Outcomes of perineal laceration repair following childbirth

Women who have third-or fourth-degree perineal laceration repairs following the birth of their first baby have considerably different outcomes that can adversely impact quality of life and have implications on subsequent deliveries, according to Virginia Commonwealth University researchers.

In the August issue of the American Journal of Obstetrics and Gynecology, researchers reported that bowel-related complications were more common following fourth-degree tear repair compared with third-degree repair. Furthermore, women with fourth-degree tears were significantly more likely to have an increased rate of combined defects of the internal and external sphincters.

"Our study demonstrates that third- and fourth-degree lacerations should not be collectively grouped together as 'severe perineal lacerations' because the outcomes appear to be significantly different," said Catherine Nichols, M.D., assistant professor of obstetrics and gynecology at VCU, and lead author of this study.

"Regardless of the initial degree of the tear, the status of the anal sphincter complex postpartum is very predictive of the likelihood of having bowel problems," she said.

According to Nichols, common complaints among women following anal sphincter repair are incontinence of stool and fecal urgency. The overall reported rate of anal sphincter lacerations is approximately 6 percent to 20 percent, with higher rates documented following forceps or vacuum delivery, she said. Risk factors for anal sphincter damage include delivery with forceps or a vacuum, having your first baby or delivering a large baby.

Some long-term effects of this type of trauma may include chronic fecal incontinence, perineal pain, recto-vaginal fistulas and pain during sexual intercourse. Many patients who experience chronic bowel incontinence may not seek medical help because they find the nature of the problem embarrassing, which can have a toll on quality of life.

"This is an issue faced by many women who deliver vaginally and it is important that we educate women about the consequences of severe vaginal tears – especially mothers-to-be," she said.

"It is interesting how few women are educated about potential bowel control problems after sustaining either a third- or fourth-degree tear," she said. "It is our obligation as obstetricians to fully inform our patients."

In this study, 56 women who sustained a third- or fourth-degree tear following their first vaginal delivery completed a questionnaire that assessed their pre-delivery bowel habits and bowel symptoms before being released from the hospital. Six to eight weeks later, patients completed another questionnaire to assess for any changes in bowel habits since delivery. This was followed by a pelvic examination and a special ultrasound of the anal canal that can determine if the muscles that were torn at delivery have healed.

Dr. Nichols and her colleagues have a dedicated perineal clinic at the VCU Medical Center's Nelson Clinic, where they evaluate women who have sustained such a laceration. They perform an extensive evaluation, including endoanal ultrasound, and can assess a patient's recovery after repair. Management strategies for improving bowel control are discussed that include physical therapy, dietary modification, and possibly surgery.

Nichols is currently involved with a clinical study examining women who are in their second pregnancy who sustained this type of vaginal tear during their first pregnancy, the goal of which is to determine the better route of delivery – cesarean versus repeat vaginal birth.