Managing perineal lacerations and pelvic floor disorders after childbirth

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Perineal lacerations and pelvic floor disorders are two common problems associated with vaginal delivery.

The lacerations, which commonly occur at time of delivery, are graded on a scale of 1 to 4, with third- and fourth-degree lacerations being the most worrisome.

“These more severe lacerations enter the anal sphincter and may disrupt the external anal sphincter, the internal anal sphincter, or both, as well as the rectal mucosa,” said Rebecca Rogers, MD, a professor of ob/gyn at Dell Medical School, University of Texas at Austin.

Dr. Rogers spoke on perineal outcomes following birth at the 2019 American College of Obstetricians and Gynecologists annual clinical and scientific meeting in Nashville, in collaboration with the American Urogynecologic Society (AUGS).

Anal sphincter damage can cause severe pain or accidental bowel leakage.

Avoiding an episiotomy and judicious use of operative vaginal delivery are two ways to decrease risk of sphincter injury as a result of severe perineal lacerations.

“If you must perform an episiotomy, cut in a mediolateral fashion,” Dr. Rogers said. “Midline episiotomy should be avoided.”

Likewise, vacuum as opposed to forceps for vaginal delivery can reduce the likelihood of severe perineal lacerations.

Two strategies for preventing perineal lacerations are antenatal perineal massage and using warm compresses during delivery. “But we do not know whether these strategies avoid the long-term impact of vaginal birth on urinary continence and pelvic support,” Dr. Rogers said.  

Of all the pelvic floor dysfunctions, prolapse is most closely associated with vaginal birth. “Thus, the more vaginal births a woman has, the more likely she will end up with a surgery for pelvic organ prolapse,” she told Contemporary OB/GYN. 

The reason may be secondary to underlying damage to the levator ani, which provides support to the pelvic organs. “If that support system is disrupted at the time of birth, it does seem to correlate with an increased risk for prolapse,” Dr. Rogers said.

Similarly, urinary incontinence increases in women who have vaginal births as compared to cesarean. “However, that effect appears to be mitigated by age, so by the time a women reaches her 50s, the effect of birth seems to be trumped by age,” Dr. Rogers said. “This correlation is not as strong, though, as the correlation between prolapse and vaginal birth.”

Roughly 200,000 operations are performed annually in the United States for pelvic organ prolapse. “Some women choose to have a cesarean delivery to avoid incontinence or prolapse; however, only a small subset of women have these poor outcomes after vaginal birth,” she said.

According to Dr. Rogers, it is up to ob/gyns to talk to patients about these problems, because many women avoid seeking care when they have pain, leakage or prolapse, due to embarrassment. “We need to start to have these dialogues with women because we take care of them throughout their lives,” she said. “It is important that our patients can access treatments if they develop these problems.”

Severe lacerations may be a more immediate outcome of vaginal birth, whereas incontinence or prolapse typically takes 5 to 15 years after delivery to develop.

“I believe practitioners should talk to their patients about the possibility of problems with continence or pain following their delivery.” Dr. Rogers said. “While the majority of women will be fine after vaginal birth, we want to be available for those who experience problems.” 

Disclosures:

Dr. Rogers has no relevant financial disclosures.