Practice Bulletin No. 165 Summary: Prevention and Management of Obstetric Lacerations at Vaginal Delivery
Lacerations are common after vaginal birth. Trauma can occur on the cervix, vagina, and vulva, including the labial, periclitoral, and periurethral regions, and the perineum. Most of these lacerations do not result in adverse functional outcomes. Severe perineal lacerations, extending into or through the anal sphincter complex, although less frequent, are more commonly associated with increased risk of pelvic floor injury, fecal and urinary incontinence, pain, and sexual dysfunction with symptoms that may persist or be present many years after giving birth. The purpose of this document is to provide evidence-based guidelines for the prevention, identification, and repair of obstetric lacerations and for episiotomy.
Clinical Management Questions
- What are prevention strategies for severe obstetric lacerations?
- What are the indications for episiotomy in contemporary obstetric practice?
- How does episiotomy affect the rate and severity of perineal lacerations?
- Which obstetric lacerations should be repaired?
- How should lacerations other than OASIS be repaired?
- What technique should be used for repair of lacerations that involve the internal and external anal sphincter?
- What are the immediate sequelae and long-term effects of severe perineal trauma?
- How should women with OASIS be managed postpartum?
- How should women with perineal lacerations be counseled about delivery in subsequent pregnancies?
Recommendations and Conclusions
The following recommendations are based on good and consistent scientific evidence (Level A):
- Because application of warm perineal compresses during pushing reduces the incidence of third-degree and fourth-degree lacerations, obstetrician–gynecologists and other obstetric care providers can apply warm compresses to the perineum during pushing to reduce the risk of perineal trauma.
- Restrictive episiotomy use is recommended over routine episiotomy.
- For full-thickness external anal sphincter lacerations, end-to-end repair or overlap repair is acceptable.
- A single dose of antibiotic at the time of repair is recommended in the setting of OASIS.
The following recommendations are based on limited or inconsistent scientific evidence (Level B):
- Perineal massage during the second stage of labor may help reduce third-degree and fourth-degree lacerations.
- If there is need for episiotomy, mediolateral episiotomy may be preferred over midline episiotomy because of the association of midline episiotomy with increased risk of injury to the anal sphincter complex; however, mediolateral episiotomy is associated with an increased likelihood of perineal pain and dyspareunia.
- Either standard suture or adhesive glue may be used to repair a hemostatic first-degree laceration or the perineal skin of a second-degree laceration.
- Continuous suturing of a second-degree laceration is preferred over interrupted suturing.
The following recommendations are based primarily on consensus and expert opinion (Level C):
- Stool softeners and oral laxatives should be prescribed to women who sustain OASIS, and counseling postpartum should include discussing ways to avoid constipation.
- Women who have a history of OASIS should be counseled that the absolute risk of a recurrent OASIS is low with a subsequent vaginal delivery; however, it is reasonable to perform a cesarean delivery based on patient request after advising of the associated risks.
- If the internal anal sphincter can be adequately identified, repair has been recommended either as a part of the distal portion of the reinforcing second layer of the rectal muscularis using a 3-0 polyglactin suture or separately from the external anal sphincter using a 3-0 monofilament polydioxanone suture.
Studies were reviewed and evaluated for quality according to the method outlined by the U.S. Preventive Services Task Force. Based on the highest level of evidence found in the data, recommendations are provided and graded according to the following categories:
Level A—Recommendations are based on good and consistent scientific evidence.
Level B—Recommendations are based on limited or inconsistent scientific evidence.
Level C—Recommendations are based primarily on consensus and expert opinion.© 2016 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved.