Expert Review
org
Repair of episiotomy and obstetrical perineal
lacerations (firstefourth)
Payton C. Schmidt, MD; Dee E. Fenner, MD
Introduction
Perineal injury is common after vaginal
childbirth, affecting up to 50% to 90% of
women, with 4% to 11% sustaining an
obstetrical anal sphincter injury
(OASIS).1 Perineal trauma—particularly
OASIS—is associated with short- and
long-term morbidity including persis-
tent perineal pain,2 dyspareunia, delayed
resumption of sexual intercourse,3 and
depression,2 and may ultimately inter-
fere with a new mother’s ability to care
for her newborn.4 Furthermore, OASIS
is associated with an increased risk of
anal incontinence,5,6 with 29% to 53% of
women reporting flatal incontinence and
5% to 10% reporting fecal incontinence
in the first 6 months postpartum.7 Flatal
and fecal incontinence can cause a new
mother embarrassment, lead to social
isolation, and significantly negatively
affect her quality of life.7
The severity and morbidity experienced
after perineal injury is dependent on the
extent of perineal damage, the technique
and materials used for repair, and the skill
and knowledge of the birth attendant. The
overall incidence of wound complications
after perineal trauma includes infection
rates of 0.1% to 23.6% and dehiscence
rates of 0.21% to 24.6%.8 The risk for
wound complications is particularly high
after anal sphincter injury, with one pro-
From the Department of Obstetrics and
Gynecology, University of Michigan, Ann Arbor,
MI.
Received May 13, 2022; revised July 7, 2022;
accepted July 7, 2022.
The authors report no conflict of interest.
The authors report no funding sources for this
study.
Corresponding author: Payton C. Schmidt, MD.
payton@med.umich.edu
0002-9378/$36.00
ª 2022 Elsevier Inc. All rights reserved.
https://doi.org/10.1016/j.ajog.2022.07.005
ajog.
Perineal injury after vaginal delivery is common, affecting up to 90% of women. Perineal
trauma is associated with both short- and long-term morbidity, including persistent pain,
dyspareunia, pelvic floor disorders, and depression, and may negatively affect a new
mother’s ability to care for her newborn. The morbidity experienced after perineal injury is
dependent on the type of laceration incurred, the technique and materials used for repair,
and the skill and knowledge of the birth attendant. After all vaginal deliveries, a sys-
tematic evaluation including visual inspection and vaginal, perineal, and rectal exams is
recommended to accurately diagnose perineal lacerations. Optimal management of
perineal trauma after vaginal birth includes accurate diagnosis, appropriate technique
and materials used for repair, providers experienced in perineal laceration repair, and
close follow-up. In this article, we review the prevalence, classification, diagnosis, and
evidence supporting different closure methods for first- through fourth-degree perineal
lacerations and episiotomies. Recommended surgical techniques and materials for
different perineal laceration repairs are provided. Finally, best practices for perioperative
and postoperative care after advanced perineal trauma are reviewed.
Key words: childbirth, episiotomy, fecal incontinence, obstetrical laceration, obstetrical
anal sphincter injury, perineum, postpartum, sphincteroplasty
spective study finding wound infection improvements in postrepair outcomes.14
and dehiscence rates of 19.8% (95% con- In a single-center quality improvement
fidence interval [CI], 15.2e25.1) and study investigating postrepair complica-
24.6% (95% CI, 19.6e30.2), respectively.9 tions, 3 major causes were identified:
Wound complications lead to worsened inexperienced surgeons, inappropriate
physical, emotional, and sexual satisfac- suture choice, and inappropriate repair
tion that can persist for up to 9 months type. A targeted educational campaign
postpartum.10 The baseline overall risk of was implemented that led to a decrease
a wound complication after OASIS repair in the incidence of repair failures from
is high and likely increases for reasons 29% to 12%.15 This highlights the
including missed diagnosis, inappropriate importance of adequate training and
repair technique, and lack of experience of skill maintenance for clinicians who
the primary surgeon.11 It is therefore perform perineal repairs after childbirth.
important that the birth attendant be well In this article, we will review the preva-
versed in how to appropriately identify lence, classification, and closure
and repair different types of perineal methods for different types of perineal
trauma to optimize short- and long-term lacerations and episiotomies, and best
outcomes. If the primary surgeon is practices for perioperative and post-
inexperienced or unfamiliar with repair operative care after advanced perineal
techniques, or there is uncertainty at de- trauma.
livery, it is best practice for another trained
provider to reexamine the tear.12 It is safe Prevalence
and appropriate for the wound to be Perineal injury occurs in up to 90% of
packed and the repair delayed 8 to 12 nulliparous and 70% of multiparous
hours until an experienced provider is women,5 with most women experi-
available.13 encing a first- or second-degree lacera-
Improving provider knowledge of tion. Using the Nationwide Inpatient
perineal laceration types, anatomy, and Sample database, which included >7
repair techniques can lead to significant million births that occurred in the
MARCH 2024 American Journal of Obstetrics & Gynecology S1005
Expert Review
FIGURE 1
Perineal anatomy
A, The superficial compartment contains the superficial transverse perineal muscle, the bulbo-
spongiosus, and the ischiocavernosus. These 3 muscles form a triangle on either side of the
perineum, with a floor formed by the perineal membrane. B, The left bulbospongiosus muscle has
been removed to demonstrate the vestibular bulb and Bartholin’s gland.
Reproduced, with permission, from Sultan et al.12
Schmidt. Perineal laceration repairs. Am J Obstet Gynecol 2024.
United States between 1998 and 2010,
Friedman et al found that approximately
3.3% of women had a third-degree
laceration and 1.1% of women had a
fourth-degree laceration.16 A prospec-
tive study conducted in the United
Kingdom looking at births that occurred
in a hospital, free-standing midwifery-
S1006 American Journal of Obstetrics & Gynecology MARCH 2024
led units, or at home found the following
prevalence rates of perineal lacerations:
first-degree, 5.5% to 16.4%; second-
degree, 29.0% to 35.1%; third-degree,
1.8% to 7.1%; and fourth-degree, 0%
to 0.3%.5 Episiotomies were performed
in 1.7% to 31.6% of births.5 Further-
more, although the rate of clinically
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detected OASIS has been reported in up
to 11% of births,1 the true incidence is
difficult to determine because studies
have reported an incidence of “missed”
anal sphincter damage of up to 35%
when postnatal ultrasound is used for
diagnosis.17 In addition, no recent data
have been published to update current
OASIS rates, particularly in the setting of
lower rates of operative vaginal de-
liveries.18 Future studies are needed to
better describe current rates of OASIS.
Definition and diagnosis
Perineal trauma after vaginal delivery
can occur spontaneously or when the
birth attendant facilitates delivery by
making an incision (episiotomy) to in-
crease the diameter of the vulvar outlet
(Figure 1).12,19 The perineum extends
from the pubic arch to the coccyx and is
divided into the anterior urogenital and
posterior anal triangles. Anterior peri-
neal trauma is defined as injury
involving the labia, anterior vagina,
urethra, or clitoris. Posterior perineal
trauma is defined as injury involving the
posterior vaginal wall, perineal muscles,
anal sphincter (external, internal, or
both), and anorectal mucosa.12
In 2012, the American College of
Obstetricians and Gynecologists
(ACOG) convened the reVITALize Ob-
stetrics Data Definitions Conference to
develop and standardize national
obstetrical clinical data definitions.1,20
Spontaneous perineal trauma is defined
on the basis of these guidelines (Table 1).
Two main types of episiotomies are
performed. A midline (also known as
median) episiotomy starts within 3 mm
of the midline in the posterior fourchette
and extends 0
to 25
downward in the
sagittal plane. A mediolateral episiotomy
starts within 3 mm of the midline in the
posterior fourchette and is directed
laterally at an angle of at least 60
from
the midline toward the ischial
tuberosity.1
Diagnosis
After all vaginal deliveries, a systematic
evaluation of perineal trauma should be
performed. Before the exam, the new
mother should be informed of the need
and reasoning for examination. A
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systematic evaluation includes visual
inspection, a thorough perineal exam,
and a digital rectal examination.1,13,21 A
rectal exam improves the detection rate
of OASIS and is therefore important to
perform after all vaginal deliveries.
Clinical examination by a knowledgeable
birth attendant vs an endoanal ultra-
sound results in no significantly different
OASIS detection rate; therefore, no
additional imaging is routinely needed
immediately after delivery.22 However, if
there is uncertainty regarding the diag-
nosis of OASIS, we recommend that a
second experienced examiner aids in
determining the degree of perineal
injury.
Perineal laceration repair
Prerepair preparation
Before repair of any laceration type, the
birth attendant should ensure adequate
lighting and patient analgesia. If anal-
gesia is inadequate, the attendant should
perform local anesthetic infiltration or
collaborate with anesthesia colleagues to
achieve regional or general anesthesia as
indicated. For OASIS repair, either
regional or general anesthesia should be
considered. We recommend that the
laceration site should then be prepared
with betadine or chlorhexidine.23
First- and second-degree perineal
laceration and episiotomy repair
For first- or second-degree laceration
repairs that involve the perineal skin,
vaginal epithelium, and perineal muscles
(if second-degree), there are 3 options:
nonsurgical management with no su-
turing, use of skin adhesive, or surgical
management with suturing. If hemo-
static, either no suturing or use of a skin
adhesive is recommended because these
closure methods are associated with
shorter procedure time, less pain, and
similar functional and cosmetic out-
comes.19,24 A prospective, non-
inferiority, randomized controlled trial
(RCT) comparing skin adhesive with
traditional suturing for the management
of first-degree perineal lacerations found
that cosmetic and functional results of
skin adhesive use were not inferior to
those of suturing. In addition, skin ad-
hesive was associated with a shorter
Expert Review
TABLE 1
Obstetrical laceration typesa
Laceration type Anatomic structures involved
First-degree Perineal skin and/or vaginal epithelium only
Second-degree Injury to perineum involving perineal muscles
Third-degree Injury to perineum involving anal sphincter complex
3a <50% of EAS thickness torn
3b >50% of EAS thickness torn
3c Both EAS and IAS torn
Fourth-degree Injury to perineum involving anal sphincter complex
(EAS and IAS) and anorectal mucosa
Rectal buttonhole tear Tear into the anorectal mucosa but intact anal
sphincter complex
EAS, external anal sphincter; IAS, internal anal sphincter.
a
Modified from: reVITALize: Obstetrics Data Definitions (version 1.0).17
Schmidt. Perineal laceration repairs. Am J Obstet Gynecol 2024.
procedure time (2.29 vs 7.88 minutes; postpartum, women in the suture group
P<.001), less need for local anesthetic, had higher median pain scores on the
less pain, and greater satisfaction.25 short-form McGill Pain Questionnaire
Another prospective RCT comparing compared with women in the skin ad-
skin adhesive with suturing for the hesive group (1.0 vs 0; P¼.04). In addi-
management of first-degree lacerations tion, they found no differences in wound
also found that the time to become pain- healing between no suture, skin adhe-
free was significantly shorter in the skin sive, and suture.27 The benefits of using
adhesive group (3.18 vs 8.65 days; skin adhesive or no suture for closure of
P<.001).26 A single-blind RCT of first- or second-degree perineal lacera-
nonsurgical management, skin adhesive, tions include reduction of pain, analgesia
and suturing for perineal skin closure in use, and dyspareunia and improved
the management of second-degree peri- breastfeeding rates at 3 months
neal lacerations noted that at 3 months postpartum.19,24,26e28 Furthermore,
TABLE 2
Recommended sutures for surgical management of obstetrical
laceration repairs1,13,18,26,28,29
Laceration degree Repair layer Suture type
First-degree Perineal skin Surgical glue if hemostatic
Vaginal epithelium 2-0 or 3-0 polyglactin or
poliglecaprone
Second-degree Rectovaginal fascia 2-0 or 3-0 polyglactin
Perineal body
Vaginal epithelium
Third-degree Internal anal sphincter 3-0 polyglactin or polydioxanone
External anal sphincter 2-0 polyglactin or 3-0 polyglactin or
polydioxanone
Fourth-degree Anorectal 3-0 or 4-0 polyglactin
or poliglecaprone
Schmidt. Perineal laceration repairs. Am J Obstet Gynecol 2024.
MARCH 2024 American Journal of Obstetrics & Gynecology S1007
Expert Review
FIGURE 2
Repair of second-degree
laceration
Continuous suturing technique for second-de-
gree laceration. Once the vaginal epithelium has
been closed to the hymenal ring, the needle is
passed from the midline to the perineal body,
and a crown stitch reapproximating the bulbo-
cavernosus muscles is performed. A sub-
cuticular stitch is carried from the inferior
perineal margin to the hymen and tied.
Reproduced, with permission, from Sultan et al.12
Schmidt. Perineal laceration repairs. Am J Obstet Gynecol
2024.
nonsurgical management reduces clin-
ical workload and human and material
resources.24 However, surgical manage-
ment with suturing may be necessary for
hemostasis or for restoring normal
anatomy depending on the depth and
complexity of the perineal laceration.
When suturing is necessary for
repairing a spontaneous perineal lacer-
ation, it is important to consider what
suture type and technique to use. Ideally,
the suture material should cause mini-
mal reaction in the tissue while keeping
S1008 American Journal of Obstetrics & Gynecology MARCH 2024
it apposed for the appropriate amount of
time. Possible suture types include
catgut; standard synthetic sutures (eg,
multifilament: polyglycolic acid [Dexon,
Medtronic plc, Dublin, Ireland] and
polyglactin 910 [VICRYL, Ethicon, Inc,
Raritan, NJ]; monofilament: poligle-
caprone [MONOCRYL, Ethicon] and
polyglyconate [Maxon, Medtronic]);
and rapidly dissolving synthetic suture
(eg, polyglactin 910 [VICRYL RAPIDE,
Ethicon]). A Cochrane review by Kettle
et al29 included 18 trials that compared
catgut, standard synthetic (multifila-
ment and monofilament), and rapidly
dissolving synthetic suture for post-
partum perineal repair. Use of catgut
compared with standard synthetic
multifilament sutures was associated
with more pain and the highest risk of
requiring resuturing. However, the use
of standard synthetic suture was associ-
ated with a greater need for removal of
unabsorbed suture material. There were
no significant short- or long-term pain
or wound healing differences between
use of standard multifilament, rapidly-
absorbing standard multifilament, and
monofilament sutures.29 Because
monofilament sutures cause less bacte-
rial seeding30 and may be less likely to
cause infection, they may be preferred.
According to these findings, in line with
ACOG recommendations, 2-0 or 3-
0 polyglactin or poliglecaprone can be
used for first-degree lacerations, and 2-
0 or 3-0 polyglactin can be used for
second-degree lacerations (Table 2).31
Consideration can be made for using
rapidly-absorbing suture, despite the
increased cost when compared with
standard synthetic sutures, because of
the lower need for postpartum suture
removal.
Repair of a second-degree perineal
laceration—which involves injury to
perineal skin, vaginal epithelium, or
both, and injury to the perineum
involving the perineal muscles—should
involve closure of each layer starting with
the vaginal epithelium and muscularis,
followed by the perineal body muscula-
ture, and finally the rectovaginal fascia
and perineal skin. According to a
Cochrane review of 16 studies, contin-
uous suturing techniques were associated
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with less pain for up to 10 days post-
partum (risk ratio [RR], 0.76; 95% CI,
0.66e0.88), reduced use of analgesia
(RR, 0.70; 95% CI, 0.59e0.84), and
reduced need for suture removal (RR,
0.56; 95% CI, 0.32e0.98) compared with
interrupted suturing techniques (both
for all layers and for perineal skin only).32
Subsequent RCTs found similar results,
with continuous suturing techniques
being associated with less short-term
pain (both on postpartum day 1 and 6
weeks postpartum)33 and improved
postpartum sexual function at 3 months
postpartum.34
Episiotomy repair is similar to repair
of a second-degree perineal laceration.
Closure of each layer involving the
vaginal epithelium, muscularis, perineal
body musculature, rectovaginal fascia,
and perineal skin should be ensured. As
is the case with second-degree laceration
repairs, studies have shown that after
episiotomy, using skin adhesive to close
the perineal skin—after closure of
vaginal layers, perineal muscles, and
perineal body—results in no differences
in reported pain and shorter procedure
duration when compared with suturing
(19 vs 23 minutes, P¼.001).35 For
episiotomy repair, continuous non-
locking intracutaneous sutures also
resulted in less short-term pain, dys-
pareunia, and amount of suture material
used.36,37 This is likely because contin-
uous suturing distributes tension more
evenly across the entire length of the
suture. In addition, using a nonlocking
technique is preferred because locking
suture can cause excessive tension lead-
ing to tissue edema and necrosis. For
perineal skin, continuous nonlocking,
subcutaneous suturing is preferred over
transcutaneous, interrupted suturing
because it avoids damage to nerve end-
ings on the skin surface leading to
pain.4,32 We therefore suggest the
following technique for second-degree
perineal laceration or episiotomy repair
(Figure 2):
1. Anchor the suture above the apex of
the laceration in the vaginal
epithelium.
2. Using a continuous, nonlocking su-
ture in a running fashion, close the
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FIGURE 3
Checklist for OASIS repairs1,19,21,39e41
OASIS, obstetrical anal sphincter injuries.
Schmidt. Perineal laceration repairs. Am J Obstet Gynecol 2024.
vaginal epithelium, underlying mus-
cularis, and rectovaginal fascia to the
level of the hymenal ring.
3. Using the same suture, transition into
the axial plane, parallel to the peri-
neal muscles.
4. Reapproximate the bulbocavernosus
and transverse perineal muscles in a
running, continuous, nonlocking
fashion.
5. Continuing with the same suture,
reapproximate the perineal skin in a
running, continuous, nonlocking,
subcuticular, and deep dermal fashion
back toward the hymenal ring.
B Alternatively, consider leaving the
skin unsutured, or close with skin
adhesive, to reduce pain and
dyspareunia.
6. Transition the suture back into the
coronal plane and anchor the suture
and knot behind the hymen.
7. Perform a rectal exam to confirm no
injury or transgression of sutures.
During repair, the following surgical
principles should be observed to reduce
complications: (1) close dead space and
ensure hemostasis to prevent hematoma
formation; (2) avoid excessive suture
tightening, which can lead to tissue
edema or necrosis and impair wound
healing; and (3) concurrently ensure
good anatomic alignment of the wound
while carefully considering the appear-
ance of the wound closure for optimal
cosmetic results.
Third- and fourth-degree laceration
repairs
Given the complexity of OASIS repairs
and that advanced perineal trauma is
associated with short- and long-term
morbidity, it is important to
MARCH 2024 American Journal of Obstetrics & Gynecology
Expert Review
optimize the surgical repair and post-
operative recovery. We recommend
using a checklist to ensure adherence
to critical care processes. Surgical
checklists may reduce errors by
ensuring critical tasks are carried out,
encouraging a team-based approach,
enhancing communication, and antic-
ipating potential complications.38
Figure 3 is a recommended checklist
for OASIS repairs.
Perioperative considerations
Before initiating OASIS repair, the
surgeon should ensure adequate anes-
thesia. Regional or general anesthesia
is recommended.21 Local anesthesia
can be used when appropriate. A Fo-
ley catheter should be placed before
initiating the repair. OASIS should be
repaired in the operating room39;
however, it can be repaired in the la-
bor suite if there is adequate lighting,
visualization, and exposure.21 The
clinician should request all needed
instruments and suture material
(Figure 3). Surgical instruments,
sponges, and sutures should be coun-
ted pre- and postoperatively. Although
no studies have investigated the use of
vaginal preparation before postpartum
perineal laceration repair, it is recom-
mended for preventing postoperative
infection after gynecologic proced-
ures.42 Therefore, it is reasonable to
perform surgical-site vaginal prepara-
tion with povidone-iodine or chlor-
hexidine gluconate if a patient is
allergic to iodine.43 Preoperative anti-
biotics should be administered before
OASIS repair. In a single-center, pro-
spective, randomized, placebo-
controlled study, the use of antibi-
otics was associated with lower rates
of postpartum wound complications,
including purulent discharge (17.2%
vs 4.1%; P¼.04) and any wound
complication (24.1% vs 8.2%;
P¼.04).23 A prospective cohort study
by Lewicky-Gaupp et al found that
antibiotic administration at the time
of primary OASIS repair was associ-
ated with decreased risk of wound
infection (adjusted odds ratio, 0.50;
95% CI, 0.27e0.94; P¼.03).9 In addi-
tion, a retrospective study found a
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Expert Review
FIGURE 4
Repair of obstetrical anal sphincter injury
A, Overlapping sphincteroplasty technique; B, (1) End-to-end sphincteroplasty technique and (2) schematic of PISA (posterior, inferior, superior, anterior)
suture placement through torn end of anal sphincter complex.
Reproduced, with permission, from Baggish MS, Karram MM, eds. Atlas of Pelvic Anatomy and Gynecologic Surgery. Fifth ed. Philadelphia, PA: Elsevier; 2020.49
Schmidt. Perineal laceration repairs. Am J Obstet Gynecol 2024.
55% decrease in wound infection or
dehiscence after implementing a
quality improvement initiative aimed
at administering antibiotics at the time
of OASIS repair.40 According to these
studies, a second- or third-generation
cephalosporin should be adminis-
tered, with consideration of adding
metronidazole40 (or gentamicin and
clindamycin in patients with severe
penicillin allergy) because it provides
adequate coverage for both vaginal
and bowel flora.1,9,23
Closure method
Repair of third- and fourth-degree lac-
erations should sequentially and sys-
tematically proceed from deep to
superficial structures: the anorectal mu-
cosa, anal sphincter complex, rec-
tovaginal fascia, perineal body
musculature, perineal skin, and vaginal
muscularis and epithelium. The ano-
rectal mucosa should be closed with
either interrupted or continuous non-
locked 3-0 or 4-0 delayed absorbable
sutures such as polyglactin or poligle-
caprone.1,13,21 To date, no studies have
S1010 American Journal of Obstetrics & Gynecology MARCH 2024
compared different suturing techniques
or suture types for closure of the ano-
rectal mucosa after fourth-degree peri-
neal laceration.
The internal anal sphincter (IAS) is
responsible for most of anal sphincter
resting tone and should be identified and
reapproximated. In a small prospective
study with historic controls, repair of the
IAS improved 1-year anal incontinence
rates.44 The IAS is thin and pale pink,
may appear similar to a “fascial” layer,13
and lies in close proximity to the ano-
rectal mucosa. As the IAS can be difficult
to identify, understanding its anatomic
relationship to the external anal
sphincter (EAS) can be helpful. The EAS
and IAS overlap for approximately 1.7
cm, with the IAS extending cephalad
approximately 1.2 cm from the proximal
margin of the EAS.45 Therefore, if the
torn EAS ends are grasped with Allis
clamps and brought toward the midline,
the IAS can be identified extending more
proximally.46 There are no studies on
different suturing techniques for repair-
ing the IAS; however, the Society of
Obstetricians and Gynaecologists of
ajog.org
Canada and the Royal College of Ob-
stetricians and Gynaecologists (RCOG)
recommend an end-to-end technique
with either mattress or interrupted su-
tures using 3-0 delayed absorbable
suture.13,21
The EAS can be repaired using 2-
0 polyglactin, 3-0 polyglactin, or poly-
dioxanone with either an end-to-end or
overlapping technique. An RCT in 2006
found no difference in suture-related
morbidity, bowel symptoms, or ano-
rectal physiology parameters at 3, 6, and
12 months postpartum between poly-
glactin and polydioxanone use for anal
sphincter repair.47 A 2013 Cochrane
meta-analysis of 6 RCTs showed no sta-
tistically significant difference in peri-
neal pain (RR, 0.08; 95% CI, 0.00e1.45),
dyspareunia (RR, 0.77; 95% CI,
0.48e1.24), or flatal incontinence (RR,
1.14; 95% CI, 0.58e2.23) when
comparing end-to-end with overlapping
techniques. The overlapping repair was
associated with a statistically significant
lower incidence of fecal urgency (RR,
0.12; 95% CI, 0.02e0.86) and lower anal
incontinence score at 1 year. However, at
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36 months, there were no differences in
flatal or fecal incontinence scores.48 If an
EAS tear is complete, either the end-to-
end or overlapping technique can be
used. For a partial EAS tear, the end-to-
end technique should be used, rather
than completely transecting the EAS
complex, to allow an overlapping repair.
For the end-to-end repair, the EAS is
identified and 4 interrupted sutures are
placed to reapproximate the posterior,
inferior, superior, and anterior portions
of the muscle (Figure 4, B). The RCOG
recommends against the use of figure-of-
8 sutures.21 For the overlapping tech-
nique (Figure 4, A), the torn ends of the
sphincter should be evaluated and
dissected from the surrounding tissue.
This undermining allows overlapping
the EAS complex without causing undue
tension on the closure. The torn ends are
overlapped and reapproximated using 2
to 4 interrupted or mattress sutures.
We suggest the following technique
for OASIS repair:
1. Begin by repairing the anorectal
mucosa using 3-0 or 4-0 delayed
absorbable sutures such as poly-
glactin or poliglecaprone. First, an-
chor the suture with the knot above
the apex of the laceration, with the
knots tied within the anorectal
lumen. Perform a running, non-
locked suture to reapproximate the
mucosa to approximately 5 mm past
the anal verge. If possible, using 3-
0 or 4-0 delayed absorbable sutures
such as polyglactin, close a second
layer over the repaired anorectal
mucosa by reapproximating the
overlying rectovaginal fascia.
2. Next, identify the IAS, which appears
as a thin, pale pink layer similar to
fascia. Place 2 to 4 interrupted su-
tures using 3-0 polyglactin or poly-
dioxanone to reapproximate the IAS
in an end-to-end fashion.
3. Identify the EAS, which appears as
thick, striated, dark red muscle.
Grasp each torn end with an Allis
clamp. Repair using either 2-0 poly-
glactin or 3-0 polyglactin or poly-
dioxanone sutures.
a. For a partial EAS tear, use an end-
to-end technique (Figure 4, A).
Ideally, 4 interrupted sutures are
placed into the posterior, inferior,
superior, and anterior portions of
the muscle. Place all 4 sutures
first, then tie each down.
b. For a complete EAS tear, when an
overlapping technique will be
used (Figure 4, B), identify the
completely torn ends. Dissect the
torn ends from the surrounding
tissue by at least 1.5 cm. Overlap
the ends by at least 1 to 1.5 cm,
then place 2 to 4 full-thickness
interrupted or mattress sutures,
passing through the full thickness
of both overlapped torn ends of
the EAS. Place all 4 sutures first,
then tie each down.
4. Once the anal sphincter complex has
been repaired, perform a second-
degree perineal laceration repair as
described above. Ensure that surgical
knots from the anal sphincter repair
are buried behind the superficial
perineal muscles to reduce the risk of
knot or suture migration to the skin,
which can cause wound dehiscence,
perineal irritation, and patient
discomfort.21
5. Perform another rectal exam to
confirm adequate repair and that
there are no injuries or suture
transgressions.
Postoperative care
After the repair, the patient should be
monitored until recovery from anes-
thesia is complete. The laceration type
and method of repair should be clearly
documented, including comprehensive
details on the technique and suture used.
The patient should be informed of the
injury that occurred and the importance
of close follow-up.
A Foley catheter should remain in
place given the increased risk for urinary
retention. A voiding trial on post-
operative day 1 is recommended to
ensure adequate bladder function.46 Pain
should be controlled using local cool
packs applied to the perineum, topical
anesthetic sprays or ointments, and an-
algesics such as acetaminophen and
nonsteroidal antiinflammatory drugs.19
Opiates are not usually needed and
should be avoided if possible given their
MARCH 2024 American Journal of Obstetrics & Gynecology
Expert Review
constipating side effects.19 Stool soft-
eners and oral laxatives should be
administered on a schedule to avoid
constipation, mitigate pain, and reduce
the risk of wound dehiscence.1,21,39 We
recommend polyethylene glycol 3350, 1
capful twice daily or mineral oil, 30 mL
twice daily for 6 weeks postpartum to
achieve toothpaste-consistency stools.
Twice-daily sitz baths should be recom-
mended until the patient’s first wound
check.1
Patients should have close, frequent
follow-up given the increased risk for
complications,41 which include wound
infection (20%e30%), wound dehis-
cence (35%), fecal urgency (up to 28%),
and rectovaginal fistula (1%e2%).23,50
Up to 53% of women report flatal in-
continence and 5% to 10% report stool
incontinence postoperatively.50 Risk
factors for wound complications after
OASIS include smoking, increasing body
mass index, fourth-degree laceration,
operative vaginal delivery, and use of
postpartum antibiotics.51 Follow-up in a
specialized peripartum pelvic floor dis-
orders clinic, if available, allows close
and frequent follow-up and individual-
ized care for a subset of women at higher
risk for pelvic floor disorders and com-
plications related to their perineal
trauma.41 We recommend that patients
be seen within 2 weeks after OASIS.9
If women have signs or symptoms of
anal sphincter compromise during
postoperative follow-up, endoanal ul-
trasound is recommended.39 Performing
endoanal ultrasound imaging to define
the extent of anal sphincter damage may
also aid in subsequent delivery plan-
ning.52 The Starck scoring system can be
used to define endosonographic anal
sphincter defect findings.53 Secondary
anal sphincter repair may be indicated if
the woman is symptomatic and there is a
persistent separation of the anal
sphincter.54
Conclusions
Up to 90% of women will sustain peri-
neal trauma after a vaginal delivery,1
which has been associated with short-
and long-term morbidity. The extent
and severity of morbidity after perineal
trauma has been linked to the amount of
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Expert Review
perineal damage, the method and ma-
terials used for repair, and the experience
level of the surgeon. Obstetricians and
birth attendants must therefore be able
to correctly identify the degree of peri-
neal trauma, perform an appropriate
repair, and provide postoperative care
after obstetrical perineal lacerations.
All obstetrical units should have pro-
viders experienced in perineal laceration
repair available. Institutional guidelines
and checklists should be used to opti-
mize pre-, peri-, and postoperative
care—particularly after OASIS.46 In this
article, we review perineal anatomy and
provide evidence-based guidelines on
perineal laceration repair techniques and
care recommendations. Maintaining and
improving provider knowledge and
repair skills is vital to providing optimal
perineal care to prevent short- and long-
term complications from obstetrical
perineal trauma. (Video File 1) -
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