Obstetric Lacerations: Prevention and Repair

Obstetric lacerations are a common complication of vaginal delivery. Lacerations can lead to chronic pain and urinary and fecal incontinence. Perineal lacerations are defined by the depth of musculature involved, with fourth-degree lacerations disrupting the anal sphincter and the underlying rectal mucosa and first-degree lacerations having no perineal muscle involvement. Late third-trimester perineal massage can reduce lacerations in primiparous women; perineal support and massage and warm compresses during the second stage of labor can reduce anal sphincter injury. Conservative care of minor hemostatic first- and second-degree lacerations without anatomic distortion reduces pain, analgesia use, and dyspareunia. Minor hemostatic lesions with anatomic disruption can be repaired with surgical glue. Second-degree lacerations are best repaired with a single continuous suture. Lacerations involving the anal sphincter complex require additional expertise, exposure, and lighting; transfer to an operating room should be considered. Limited evidence suggests similar results from overlapping and end-to-end external sphincter repairs. Postdelivery care should focus on controlling pain, preventing constipation, and monitoring for urinary retention. Acetaminophen and nonsteroidal anti-inflammatory drugs should be administered as needed. Opiates should be avoided to decrease risk of constipation; need for opiates suggests infection or problem with the repair. Osmotic laxative use leads to earlier bowel movements and less pain during the first bowel movement. Simulation models are recommended for surgical technique instruction and maintenance, especially for third- and fourth-degree repairs.

Perineal and vaginal lacerations are common, affecting as many as 79% of vaginal deliveries, and can cause bleeding, infection, chronic pain, sexual dysfunction, and urinary and fecal incontinence.^1,2

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

Grading of Lacerations

Criteria from the American College of Obstetricians and Gynecologists (ACOG) help determine repair techniques and estimate prognosis.¹ Figure 1 shows the muscles affected by perineal lacerations.

**Muscular anatomy of the female perineum.**
Illustration by Dave Klemm

FIRST- AND SECOND-DEGREE LACERATIONS

First-degree lacerations involve only the perineal skin without extending into the musculature.¹ Second-degree lacerations involve the perineal muscles without affecting the anal sphincter complex.

THIRD-DEGREE LACERATIONS

Approximately 3% of lacerations involve clinically evident obstetric anal sphincter injuries, doubling the risk of fecal incontinence at five years postpartum.^3,4 These lacerations are further classified by the extent of anal sphincter injury (Table 1).¹

The majority of obstetric anal sphincter injuries are third-degree lacerations that involve the anal sphincter complex without disrupting the rectal mucosa.¹ The anal sphincter complex comprises the larger external anal sphincter containing striated muscle and a distinct capsule plus the small internal anal sphincter of involuntary smooth muscle that often cannot be identified.

FOURTH-DEGREE LACERATIONS

Fourth-degree lacerations are the most severe, involving the rectal mucosa and the anal sphincter complex.¹ Disruption of the fragile internal anal sphincter routinely leads to epithelial injury. Fourth-degree lacerations occur in less than 0.5% of patients.¹ Figure 2 shows a fourth-degree perineal laceration.

Fourth-degree perineal laceration. A fourth-degree laceration is the most severe obstetric laceration, with disruption of the perineal body (comprising the bulbospongiosus and transverse perineal muscles), the external anal sphincter, and the internal anal sphincter, which leads to disruption of the rectal mucosa. In a third-degree laceration, the injury is limited to part or all of the anal sphincter complex. In a second-degree laceration, the injury is confined to the perineal body. A first-degree laceration spares the perineal body and affects only vaginal mucosa and perineal skin.
Illustration by Dave Klemm

Prevention of Obstetric Lacerations

BEFORE DELIVERY

A Cochrane review demonstrated that digital perineal self-massage starting at 35 weeks' gestation reduces the rate of perineal lacerations in primiparous women with a number needed to treat of 15 to prevent one laceration.⁵ Because the review included fewer than 2,500 patients, reductions could not be demonstrated for specific laceration grades. Women reported that self-massage was initially uncomfortable, unpleasant, and even painful, but nearly 90% would recommend the technique to others.⁶

DURING DELIVERY

Studies of prevention during delivery have focused on prevention of obstetric anal sphincter injuries. Most risk factors involve labor management, including labor induction, labor augmentation, use of epidural anesthesia, delivery with persistent occipitoposterior positioning, and operative vaginal deliveries⁷ (Table 2^1,8,9 ). Although epidural anesthesia increases risk of obstetric anal sphincter injuries through increased operative vaginal delivery, epidural use reduces lacerations overall.¹⁰

*Information from references 1, 8, and 9*.

Several labor techniques can reduce anal sphincter injuries. During the second stage of labor, perineal massage and application of a warm compress to the perineum are beneficial.¹¹ Perineal support during delivery, variably described as squeezing the lateral perineal tissue with the first and second fingers of one hand to lower pressure in the middle posterior perineum while the other hand slows the delivery of the fetal head, reduces obstetric anal sphincter injuries, with a number needed to treat of 37 in a systematic review.^12,13

Routine episiotomy does not reduce anal sphincter lacerations and is not recommended.¹⁴ Mediolateral episiotomy is not protective for obstetric anal sphincter injuries, and midline episiotomy increases the risk.⁹ Neither delaying maternal pushing following full cervical dilation nor altering birthing position reduces obstetric anal sphincter injuries.^15,16

Evaluation for Repair

INSPECTION AFTER DELIVERY

Lacerations following vaginal delivery most commonly occur in the perineal body. Thorough perineal inspection, including a digital rectal examination, is recommended following any vaginal delivery.⁸ Proper lighting and good visualization aid evaluation focused on hemostasis, anatomic distortion, and anal sphincter integrity.²

MANAGING MINOR LACERATIONS

First- and second-degree perineal lacerations occur in approximately 50% of women, and most do not result in adverse functional outcomes.^1,2 A Cochrane review demonstrated identical clinical outcomes at eight weeks with first- and second-degree lacerations with and without surgical repair.² Leaving hemostatic, anatomically approximated first- and second-degree perineal lacerations without repair reduces pain, analgesia use, and dyspareunia at three months postpartum.² Conservative care is also associated with higher breastfeeding rates.¹⁷ Without long-term comparison of surgical and conservative care, ACOG leaves decisions to the physician's clinical judgment.¹

VAGINAL AND VULVAR LACERATIONS

Vaginal and vulvar tearing most often occurs on the vaginal wall, introitus (i.e., periclitoral, periurethral), or labia. Typically, these lacerations are superficial and require repair only for persistent bleeding or anatomic distortion such as a labial avulsion, where removed tissue disrupts skin integrity.¹

Laceration Repair Technique

ANALGESIA AND EXPOSURE

Before starting an obstetric repair, patient comfort should be verified; local anesthetic should be used if needed. Appropriate instruments and materials should be assembled (Table 3^8,18 ), and the perineum should be positioned at a comfortable height for the physician. Visualization and adequate lighting are essential. Transfer to an operating room should be considered to ensure optimal exposure and lighting when a third- or fourth-degree laceration is recognized.¹⁸ A knowledgeable repair team is also recommended, with expert consultation considered if a physician with experience in anal sphincter repair is not present.¹⁸

Several types of absorbable sutures have been demonstrated to be equivalent for perineal laceration repair.¹⁹ Absorbable synthetic sutures cause less short-term pain and pain medication use than catgut suture.²⁰ Multifilament and monofilament absorbable sutures result in similar outcomes at six weeks postpartum.²¹

VAGINAL AND VULVAR LACERATIONS

Vaginal lacerations include disruption of the vaginal floor and side walls, and vulvar lacerations include periurethral, periclitoral, or labial tears within the introitus. Small tears of these structures are often superficial and hemostatic and can be left unrepaired.^1,17 Closure methods have not been compared; interrupted or running sutures can be employed.

FIRST-DEGREE LACERATIONS: REPAIR OPTIONS

If first-degree lacerations require repair, consider use of surgical glue for hemostatic lesions. Surgical glue repairs are faster, require less local anesthetic, and cause less pain with similar functional and cosmetic results at six weeks post-partum.²² Sutures can be helpful to stop bleeding.

SECOND-DEGREE LACERATIONS: PERINEAL REPAIR

Repair of a second-degree laceration occurs in three stages: the rectovaginal fascia (also called the rectovaginal septum), the perineal body musculature, and the vaginal mucosa. Continuous suturing causes less short-term pain and pain medication use than interrupted suturing.²³ The repair should be performed in a deep to superficial manner.⁸ In addition to verifying the integrity of the anal sphincter complex, before repairing the apex of the vaginal laceration, the bulbospongiosus and transverse perineal muscles of the perineal body should be identified (Figure 1 and Figure 3). A retractor can be employed if necessary to visualize the laceration apex within the vagina.

Second-degree perineal laceration repair. A perineal laceration repair is accomplished in three stages with a continuous suture. *(A)* An anchor stitch is placed above the vaginal apex, and a running stitch is continued to the hymenal ring. *(B)* The bulbospongiosus and transverse perineal muscles are attached with continuous sutures through the capsules. *(C)* The fascia over the perineum is re-approximated if necessary, using a continuous subcuticular suture. At the hymenal ring, the suture is tied with the knot directed into the vagina.
Illustration by Dave Klemm

Vaginal Repair. After placing an anchoring suture 1 cm above the vaginal laceration apex, a running stitch is used to close vaginal mucosa and underlying fascia (Figure 3A). Locking sutures can be used if needed for hemostasis. After the running sutures are brought to the hymenal ring, proceed to the perineal muscle repair.

Perineal Muscle Repair. The ends of the bulbospongiosus muscle are reapproximated with one or two running sutures without locking, using an Allis clamp or needle to extend retracted muscle ends if necessary. The transverse perineal muscle ends are then similarly approximated (Figure 3B).

Rectovaginal Fascia Repair. The repair is finished by a running suture in the subcutaneous fascia ending at the hymenal ring (Figure 3C). The knot should be directed into the vagina behind the hymen. The skin does not require closure because a skin suture layer increases perineal pain at three months postpartum.²⁴

THIRD-DEGREE LACERATIONS: ANAL SPHINCTER COMPLEX REPAIR

The anal sphincter complex is important to future continence and, therefore, quality of life. At five years after delivery, 17% of women with obstetric anal sphincter injuries report some liquid stool incontinence compared with 8% of women who experienced a vaginal delivery without obstetric anal sphincter injuries.³

The first step of the repair involves the internal anal sphincter. If the internal anal sphincter can be identified and is disrupted, it should be repaired using an absorbable synthetic suture.¹ ACOG recommends a 3-0 monofilament suture for the internal sphincter repair.¹

There are two techniques for external sphincter repair when the sphincter is completely separated: end-to-end repair of the muscle or overlapping repair. Two small trials suggested that fecal incontinence rates are similar after either repair.^25,26 If an external sphincter laceration is partial, the end-to-end repair is recommended for the lacerated portion vs. dividing the sphincter for an overlapping repair.¹

In the overlapping technique, the free muscle ends are overlapped and joined by mattress sutures.²⁷ This technique often requires dissection of the ends of the sphincter to allow overlap.²⁸ For the end-to-end repair, the capsule is included to connect the most posterior part of the defect, followed by the superior and inferior elements of both ends, and ending with the anterior elements. Plain or figure-of-eight interrupted sutures can be used.²⁸ Similar to any muscle repair, the connective tissue is the essential element to anchor the repair. Use of a 2-0 absorbable suture is recommended for the anal sphincter (Table 4^1,18,28 ). Despite limited evidence of ischemia or repair success with figure-of-eight sutures, British guidelines recommend against their use.²⁰ Following sphincter repair, the remaining second-degree laceration is repaired, as discussed previously.

*Information from references 1, 18, and 28*.

FOURTH-DEGREE LACERATIONS: RECTAL MUCOSA REPAIR

Because of the risk and infrequency of severe lacerations, these repairs should be completed by the most experienced physicians providing obstetric care.²⁰ The rectal mucosa is repaired using an absorbable suture with a noncutting needle. A 4-0 absorbable suture is recommended (Table 4^1,18,28 ). After placing an anchor stitch with the knot within the rectum above the apex of the lesion, running sutures are placed within 0.5 cm to the anal verge.¹ A second layer of sutures is recommended to reform the internal sphincter capsule and to protect the mucosal suture layer.¹ The internal anal sphincter is small and difficult to identify; therefore, stabilization with an Allis clamp is often required.²⁹ A 3-0 suture on a tapered needle is recommended for this layer¹⁷ (Table 4^1,18,28 ). A separate repair of the internal anal sphincter is sometimes recommended because of high fecal incontinence risk from postpartum internal anal sphincter defects.^20,30 Following this repair, the external anal sphincter is repaired, as discussed previously.

After Delivery

After laceration repair, care should focus on controlling pain, preventing constipation, and monitoring for urinary retention. The patient can keep the area clean and dry by blotting after toileting.⁸

PREVENTING CONSTIPATION

Laxatives should be offered to all patients to minimize the potential for repair breakdown from straining during defecation.⁸ Osmotic laxative use leads to earlier bowel movements and less pain during the first bowel movement.³¹ Stool softeners do not appear to prevent constipation.³²

PAIN CONTROL

During the first two days after delivery, local cooling applied to the perineum appears to reduce pain.³³ Acetaminophen and nonsteroidal anti-inflammatory drugs should be sufficient for pain control.³⁴ The use of opiates should be avoided to decrease risk of constipation; a need for opiates suggests infection or a problem with the repair.⁸ Topical anesthetics are not effective, and rectal suppositories are minimally effective and increase the risk of disruption of an anal sphincter repair.^35,36

ACTIVITY

Recent ACOG recommendations view postpartum care as an ongoing, individualized process with women receiving care from the delivering physician within three weeks of delivery and continued care as needed to monitor for side effects.³⁷ To prevent urinary incontinence, pelvic floor exercises are recommended beginning two to three days after delivery, with formal pelvic floor rehabilitation with biofeedback physiotherapy an option for patients with obstetric anal sphincter injuries.^1,8

Physician Training in Perineal Repair

Physician training for obstetric laceration repairs can be challenging. Recognizing the importance of simulation for resident training, a detailed beef tongue simulation model has been recommended, with added anal canal and external anal sphincter to simulate a perineal tear.³⁸ A video from the Society of Gynecologic Surgeons demonstrates a fourth-degree repair using this model (https://www.mdedge.com/obgyn/article/189883/surgery/instructional-video-fourth-degree-obstetric-laceration-repair-using). The Advanced Life Support in Obstetrics course offered by the American Academy of Family Physicians includes instruction on obstetric laceration repair.³⁹

This article updates a previous article by Leeman, et al.^²⁹

Data Sources: PubMed searches were completed using the key terms obstetric laceration, perineal laceration, and obstetric anal sphincter injury. The searches included systematic reviews, meta-analyses, randomized controlled trials, review articles, and practice guidelines. References from these sources were monitored. We also searched the Cochrane database, Essential Evidence Plus, and Clinical Evidence. References in these resources were also searched. Search dates: March, April, May, and August 2020, and February 2021.

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Department of the Navy, Department of the Air Force, Uniformed Services University of the Health Sciences, Department of Defense, or the U.S. government.

Editor's Note: Dr. Arnold is contributing editor for AFP.

Additional Information: Dr. Leli passed away while deployed to the Middle East with the U.S. Air Force after completion of this article. An outstanding young physician, teacher, and role model, her legacy lives on in the students, residents, and colleagues whose lives she touched.

MICHAEL J. ARNOLD, MD, FAAFP, is an associate professor in the Department of Family Medicine at the Uniformed Services University of the Health Sciences, Bethesda, Md.

KERRY SADLER, MD, is a faculty member in the Naval Hospital Jacksonville (Fla.) Family Medicine Residency Program.

KELLIANN LELI, MD, was a faculty member in the Travis Air Force Base (Calif.) Family Medicine Residency at the time this article was written.

†Deceased

Address correspondence to Michael J. Arnold, MD, FAAFP, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd., Bethesda, MD 20814 (email: michael.arnold@usuhs.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

1.Committee on Practice Bulletins–Obstetrics. ACOG practice bulletin no. 198: prevention and management of obstetric lacerations at vaginal delivery. Obstet Gynecol. 2018;132(3):e87-e102.
2.Elharmeel SM, Chaudhary Y, Tan S, et al. Surgical repair of spontaneous perineal tears that occur during childbirth versus no intervention. Cochrane Database Syst Rev. 2011(8):CD008534.
3.Temtanakitpaisan T, Bunyacejchevin S, Koyama M. Obstetrics anal sphincter injury and repair technique: a review. J Obstet Gynaecol Res. 2015;41(3):329-333.
4.Evers EC, Blomquist JL, McDermott KC, et al. Obstetrical anal sphincter laceration and anal incontinence 5–10 years after childbirth. Am J Obstet Gynecol. 2012;207(5):425.e1-425.e6.
5.Beckmann MM, Stock OM. Antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev. 2013(4):CD005123.
6.Labrecque M, Eason E, Marcoux S. Women's views on the practice of prenatal perineal massage. BJOG. 2001;108(5):499-504.
7.Kudish B, Blackwell S, Mcneeley SG, et al. Operative vaginal delivery and midline episiotomy: a bad combination for the perineum. Am J Obstet Gynecol. 2006;195(3):749-754.
8.Goh R, Goh D, Ellepola H. Perineal tears—a review. Aust J Gen Pract. 2018;47(1–2):35-38.
9.Pergialiotis V, Bellos I, Fanaki M, et al. Risk factors for severe perineal trauma during childbirth: an updated meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2020;247:94-100.
10.Myrick TG, Sandri KJ. Epidural analgesia and any vaginal laceration. J Am Board Fam Med. 2018;31(5):768-773.
11.Aasheim V, Nilsen ABV, Reinar LM, et al. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev. 2017(6):CD006672.
12.Bulchandani S, Watts E, Sucharitha A, et al. Manual perineal support at the time of childbirth: a systematic review and meta-analysis. BJOG. 2015;122(9):1157-1165.
13.Laine K, Skjeldestad FE, Sandvik L, et al. Incidence of obstetric anal sphincter injuries after training to protect the perineum: cohort study. BMJ Open. 2012;2(5):e001649.
14.Jiang H, Qian X, Carroli G, et al. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017(2):CD000081.
15.Roberts CL, Torvaldsen S, Cameron CA, et al. Delayed versus early pushing in women with epidural analgesia: a systematic review and meta-analysis. BJOG. 2004;111(12):1333-1340.
16.Kibuka M, Thorton JG. Position in the second stage of labour for women with epidural anaesthesia. Cochrane Database Syst Rev. 2017(2):CD008070.
17.Lundquist M, Olsson A, Nissen E, et al. Is it necessary to suture all lacerations after a vaginal delivery?. Birth. 2000;27(2):79-85.
18.Barbieri RL. Develop and use a checklist for 3rd- and 4th-degree perineal lacerations. OBG Manag. 2013;25(8):8-12.
19.Kettle C, Dowswell T, Ismail KM. Absorbable suture materials for primary repair of episiotomy and second degree tears. Cochrane Database Syst Rev. 2010(6):CD000006.
20.Royal College of Obstetricians & Gynaecologists. The management of third- and fourth-degree perineal tears. Green-top guideline no. 29: June 2015. Accessed February 3, 2021. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-29.pdf
21.Kokanalı D, Ugur M, Kuntay Kokanalı M, et al. Continuous versus interrupted episiotomy repair with monofilament or multifilament absorbed suture materials: a randomised controlled trial. Arch Gynecol Obstet. 2011;284(2):275-280.
22.Feigenberg T, Maor-Sagie E, Zivi E, et al. Using adhesive glue to repair first degree perineal tears: a prospective randomized controlled trial. Biomed Res Int. 2014(2014):526590.
23.Kettle C, Dowswell T, Ismail KM. Continuous and interrupted suturing techniques for repair of episiotomy or second-degree tears. Cochrane Database Syst Rev. 2012(11):CD000947.
24.Gordon B, Mackrodt C, Fern E, et al. The Ipswich childbirth study: 1. A randomised evaluation of two stage postpartum perineal repair leaving the skin unsutured. Br J Obstet Gynaecol. 1998;105(4):435-440.
25.Farrell SA, Flowerdew G, Gilmour D, et al. 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 [published correction appears in Obstet Gynecol. 2012;120(6):1482]. Obstet Gynecol. 2012;120(4):803-808.
26.Rygh AB, Körner H. The overlap technique versus end-to-end approximation technique for primary repair of obstetric anal sphincter rupture: a randomized controlled study. Acta Obstet Gynecol Scand. 2010;89(10):1256-1262.
27.Meister MR, Rosenbloom JI, Lowder JL, et al. Techniques for repair of obstetric anal sphincter injuries. Obstet Gynecol Surv. 2018;73(1):33-39.
28.Malek J, Illston JD, Ballard AC, et al. Instructional video for fourth-degree obstetric laceration repair using modified beef tongue model. December 7, 2018. Accessed May 6, 2020. https://www.mdedge.com/obgyn/article/189883/surgery/instructional-video-fourth-degree-obstetric-laceration-repair-using
29.Leeman L, Spearman M, Rogers R. Repair of obstetric perineal lacerations. Am Fam Physician. 2003;68(8):1585-1590. Accessed November 3, 2020. https://www.aafp.org/afp/2003/1015/p1585.html
30.Mahony R, Behan M, Daly L, et al. Internal anal sphincter defect influences continence outcome following obstetric anal sphincter injury. Am J Obstet Gynecol. 2007;196(3):217.e1-217.e5.
31.Mahony R, Behan M, O'Herlihy C, et al. Randomized, clinical trial of bowel confinement vs. laxative use after primary repair of a third-degree obstetric anal sphincter tear. Dis Colon Rectum. 2004;47(1):12-17.
32.Castle SC, Cantrell M, Israel DS, et al. Constipation prevention: empiric use of stool softeners questioned. Geriatrics. 1991;46(11):84-86.
33.East CE, Dorward ED, Whale RE, et al. Local cooling for relieving pain from perineal trauma sustained during childbirth. Cochrane Database Syst Rev. 2020(10):CD006304.
34.Chou D, Abalos E, Gyte GML, et al. Paracetamol/acetaminophen (single administration) for perineal pain in the early postpartum period. Cochrane Database Syst Rev. 2013(1):CD008407.
35.Hedayati H, Parsons J, Crowther CA. Topically applied anaesthetics for treating perineal pain after childbirth. Cochrane Database Syst Rev. 2005(2):CD004223.
36.Hedayati H, Parsons J, Crowther CA. Rectal analgesia for pain from perineal trauma following childbirth. Cochrane Database Syst Rev. 2003(3):CD003931.
37.McKinney J, Keyser L, Clinton S, et al. ACOG committee opinion no. 736: optimizing postpartum care. Obstet Gynecol. 2018;132(3):784-785.
38.Illston JD, Ballard AC, Ellington DR, et al. Modified beef tongue model for fourth-degree laceration repair simulation. Obstet Gynecol. 2017;129(3):491-496.
39.American Academy of Family Physicians. Advanced Life Support in Obstetrics (ALSO^â). Accessed November 10, 2020. https://www.aafp.org/cme/programs/also.html

Mobility Assistive Device Use in Older Adults

Jun 15, 2021

AFP 2021: Updates, New Fellow, Top 20 Articles, AFP Statistics, and Thanking Peer Reviewers

[afp20210615p745-b1] 1.Committee on Practice Bulletins–Obstetrics. ACOG practice bulletin no. 198: prevention and management of obstetric lacerations at vaginal delivery. Obstet Gynecol. 2018;132(3):e87-e102.

[afp20210615p745-b2] 2.Elharmeel SM, Chaudhary Y, Tan S, et al. Surgical repair of spontaneous perineal tears that occur during childbirth versus no intervention. Cochrane Database Syst Rev. 2011(8):CD008534.

[afp20210615p745-b3] 3.Temtanakitpaisan T, Bunyacejchevin S, Koyama M. Obstetrics anal sphincter injury and repair technique: a review. J Obstet Gynaecol Res. 2015;41(3):329-333.

[afp20210615p745-b4] 4.Evers EC, Blomquist JL, McDermott KC, et al. Obstetrical anal sphincter laceration and anal incontinence 5–10 years after childbirth. Am J Obstet Gynecol. 2012;207(5):425.e1-425.e6.

[afp20210615p745-b5] 5.Beckmann MM, Stock OM. Antenatal perineal massage for reducing perineal trauma. Cochrane Database Syst Rev. 2013(4):CD005123.

[afp20210615p745-b6] 6.Labrecque M, Eason E, Marcoux S. Women's views on the practice of prenatal perineal massage. BJOG. 2001;108(5):499-504.

[afp20210615p745-b7] 7.Kudish B, Blackwell S, Mcneeley SG, et al. Operative vaginal delivery and midline episiotomy: a bad combination for the perineum. Am J Obstet Gynecol. 2006;195(3):749-754.

[afp20210615p745-b8] 8.Goh R, Goh D, Ellepola H. Perineal tears—a review. Aust J Gen Pract. 2018;47(1–2):35-38.

[afp20210615p745-b9] 9.Pergialiotis V, Bellos I, Fanaki M, et al. Risk factors for severe perineal trauma during childbirth: an updated meta-analysis. Eur J Obstet Gynecol Reprod Biol. 2020;247:94-100.

[afp20210615p745-b10] 10.Myrick TG, Sandri KJ. Epidural analgesia and any vaginal laceration. J Am Board Fam Med. 2018;31(5):768-773.

[afp20210615p745-b11] 11.Aasheim V, Nilsen ABV, Reinar LM, et al. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev. 2017(6):CD006672.

[afp20210615p745-b12] 12.Bulchandani S, Watts E, Sucharitha A, et al. Manual perineal support at the time of childbirth: a systematic review and meta-analysis. BJOG. 2015;122(9):1157-1165.

[afp20210615p745-b13] 13.Laine K, Skjeldestad FE, Sandvik L, et al. Incidence of obstetric anal sphincter injuries after training to protect the perineum: cohort study. BMJ Open. 2012;2(5):e001649.

[afp20210615p745-b14] 14.Jiang H, Qian X, Carroli G, et al. Selective versus routine use of episiotomy for vaginal birth. Cochrane Database Syst Rev. 2017(2):CD000081.

[afp20210615p745-b15] 15.Roberts CL, Torvaldsen S, Cameron CA, et al. Delayed versus early pushing in women with epidural analgesia: a systematic review and meta-analysis. BJOG. 2004;111(12):1333-1340.

[afp20210615p745-b16] 16.Kibuka M, Thorton JG. Position in the second stage of labour for women with epidural anaesthesia. Cochrane Database Syst Rev. 2017(2):CD008070.

[afp20210615p745-b17] 17.Lundquist M, Olsson A, Nissen E, et al. Is it necessary to suture all lacerations after a vaginal delivery?. Birth. 2000;27(2):79-85.

[afp20210615p745-b18] 18.Barbieri RL. Develop and use a checklist for 3rd- and 4th-degree perineal lacerations. OBG Manag. 2013;25(8):8-12.

[afp20210615p745-b19] 19.Kettle C, Dowswell T, Ismail KM. Absorbable suture materials for primary repair of episiotomy and second degree tears. Cochrane Database Syst Rev. 2010(6):CD000006.

[afp20210615p745-b20] 20.Royal College of Obstetricians & Gynaecologists. The management of third- and fourth-degree perineal tears. Green-top guideline no. 29: June 2015. Accessed February 3, 2021. https://www.rcog.org.uk/globalassets/documents/guidelines/gtg-29.pdf

[afp20210615p745-b21] 21.Kokanalı D, Ugur M, Kuntay Kokanalı M, et al. Continuous versus interrupted episiotomy repair with monofilament or multifilament absorbed suture materials: a randomised controlled trial. Arch Gynecol Obstet. 2011;284(2):275-280.

[afp20210615p745-b22] 22.Feigenberg T, Maor-Sagie E, Zivi E, et al. Using adhesive glue to repair first degree perineal tears: a prospective randomized controlled trial. Biomed Res Int. 2014(2014):526590.

[afp20210615p745-b23] 23.Kettle C, Dowswell T, Ismail KM. Continuous and interrupted suturing techniques for repair of episiotomy or second-degree tears. Cochrane Database Syst Rev. 2012(11):CD000947.

[afp20210615p745-b24] 24.Gordon B, Mackrodt C, Fern E, et al. The Ipswich childbirth study: 1. A randomised evaluation of two stage postpartum perineal repair leaving the skin unsutured. Br J Obstet Gynaecol. 1998;105(4):435-440.

[afp20210615p745-b25] 25.Farrell SA, Flowerdew G, Gilmour D, et al. 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 [published correction appears in Obstet Gynecol. 2012;120(6):1482]. Obstet Gynecol. 2012;120(4):803-808.

[afp20210615p745-b26] 26.Rygh AB, Körner H. The overlap technique versus end-to-end approximation technique for primary repair of obstetric anal sphincter rupture: a randomized controlled study. Acta Obstet Gynecol Scand. 2010;89(10):1256-1262.

[afp20210615p745-b27] 27.Meister MR, Rosenbloom JI, Lowder JL, et al. Techniques for repair of obstetric anal sphincter injuries. Obstet Gynecol Surv. 2018;73(1):33-39.

[afp20210615p745-b28] 28.Malek J, Illston JD, Ballard AC, et al. Instructional video for fourth-degree obstetric laceration repair using modified beef tongue model. December 7, 2018. Accessed May 6, 2020. https://www.mdedge.com/obgyn/article/189883/surgery/instructional-video-fourth-degree-obstetric-laceration-repair-using

[afp20210615p745-b29] 29.Leeman L, Spearman M, Rogers R. Repair of obstetric perineal lacerations. Am Fam Physician. 2003;68(8):1585-1590. Accessed November 3, 2020. https://www.aafp.org/afp/2003/1015/p1585.html

[afp20210615p745-b30] 30.Mahony R, Behan M, Daly L, et al. Internal anal sphincter defect influences continence outcome following obstetric anal sphincter injury. Am J Obstet Gynecol. 2007;196(3):217.e1-217.e5.

[afp20210615p745-b31] 31.Mahony R, Behan M, O'Herlihy C, et al. Randomized, clinical trial of bowel confinement vs. laxative use after primary repair of a third-degree obstetric anal sphincter tear. Dis Colon Rectum. 2004;47(1):12-17.

[afp20210615p745-b32] 32.Castle SC, Cantrell M, Israel DS, et al. Constipation prevention: empiric use of stool softeners questioned. Geriatrics. 1991;46(11):84-86.

[afp20210615p745-b33] 33.East CE, Dorward ED, Whale RE, et al. Local cooling for relieving pain from perineal trauma sustained during childbirth. Cochrane Database Syst Rev. 2020(10):CD006304.

[afp20210615p745-b34] 34.Chou D, Abalos E, Gyte GML, et al. Paracetamol/acetaminophen (single administration) for perineal pain in the early postpartum period. Cochrane Database Syst Rev. 2013(1):CD008407.

[afp20210615p745-b35] 35.Hedayati H, Parsons J, Crowther CA. Topically applied anaesthetics for treating perineal pain after childbirth. Cochrane Database Syst Rev. 2005(2):CD004223.

[afp20210615p745-b36] 36.Hedayati H, Parsons J, Crowther CA. Rectal analgesia for pain from perineal trauma following childbirth. Cochrane Database Syst Rev. 2003(3):CD003931.

[afp20210615p745-b37] 37.McKinney J, Keyser L, Clinton S, et al. ACOG committee opinion no. 736: optimizing postpartum care. Obstet Gynecol. 2018;132(3):784-785.

[afp20210615p745-b38] 38.Illston JD, Ballard AC, Ellington DR, et al. Modified beef tongue model for fourth-degree laceration repair simulation. Obstet Gynecol. 2017;129(3):491-496.

[afp20210615p745-b39] 39.American Academy of Family Physicians. Advanced Life Support in Obstetrics (ALSO^â). Accessed November 10, 2020. https://www.aafp.org/cme/programs/also.html

Clinical recommendation	Evidence rating	Comments
Digital perineal self-massage starting at 35 weeks' gestation reduces perineal lacerations during labor in primiparous women with a number needed to treat of 15 to prevent one laceration.⁵	A	Cochrane review involving four trials with 2,497 women
Perineal massage, warm compresses, and perineal support during the second stage of labor reduce anal sphincter injury.^11,12	A	Cochrane review with four studies involving 1,799 women for warm compresses, six studies involving 2,618 women for perineal massage, and a systematic review of manual perineal support including six randomized and nonrandomized studies involving 81,391 women
Repairing hemostatic first- and second-degree lacerations does not improve short-term outcomes compared with conservative care.²	B	Cochrane review involving two studies with 154 women showing similar results in both groups
During a suture repair of a first- or second-degree laceration, leaving the skin unsutured reduces pain and dyspareunia at three months postpartum.²⁴	B	Randomized controlled trial of 1,780 women with first- or second-degree lacerations
Surgical glue can repair first-degree lacerations with similar cosmetic and functional outcomes with less pain, less time, and lower local anesthetic use.²²	B	Randomized controlled trial of 102 patients, with 74 patients randomized to surgical glue
Continuous suturing of second-degree perineal tears reduces short-term pain and pain medication use.²³	A	Cochrane review involving 16 studies with 8,184 women showed improvements in continuous suture group but no differences in long-term pain
Local perineal cooling during the first three days after perineal repair reduces pain.³³	B	Cochrane review involving 10 studies with 1,825 women showed improvement in pain compared with no treatment

Degree	Description
First	Laceration of perineal skin only
Second	Laceration involving the perineal muscles but not involving the anal sphincter
Third	Laceration involving the anal sphincter muscles Less than 50% external anal sphincter involvement More than 50% external anal sphincter involvement External and internal anal sphincter
Fourth	Laceration involving the anal sphincter complex and rectal epithelium

Degree	Repair	Suture
Fourth	Anal mucosa	4-0 braided polyglactin 910 (Vicryl), SH needle or 4-0 monofilament polydioxanone (PDS), SH needle
Fourth	Perianal fascia and internal anal sphincter	3-0 braided polyglactin 910 (Vicryl), SH needle or 3-0 monofilament polydioxanone, SH needle
Third	External anal sphincter	2-0 braided polyglactin 910 (Vicryl), CT-1 needle or 2-0 monofilament polydioxanone, CT-1 needle
Second	All: vaginal mucosa with perivaginal fascia, perineal body, and perineal fascia	3-0 braided polyglactin 910 (Vicryl), CT-1 needle or 3-0 monofilament polydioxanone, CT-1 needle
First or vaginal	Any necessary due to bleeding or anatomic disruption	Consider surgical glue if hemostatic or 3-0 braided polyglactin 910 (Vicryl), CT-1 needle or 3-0 monofilament polydioxanone, CT-1 needle

My account

My account

Obstetric Lacerations: Prevention and Repair

WHAT'S NEW ON THIS TOPIC

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Grading of Lacerations