Perineal Trauma Management

Preoperative Preparation

The American College of Obstetricians and Gynecologists recommends performing surgical-site vaginal preparation with povidone-iodine or chlorhexidine gluconate (if allergic to iodine) before episiotomy repair, and administering prophylactic antibiotics (e.g., first-generation cephalosporin or second-generation cephalosporin) for complex lacerations 1
Adequate anesthesia, good visualization and exposure, and proper counting of surgical instruments, sponges, and sutures are essential for proper repair 1

The American College of Obstetricians and Gynecologists suggests using continuous, non-locking suture (3-0 or 4-0 delayed absorbable such as polyglactin or poliglecaprone) to close the vaginal epithelium, underlying muscularis, and rectovaginal fascia to the level of the hymenal ring, with anchor suture placed above the apex of the laceration in vaginal epithelium 1
Perineal skin should be reapproximated using continuous, non-locking, subcuticular technique, and internal anal sphincter repair should be performed using an end-to-end technique with mattress or interrupted sutures and 3-0 delayed absorbable suture 1
External anal sphincter repair can be performed using either end-to-end or overlapping technique, with consideration of PISA (posterior, inferior, superior, anterior) suture placement for end-to-end technique, and rectovaginal fascia repair and perineal body reconstruction should be performed to reapproximate tissues 1

The American College of Obstetricians and Gynecologists recommends using acetaminophen and NSAIDs as first-line treatment for postoperative pain, with opiate use only if necessary, and ice packs for local relief 1

The American College of Obstetricians and Gynecologists suggests using stool softeners (polyethylene glycol 4450 or mineral oil) twice daily for six weeks to achieve soft stool consistency, and daily cleaning under running water, especially after bowel movements 1
Sitz baths twice daily until first wound check, and rinsing or alternate cold and warm water douches can be performed 1

The American College of Obstetricians and Gynecologists recommends clear documentation of laceration type and repair technique, as well as early follow-up within two weeks, ideally in a specialized postpartum perineal clinic, with patient education on degree of injury and consideration of endoanal ultrasound if concern for anal sphincter compromise 1
A multidisciplinary approach in a referral center is required for the management of vaginal lacerations, with primary objectives being bleeding control and contamination management, as recommended by the American Society of Anesthesiologists and the American College of Surgeons 2

Potential complications include wound infection, wound breakdown, fecal urgency, anal incontinence, and dyspareunia, which can be avoided by using continuous non-locking suturing techniques, adequate antibiotic prophylaxis, sufficient bowel management postoperatively, and adequate follow-up 1