/ /

  • linkedin
  • Increase Font
  • Sharebar

    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.

     

     

    Case vignette: Four months after spontaneous vaginal delivery, a 34-year-old G4P4 presents with vaginal bulging that interferes with her daily life. With each of her deliveries, she sustained a second-degree laceration, which was repaired.

    Diagnosis: Pelvic organ prolapse

    Multiple deliveries with spontaneous perineal lacerations have been associated with development of prolapse beyond the hymen.33 Pelvic organ prolapse (POP) surgery is more common in women with a history of both noninstrumented and instrumented vaginal deliveries as compared to women with only cesarean deliveries.34 No preventative strategies have been identified to prevent development of POP. Treatment options are individualized based on a patient’s age, surgical history, and desire for future childbearing. Postpartum pelvic floor muscle training has not been shown to help correct POP.35

    Case vignette: A 23-year-old G2P2 presents 1 week postpartum with foul-smelling vaginal discharge and fever. On vaginal examination with speculum, a purulent sponge is found posterior to the cervix and removed with ring forceps.

    Diagnosis: Unintended retention of foreign object

    When sponges become soaked in blood they can be difficult to identify; the rare complication of unintended retention of foreign object (URFO) is preventable. Retained surgical sponges, needles, or instruments can cause both infection and psychological harm. The average cost related to a URFO is > $200,000, including legal defense, indemnity payments and surgical costs.36 The Minnesota Department of Health reported that in 2006, retained sponges during vaginal delivery were more frequent than all other types of URFOs.37 Findings from an earlier 1996 study also showed that vaginal delivery was the most likely reason for a URFO and in that review, none of the 11 cases of vaginally retained sponges were associated with a sponge count.38

    Next: Use of biologic grafts in pelvic organ prolapse surgery

    Operating room principles apply to the repair of perineal trauma. These principles include before and after counts of sponges and needles, use of radio-detectable sponges with safety features such as tags, and vaginal examination followed by pelvic radiograph when a retained sponge is suspected.39 Using sponges that are larger, such as 8 inches or 18 inches (mini-laparotomy sponge), rather than the 4×4-inch gauze may also help reduce URFO.37

    URFO may also occur if packing is placed for bleeding. When this is done, we recommend placing an arm band on the patient that stays on until the packing is removed. If a foreign body is found, that should be disclosed to the patient as well as to the hospital. The Joint Commission considers URFO a sentinel event and accredited organizations are expected to respond as part of a patient safety program.

    Conclusion

    Perineal lacerations are common and most resolve without sequelae. Good surgical technique helps prevent URFO and laceration repair should be conducted as any surgical procedure with good lighting, adequate analgesia, and appropriate help and equipment. Rectal examination at the time of vaginal delivery may help prevent missing fourth-degree lacerations. Avoiding routine episiotomy limits perineal trauma, which in turn may limit complications. For women with severe lacerations, including third- and fourth-degree lacerations, postpartum follow-up is important as these patients are at higher risk for FI, pain, and fistulae. Severe complications are rare and providers should be familiar with perineal complications following vaginal delivery.

    References

    1. Smith LA , Price N, Simonite V, Burns EE. Incidence of and risk factors for perineal trauma: a prospective observational study. BMC Pregnancy Childbirth. 2013;7;13:59.

    2. Leeman LM 1, Rogers RG, Greulich B, Albers LL . Do unsutured second-degree perineal lacerations affect postpartum functional outcomes? J Am Board Fam Med. 2007 Sep-Oct;20(5):451-7.

    3. Pergialiotis V, Vlachos D, Protopapas A, Pappa K, Vlachos G. Risk factors for severe perineal lacerations during childbirth. Int J Gynaecol Obstet. 2014;125(1):6-14.

    4. Friedman AM1, Ananth CV, Prendergast E, D’Alton ME , Wright JD. Evaluation of third-degree and fourth-degree laceration rates as quality indicators. Obstet Gynecol. 2015;125(4):927-37.

    5. Sultan AH. Obstetric perineal injury and anal incontinence. Clin Risk. 1999;5:193–196.

    6. LaCross A, Groff M, Smaldone A. Obstetric anal sphincter injury and anal incontinence following vaginal birth: a systematic review and meta-analysis. J Midwifery Womens Health. 2015;60(1):37-47.

    7. Fenner DE1, Genberg B, Brahma P, Marek L, DeLancey JO. Fecal and urinary incontinence after vaginal delivery with anal sphincter disruption in an obstetrics unit in the United States. Am J Obstet Gynecol. 2003;189(6):1543-50.

    8. Farrell SA1, Flowerdew G, Gilmour D, Turnbull GK, Schmidt MH, Baskett TF, Fanning CA . 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 Oct;120(4):803-8.

    9. Practice Bulletin No. 165: Prevention and Management of Obstetric Lacerations at Vaginal Delivery. American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics. Obstet Gynecol. 2016 Jul;128(1):e1-e15

    10. Brown HW, Wang L, Bunker CH, Lowder JL. Lower reproductive tract fistula repairs in inpatient US women, 1979-2006. Int Urogynecol J. 2012;23(4):403-10.

    11. Priddis H, Dahlen HG, Schmied V, et al. Risk of recurrence, subsequent mode of birth and morbidity for women who experienced severe perineal trauma in a first birth in New South Wales between 2000-2008: a population based data linkage study. BMC Pregnancy Childbirth. 2013;13:89.

    12. Rogers, Rebecca G.; Jeppson, Peter C. Current Diagnosis and Management of Pelvic Fistulae in Women. Obstet Gynecol. 2016;128(3):635-650.

    13. Reisenauer C Presentation and management of rectovaginal fistulas after delivery. Int Urogynecol J. 2016 Jun;27(6):859-64.

    14. Saleem Z, Rydhstrom H. Vaginal hematoma during parturition: a population-based study. Acta Obstet Gynecol Scand 2004;83:560–2.

    15. Ä°skender C1, Topçu HO1, Timur H1, et al. Evaluation of risk factors in women with puerperal genital hematomas. J Matern Fetal Neonatal Med. 2016;29(9):1435-9. doi: 10.3109/14767058.2015.1051018. Epub 2015 Jun 5.

    16. Guerriero S, Ajossa S, Bargellini R, et al. Puerperal vulvovaginal hematoma: sonographic findings with MRI correlation. J Clin Ultrasound. 2004;32:415–18.

    17. Mawhinney S, Holman R. Puerperal genital haematoma: a commonly missed diagnosis. Obstetric Gynaecol. 2007;9:195–200.

    18. Williams MK1, Chames MC. Risk factors for the breakdown of perineal laceration repair after vaginal delivery. Am J Obstet Gynecol. 2006 Sep;195(3):755-9.

    19. Duggal N, Mercado C, Daniels K, Bujor A, Caughey AB , El-Sayed YY. Antibiotic prophylaxis for prevention of postpartum perineal wound complications: a randomized controlled trial. Obstet Gynecol. 2008;111(6):1268-73.

    20. Lewicky-Gaupp C, Leader-Cramer A, Johnson LL , Kenton K, Gossett DR. Wound complications after obstetric anal sphincter injuries. Obstet Gynecol. 2015 May;125(5):1088-93.

    21. Dudley LM 1, Kettle C, Ismail KM. Secondary suturing compared to non-suturing for broken down perineal wounds following childbirth. Cochrane Database Syst Rev. 2013 Sep 25;(9):CD008977.

    22. Uygur D1, Yesildaglar N, Kis S, Sipahi T. Early repair of episiotomy dehiscence. Aust N Z J Obstet Gynaecol. 2004 Jun;44(3):244-6.

    23. Oud L1, Watkins P2. Necrotizing Fasciitis Associated with Pregnancy: a Population-Based Cohort Study. Infect Dis Ther. 2014 Dec;3(2):307-20.

    24. Wood SC 1. Clinical manifestations and therapeutic management of vulvar cellulitis and abscess: Methicillin-resistant Staphylococcus aureus, necrotizing fasciitis, Bartholin abscess, Crohn disease of the vulva, hidradenitis suppurativa. Clin Obstet Gynecol. 2015 Sep;58(3):503-11.

    25. Yip SK1, Sahota D, Pang MW, Chang A. Postpartum urinary retention. Acta Obstet Gynecol Scand. 2004 Oct;83(10):881-91.

    26. Ching-Chung L, Shuenn-Dhy C, Ling-Hong T, Ching-Chang H, Chao-Lun C, Po-Jen C. Postpartum urinary retention: assessment of contributing factors and long-term clinical impact. Aust N Z J Obstet Gynaecol. 2002;42(4):365-8.

    27. Leeman LM1, Rogers RG. Sex after childbirth: postpartum sexual function. Obstet Gynecol. 2012 Mar;119(3):647-55

    28. Hartmann K, Viswanathan M, Palmieri R, Gartlehner G, Thorp J, Lohr KN. Outcomes of routine episiotomy: a systematic review. JAMA. 2005;293:2141–8.

    29. Fodstad K1,2, Staff AC3,4, Laine K4 Sexual activity and dyspareunia the first year postpartum in relation to degree of perineal trauma. Int Urogynecol J. 2016 Oct;27(10):1513-23.

    30. Blomquist JL, McDermott K, Handa VL. Pelvic pain and mode of delivery. Am J Obstet Gynecol. 2014;210(5):423.e1-e6.

    31. Solans-Domènech M1, Sánchez E, Espuña- Pons M; Pelvic Floor Research Group (Grup de Recerca del Sòl Pelvià; GRESP Urinary and anal incontinence during pregnancy and postpartum: incidence, severity, and risk factors. Obstet Gynecol. 2010 Mar;115(3):618-28.

    32. Boyles SH1, Li H, Mori T, Osterweil P, Guise JM. Effect of mode of delivery on the incidence of urinary incontinence in primiparous women. Obstet Gynecol. 2009 Jan;113(1):134-41.

    33. Handa VL, Blomquist JL, McDermott KC, Friedman S, Muñoz A. Pelvic floor disorders after vaginal birth: effect of episiotomy, perineal laceration, and operative birth. Obstet Gynecol. 2012 Feb;119(2 Pt 1):233-9.

    34. Leijonhufvud A, Lundholm C, Cnattingius S, Granath F, Andolf E, Altman D. Risks of stress urinary incontinence and pelvic organ prolapse surgery in relation to mode of childbirth. Am J Obstet Gynecol. 2011 Jan;204(1):70.e1-7.

    35. Bø K1, Hilde G2, Stær-Jensen J3, Siafarikas F3, Tennfjord MK2, Engh ME3 Postpartum pelvic floor muscle training and pelvic organ prolapse--a randomized trial of primiparous women. Am J Obstet Gynecol. 2015 Jan;212(1):38.e1-7.

    36. Regenbogen, et al: Prevention of retained surgical sponges: A decision-analytic model predicting relative cost-effectiveness. Surgery. 2009;145:527-35.

    37. Chagolla BA 1, Gibbs VC, Keats JP, Pelletreau B. A system-wide initiative to prevent retained vaginal sponges. MCN Am J Matern Child Nurs. 2011 Sep-Oct;36(5):312-7.

    38. Kaiser CW, Frideman S, Spurling KP, Slowick T, Kaiser HA. The retained surgical sponge. Annals Surg. 1996:224(1):79–84.

    39. Lamont T, Dougall A, Johnson S, Mathew D, Scarpello J, Morris E. Reducing the risk of retained swabs after vaginal birth: summary of a safety report from the National Patient Safety Agency. BMJ. 2010 Jul 19;341:c3679.

    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.

    0 Comments

    You must be signed in to leave a comment. Registering is fast and free!

    All comments must follow the ModernMedicine Network community rules and terms of use, and will be moderated. ModernMedicine reserves the right to use the comments we receive, in whole or in part,in any medium. See also the Terms of Use, Privacy Policy and Community FAQ.

    • No comments available

    Poll

    Latest Tweets Follow