RCOG Guidelines Update Management of Severe Perineal Tears

Laurie Barclay, MD

June 15, 2015

Early diagnosis and proper repair, management, and treatment of third- and fourth-degree perineal tears during childbirth are crucial in reducing physical and mental complications, according to Royal College of Obstetricians and Gynaecologists (RCOG) guidelines published online June 12 on the RCOG website.

"Obstetricians who are appropriately trained are more likely to provide a consistent, high standard of repair and contribute to reducing the extent of morbidity associated with such injuries," Dr Manish Gupta, RCOG Guideline Committee cochair, said in an RCOG news release.

Although 90% of women have some degree of perineal tearing during childbirth, some have a third-degree tear extending from the vaginal wall and perineum to the anal sphincter, and some have a fourth-degree tear extending to the lining of the anal canal.

Incidence of obstetric anal sphincter injuries (OASIS) in the United Kingdom is 2.9% (range, 0% - 8%) overall: 6.1% among first-time mothers and 1.7% among women who previously delivered. From 2000 to 2012, the incidence of reported OASIS in England tripled, going from 1.8% to 5.9%.

"With increased awareness and training, there appears to be an increase in detection of more extensive tearing, it does not mean women are receiving a substandard quality of care," Dr Gupta said.

Risk factors for severe tearing include Asian ethnicity, first delivery, large birth weight, shoulder dystocia, prolonged labor, and instrumental delivery. Other maternal factors of potential importance include advanced age at first delivery and higher body mass index.

Because these risk factors do not always predict OASIS, clinicians need to know how to detect OASIS early and to be appropriately trained in its repair. Poor surgical technique or use of suboptimal materials may compromise the outcome of repair.

"Severe tearing can affect many aspects of a woman's life longer term, including her physical and mental health, as well as future pregnancies," lead author Ruwan Fernando, MBBS, from the Faculty of Medicine, Department of Surgery & Cancer, Imperial College London, United Kingdom, said in the news release.

Mothers who sustained OASIS in an earlier pregnancy should receive counseling regarding the risks of additional tearing in a subsequent delivery and the option of elective cesarean delivery.

"Currently, there is a need for further research regarding the optimal mode of delivery following third- or fourth-degree perineal tears in a subsequent pregnancy," Dr Fernando added. "Clear documentation, including drawings, together with providing women with a clear explanation of the possible delivery options and associated risks are therefore extremely important."

This third edition of the evidence-based guideline for clinicians updates previous versions of March 2007 and July 2001 and is accompanied by RCOG Patient Information on perineal tearing.

Some of the additional recommendations, new for 2015, include the following:

  • evidence for the protective effect of episiotomy is conflicting;

  • mediolateral episiotomy should be considered in instrumental deliveries;

  • perineal protection at crowning can be protective;

  • warm compression during the second stage of labor lowers the risk for OASIS;

  • OASIS may be repaired in the delivery room in certain circumstances after discussion with a senior obstetrician;

  • figure of eight sutures should be avoided during OASIS repair;

  • after repair, rectal examination is needed to ensure sutures have not been inserted through the anorectal mucosa, and any such sutures should be removed;

  • continuous or interrupted technique is suitable for suture repair of the torn anorectal mucosa;

  • end-to-end technique should be used for partial thickness (all 3a and some 3b) tears; and

  • 3-0 polyglactin is preferable to polydioxanone for suture repair of the anorectal mucosa.

Conflict-of-interest information is available in the guideline.

"The Management of Third- and Fourth-Degree Perineal Tears." RCOG. Green-top Guideline No. 29. Published online June 12, 2015. Full text

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