Repair of episiotomy and perineal lacerations associated with childbirth
- Marc R Toglia, MD
Marc R Toglia, MD
- Director, Urogynecology Associates of Philadelphia
- Chief, Division of Urogynecology - Mainline Hospitals
- Associate Professor of Obstetrics and Gynecology
- Thomas Jefferson School of Medicine
- Philadelphia, PA
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 occurs frequently at the time of an otherwise uncomplicated delivery and, if neglected, can contribute to anal and fecal incontinence . 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 episiotomy incisions and perineal lacerations associated with childbirth will be reviewed here. Evaluation and management of vaginal lacerations are discussed separately. (See "Evaluation and management of female lower genital tract trauma", section on 'Vagina'.)
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. The anorectal sphincter complex is comprised of two structures with different, but overlapping, roles for maintaining continence (figure 3). The external anal sphincter (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 . It is entirely under involuntary control and contributes to maintaining anal continence at rest . The puborectalis portion of the levator ani complex also plays an important role in continence of solid stool. The external anal sphincter is innervated by the pudendal nerve, which may be susceptible to injury during delivery.
In 1999, Sultan proposed refining the traditional classification system for obstetric perineal lacerations . The revised system provided a subclassification for third degree lacerations:
●First degree lacerations involve injury to the skin and subcutaneous tissue of the perineum and vaginal epithelium only. The perineal muscles remain intact.
- 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.
- Sultan AH, Kamm MA, Hudson CN, et al. Anal-sphincter disruption during vaginal delivery. N Engl J Med 1993; 329:1905.
- Dudding TC, Vaizey CJ, Kamm MA. Obstetric anal sphincter injury: incidence, risk factors, and management. Ann Surg 2008; 247:224.
- Delancey JO, Toglia MR, Perucchini D. Internal and external anal sphincter anatomy as it relates to midline obstetric lacerations. Obstet Gynecol 1997; 90:924.
- Sultan AH. Obstetric perineal injury and anal incontinence (editorial). Clin Risk 1999; 5:193.
- RCOG. Management of third and fourth degree perineal tears. Green-top guideline no. 29. March 2007. www.rcog.org.uk/files/rcog-corp/GTG2911022011.pdf (Accessed on May 08, 2012).
- Andrews V, Sultan AH, Thakar R, Jones PW. Occult anal sphincter injuries--myth or reality? BJOG 2006; 113:195.
- 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.
- American College of Obstetricians and Gynecologists Women's Health Care Physicians, Committee on Gynecologic Practice. Committee Opinion No. 571: Solutions for surgical preparation of the vagina. Obstet Gynecol 2013; 122:718.
- Basevi V, Lavender T. Routine perineal shaving on admission in labour. Cochrane Database Syst Rev 2001; :CD001236.
- 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.
- 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; 10:CD005125.
- Royal College of Obstetricians and Gynaecologists. The management of third- and fourth-degree perineal tears. Green-top guideline No. 29, March 2007.
- American College of Obstetricians and Gynecologists. ACOG Practice Bulletin No. 120: Use of prophylactic antibiotics in labor and delivery. Obstet Gynecol 2011; 117:1472.
- 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.
- 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.
- 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.
- Kettle C, Dowswell T, Ismail KM. Absorbable suture materials for primary repair of episiotomy and second degree tears. Cochrane Database Syst Rev 2010; :CD000006.
- McElhinney BR, Glenn DR, Dornan G, Harper MA. Episiotomy repair: Vicryl versus Vicryl rapide. Ulster Med J 2000; 69:27.
- 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.
- Malouf AJ, Norton CS, Engel AF, et al. Long-term results of overlapping anterior anal-sphincter repair for obstetric trauma. Lancet 2000; 355:260.
- 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.
- 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.
- Fernando RJ, Sultan AH, Kettle C, Thakar R. Methods of repair for obstetric anal sphincter injury. Cochrane Database Syst Rev 2013; 12:CD002866.
- 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.
- 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.
- 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.
- 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.
- Lundquist M, Olsson A, Nissen E, Norman M. Is it necessary to suture all lacerations after a vaginal delivery? Birth 2000; 27:79.
- Fleming VE, Hagen S, Niven C. Does perineal suturing make a difference? The SUNS trial. BJOG 2003; 110:684.
- 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.
- Lewicky-Gaupp C, Leader-Cramer A, Johnson LL, et al. Wound complications after obstetric anal sphincter injuries. Obstet Gynecol 2015; 125:1088.
- Goldaber KG, Wendel PJ, McIntire DD, Wendel GD Jr. Postpartum perineal morbidity after fourth-degree perineal repair. Am J Obstet Gynecol 1993; 168:489.
- Williams MK, Chames MC. Risk factors for the breakdown of perineal laceration repair after vaginal delivery. Am J Obstet Gynecol 2006; 195:755.
- 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.
- Thompson JD. Relaxed vaginal outlet, rectocele, fecal incontinence, and rectovaginal fistula. In: TeLinde's Operative Gynecology, 7th ed, Thompson JD, Rock JA (Eds), JB Lippincott, Philadelphia 1992. p.941.
- Dudley LM, Kettle C, Ismail KM. Secondary suturing compared to non-suturing for broken down perineal wounds following childbirth. Cochrane Database Syst Rev 2013; 9:CD008977.
- Ramin SM, Gilstrap LC 3rd. Episiotomy and early repair of dehiscence. Clin Obstet Gynecol 1994; 37:816.
- Hankins GD, Hauth JC, Gilstrap LC 3rd, et al. Early repair of episiotomy dehiscence. Obstet Gynecol 1990; 75:48.
- 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.
- Monberg J, Hammen S. Ruptured episiotomia resutured primarily. Acta Obstet Gynecol Scand 1987; 66:163.
- Ramin SM, Ramus RM, Little BB, Gilstrap LC 3rd. Early repair of episiotomy dehiscence associated with infection. Am J Obstet Gynecol 1992; 167:1104.
- 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.
- Nelson RL, Gladman E, Barbateskovic M. Antimicrobial prophylaxis for colorectal surgery. Cochrane Database Syst Rev 2014; 5:CD001181.
- Chiarelli P, Cockburn J. Postpartum perineal management and best practice. Aust Coll Midwives Inc J 1999; 12:14.
- Kettle C, Tohill S. Perineal care. BMJ Clin Evid 2011; 2011.
- Rosenberg J, Kehlet H. Early discharge after external anal sphincter repair. Dis Colon Rectum 1999; 42:457.
- Mahony R, Behan M, O'Herlihy C, O'Connell PR. Randomized, clinical trial of bowel confinement vs. laxative use after primary repair of a third-degree obstetric anal sphincter tear. Dis Colon Rectum 2004; 47:12.
- Minassian VA, Jazayeri A, Prien SD, et al. Randomized trial of lidocaine ointment versus placebo for the treatment of postpartum perineal pain. Obstet Gynecol 2002; 100:1239.
- Hedayati H, Parsons J, Crowther CA. Topically applied anaesthetics for treating perineal pain after childbirth. Cochrane Database Syst Rev 2005; :CD004223.
- PREOPERATIVE PREPARATION
- CHOICE OF SUTURE
- SURGICAL TECHNIQUE
- Third and fourth degree tears
- First and second degree tears
- Third and fourth degree lacerations
- MEDIOLATERAL EPISIOTOMY REPAIR
- SECONDARY REPAIR OF EPISIOTOMY BREAKDOWN
- Early versus delayed repair
- Wound care
- Preoperative preparation
- POSTOPERATIVE CARE
- MANAGEMENT OF FUTURE DELIVERIES
- DELAYED SURGICAL MANAGEMENT OF THE DISRUPTED ANAL SPHINCTER
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS