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    Managing complications of perineal lacerations

    When perineal lacerations are severe, it’s important that ob/gyns know how to accurately diagnose and appropriately manage them.

    Perineal lacerations occur in up to 80% of vaginal deliveries.1 Lacerations commonly occur on the perineum and vagina but can also occur on the labia, clitoris, urethra, and cervix. The severity of lacerations varies from minor lacerations that affect the skin or superficial structures of the perineum to more severe lacerations that damage the muscles of the anal sphincter complex and rectum. Laceration repair is not required for minor lacerations that are not bleeding or distorting anatomy.2 Obstetric anal sphincter injuries (OASIS) are severe perineal lacerations that extend into or through the anal sphincter complex. Major risk factors for severe lacerations include operative deliveries (forceps or vacuum), midline episiotomy, and larger birth weight. Additional risk factors for severe lacerations include labor induction and augmentation, Asian ethnicity, epidural anesthesia, persistent occiput posterior, and primiparity.3,4 Table 1 lists the classification of perineal lacerations.5

    Determining the extent of a perineal laceration sustained after delivery is critical for repair and postpartum counseling for, despite adequate repair, complications may arise. Some complications, such as anal incontinence, may develop years after the trauma. This article reviews complications that may occur following perineal trauma, techniques to help prevent these complications, and best practices for management using case vignettes.

    Case vignette: A 30-year-old G1P1 reports fecal incontinence 4 months after repair of a fourth-degree laceration.

    Diagnosis: Fecal incontinence

    Fecal incontinence (FI) is a potential consequence of OASIS. Midline episiotomy (even without extension into the sphincter) is also a risk factor for FI and fourth-degree laceration has a higher risk compared to third-degree lacerations.6,7

    Repair of a fourth-degree laceration begins with repair of the rectal mucosa with either a subcuticular running or interrupted suture of 4-0 or 3-0 polyglactin (Vicryl). Next, the internal anal sphincter is identified and repaired with either a running or interrupted suture technique. The internal anal sphincter often has a whitish appearance with distant sheen from the striated, red appearance of the external anal sphincter (Figure 1). Overlapping repair of the sphincter requires complete sphincter disruption and 1 cm to 1.5 cm of torn muscle on either end. For this repair, grasp the ends of the torn anal sphincter with Allis clamps, pull the sphincter ends over each other in a double-breasted fashion and then suture them back together using either polyglactin (Vicryl) or polydiaxanone (PDS).

    Recommended: Sexual health and function in pregnancy

    In contrast, with an end-to-end repair, the external anal sphincter is approximated and sutured, usually with 4 sutures to recreate the cylindrical shape of the muscle. No long-term differences are seen in FI rates for end-to-end versus overlapping repairs.8

    Limited, retrospective data support an association between mediolateral episiotomy and decreased rates of OASIS. Theoretically, that in turn would decrease rates of FI. Evidence does not support routine episiotomy, although mediolateral may be preferred over midline when episiotomy is needed.9 Non-surgical treatment options for FI include increased intake of fiber and use of biofeedback, physical therapy, loperamide, and anal plugs. Women who develop postpartum FI may consider a cesarean delivery in subsequent pregnancies to help prevent deteriorating function.9

    NEXT: Fistulas

    Sara B. Cichowski, MD
    Dr Cichowski is a board-certified FPMRS Obstetrician and Gynecologist and assistant professor at the University of New Mexico and New ...
    Rebecca G. Rogers, MD
    Dr Rogers is Associate Chair for Clinical Integrations and Operations, Dell Medical School, The University of Texas at Austin.

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