Perineal Laceration Repair

Aka: Perineal Laceration Repair, Episiotomy Repair, Obstetric Laceration Repair, Obstetrical Laceration, Female Perineal Laceration, First-degree Perineal Laceration, Second Degree Perineal Laceration, Third Degree Perineal Laceration, Fourth Degree Perineal Laceration

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II. Precautions

  1. Routine episiotomy offers no maternal benefits
    1. Limit use to fetal indications
    2. Hartmann (2005) JAMA 293:2141-8 [PubMed]

III. Epidemiology

  1. Perineal and vaginal Lacerations complicate vaginal deliveries in 79% of cases

IV. Definitions

  1. Anal Sphincter Complex
    1. Large External anal sphincter (Striated Muscle)
    2. Capsule
    3. Small Internal Anal Sphincter (involuntary Smooth Muscle, difficult to identify on exam)

V. Grading: Perineal Lacerations

  1. Perineal Lacerations WITHOUT anal sphincter involvement (50% of vaginal deliveries)
    1. First degree Laceration
      1. Vaginal Laceration
      2. Perineal skin torn without Muscle involvement
    2. Second degree Laceration
      1. First degree Laceration and
      2. Perineal Muscles torn
  2. Perineal Lacerations WITH anal sphincter involvement (3% of perineal Lacerations)
    1. Third degree Laceration
      1. Second degree Laceration and
      2. External anal sphincter torn
        1. Degree 3a: External anal sphincter torn<50%
        2. Degree 3b: External anal sphincter torn>50%
        3. Degree 3c: External AND internal anal sphincter torn
    2. Fourth degree Laceration (<0.5% of perineal Lacerations)
      1. Third degree Laceration AND
      2. Complete anal sphincter complex tear AND
      3. Rectal mucosa torn

VI. Risk Factors: Third and Fourth Degree Perineal Lacerations (anal sphincter involvement)

  1. Age <20 years
  2. Asian ethnicity
  3. Nulliparous
  4. Vaginal Birth after Cesarean
  5. Large fetal weight (>4000 g or 8 lb 13.1 oz)
  6. Occipitotransverse position
  7. Occipitoposterior position
  8. Epidural Anesthesia (mixed)
    1. Epidural Anesthesia reduces overall risk of perineal Lacerations
    2. Anal sphincter involvment is more likely in the perineal Lacerations that do occur
  9. Delivery Factors
    1. Lithotomy position for delivery
    2. Midline episiotomy
    3. Operative Vaginal Delivery (Vacuum Assisted Delivery, Forceps Assisted Delivery)
    4. Oxytocin
    5. Prolonged Second Stage of Labor (>1 hour)

VII. Preparation

  1. Suture
    1. Polyglactin 910 (Vicryl) or Monofilament Polydioxanone
      1. Vicryl 3-0 on CT-1 needle
        1. Used to close vaginal mucosa and perineal Muscles
      2. Vicryl 4-0 on SH needle
        1. Used to close perineal skin
        2. Used to close rectal mucosa
      3. Efficacy
        1. Polyglactin is less associated with discomfort
        2. Greenberg (2004) Obstet Gynecol 103:1308-13 [PubMed]
    2. Polydioxanone sulfate (PDS)
      1. PDS 2-0 on CT-1 needle
        1. Used to close external anal sphincter
  2. Anesthetic
    1. Lidocaine 1%
    2. Syringe 10 cc with 27 gauge 1.5 inch needle
  3. Instruments
    1. Needle driver
    2. Hemostats
    3. Suture scissors and Metzenbaum scissors
    4. Forceps with teeth
    5. Gelpi or Deaver retractor (as needed for third and fourth perineal Lacerations)
    6. Allis Clamps (2)

VIII. Management: General Approach

  1. Good lighting and tissue exposure allows for adequate Hemostasis, anatomic reapproximation, anal sphincter repair
  2. Minor Lacerations (first and Second Degree Perineal Lacerations)
    1. First and Second Degree Perineal Lacerations with adequate Hemostasis do not require suturing
      1. Outcomes between repair and no repair are similar at 8 weeks
      2. Pain (including Dyspareunia) is less without repair at 3 months
      3. ACOG supports both conservative treatment (no repair) and perineal repair
      4. Elharmeel (2011) Cochrane Database Syst Rev (8): CD008534 [PubMed]
    2. Other minor vaginal and vulvar Lacerations
      1. Minor vaginal wall, periclitoral, periurethral or labial tears do not require repair
      2. Repair is only indicated for Hemostasis and correction of distorted tissue

IX. Management: Vaginal Laceration Repair

  1. Description
    1. Closure of vaginal mucosa and rectovaginal fascia or septum (behind hymenal ring)
    2. Vaginal tears may involve both sides of vaginal floor
  2. General
    1. Indicated in first through fourth degree Lacerations
    2. Repaired with Vicryl 3-0 on CT-1 needle
  3. Anchor Suture 1 cm above apex of vaginal Laceration
  4. Use continuous, Running stitch (continuous) to close vaginal mucosa
    1. Locking Suture is optional (used for Hemostasis)
    2. Continuous RunningSuture is preferred over interrupted, associated with less pain
  5. Each pass should include
    1. Vaginal mucosa
    2. Rectovaginal fascia (important for vaginal support)
  6. Continue RunningSuture up to hymenal ring
    1. May be tied off proximal to hymenal ring or
    2. May be passed under hymenal ring to perineum
      1. May be used for closing perineal skin (see below)

X. Management: Perineal Muscle repair

  1. Description
    1. Bulbocavernosus and transverse perineal Muscle reapproximated and closed
  2. General
    1. Indicated in second through fourth degree Lacerations
    2. Repaired with Vicryl 3-0 on CT-1 needle
    3. Avoid locking Suture
  3. Close each Muscle body with interrupted figure 8 Suture
    1. Closure of bulbocavernosus Muscle
      1. Located immediately below introitus
      2. Located above transverse perineal Muscle
    2. Closure of transverse perineal Muscle
      1. Located above external anal sphincter

XI. Management: Rectal mucosa and internal sphincter repair

  1. Performed by most experienced clinician
  2. Repair before the external anal sphincter
  3. Description
    1. Closure of rectal mucosa
    2. Closure of internal anal sphincter
  4. General
    1. Indicated in fourth degree Lacerations
    2. Closed with Vicryl 4-0 on SH needle
    3. Gelpi retractor used to maximize visualization
  5. Close rectal mucosa with RunningSuture
    1. Start above apex of rectal mucosal tear
    2. Keep Suture passes closely spaced
    3. Do not Suture complete thickness of rectal mucosa
      1. Risk of Anal Fistula formation
    4. Continue Suture to anal verge on perineal skin
  6. Close internal anal sphincter
    1. Allis clamp placed at each end of internal sphincter
    2. Close internal anal sphincter with monofilament PDS 3-0 on tapered needle

XII. Management: External anal sphincter repair

  1. Description
    1. Closure of external anal sphincter
  2. General
    1. Indicated in third and fourth degree Lacerations
    2. Repaired with Polydioxanone (PDS) 2-0 on CT-1 needle
  3. Identify external anal sphincter ends
    1. Clamp each external anal sphincter Muscle
    2. Must include rectal sphincter sheath (capsule)
      1. Must be included in closure for adequate strength
  4. Close external anal sphincter
    1. Option 1: End to end external anal sphincter closure
      1. Standard method and preferred for partial spincter Lacerations
        1. Some studies have shown with poorer functional outcomes compared with option 2
        2. However later studies have shown similar outcomes
        3. Farrell (2012) Obstet Gynecol 120(4): 803-8 [PubMed]
        4. Kammerer-Doak (1999) Am J Obstet Gynecol 181:1317 [PubMed]
        5. Rygh (2010) Acta Obstet Gynecol Scand 89(10):1256-62 [PubMed]
      2. Close sphincter with 4 interrupted Sutures including the connective tissue
        1. Simple interrupted Sutures or figure of 8
          1. Figure of 8 Suture may provide better support, but may risk tissue ischemia
          2. British guidelines recommend simple interrupted Suture
        2. First
          1. Posterior (3:00) position including capsule
        3. Next
          1. Inferior (6:00) position
          2. Superior (12:00) position
        4. Last
          1. Anterior (9:00) position
    2. Option 2: Overlapping external anal sphincter closure
      1. May be preferred method due to better outcomes
      2. May require dissection of spincter ends to allow for overlap
      3. Overlap each end of external anal sphincter
        1. Allow sufficient overlap to place 3 Sutures
      4. Place 3 mattress Sutures through overlapped edges
        1. Pass Suture through superior end and inferior end
        2. Pass Suture through inferior, then superior end
        3. Tie at top overlying superior sphincter edge

XIII. Management: Perineal Skin Repair

  1. Description
    1. Bulbocavernosus and transverse perineal Muscle closed
  2. General
    1. Indicated in first through fourth degree Lacerations
    2. Closure of perineal skin is controversial
      1. May be associated with higher rate perineal pain
        1. Gordon (1998) Br J Obstet Gynaecol 105:435-40 [PubMed]
      2. Some advocate closure only as needed
        1. Indicated if skin not well approximated
      3. Surgical glue has been used with less pain and similar outcome for first degree Lacerations
        1. Feigenberg (2014) Biomed Res Int +PMID: 25089271 [PubMed]
    3. Repair materials
      1. Vicryl 4-0 on SH needle or
      2. Vicryl 3-0 on CT-1 continued from vaginal mucosa
  3. Running deep Suture
    1. Start unlocked continuous Suture from below introitus (anterior to hymenal ring)
      1. May be continued from vaginal mucosa
        1. Passed from behind hymenal ring via deep layer
    2. Continue RunningSuture down to posterior tear edge
  4. Running subcuticular Suture
    1. Subcuticular Suture starts at posterior perineal tear
    2. Run back up to introitus
    3. Tie off perineal skin Suture
      1. Pass through deep tissue and tie behind hymen or
      2. Tie deep to perineal skin

XIV. Management: Home

  1. Constipation Prevention
    1. Osmotic Laxatives (e.g. Miralax) to prevent Constipation and straining at stool
    2. Decreases risk of perineal repair breakdown
    3. Avoid Opioids
    4. Avoid rectal suppositories
  2. Analgesia
    1. Cool compress to perineum for first 2 days after delivery
    2. Acetaminophen alternated with NSAIDs (e.g. Ibuprofen) offers sufficient analgesia
    3. Consider local infection if pain is severe enough to require Opioid Analgesics
    4. Avoid Topical Analgesics (ineffective)
  3. Pelvic Floor Exercises
    1. Start 2-3 days after delivery

XV. Complications

  1. Local lnfection
  2. Chronic perineal pain including Sexual Dysfunction (e.g. Dyspareunia)
    1. Associated with perineal skin closure
  3. Urinary Incontinence and Fecal Incontinence
    1. Associated with third and fourth degree tears
    2. Liquid Stool Incontinence at 5 years in 17% of anal sphincter injuries (double the risk of first and second degree tears)
  4. Anal Fissure
    1. Associated with fourth degree tears

XVI. Prevention: Perineal Lacerations

  1. Antepartum
    1. Digital perineal self massage starting at 35 weeks
      1. Beckmann (2013) Cochrane Database Syst Rev (4): CD005123 [PubMed]
  2. Second Stage of Labor
    1. Perineal massage
    2. Warm compress to perineum
  3. Delivery
    1. Perineal support
      1. First and second fingers of one of examiner's hands pinches together mid-posterior perineum
      2. Other hand slows delivery of fetal head
  4. Avoid unhelpful maneuvers that do not reduce third or Fourth Degree Perineal Lacerations
    1. Avoid midline episiotomy (aside from other indication such as Shoulder Dystocia Management)
    2. Avoid mediolateral episiotomy
  5. Other measures that do NOT reduce third or Fourth Degree Perineal Lacerations
    1. Altering birth position

XVII. References

  1. Arnold (2021) Am Fam Physician 103(12): 745-52 [PubMed]
  2. Leeman (2003) Am Fam Physician 68:1585-90 [PubMed]
  3. Marquardt in Pfenninger (1994) Procedures, p. 785-93
  4. Miller (1989) Obstetrics Illustrated, p. 374-6

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