Case vignette continued: After 3 days of oral antibiotics, the patient returns complaining of increased pain and fever. On examination, you see a black wound with foul smell and crepitus.
Diagnosis: Necrotizing fasciitis
Perineal infection and breakdown is a rare cause of necrotizing fasciitis (NF). The reported incidence of NF postpartum has risen from 1.1 to 3.8 per 100,000 total estimated pregnancies per year.23 Laboratory findings may include leukocytosis with left shift, elevated creatinine kinase and lactate. Blood and wound cultures are recommended. Radiographic imaging may help determine what tissue is involved by demonstrating gas in the tissue planes but it is not necessary for the diagnosis. Suspected NF based on exam findings including crepitus, a black eschar and decreased sensation of the wound requires intervention. Treatment includes prompt surgical exploration and wide debridement of necrotic tissue. Broad-spectrum antibiotics are essential and hemodynamic support is often necessary.24
Case vignette: An 18-year-old G1P1 has increasing abdominal distention 12 hours after delivery with a repaired second-degree laceration and inability to pass urine for 6 hours. Her second stage lasted approximately 3 hours with good explosive efforts.
Diagnosis: Puerperal urinary retention
Spontaneous voiding after delivery should be monitored. Depending on the definition, the prevalence of puerperal urinary retention (PUR) ranges from 0.45% to 14.1%.25 Risk factors for PUR include nulliparity, longer labor, instrumental delivery, lacerations, and epidural anesthesia.26 A simple way to check for urinary retention is a bladder scanner (ultrasound). However, because a bladder scanner is not specific, sometimes a postpartum uterus or free fluid in the pelvis can falsely elevate the measured postvoid residual (PVR). If urinary retention is suspected, a catheter should be placed and continuous drainage initiated until the patient is ready for a voiding trial. One way to perform a voiding trial is to backfill the bladder with 300 mL of normal saline, remove the catheter, and have the patient attempt to void. Other clinicians remove the catheter, wait for spontaneous voiding, and then check a PVR with bladder scan. While a normal PVR has not been determined, some providers use a cutoff of < 100 mL or 1/3 the voided volume. Women who develop PUR with a delayed or missed diagnosis may develop long-term voiding dysfunction. If there is ongoing voiding dysfunction or a patient is unable to pass a voiding trial or to resume spontaneous voiding, she should be managed with either an indwelling catheter or intermittent self-catheterization until referral to an appropriate specialist can be accomplished.
Case vignette: A 27-year-old G1P1 complains of painful intercourse 8 weeks after a vaginal delivery of a 4-kg male complicated by a second-degree laceration.
Approximately 41% to 83% of women at 2 to 3 months postpartum report sexual dysfunction, including dyspareunia.27 Risk factors for development of postpartum dyspareunia are not well known. Routine episiotomy is associated with more pain and slower time to first intercourse than when episiotomy use is restricted, or in women who sustain spontaneous lacerations.28 A recent study revealed that OASIS was a strong predictor of delayed resumption of intercourse and the strongest predictor of dyspareunia postpartum compared to that in women without sphincter laceration.29
Longer longitudinal data 6 to 11 years after first delivery suggest that women who deliver vaginally with perineal trauma either from a spontaneous laceration or episiotomy do not have increased rates of dyspareunia. However perineal trauma from forceps or a baby ≥ 4 kg remain associated with dyspareunia.28,30 Importantly, cesarean delivery carries the same risk of dyspareunia as vaginal delivery 6 to 11 years after first delivery.30 Experts recommend assessing the perineum when dyspareunia is present and encouraging patients to use vaginal lubricants during intercourse.27 Women with levator spasms following perineal laceration may benefit from physical therapy. Significant scarring that leads to vaginal stenosis may require surgical revision or use of vaginal dilators.
Case vignette: A 32-year-old G3P3 reports urinary incontinence while jogging with her 4-month-old. She sustained only a minor first-degree laceration at the time of her delivery.
Diagnosis: Stress urinary incontinence
The incidence of stress urinary incontinence (SUI) during pregnancy is 39.1% and increases with each trimester.31 Developing SUI during pregnancy is a risk factor for having postpartum SUI. Fortunately, the majority of women (72.4% in one study) have resolution of their symptoms over time.32 Options for management of persistent SUI include physical therapy, pessaries, incontinence tampons, and surgery. Most physicians would wait to perform an anti-incontinence procedure until a patient’s childbearing is complete, and delay surgical therapy until at least 6 months after delivery because symptoms may resolve.