Obstetric Lacerations: Prevention and Repair

 

Am Fam Physician. 2021 Jun 15;103(12):745-752.

Published online: April 19, 2021.

Author disclosure: No relevant financial affiliations.

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

WHAT'S NEW ON THIS TOPIC

Obstetric Lacerations

Surgical glue repairs of hemostatic first-degree lacerations are faster, require less anesthetic, and cause less pain than suture repairs with similar results at six weeks postpartum.

Approximately 3% of obstetric lacerations involve clinically evident obstetric anal sphincter injuries, which double the risk of fecal incontinence at five years postpartum.

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingComments

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


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.

The Authors

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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.

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