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This article reviews complications that may occur following perineal trauma, techniques to help prevent these complications, and best practices for management using case vignettes.
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.
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).
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
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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
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.
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.
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. Ã°skender C1, TopÃ§u 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-DomÃ¨nech M1, SÃ¡nchez E, EspuÃ±a- Pons M; Pelvic Floor Research Group (Grup de Recerca del SÃ²l PelviÃ ; 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, MuÃ±oz 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. BÃ¸ K1, Hilde G2, StÃ¦r-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.