposure, a vaginal pack can be used to prevent
uterine bleeding from obscuring the surgical field and a self-retaining retractor,
such as a Gelpie or Weitlander, is helpful if an assistant is not readily available.
(See "Pharmacologic management of pain during labor and delivery".)

The aim of reconstructive surgery is to restore the continuity of both the external
and internal anal sphincters [4]. In addition, a thick perineal body and rectovaginal
septum should be created to provide muscular and structural support in the thin
area between the anterior anorectum and vagina. Proper reconstruction will also
result in lengthening of the anal canal and restoration of a functional high pressure
zone within it.

The goal of sphincter repair (either primary or secondary) is reconstruction of a

muscular cylinder that is at least 2 cm thick and 3 cm long [4,21]. This results in an
anatomically and functionally correct anal canal. Simple plication of the severed
ends of the external anal sphincter (EAS) with two or three interrupted, absorbable
sutures is commonly performed, but may be inadequate since this approach is
frequently associated with persistent sphincter defects and symptomatology [22].
Meticulous hemostasis and anatomic reapproximation of all disrupted tissue
layers are the key principles for preventing complications and restoring fecal
competence.

The optimal repair consists of a multilayer closure (figure 4):

● If a fourth-degree laceration is present, we repair the torn anal mucosa using

a continuous (nonlocking) 3/0 or 4/0 braided polyglactin on a tapered needle;
a monofilament suture such as poliglecaprone 25 is also acceptable.
Interrupted sutures can be used, but result in a larger quantity of foreign body
because of multiple knots.

● The internal anal sphincter should be properly identified and repaired as a

separate layer [4,23]. It often retracts laterally and superiorly and appears as
thickened, pale pink, shiny tissue just above the anal mucosa that some
clinicians refer to as perirectal fascia. Reapproximation of this layer is
important for the strength and integrity of the repair and for achieving anal
continence [24]. We use a continuous 3/0 polyglactin suture or 3/0
monofilament synthetic suture (eg, poliglecaprone 25) on a tapered needle for
this repair.

● The external sphincter is then identified and repaired. The repair begins by
identifying and grasping the two severed ends of the dark red EAS muscle
with Allis clamps. It may be necessary to push the Allis clamp deep into the
surrounding connective tissue to locate the sphincter since one or both ends
typically retract when it ruptures.

● The repair consists of either an end-to-end or overlapping plication of the

disrupted EAS and its capsule using interrupted or figure-of-eight sutures; 2/0
or 3/0 polydioxanone or 2/0 polyglactin suture on a cut tapered 1 or 2 needle
are reasonable suture choices (figure 5 and figure 6). We recommend not
using chromic suture for repair of the anal sphincter.

We typically place at least four or five interrupted sutures, but we are not
opposed to placing more if it is possible. It may be necessary to sharply
mobilize either sphincter end to achieve a better anastomosis and minimize
tension.

In a 2013 meta-analysis of randomized trials comparing the overlap and end-

to-end techniques, the overlap technique was associated with a nonstatistical
lower risk of one or more anal incontinence symptoms (RR 0.90, 95% CI 0.68-
1.17; 5 trials, n = 2221), but this was primarily in the first 12 months after
delivery and disappeared at 24 and 36 months [25]. There were no significant
differences between procedures in perineal pain, dyspareunia, or quality of life
at 6 weeks, 3 months, 6 months, and 12 months after repair. Limitations of
these trials were the inclusion of multiparous women and women with partial
tears, and differences in measurement of outcomes and surgical experience.

Subsequent to this meta-analysis, a randomized trial of the overlap and end-

to-end techniques limited to primiparous women with complete tears reported
that at 6 and 12 months postpartum the overlap technique was associated
with a higher rate of flatal incontinence (6 months: 61 versus 39 percent, p =
0.005; 12 months: 56 versus 31 percent, p = 0.12) and a trend toward a higher
rate of fecal incontinence (6 months: 15 versus 8 percent, p>.2; 12 months 16
versus 6 percent, p = 0.17) [26]. Another randomized trial of the two
techniques in primiparous and multiparous women with either partial or
complete tears found the overlap repair was not superior to the end-to-end
technique with respect to fecal incontinence at 12 months [27]. Others have
observed that the incidence of residual anal sphincter damage on endoanal
ultrasonography is similar for the two techniques [3,27].
 In the absence of clear evidence favoring one technique over the other, the
choice of overlap or end-to-end repair should be based on the surgeon’s
preference and experience.

After the sphincter repair is completed, the next task is to rebuild the distal
rectovaginal septum and perineal body. This layer helps to maintain the proper
spatial distance between the anus and vagina, and may prevent suture erosion
from the deeper layers. Another goal of this layer is to help take the tension off of
the underlying sphincter repair. We typically use an interrupted 2/0 polyglactin
suture on a cutting needle.

The end result of the surgical repair should be reconstruction of an adequate

perineal body, a thickened rectovaginal septum, and an intact cylindrical sphincter
complex that is approximately 2 cm wide and 3 cm long. The anus should easily
admit one finger following the procedure, although skeletal muscle paralysis
induced by anesthesia may temporarily weaken the tone of the anal canal.

The remainder of the repair is as described below for first- and second-degree
tears (figure 7).

First- and second-degree tears — If there is no third- or fourth-degree extension,

vaginal lacerations with extensions into the perineal body have traditionally been
repaired in layers using a series of continuous suture techniques. The repair
begins at the apex of the vaginal laceration and ends with a subcuticular closure
that terminates just above the level of the posterior fourchette.

Continuous nonlocking suture techniques for repair of the vagina, perineal

muscles, and skin appear to be preferable to traditional interrupted methods. The
continuous technique is faster and uses the smallest amount of suture material;
the only advantage of an intermittent technique is that if one suture breaks, there
are others to hold the repair in place; however, this is probably not critical in the
perineum. A continuous subcuticular closure of the perineal skin is preferred to
interrupted transcutaneous stitches, as a meta-analysis of randomized trials of
continuous versus interrupted suture techniques for perineal closure found that
the continuous suturing technique was associated with [28]:

● Less pain for up to 10 days postpartum (RR 0.76, 95% CI 0.66-0.88; nine
trials), especially when used for all layers.

● Less need for analgesia for up to 10 days postpartum (RR 0.70, 95% CI 0.59-
0.84).

● Less need for suture removal (RR 0.56, 95% CI 0.32-0.98), but no significant
differences in the need for resuturing of wounds or long-term pain.

● A trend in reduction of dyspareunia up to three months postpartum (RR 0.86,

95% CI 0.67-1.09).

The differences in pain between the two techniques may be due to increased
suture tension with interrupted stitches, which may lead to edema and pain. With
continuous sutures, the tension is transferred along the length of a single suture
and the subcuticular layer is placed well below the skin surface, thus avoiding the
nerve endings.

The vaginal epithelium is reapproximated first, and should include any underlying
divided tissue in order to build up the rectovaginal septum. Care should be taken
to identify and incorporate the apex of the episiotomy in the repair. If the apex of
the episiotomy extends out of the field of vision, a suture can be placed below the
apex and the suture tail used as a purchase to pull the apex into view. An
absorbable suture (typically a 2/0 polyglactin 910) is usually used for the repair.
The anatomical landmarks, such as the vermilion border and hymenal ring, should
be identified and reapproximated. Theoretically, use of a locking stitch will prevent
pulling the suture too tight and shortening the vagina; we do not use a locking
stitch, as there is no evidence to support this theory. We prefer to close with a
loose, continuous nonlocking technique to reduce the risk of narrowing the vagina,
and make sure that the sutures are not placed too wide of the edge.

Following closure of the vaginal portion of the laceration down to the level of the
hymenal ring, the perineal body and bulbocavernosus muscle are then
reapproximated. The same suture is usually passed through the vaginal layer
above through to the deep perineal layer, in what is commonly referred to as the
"transition stitch." The suture is then placed through the superficial
bulbocavernosus muscle on each side in a "V" configuration, commonly referred to
as the "crown" stitch. Some surgeons prefer to close this layer with three to four
interrupted sutures to approximate the deep and superficial perineal muscles. The
critical point is to realign the muscles so that the skin edges can be
reapproximated with minimal tension.

The suture is next passed through the deep perineal tissue from side to side in a
vertical direction until the edge of the perineal tear is reached. At this point, the
suture is brought back up in the reverse direction along the perineal body in a
subcuticular manner and tied at, or just inside, the introitus with a loop knot.

Some authors have proposed leaving the perineal skin open, to heal by secondary
intention, because avoiding suture material has been associated with better skin
sensation when assessed one year postpartum [29]. Two randomized trials
attempted to evaluate whether suturing or nonsuturing of first- and second-degree
perineal lacerations improved outcome [30,31]. There was a similar degree of
postpartum discomfort with both approaches, but one study described better
wound healing when subcuticular closure was performed [31]. A meta-analysis of
the two trials concluded there was insufficient evidence to recommend surgical
repair over nonsurgical management, and more data were needed [32].

OUTCOME
The comparative outcomes of women who undergo episiotomy and repair versus
those who do not undergo episiotomy are reviewed separately. (See "Approach to
episiotomy", section on 'Advantages of restricted use of episiotomy'.)

Third- and fourth-degree lacerations — Possible complications from third- and

fourth-degree laceration and repair include breakdown, infection, and symptoms of
pelvic floor dysfunction.

Repairs of third- and fourth-degree lacerations appear to be at increased risk of

infection and breakdown compared with repairs of first- and second-degree
lacerations. A prospective cohort study of over 250 women with third- and fourth-
degree lacerations reported a nearly 25 percent incidence of wound breakdown
and 20 percent incidence of wound infection [33]. For comparison, the incidence
of breakdown of all types of perineal wounds has been reported between 0.1 and
nearly 5 percent [34-36]. It is not known if the infection and breakdown risks vary
among the end-to-end and overlap techniques, although the choice of sphincter
repair seems unlikely to impact infection risk.

Third- and fourth-degree lacerations are associated with symptoms of pelvic floor
dysfunction such as incontinence and prolapse. These symptoms may vary with
the repair technique, but more data are needed for definitive conclusion [25]. The
impact of episiotomy and perineal laceration on pelvic floor function is reviewed in
detail separately. (See "Effect of pregnancy and childbirth on urinary incontinence
and pelvic organ prolapse" and "Fecal and anal incontinence associated with
pregnancy and childbirth: Counseling, evaluation, and management".)

MEDIOLATERAL EPISIOTOMY REPAIR

Repair of mediolateral episiotomies is approached by first reapproximating the

transverse perineal and bulbocavernosus muscles. Larger suture bites should be
taken on the lateral side of the incision because the two surfaces are unequal, with
the lateral aspect having a larger area than the medial. The remainder of the repair
is similar to that described above.

SECONDARY REPAIR OF EPISIOTOMY BREAKDOWN

Episiotomy infection and dehiscence are uncommon, but important postpartum

complications. Signs of episiotomy infection include fever, wound tenderness, and
purulent discharge, typically occurring six to eight days following delivery.

Early versus delayed repair — Traditionally, secondary repair of episiotomy

breakdown was deferred for a minimum of two to three months [37]. The purpose
for delay was to allow sufficient time for revascularization of the wound edges and
formation of scar tissue, which was thought to be of value during reanastomosis
of the torn sphincter. However, few data support this approach and it commits the
woman to an extended period of physical, social, and sexual disability because of
continuous incontinence. Available evidence, although extremely limited and
inconclusive, supports re-repair of both superficial and deep episiotomy
dehiscence within the first two weeks following childbirth, which may result in a
reduction in perineal pain during the healing process up to six months postdelivery
and a reduction in dyspareunia [38].

Early repair of episiotomy breakdown has replaced the traditional approach and
has overall success rates of 87 to 100 percent [39-44]. Disadvantages of an early
procedure include:

● It prolongs hospitalization early in the postpartum period, which could

interfere with breastfeeding and maternal-infant bonding.

● It removes the possibility of spontaneous closure, which could occur in some

cases.
 ● Some early attempts at repair may fail, resulting in a need for subsequent
surgical procedures.

Wound care — The open wound should be inspected for evidence of bacterial

overgrowth, exudate, necrotic tissue, and suture fragments. It should be débrided
at the bedside, using low pressure irrigation with warm isotonic (normal) saline,
mechanical debridement, and sharp dissection, as needed. In some cases,
transfer to an operating room and regional or local anesthesia may be necessary
to remove nonviable tissue (see "Basic principles of wound management"). Sitz
baths are offered several times daily for patient comfort.

Women with clinically-evident cellulitis should be treated with broad spectrum

antibiotics. (See "Cellulitis and skin abscess in adults: Treatment".)

Early secondary repair is performed when the wound surface is free from exudate
and covered by pink granulation tissue. If cellulitis was present, it should be
resolved. On average, it will take six to eight days of aggressive wound care before
the repair can be attempted.

Preoperative preparation — In patients with superficial disruption of a first- or

second-degree laceration, some surgeons give a single preoperative dose of a
broad spectrum antibiotic, such as a cephalosporin. The value of antibiotics in this
setting has not been studied in randomized trials.

In contrast, women with third- and fourth-degree lacerations and breakdowns are
similar to patients undergoing colorectal surgery. As such, they receive antibiotic
prophylaxis with aerobic and anaerobic coverage, such as a second generation
cephalosporin or cephazolin plus metronidazole (table 1) [45]. There is no
evidence on which to base a recommendation for a preoperative bowel regimen
before anal surgery. In secondary closures that involve re-repair of the anal
sphincter and/or rectal mucosa, we feel the use of an enema the night before
surgery to remove the potential for perioperative fecal contamination is sufficient
preparation of the lower colon and anorectum. The use of a mechanical bowel
prep is unnecessary. (See "Antimicrobial prophylaxis for prevention of surgical site
infection following gastrointestinal procedures in adults", section on 'Colorectal
procedures'.)

Procedure — Secondary repair is performed in the same way as the primary

episiotomy/perineal laceration repair described above. Some surgeons use
interrupted, rather than continuous, sutures.

POSTOPERATIVE CARE

There is a paucity of evidence-based information regarding care of the perineum

after childbirth, with or without episiotomy [46,47]. In cases in which a third- or
fourth-degree laceration occurs, immediate care should include adequate pain
control, avoidance of constipation, and evaluation for urinary retention [7]. Stool
softeners and oral laxatives should be considered in these circumstances, and the
patient should be counseled on ways to avoid constipation.

Our approach to perineal care is presented in detail separately. (See "Postpartum

perineal care and management of complications".)

MANAGEMENT OF FUTURE DELIVERIES

The management of future deliveries after repair of a third- or fourth-degree

laceration is discussed separately. (See "Obstetric anal sphincter injury (OASIS)",
section on 'Approach to future delivery'.)

DELAYED SURGICAL MANAGEMENT OF THE DISRUPTED ANAL

SPHINCTER
Delayed surgical management of the disrupted anal sphincter is discussed
separately. (See "Delayed surgical management of the disrupted anal sphincter".)

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Basics)")

SUMMARY AND RECOMMENDATIONS

● Occult injury to the anal sphincter occurs frequently at the time of vaginal
delivery and can contribute to anal incontinence. (See 'Introduction' above.)

● Initially, the key task is to examine the perineum and vagina thoroughly to
determine the extent of injury and severity of bleeding. This assessment
should include a rectovaginal examination of the anal sphincter complex and
 rectal mucosa. Unrecognized injury to the anal sphincter complex is common
after vaginal delivery. (See 'Preoperative preparation' above.)

● The anal sphincter can be disrupted even though the perineum is intact. (See
'Classification' above.)

● We do not routinely administer antibiotics prior to repair of first- and second-

degree obstetric lacerations. For repair of a third- or fourth-degree obstetric
laceration, we suggest administration of a single dose of a broad spectrum
antibiotic (second generation cephalosporin [eg, cefotetan or cefoxitin;
clindamycin if beta lactam allergy] (table 1)) rather than no antibiotics (Grade
2C). (See 'Antibiotics' above.)

● Absorbable synthetic suture, such as standard polyglactin 910 (Vicryl) or

rapidly absorbable polyglactin 910 (Vicryl Rapide), is preferred to catgut as it
significantly reduces short-term perineal pain and analgesic use within 10
days, and is associated with a lower rate of suture dehiscence. (See 'Choice
of suture' above.)

● The aim of reconstructive surgery is to restore the continuity of both the

external and internal anal sphincters and create a thick perineal body and
rectovaginal septum. Reapproximation of the internal sphincter is important
for the strength and integrity of the repair and for achieving anal continence.
Proper reconstruction will lengthen the anal canal and restore the functional
high pressure zone. (See 'Third- and fourth-degree tears' above.)

● It is unclear whether an overlapping repair yields better long-term results than

a traditional end-to-end repair. Either technique is reasonable. (See 'Third- and
fourth-degree tears' above.)

● In general, early re-repair of an episiotomy breakdown is desirable to minimize

both short-term and long-term perineal pain. (See 'Early versus delayed repair'
above.)
REFERENCES

1. Bols EM, Hendriks EJ, Berghmans BC, et al. A systematic review of etiological
factors for postpartum fecal incontinence. Acta Obstet Gynecol Scand 2010;
89:302.

2. Sultan AH, Kamm MA, Hudson CN, et al. Anal-sphincter disruption during
vaginal delivery. N Engl J Med 1993; 329:1905.

3. Dudding TC, Vaizey CJ, Kamm MA. Obstetric anal sphincter injury: incidence,
risk factors, and management. Ann Surg 2008; 247:224.

4. Delancey JO, Toglia MR, Perucchini D. Internal and external anal sphincter
anatomy as it relates to midline obstetric lacerations. Obstet Gynecol 1997;
90:924.

5. Sultan AH. Obstetric perineal injury and anal incontinence (editorial). Clin Risk
1999; 5:193.

6. Practice Bulletin No. 165 Summary: Prevention and Management of Obstetric

Lacerations at Vaginal Delivery: Correction. Obstet Gynecol 2016; 128:411.

7. Royal College of Obstetricians and Gynaecologists. Green-top guideline no. 2

9: The management of third- and fourth-degree perineal tears. March 2007. ht
tps://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg29/ (Ac
cessed on September 26, 2016).

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

9. Frudinger A, Bartram CI, Spencer JA, Kamm MA. Perineal examination as a

predictor of underlying external anal sphincter damage. Br J Obstet Gynaecol
1997; 104:1009.
10. ACOG Practice Bulletin No. 195: Prevention of Infection After Gynecologic
Procedures. Obstet Gynecol 2018; 131:e172.

11. Basevi V, Lavender T. Routine perineal shaving on admission in labour.

Cochrane Database Syst Rev 2001; :CD001236.

12. Knight M, Chiocchia V, Partlett C, et al. Prophylactic antibiotics in the

prevention of infection after operative vaginal delivery (ANODE): a multicentre
randomised controlled trial. Lancet 2019; 393:2395.

13. Duggal N, Mercado C, Daniels K, et al. Antibiotic prophylaxis for prevention of

postpartum perineal wound complications: a randomized controlled trial.
Obstet Gynecol 2008; 111:1268.

14. Buppasiri P, Lumbiganon P, Thinkhamrop J, Thinkhamrop B. Antibiotic

prophylaxis for third- and fourth-degree perineal tear during vaginal birth.
Cochrane Database Syst Rev 2014; :CD005125.

15. Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 199:

Use of Prophylactic Antibiotics in Labor and Delivery. Obstet Gynecol 2018;
132:e103.

16. Schinkel N, Colbus L, Soltner C, et al. Perineal infiltration with lidocaine 1%,
ropivacaine 0.75%, or placebo for episiotomy repair in parturients who
received epidural labor analgesia: a double-blind randomized study. Int J
Obstet Anesth 2010; 19:293.

17. Mackrodt C, Gordon B, Fern E, et al. The Ipswich Childbirth Study: 2. A

randomised comparison of polyglactin 910 with chromic catgut for
postpartum perineal repair. Br J Obstet Gynaecol 1998; 105:441.

18. Greenberg JA, Lieberman E, Cohen AP, Ecker JL. Randomized comparison of
chromic versus fast-absorbing polyglactin 910 for postpartum perineal repair.
Obstet Gynecol 2004; 103:1308.
19. Kettle C, Dowswell T, Ismail KM. Absorbable suture materials for primary
repair of episiotomy and second degree tears. Cochrane Database Syst Rev
2010; :CD000006.

20. McElhinney BR, Glenn DR, Dornan G, Harper MA. Episiotomy repair: Vicryl
versus Vicryl rapide. Ulster Med J 2000; 69:27.

21. Aronson MP, Lee RA, Berquist TH. Anatomy of anal sphincters and related
structures in continent women studied with magnetic resonance imaging.
Obstet Gynecol 1990; 76:846.

22. Malouf AJ, Norton CS, Engel AF, et al. Long-term results of overlapping
anterior anal-sphincter repair for obstetric trauma. Lancet 2000; 355:260.

23. Lindqvist PG, Jernetz M. A modified surgical approach to women with

obstetric anal sphincter tears by separate suturing of external and internal
anal sphincter. A modified approach to obstetric anal sphincter injury. BMC
Pregnancy Childbirth 2010; 10:51.

24. Mahony R, Behan M, Daly L, et al. Internal anal sphincter defect influences
continence outcome following obstetric anal sphincter injury. Am J Obstet
Gynecol 2007; 196:217.e1.

25. Fernando RJ, Sultan AH, Kettle C, Thakar R. Methods of repair for obstetric
anal sphincter injury. Cochrane Database Syst Rev 2013; :CD002866.

26. Farrell SA, Flowerdew G, Gilmour D, et al. Overlapping compared with end-to-
end repair of complete third-degree or fourth-degree obstetric tears: three-
year follow-up of a randomized controlled trial. Obstet Gynecol 2012; 120:803.

27. Rygh AB, Körner H. The overlap technique versus end-to-end approximation
technique for primary repair of obstetric anal sphincter rupture: a randomized
controlled study. Acta Obstet Gynecol Scand 2010; 89:1256.
28. Kettle C, Dowswell T, Ismail KM. Continuous and interrupted suturing
techniques for repair of episiotomy or second-degree tears. Cochrane
Database Syst Rev 2012; 11:CD000947.

29. Grant A, Gordon B, Mackrodat C, et al. The Ipswich childbirth study: one year
follow up of alternative methods used in perineal repair. BJOG 2001; 108:34.

30. Lundquist M, Olsson A, Nissen E, Norman M. Is it necessary to suture all

lacerations after a vaginal delivery? Birth 2000; 27:79.

31. Fleming VE, Hagen S, Niven C. Does perineal suturing make a difference? The
SUNS trial. BJOG 2003; 110:684.

32. Elharmeel SM, Chaudhary Y, Tan S, et al. Surgical repair of spontaneous

perineal tears that occur during childbirth versus no intervention. Cochrane
Database Syst Rev 2011; :CD008534.

33. Lewicky-Gaupp C, Leader-Cramer A, Johnson LL, et al. Wound complications

after obstetric anal sphincter injuries. Obstet Gynecol 2015; 125:1088.

34. Goldaber KG, Wendel PJ, McIntire DD, Wendel GD Jr. Postpartum perineal
morbidity after fourth-degree perineal repair. Am J Obstet Gynecol 1993;
168:489.

35. Williams MK, Chames MC. Risk factors for the breakdown of perineal
laceration repair after vaginal delivery. Am J Obstet Gynecol 2006; 195:755.

36. Stock L, Basham E, Gossett DR, Lewicky-Gaupp C. Factors associated with

wound complications in women with obstetric anal sphincter injuries (OASIS).
Am J Obstet Gynecol 2013; 208:327.e1.

37. Thompson JD. Relaxed vaginal outlet, rectocele, fecal incontinence, and recto
vaginal fistula. In: TeLinde's Operative Gynecology, 7th ed, Thompson JD, Rock
JA (Eds), JB Lippincott, Philadelphia 1992. p.941.
38. Dudley LM, Kettle C, Ismail KM. Secondary suturing compared to non-suturing
for broken down perineal wounds following childbirth. Cochrane Database
Syst Rev 2013; :CD008977.

39. Ramin SM, Gilstrap LC 3rd. Episiotomy and early repair of dehiscence. Clin
Obstet Gynecol 1994; 37:816.

40. Hankins GD, Hauth JC, Gilstrap LC 3rd, et al. Early repair of episiotomy
dehiscence. Obstet Gynecol 1990; 75:48.

41. Hauth JC, Gilstrap LC 3rd, Ward SC, Hankins GD. Early repair of an external
sphincter ani muscle and rectal mucosal dehiscence. Obstet Gynecol 1986;
67:806.

42. Monberg J, Hammen S. Ruptured episiotomia resutured primarily. Acta Obstet

Gynecol Scand 1987; 66:163.

43. Ramin SM, Ramus RM, Little BB, Gilstrap LC 3rd. Early repair of episiotomy
dehiscence associated with infection. Am J Obstet Gynecol 1992; 167:1104.

44. Arona AJ, al-Marayati L, Grimes DA, Ballard CA. Early secondary repair of
third- and fourth-degree perineal lacerations after outpatient wound
preparation. Obstet Gynecol 1995; 86:294.

45. Nelson RL, Gladman E, Barbateskovic M. Antimicrobial prophylaxis for

colorectal surgery. Cochrane Database Syst Rev 2014; :CD001181.

46. Chiarelli P, Cockburn J. Postpartum perineal management and best practice.

Aust Coll Midwives Inc J 1999; 12:14.

47. Kettle C, Tohill S. Perineal care. BMJ Clin Evid 2011; 2011.

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