Management of

PerinealTrauma: An
Update dr R.M. Sonny Sasotya, SpOG(K)
Divisi Uroginekologi dan Rekonstruksi
Departemen Obstetri dan Ginekologi,
Rumah Sakit Hasan Sadikin –
Universitas Padjadjaran
Classification of
Perineal Lacerations
 First degree: Injury to Perineal skin only
 Second degree: Injury to perineum involving perineal
muscles but not anal sphincter
 Third degree: Injury to perineum involving anal
sphincter complex.
3a : < 50% of external anal sphincter thickness torn.
3b : > 50% of external anal sphincter torn.
3c : Both external and internal anal sphincter torn.
Fourth degree: Injury to perineum involving anal
sphincter complex (external and internal anal sphincter)
and anal epithelium

 (Modified from American College of Obstetricians

and Gynecologists. ACOG, 2018. Obstetric Lacerations at
Vaginal Delivery. )
 53-79% of women who delivered vaginally will
experience perineal laceration

The most common are first and second degree.

How prevalent
is perineal
Update:
laceration?
• Third and fourth degree is now classified as obstetric anal
sphincter injuries (OASIS)
• It is difficult to accurately estimate the incidence of OASIS. In
the US, third-degree laceration is estimated to be around 3.3%
and fourth degree 1.1%.
Incidence of
OASIS in ten
countries
Occult anal
sphincter
injury
OASIS
 Most common risk factors of OASIS are:
Large baby (mean
Forceps delivery (OR Ventouse delivery Midline episiotomy
difference 192.88 gr;
5.50; 95% CI, 3.17- (OR 3.98;95% CI, (OR 3.82; 95% CI,
95% CI 139.80-
9.55) 2.60-6.09) 2.60-6.09)
245.96g)

Risk factors

The risk of anal sphincter trauma is greater

in primiparous women delivering by
operative vaginal delivery and episiotomy.
 Primiparity (OR 3.24; 95% CI 2.20-4.76)

Asian ethnicity(OR 2.74; 95% CI, 1.31-5.72)

Labour induction (OR 1.08;95% CI, 1.31-5.72)

Risk factor Labour augmentation (OR 1.95;95% CI 1.56-2.44)

Epidural anesthesia (OR 1.95;95%CI, 1.66-2.32)

Persistent posterior occiput presentation (OR 3.09;95% CI, 1.81-5.29)

Familial predisposition (RR 1.9; 95% CI, 1.6-2.3)

  Routine episiotomy offers no immediate benefit
to reduce perineal laceration (ACOG, 2018):
 No reduction to the risk of severe perinal laceration
and pelvic floor dysfunction (Pooled OR 1.74; 95% CI,
1.28-2.38) (ACOG, 2018)
Does episiotomy  Routine episiotomy does not improve postpartum
sexual function.
reduce the risk of  Episiotomy is not associated to increased risk of
pelvic organ prolapse or urinary incontinence.
OASIS? Multiple gestation with spontaneous laceration
increases the risk of prolapse all the way to the
hymen (OR 2.34; 95% CI, 1.13-4.86) (ACOG, 2018).
 Restrictive episiotomy is better than routine episiotomy.

• Restrictive episiotomy (28%) decreases the risk of perineal trauma (RR 0.67; 95% CI,
00.49-0.91), posterior perineal trauma (RR 0.88, 95% CI, 0.84-0.92), trauma requiring
suture (RR 0.71, 95% CI, 0.61-0.81) and complication on day 7 (RR 0.69; 95% CI, 0.56-
When is 0.85) compared to routine (75%) episiotomy.
• However, risk of anterior perineal trauma increases with restrictive episiotomy (RR
episiotomy 1.84; 95% CI, 1.61-2.10)

indicated? ACOG Recommends: give episiotomy only when clinically indicated

based on the patient’s clinical condition.

If indicated, mediolateral episiotomy is a better choice in

primiparous women to reduce the risk of OASIS (adjusted OR 0.4;
95% CI, 0.2-0.9)
ACOG, 2018
 Perineal massage or manual perineal protection

Warm perineal compress

How to
Prevent
Delivery position

Delayed pushing
 Perineal massage decreases the risk of trauma
Manual requiring suture (RR 0.91; 95% CI: 0.86-0.96)

Perineal
Massage or
Daily perineal massage, combined with pelvic floor
Support exercises during the last weeks of pregnancy
increases the possibilit50y of intact perineum
(17.6%) compared to those without (6.9%)

Vieira et al, 2018

Vieira F, Guimares JV. Eur. J. Obstet. Gynecol. Reprod. Biol. 2018
 Central
Ritgen
maneuvre
Palmar Manual
Support Perineal
Protection: Old
Central techniques,
Flexion new evidence
digital
technique
Support
Ritgen
maneuver
Central
Palmar
Support
Flexion
technique
Central
digital
support
 Currently, evidence on the effectiveness of MPP
to reduce OASIS is contradictory. Three
nonrandomized trials found a significant
reduction of OASIS (RR 0.45; 95% CI, 0.4-0.5), but
Manual other authors disagree.
perineal
protection
There is not enough evidence to recommend a
specific maneuver to protect the perineum.
 Warm compress on the perineum during the
second stage of labor versus no warm compress =
compress use significantly reduced third- and
fourth-degree lacerations (RR 0.48; 95% CI, 0.28-
0.84).
Warm
Compress
Warm compresses did not decrease the rate of a
woman having an intact perineum following
delivery (RR 1.05, 95% CI, 0.86-1.26).

ACOG, 2018
 Lateral birthing position with delayed pushing was
compared with lithotomy positions and pushing at
complete dilatation in women with epidural
anesthesia 
 Lateral position with delayed pushing more likely to
deliver with intact perineum (40% vs 12%, p < .001)
Delivery
 (ACOG, 2018) position and
delayed
pushing
 Periclitoral, periurethral, and actively
Which bleeding labial wound
laceration
should be
First and second degree tear reparation
repaired? should depend on the patient’s clinical
condition first and foremost.
 Suture not always
necessary, but
approximate tissues.

First and If needed: continuous

second degree suture > interrupted
laceration suture

Use synthetic absorbable

(ie. Polyglactin)
  The decision to repair should always depend on the
patient’s clinical condition.
Vulvar,  Continuous or interrupted suture

vaginal, and  2-0 chromic or polyglactin.

 In cervical laceration, use absorbable suture at the
cervical apex of the laceration, and then use interrupted or
continuous with 2-0 chromic or polyglactin towards
the operator.
  Subcuticular running repair, transvaginal
approach and interrupted suture with
Anal mucosa knots tied in the anal lumen
laceration  Use 3-0 polyglactin or chromic
 Second layer placed on the rectal muscle
using 3-0 polyglactin
Meister MR, Rosenbloom JI, Lowder JL. Obstet Gynecol Surv. 2018
  End-to-End
 Approximate and suture
torn ends of the external
anal sphincter

 Overlap
External and  Requires full thickness
disruption; should not be
internal anal used for grade 3a and partial
thickness 3b
sphincter
 3-0 polyglactin, 3-0
laceration polydioxanone, or 2-0
polyglactin.

(ACOG, 2018. Image taken from

Sultan et al, 1999.)
  Use end-to-end or overlap for full thickness
External and rupture.
internal anal  No significant difference in perineal pain,
dyspareunia, and flatal incontinence between
sphincter end-t0-end and overlap techniques. Overlap
laceration repair decreases incidence of fecal urgency and
anal incontinence.
  Administration of second-generation
cephalosporin (cefoetan or cefoxitin) vs
Antibiotics placebo in women with OASIS:
 Significant decrease of complication after 2 weeks
(88% vs 24%, P = .04)
  Pain management
 Analgesia
Immediate
 Reduce constipation
post-OASIS  Stool softener
care  Oral laxative
 Evaluate urinary retention
  Level A:
 Application of warm perineal compress during pushing reduces the risk of
perineal trauma
 Use restrictive instead of routine episiotomy
 Use end-to-end or overlap repair for full-thickness external anal sphincter
lacerations
 Level B:
 Usage of a single dose of antibiotics at the time of repair is reasonable in
OASIS
ACOG  Perineal massage during second stage of labor may help reduce third or fourth
degree laceration
 If necessary, mediolateral episiotomy is preferred over midline
Recommendation  Continuous suture of a second degree laceration is preferred over interrupted
suture.
 Level C
 Stool softeners and oral laxatives should be prescribed to women who sustain
OASIS
 Counsel women with a history of OASIS of a low risk for recurrent OASIS in
next vaginal delivery
 In internal anal sphincter laceration, repair by reinforcing second layer of
rectal muscle using 3-0 polyglactin suture or separately from the EAS using 3-0
monofilament polydioxanone suture.
Thank you.