Practice development Innovations

Management of perineal and

vaginal injuries during childbirth
This article examines clinical best practice, quality data and research
pertaining to injuries of the perineum and vagina sustained during childbirth.
Prevention is essential, however the ability to recognise anal sphincter
rupture, periurethral tears and vaginal trauma is also critical to preventing
Authors:
Ruchi Puri, serious life-altering complications. Principles of treatment are outlined, while
Phyllis Leppert a future research agenda and clinical practice policies are discussed.

INTRODUCTION n Clitoridectomy (the surgical removal of the

Page points
1. Periurethral tears and vaginal trauma
are very serious and complicated injuries
Whether it is a partial or complete laceration, clitoris, common in female circumcision)
periurethral tears and vaginal trauma are very n Clitoridectomy and partial or total excision
serious and complicated injuries. Rupture of of the labia minora
the external anal sphincter during childbirth n Infibulation, clitoridectomy, excision of the

2. The anal sphinctor can be damaged also demands careful medical attention as it labia minora, labia majora and suturing
when performing an episiotomy has the potential to be a devastating injury[1, 2]. of the two sides of the remnant tissue
3. Clinicians need to develop the If unrecognised or inadequately repaired, together
knowledge and skills to prevent or these complications can lead to anal n Any other form of tissue damage such

minimise injury during childbirth
incontinence, urinary incontinence and,
in the worst scenario, fistula formation.
In circumstances where a patient has
undergone female circumcision prior to
pregnancy, the health consequences can also
be severe[3, 4].
as cauterisation, manipulation and
application of corrosive substances[2, 4].
A small opening is left for the passage of
urine and menstrual blood. Upon healing, scar
tissue bridges across the vagina.

References
1. Phillips C, Ash M. Childbirth and
the pelvic floor: the gynaecological
consequences. Reviews in
Gynaecological Practice 2005; 5:
1522.
2. Sultan AH, Thakar R. Lower
genital tract and anal sphincter
trauma. Best Pract Res Clin Obstet
Gynaecol. 2002; 16 (1): 99115.
3. Rushwas H. Female genital
mutilation (FGM) management
during pregnancy, childbirth
and the postpartum period. Int J
Gynaecol Obstet 2000; 70: 99104.
4. Leppert PC. Uniqueness of
Womens Health. Chapter I. In
Primary Care for Women, second
edition. Leppert, PC, Peipert, JK. Eds.
New York, Lippincott Williams and
Wilkins. 2004 p 23.
5. Leppert, PC. The Reproductive
Age Woman. Chapter 11. In Primary
Care for Women. Ibid. 108111.
TYPES OF INJURY
Tears of the perineum are classified according
to the type of tissue involved, however
clinicians disagree in their categorisation when
tears involve the anal sphincter (see glossary
on opposite page for definitions). It is generally
agreed that first-degree lacerations involve
the vaginal epithelium or perineal skin only.
Many of these tears, especially if small, will heal
without suturing. Second-degree lacerations
involve the perineal muscles, but not the anal
sphincter. Third-degree tears involve the anal
muscles, and fourth-degree tears involve the
anal epithelium[2].
However, there are inconsistencies in the
classification of third- and fourth-degree
tears in various obstetrics texts, with some
recommending a subclassification of third-
degree tears, which describe the extent of
trauma to the sphincter[2].
Female circumcision
Female circumcision can result in damage to
the vaginal and perineal areas, and is classified
into four types:
ANATOMY
The female perineum is a complex interlocking
area of muscles, fibrous connective tissues
and fascia, and is conceptually triangular in
shape. It provides a physical barrier between
the vagina and the rectum, anchors the
anorectum and vagina, maintains urinary and
faecal continence, and prevents expansion
of the urogenital hiatus in the levator ani
muscles. The perineal body is innervated by
the pudendal nerve, which can be damaged
during an episiotomy, a common obstetrical
procedure[5]. The anal sphincter is a strong
muscle that constantly remains in a contracted
state. When cut or torn it can either pull apart
or retract, making it difficult to identify on
visual inspection.
PREVENTION OF INJURY
It is important for clinicians to develop the
knowledge and skills to prevent or minimise
injury during childbirth. Firstly it is obligatory
for clinicians to prevent infection by hand
scrubbing, wearing sterile gloves and taking
care when handling the perineum and vulva.

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 Management of perineal and vaginal injuries during childbirth

Practice development
Vagina Vagina
Laceration
External sphincter
Internal sphincter
Anal mucosa

Figure 1- The anatomy of a typical third-degree perineal laceration

Care must also be taken to minimise faecal to slowly stretch[5, 6, 7]. Extension of the foetal
contamination of the birth canal. When head too suddenly or too soon are some of the
possible, the vagina and perineum should most common causes of periurethal tears and
be cleaned with a locally available antiseptic lacerations of the perineum.
agent before and after birth. If the foetus is in a non-vertex (non-
Secondly, it is essential to manage the head first) position, the birth is considered
second stage of labour with a controlled complicated and must be managed by
delivery that minimises trauma. Allowing clinicians in an equipped facility. This may
the patient to push voluntarily, rather than entail moving the patient to a facility capable
in a concerted effort, and placing her in a of providing caesarean delivery if the attendant
sitting or squatting position enables the feels it is safe.
foetus to descend through the birth canal in A patient with previous serious trauma of
a controlled fashion. Many patients naturally the perineum, vulva or vagina needs expert
feel an urge to push between contractions attention during childbirth so any damaged
and this is also helpful. It is estimated that tissue can be repaired, and to avoid any
pushing contributes 30% of the force needed unnecessary haemorrhage or infection.
to advance the human foetus through the In cases of haemorrhage and infection,
bony pelvis, while uterine contractions labour may become prolonged or obstructed
provide the remaining 70%[5]. causing traumatic pressure wounds to the
The foetal head should be delivered in vagina and subsequent fistula formation.
a controlled manner to help prevent both Vaginal fistula repair and healing is a
perineal tearing and periurethal lacerations. complex process and surgical correction References
Delivering the head between contractions and needs to be performed by highly skilled 6. Woodman PJ, Graney DO.
applying gentle counter pressure on the fetal clinicians. Fistulas can also form following Anatomy and physiology of
head helps to control its flexion and extension inadequate repair of vaginal, perineal and the female perineal body with
relevance to obstetrical injury
(two important mechanisms of labour) (see periurethal tears due to poor healing or
and repair. Clin Anat 2002; 15:
glossary). The idea is to allow the perineum inappropriate surgical technique. 321334.
7. Fraser, DM, Cooper, MA. Myles
Textbook for Midwives. 15th
GLOSSARY edition. 2009: 1148.
8. Hudelist G, Mastoroudes
Perineal laceration/tear: injury to the tissue located inbetween the vagina and the anus H, Gorti M. The role of
Peri-uretheral laceration: damage to tissue surrounding the urethra episiotomy is instrumental
delivery: is it preventative
Episiotomy: a deliberate surgical incision running from the vagina towards the anus (median) or angled laterally from for severe perineal injury? J
the vagina through the perineum (mediolateral) Obstet Gynaecol 2008; 28 (5):
469473.
Flexion: foetal chin moving in the direction of the foetal chest
9. McGuinness M, Norr K, Nacion
Extension: the back of the foetal head moving toward the knap of the foetal neck K. Comparisons between
different perineal outcomes
Third-degree: damage of the vagina, perineal body, and involving part of the anal sphincter
on tissue healing. J Nurse
Fourth-degree tear: damage to vagina, perineal body, anal sphincter and rectal mucosa Midwifery 1991; 36 (3):
192198.
Sitz bath: solution of water that is warm or cold and includes salt or baking soda that the patient sits in up to the hip

www.woundsinternational.com 14
 Practice development Innovations
Page points
1. There are two types of episiotomies:
midline and mediolateral
2. Training for clinicians should include
the observation and repair of a
sufficient number of episiotomies to
ensure safe practice
3. There is a need to determine the risk of
recurrence in patients following severe
childbirth injury repair
References
10. Thacker SB, Banta HD. Benefits
and risks of episiotomy, an
interpretative review of the English
language literature, 18601980.
Obstetrics and Gynecological Survey
1983; 38: 322338.
11. Fullerton JT, Thompson JB.
Examining the evidence for the
International Confederation of
Midwives essential competencies
for midwifery practice. Midwifery
2005; 21: 21.
12. World Health Organization,
Essential Surgical Care
Manual. Available at: http://
www.steinergraphics.com/
surgical/004_12.4I.html
13. Ruberg RL. Role of nutrition in
wound healing. Surg Clin North Am.
1984; 64(4): 705-14.
15 Wounds International Vol 2 | Issue 2 | Wounds International 2011
EPISIOTOMY, INSTRUMENT
DELIVERY AND THE REPAIR
OF LACERATIONS
Many recent studies indicate that
episiotomy does not prevent severe perineal
damage and thus should not be widely
practised[8, 9, 10].
There are two types of episiotomies: midline
and mediolateral. A midline episiotomy means
the surgical incision is made vertically in line
with the anus, while the mediolateral incision
is angled midway between the anus and the
ischial tuberosity.
Whether the mediolateral episiotomy
protects the perineum from trauma is
controversial, since studies have produced
contradicting results. Some experts indicate
that midline episiotomy in vaginal instrument
deliveries can lead to severe trauma and
should be avoided[8].
When an instrument delivery is indicated,
surgeons often have different preferences.
For example, US clinicians tend to use forceps
and a midline episiotomy, while European
clinicians use the vacuum extractor and
mediolateral episiotomy[8].
The recommended method of repair is
continuous suture with polyglactin suture as
this is associated with the best outcome[2].
These studies also show the increased risk
for severe trauma extending into the anal
sphincter with the use of episiotomy [Fig 1].
As noted previously, a sphincter laceration
may go unnoticed by clinicians necessitating
routine systematic inspection of the vagina
with adequate exposure and lighting for
all deliveries. Training for clinicians should
include the observation and repair of a
sufficient number of episiotomies to ensure
safe practice[2, 5,10,11]. This training should also
extend to periurethral tears, recognising
anal sphincter tears and periurethal tears
extending into the urethra.
In the past, it has been taught that a severe
laceration involving the anus should be
repaired as soon as diagnosed, but Sultan and
Thakar state in their research that delaying a
repair could be justified until an experienced
clinician is available[2]. They believe that all anal
sphincter lacerations should be repaired in an
operating room where there is better lighting,
sterility and access to appropriate surgical
instruments[2].
The World Health Organizations Essential
Surgical Repair Manual recommends a
one-time administration of ampicillin with
metronidazole orally for prophylaxis[12]. Stool
softeners also have shown positive outcomes
by preventing constipation.
HEALING
Keeping the wound clean with routine sitz
baths (see glossary), reinforcing personal
hygiene (such as washing ones hands before
using the toilet and cleansing the perineum
after using the toilet) and ensuring that the
patient has adequate nutrition following
childbirth can help prevent further
complications and promote a good quality
of life[13].
Those who have sustained childbirth
injuries that involve the anus should be
examined by a competent professional
six to eight weeks after birth so a careful
history of bowel, bladder and sexual
function can be taken alongside a rectal
and vaginal examination.
It is recommended by some that patients
with severe childbirth trauma necessitating
anal sphincter repair undergo caesarean
section in subsequent pregnancies[2],
but many other clinicians disagree and
recommend vaginal birth. Unfortunately,
there is not enough research to support
either method and the medical literature is
lacking in this regard.
CONCLUSION
In the future, the research agenda needs to
include adequate training of clinicians on
the detection of anal sphincter lacerations
and their repair. There is a need to determine
the risk of recurrence in patients following
severe childbirth injury repair to guide the
management of future pregnancies and
determine the appropriate mode of delivery.
The role of nutrition in the healing process
of these injuries and the role of pelvic floor
muscle for patients with continence issues
during post-operative recovery are also
worth studying.
AUTHOR DETAILS
Ruchi Puri, MD is a Fellow in Global Health,
Department of Obstetrics and Gynecology, Duke
University School of Medicine in Durham, North
Carolina, US.
Phyllis Leppert, MD, PhD is Professor of Obstetrics
and Gynecology and Professor of Pathology,
Duke University School of Medicine in Durham,
North Carolina, US.