Perineal Lacerations

Excerpt

Obstetric perineal lacerations, frequently occurring during childbirth, can affect the perineum, labia, vagina, and cervix. While most lacerations heal without long-term issues, severe cases can result in prolonged pain, sexual dysfunction, and embarrassment. These severe lacerations need prompt identification and proper repair during delivery. Perineal trauma is common in vaginal births, with lacerations occurring spontaneously or due to medical interventions like episiotomies. The majority of these lacerations are first- or second-degree and usually require suturing. However, severe lacerations, particularly obstetric anal sphincter injuries, which occur in approximately 4% to 11% of vaginal deliveries in the United States, can lead to significant complications like pelvic floor dysfunction and incontinence.

Risk factors for perineal lacerations include first-time childbirth, operative deliveries, larger babies, certain fetal positions, and specific maternal factors such as age and ethnicity. Episiotomies, particularly the midline type, are linked with higher rates of severe lacerations, although mediolateral episiotomies, while harder to repair, can reduce severe tears. Episiotomy use is now more restricted, with guidelines recommending it only when necessary. Most first-degree lacerations do not require suturing unless there is significant bleeding or anatomical distortion. For second-degree tears, continuous suturing is preferred to reduce postpartum pain. Third- and fourth-degree lacerations involve a more complex repair process, often requiring stepwise techniques to restore both the perineal and rectal tissues. Follow-up care following perineal laceration repair is crucial and includes pain management, preventing constipation, and monitoring for urinary retention. Infection and wound breakdown are potential complications, with long-term issues including incontinence and dyspareunia. Preventative measures, such as perineal massage in late pregnancy and careful intrapartum techniques, can help reduce the risk and severity of perineal lacerations.