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Repair of perineal lacerations associated with childbirth

Repair of perineal lacerations associated with childbirth
Literature review current through: Sep 2023.
This topic last updated: Sep 23, 2022.

INTRODUCTION — Vaginal and perineal trauma commonly occurs with vaginal delivery. This topic will review evaluation and repair of perineal and other obstetric lacerations, such as labial, sulcal, and periurethral lacerations, as well as repair of episiotomy.

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'.)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transgender and gender diverse individuals.

INCIDENCE AND CLINICAL SEQUALAE — Approximately 70 percent of individuals who have a vaginal birth will experience injury to the vagina or perineum that may require surgical repair [1,2]. 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 result in anal and fecal incontinence [3]. Even when recognized and repaired, persistent sphincter dysfunction is considered to be the most common cause of postpartum anal incontinence [4,5].

ANATOMY — The muscles of the female pelvic floor and perineum are shown in the following figures (figure 1 and figure 2).

Perineal body – 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, the posterior fibers of the bulbocavernosus muscles, and fibers of the external anal sphincter (EAS).

Anorectal sphincter – The anorectal sphincter complex is comprised of two distinct structures with different, but overlapping, roles for maintaining continence (figure 3).

External anal sphincter (EAS) – 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 EAS is innervated by the inferior branch of the pudendal nerve, which may be susceptible to injury during delivery.

Internal anal sphincter (IAS) – The internal anal sphincter (IAS) lies between the external sphincter and the anal canal and represents a thickened condensation of the longitudinal smooth muscle fibers of the rectum (figure 3). The IAS extends more than a centimeter above the cephalad margin of the external sphincter [6]. It is entirely under involuntary control and is responsible for 50 to 80 percent of the resting tone of the sphincter and maintaining anal continence at rest [6].

Puborectalis – The puborectalis portion of the levator ani complex also plays an important role in continence of solid stool.

CLASSIFICATION — In 1999, Sultan proposed refining the traditional classification system for obstetric perineal lacerations [7]. The revised system provided a subclassification for third-degree lacerations [8]:

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 – Injury to the perineum that involves both the anal sphincter complex (EAS and IAS) and anal 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 [8,9]. 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, prior to the suturing of any injuries [6]. This assessment should include both visual inspection and digital palpation, including routine rectal examination, . 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 [10].

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. Good lighting is essential. Examination may be performed with the patient in the "frog leg" position or in lithotomy, if preferred. 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 should be performed routinely to exclude injury to the anorectal mucosa and anal sphincter. Digital rectal examination 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 [4,11].

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. Delivering the placenta prior to suturing is preferred, if possible given the volume of bleeding from the laceration, to avoid disrupting the sutures with placental delivery.

If feces are obviously present, it should be removed and the tissues irrigated thoroughly. We perform a gentle scrub with chlorhexidine under such conditions [12].

Perineal shaving is unnecessary [13].

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 [14]. This trial is reviewed in detail in a related topic. (See "Assisted vaginal birth", 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) [15-17]. 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 a single dose of antibiotic to reduce the incidence of postoperative infection for third- and fourth-degree lacerations [9,17].

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, redosing of the epidural 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 [18]. (See "Pudendal and paracervical block".)

CHOICE OF SUTURE — The choice of sutures for repair of perineal lacerations has traditionally been one of personal preference, although recent data have suggested that synthetic absorbable suture material is associated with less short-term perineal pain and less wound dehiscence compared with catgut suture. 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 [19-21]. 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 [21]. 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 [21]. When catgut and glycerol-impregnated catgut were compared, results were similar for most outcomes, although the latter was associated with more short-term pain.

Rapidly absorbed polyglactin 910 suture (commercial name Vicryl Rapide, 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. Rapidly absorbed 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 [22].

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 [6]. 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 [6,23]. 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 [24]. 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) [25]:

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 [6,26]. 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 [27]. We use a continuous 3/0 polyglactin suture or 3/0 monofilament synthetic suture (eg, polydioxanone) 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 [25]; 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 (risk ratio [RR] 0.90, 95% CI 0.68-1.17; five trials, n = 2221), but this was primarily in the first 12 months after delivery and disappeared at 24 and 36 months [28]. 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) [29]. 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 [30]. Others have observed that the incidence of residual anal sphincter damage on endoanal ultrasonography is similar for the two techniques [5,30].

In the absence of clear evidence favoring one technique over the other, the choice of overlap or end-to-end repair should be based upon the surgeon's preference and experience. In the United States, end-to-end repair is more commonly practiced than the overlapping technique with full thickness external anal sphincter tears. End-to-end repair is almost universally practiced in a partial thickness EAS tear.

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.

There is robust evidence that continuous nonlocking suture techniques for repair of the vagina, perineal muscles, and skin are superior to traditional interrupted methods with regards to reducing postpartum perineal pain. 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 [31]:

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 [32]. Two randomized trials attempted to evaluate whether suturing or nonsuturing of first- and second-degree perineal lacerations improved outcome [33,34]. There was a similar degree of postpartum discomfort with both approaches, but one study described better wound healing when subcuticular closure was performed [34]. A meta-analysis of the two trials concluded there was insufficient evidence to recommend surgical repair over nonsurgical management, and more data were needed [35].

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 'Lack of advantages for episiotomy use'.)

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 [36]. For comparison, the incidence of breakdown of all types of perineal wounds has been reported between 0.1 and nearly 5 percent [37-39]. 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 [28]. 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 [40]. 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 patient 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 [41].

Early repair of episiotomy breakdown has replaced the traditional approach and has overall success rates of 87 to 100 percent [42-47]. 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 "Acute cellulitis and erysipelas 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.

By 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) [48]. 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 [49,50]. Our approach to perineal care is presented in detail separately. (See "Postpartum perineal care and management of complications".)

Third- and fourth-degree laceration – 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 [9,25]. Stool softeners and oral laxatives should be prescribed (we advise at least three days of therapy) and patients should be counseled on ways to avoid constipation [25]. Ice packs or cold gel pads applied to the perineum for 24 to 72 hours may be used to reduce pain. Nonsteroidal anti-inflammatory or opiate pain medication may also be offered for pain control.

Other perineal injury –Patients who sustain significant perineal injury should be monitored for immediate postpartum urinary retention [25]. Those who are unable to adequately void, or who develop worsening pelvic discomfort, should be promptly evaluated for urinary retention, both during hospitalization and after discharge from the hospital.

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".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topics (see "Patient education: Vaginal tearing during childbirth (The Basics)")

SUMMARY AND RECOMMENDATIONS

Anatomy and perineal laceration classification – The muscles of the female pelvic floor and perineum are shown in the following figures (figure 1 and figure 2). Perineal lacerations are described based on the depth and anatomy of injury, including the anal sphincter, down to the anal mucosa. The anal sphincter can be disrupted even though the perineum is intact. (See 'Anatomy' above and 'Classification' above.)

Examination – Initially, the key task is to examine the perineum and vagina thoroughly to determine the extent of injury (ie, classification) and severity of bleeding. After vaginal delivery, it is important to perform a thorough rectovaginal examination of the anal sphincter complex and rectal mucosa. Unrecognized injury to the anal sphincter complex occurs commonly after vaginal delivery. (See 'Preoperative preparation' above.)

Use of antibiotics

First- and second-degree lacerations – We do not routinely administer antibiotics prior to repair of first- and second-degree obstetric lacerations.

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

Suture type – Absorbable synthetic suture, such as standard polyglactin 910 (Vicryl) or rapid absorption 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.)

Anal sphincter repair – 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. (See 'Third- and fourth-degree tears' above.)

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.)

For full thickness external anal sphincter lacerations, either an end-to-end repair or overlapping repair is acceptable. (See 'Third- and fourth-degree tears' above.)

Disruption of primary repair – 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.)

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Topic 5399 Version 52.0

References

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