9. Repair the external anal sphincter with a 2-0 suture
Use a 2-0 suture to repair the external anal sphincter. Most obstetricians are familiar with the end-to-end repair. Many colorectal surgeons prefer an overlapping technique. Results of randomized trials indicate that an end-to-end repair is as effective as an overlapping technique.9
Often, obstetricians try to ensure that the knots are buried within the body of the external anal sphincter muscle, rather than on the surface of the fascial sheath of the sphincter. Many obstetricians recommend placing 4 interrupted sutures for the repair starting at the 3 o’clock position and moving to the 6 o’clock and then 12 o’clock positions and finishing with the 9 o’clock position.
Repair of the 1st- and 2nd-degree vaginal laceration and perineal body is then completed in the usual fashion.
10. Identify the patient as a “high risk” postpartum patient who warrants extra attention
Women who have had a 3rd- or 4th-degree perineal tear should receive a high level of attention to perineal care, a low-residue diet, a stool softener and/or laxative, and physical examination of the progress of wound healing. In one randomized trial, women with a 3rd-degree tear were randomly assigned to treatment with codeine (“bowel confinement regimen”) or lactulose. The women who received lactulose had earlier and less painful bowel movements postpartum.10
The presence of fever, excessive vaginal discharge, or excessive perineal pain should be carefully monitored using a standardized process. After a difficult vaginal delivery, perineal edema may be severe and elevation of the foot of the bed may be of benefit to accelerate the resolution of the edema.
11. Schedule an early return clinical visit to examine the healing process
Breakdown of 3rd- and 4th-degree repairs is not common but typically occurs about 1 week after delivery. Most low-risk women are not scheduled for a 1-week postpartum check. A woman with a 3rd- or 4th-degree laceration, however, should be examined about 1 week after delivery. If breakdown occurs, repair it
immediately.11
12. Assess long-term clinical outcomes
Third- and 4th-degree lacerations are a common cause of anal incontinence.12-14 In an observational study with at least 5 years of follow‑up, 19% of women with a 3rd- or 4th-degree laceration reported symptoms of anal incontinence. By contrast, 10% of women who had a vaginal delivery without such a severe laceration and 9% of women who had a cesarean delivery reported symptoms of incontinence. A plan to monitor long-term clinical outcomes is of value in longitudinal tracking of the long-term health of these women.
INSTANT POLL
• Does your labor and delivery unit have a standardized checklist for the repair of 3rd- and 4th-degree lacerations?
• Do you think a checklist would improve patient care, or hinder individualized decision making?
• Do you recommend prophylactic antibiotics for all women with a 3rd- or 4th-degree perineal laceration?
Our readers want to know! What are your clinical pearl for the repair of a 3rd- or 4th-degree laceration?
Tell us—at rbarbieri@frontlinemedcom.com. Please include your name and city and state.Initiate a checklist for your unit today
Many uncommon but significant events in obstetrics have a standardized approach to diagnosis and treatment. Interestingly, many obstetric units have not developed standardized protocols for these significant events. A multidisciplinary process, which is led by obstetricians but includes midwives, obstetric nurses, and anesthesiologists, could be used to develop and test surgical checklists for your labor unit. It is likely that the participants in the process will find it professionally rewarding, and a new surgical checklist may help improve patient care.
RELATED ARTICLES
Does mediolateral episiotomy reduce the risk of anal sphincter injury in operative vaginal delivery? Errol R. Norwitz, MD, PhD (Examining the Evidence, August 2012)
Stop performing median episiotomy! Robert L. Barbieri, MD (Editorial, April 2012)