Management of Breakdown of Obstetrical Anal Sphincter Repairs
Obstetric anal sphincter injuries (OASIS) include 3rd and 4th degree lacerations. Risk factors include forceps or vacuum delivery, midline episiotomy, first vaginal delivery, higher infant birth weight (> 3500gms), vertex malpresentation (primarily occiput posterior), and shoulder dystocia. Fourth degree lacerations are associated with a higher rate of anal incontinence than 3rd degree lacerations, although both may be associated with anal incontinence remote from delivery. A large retrospective review of women with OASIS found a rate of wound complications of 7.3% including infection, breakdown, secondary repair, packing, and operative intervention. These complications were more common in women with increased body mass index, smoking history, operative vaginal delivery, 4th degree laceration, and postpartum antibiotics, while intrapartum antibiotics decreased risk. Most complications (72%) occurred in the first two weeks. A prospective study with close outpatient follow-up at 1, 2, 6 and 12 weeks postpartum found a higher risk, with 25% of women with OASIS injuries experiencing wound breakdown and 20% having wound infection. The authors suggest early follow-up for women with OASIS may reduce readmissions.
Breakdown of 4th degree lacerations is strongly associated with infection. A single dose of prophylactic antibiotics, such as a second-generation cephalosporin, at the time of the repair is reasonable for women who sustain a 3rd or 4th degree laceration. Antibiotic prophylaxis decreases the incidence of perineal infection following repair.
Women with perineal breakdown of OASIS repairs may present with pain, anal incontinence, fever, or malodorous discharge. Postpartum women reporting these symptoms should be promptly examined, including a rectal examination to assess the perineum for abscess, hematoma, and the extent of the breakdown. If an infected laceration repair is confirmed, then the wound should be debrided with removal of necrotic tissue with antibiotic therapy and subsequent wound care.
Controversy exists regarding immediate versus delayed repair of all perineal breakdown, including 4th degree laceration repairs. Conventional practice has been to delay repair for two to three months to ensure complete tissue recovery prior to attempted repair and allow for possible spontaneous healing. Delayed repair is challenging for patients who often suffer from anal incontinence, inability to resume sexual activity, and pain. Recent studies have suggested the potential benefits to early re-closure such as more rapid healing and earlier resumption of sexual intercourse, though these studies have limitations. In the studies where early closure of perineal breakdown was performed, women underwent aggressive daily debridement of the perineal wound and received antibiotics. Once all signs of infection had completely resolved, a repair was performed. In these series, perineal repair was attempted as early as 7 to 10 days following delivery. There is currently insufficient evidence to provide a definitive recommendation for early or delayed repair for perineal wound dehiscence.
Women who sustain 4th degree lacerations at the time of delivery are at risk for long term complications including anal incontinence in up to 30% of women, fistula formation, and dyspareunia. With subsequent deliveries, they are at increased risk of sustaining another severe perineal laceration and worsening of anal incontinence symptoms. The risk of recurrent OASIS in women with OASIS at their first delivery is reported as 3.7 to 7.5%. Risks with future deliveries and screening for ongoing pelvic floor dysfunction should be discussed.
Lewicky-Gaupp C, Leader-Cramer A, Johnson LL, Kenton K, Gossett DR. Wound complications after obstetric anal sphincter injuries. Obstet Gynecol. 2015 May;125(5):1088-1093. doi: 10.1097/AOG.0000000000000833. PMID: 25932836.
Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 198: Prevention and Management of Obstetric Lacerations at Vaginal Delivery. Obstet Gynecol. 2018 Sep;132(3):e87-e102. doi: 10.1097/AOG.0000000000002841. PMID: 30134424.
Lewicky-Gaupp C, Mueller MG, Collins SA, Tavathia M, Geynisman-Tan J, Kenton KS. Early Secondary Repair of Obstetric Anal Sphincter Injury Breakdown: Contemporary Surgical Techniques and Experiences From a Peripartum Subspecialty Clinic. Female Pelvic Med Reconstr Surg. 2021 Feb 1;27(2):e333-e335. doi: 10.1097/SPV.0000000000000921. PMID: 33002897.
Dudley LM, Kettle C, Ismail KM. Secondary suturing compared to non-suturing for broken down perineal wounds following childbirth. Cochrane Database Syst Rev. 2013 Sep 25;(9):CD008977. doi: 10.1002/14651858.CD008977.pub2. PMID: 24065561.
Revised: October 2012; Revised March 2017, Revised September 2018; Reaffirmed March 2020. Reaffirmed December 2021
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