Case vignette: A 23-year-old G1P1 with a fourth-degree laceration presents 6 weeks postpartum with a complaint that on defecation, stool is coming out of her vagina.
Diagnosis: Rectovaginal fistula/perineal-rectal fistulas
Rectovaginal fistulas (RVFs) may develop from poor-healing, unidentified, or unrepaired perineal lacerations. In the United States, fistula rates following perineal trauma have declined over the past 30 years.10 Patients with fistulas may complain of stool, gas, or foul discharge from the vagina. Women who have sustained a third- or fourth-degree laceration are at particular risk for RVF development, although the incidence remains low.11,12 Identification of a rectovaginal or perineal rectal fistula may be aided by dyeing the gel used during a rectal exam blue and attempting to push it up through the fistula tract. A dimple or indentation on the perineum may represent a fistula tract. Vaginoscopy and exam under anesthesia can help to make the diagnosis. Repair by physicians familiar with fistula repairs is recommended and for complex repairs, the involvement of multiple specialists such as urogynecologic and colorectal surgeons may be necessary.12 The type of repair should be tailored to the patient’s presentation.13
Case vignette: A 34-year-old G1P1 at 24 hours post—vacuum-assisted delivery complains of increased perineal pressure and pain. She is tachycardic and visibly uncomfortable. On exam, there is an expanding 12 x 15-cm labial mass.
Diagnosis: Puerperal genital hematomas
Puerperal genital hematomas (PGH), while rare (occurring in 1 per 500 to 1 per 12,500 deliveries),15 may become life-threatening obstetric emergencies. Risk factors for PGH include nulliparity, instrumental delivery, and mediolateral episiotomy.15 Rupture of the anterior branches of the internal iliac artery are frequently responsible for PGH.16 PGH may present as vulvar or vaginal damage to branches of the uterine artery and may dissect into the retroperitoneal space, remaining clinically occult. In this situation an ultrasound, computed tomography, or magnetic resonance imaging may be useful in confirming the diagnosis. Vaginal-perineal hematomas may also dissect into the ischiorectal fossa. While not avoidable, identification and careful repair of all bleeding lacerations at the time of delivery helps to limit PGH.
Identification of PGH is paramount; careful vaginal and perineal examination will help decide further care as management of PGH depends on patient hemodynamic stability, PGH location and size. One option for a hematoma that appears stable (ie, non-expanding) is careful monitoring, which may include serial hematocrits, repetitive examinations, and transfusion or fluid resuscitation for the patient as appropriate. Other options to consider for unstable patients or expanding hematomas include exam under anesthesia with repair, packing, or drain placement. Interventional radiology to occlude the bleeding vessel may be helpful in the case of retroperitoneal hematomas. However, access to interventional radiology may be limited so careful attention to the stability of the patient is key to ensure transfer to a higher level of care if necessary.17
Case vignette: A 38-year-old G2P2 smoker who had a mediolateral episiotomy to expedite delivery for fetal distress presents 5 days postpartum with increasing perineal pain and malodorous discharge.
Diagnosis: Perineal infection/wound breakdown
Infections and wound breakdown may complicate laceration healing. Risk factors for breakdown of a perineal laceration include operative deliveries, mediolateral episiotomy, and meconium-stained amniotic fluid.18 Severe third- and fourth-degree lacerations are more prone to infection and break down. A single dose of broad-spectrum antibiotics (such as cefotetan or cefoxitin) at the time of third- or fourth-degree laceration repair is recommended.19,20 Women who sustain a third- or fourth-degree laceration should return for early follow-up for wound evaluation and to aid early identification of wound breakdown/infection.20
Limited evidence-based guidelines exist for treatment of wound breakdown and infection.21 Careful examination of the wound should include rectal examination to evaluate for unrecognized fourth-degree laceration, which could further contribute to wound infection and breakdown. Some evidence indicates that early closure of dehisced episiotomy or laceration repair may also be an option, but only after all evidence of infection has resolved.22 Antibiotics that cover skin flora, such as amoxicillin or cephalexin, should be given when signs of infection such as purulent exudate, erythema, or fever are present.