Management of Obstetric Perineal Injuries

Classification and Diagnostic Approach

The American College of Obstetricians and Gynecologists (ACOG) classifies obstetric perineal injuries into four degrees, with third- and fourth-degree tears requiring intensive management due to their association with long-term anal incontinence in 35-60% of women 1, 2
After every vaginal delivery, a systematic evaluation including visual inspection, thorough perineal examination, and digital rectal examination should be performed to detect obstetric perineal injuries, with the rectal exam being mandatory to improve OASIS detection rates 1, 2, 3
Adequate lighting and patient positioning are essential before examination to ensure accurate diagnosis 1, 3

For hemostatic first-degree tears, using skin adhesive or no suturing rather than traditional suturing reduces pain, procedure time, and achieves equivalent functional outcomes 1, 2, 3
For second-degree tears, if hemostatic, using skin adhesive or no suturing for the perineal skin after repairing deeper layers reduces pain, dyspareunia, and improves breastfeeding rates at 3 months 1, 2, 3
OASIS repairs require regional or general anesthesia, antibiotic prophylaxis, and use of a surgical checklist to ensure adherence to critical care processes and reduce errors 4, 5
Post-operative care for OASIS includes stool softeners, pain control, sitz baths, early follow-up, and patient education to achieve optimal outcomes 5

The prevalence of obstetric perineal injuries varies by degree, with first-degree injuries occurring in 5.5-16.4% of vaginal births, second-degree in 29.0-35.1%, third-degree in 1.8-7.1%, and fourth-degree in 0-0.3% 1, 2, 3