The Obstetrician & Gynaecologist 2007;9:3:164-170
doi: 10.1576/toag.9.3.164.27336
Copyright © 2007 by the Royal College of Obstetricians and Gynaecologists.
Postpartum care of the perineum
Myra Fitzpatrick, MRCOG, Lecturer1 and
Colm O'Herlihy, FRCOG, Professor of Obstetrics and Gynaecology2
1. National Maternity Hospital Department of Obstetrics and Gynaecology Holles Street, Dublin 2 Republic of Ireland Email: myrafitzpatrick{at}hotmail.com (corresponding author)
2. National Maternity Hospital Dublin, Republic of Ireland
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Abstract
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Key content:- Vaginal birth is traumatic to the pelvic floor and perineum.
- Faecal incontinence, perineal pain, urinary incontinence and dyspareunia can all be long-term effects of such damage.
- Recognition and management of perineal trauma postpartum is vital.
- Women rarely volunteer information regarding faecal incontinence and dyspareunia.
- A dedicated pelvic floor clinic may be the most appropriate setting in which to care for women who are affected.
Learning objectives:
- To learn about the guidelines in place for the repair of perineal trauma following delivery.
- To recognise that anal sphincter damage may require follow-up and appropriate investigation.
- To learn that direct questioning of women about dyspareunia and faecal incontinence is necessary to elicit information.
Ethical issues:
- Is it the responsibility of women to present with their problems or should nursing and medical staff look for them?
- Financial constraints inappropriately limit the provision of small, highly focused clinics.
Please cite this article as: Fitzpatrick M, O'Herlihy C, Postpartum care of the perineum. The Obstetrician & Gynaecologist 2007;9:164–170.
Keywords biofeedback physiotherapy / obstetric anal sphincter injury / pelvic floor assessment / perineal trauma / vaginal delivery
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Introduction
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Reduced perinatal and maternal mortality rates in recent decades have focused increasing attention on maternal morbidity and the long-term sequelae of childbirth. Antenatal education encourages expectant women to anticipate normal vaginal delivery, with early restoration of normal pelvic function following routine pelvic floor exercises. Until recently, little attention was given to the common problem of perineal damage at delivery and its potentially debilitating consequences on faecal continence and sexual function.
It is estimated that over 85% of women who have a vaginal delivery will sustain some degree of perineal trauma, 60–70% of whom will require suturing.1,2 The Royal College of Obstetricians and Gynaecologists (RCOG)3 has issued guidelines regarding the classification of spontaneous tears, which allows differentiation to be made between injuries to the external and internal anal sphincters and anal epithelium (see Table 1). The incidence of clinical third- and fourth-degree tears varies widely. It is reported at between 0.5–3% in Europe and 6–9% in the USA.4,5 Large prospective studies have shown, however, that up to 25% of primiparous women experience altered faecal continence postnatally and up to one-third have evidence of some anal sphincter trauma after their first vaginal delivery.6 In the majority these symptoms and injuries are relatively minor and transient but persistent incontinence of flatus or urgency of defaecation are emotionally and socially debilitating and can delay return to work after delivery.
Although faecal incontinence has predominated in much of the recent research regarding perineal trauma, it is by no means the only consequence. Dyspareunia is common in the postnatal period, with up to 60% of women experiencing coital difficulty at 3 months and 30% at 6 months.7 Superficial dyspareunia can be secondary to scar tissue formation, poor anatomical reconstruction following perineal trauma or vaginal dryness and atrophy. Urinary difficulties in the postpartum period are a common occurrence and they warrant attention regarding their management.
Anal sphincter injury and tears of a lesser degree can have a significant emotional impact on a woman's physical and emotional wellbeing. Concerns identified by women include anxieties regarding the effects of the injury on continence, body image and sexual function. Poor exchange of information and communication on the part of healthcare professionals does little to alleviate these worries.8
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Immediate management of perineal trauma
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The RCOG's guidelines3 recommend suturing of first and second-degree tears with an absorbable synthetic material such as rapid-absorption polyglactin 910 (Vicryl Rapide® [Ethicon, Brussels, Belgium]). A loose, continuous non-locking technique to appose each layer is recommended as it is associated with less short-term pain than the more traditional interrupted method. The practice of non-suturing of first and second-degree tears is associated with poorer wound healing and potential perineal deformity.3
The sequelae associated with third- and fourth-degree tears are of sufficient significance that it is now accepted that only trained personnel should undertake anal sphincter repair under optimum conditions. The procedure should be performed in the operating theatre with adequate equipment, lighting, assistance and analgesia.9 Access to regional or general analgesia ensures that the woman is pain-free and the sphincter relaxed, allowing identification of the torn muscle margins and their approximation.10
Polydioxanone (PDS II® [Ethicon]) is recommended for repair of the sphincter muscle because of its longer half-life and the decreased risk of infection, although knot migration is a potential consequence with the use of this long-acting material.
The principal controversy regarding primary anal sphincter repair pertains to technique. Two methods are commonly employed. The first is an end-to-end approximation of the torn anal sphincter ends, a method traditionally performed by obstetricians. Overlapping of the torn external sphincter ends is the second technique and is favoured by colorectal surgeons at secondary repair procedures. A recent study11 has reported the latter method to be superior in outcome at 1 year, although several other studies have failed to show any advantage of one method over the other.12–14 Recent work has also highlighted the importance of adequate identification and repair of tears to the internal anal sphincter, to reduce subsequent faecal incontinence symptoms.15
It is apparent from published data that, regardless of the mode of repair employed, the outcome of primary repair is often suboptimal, at least as identified by subsequent ultrasound appearances of the sphincter.16 The quality of primary repair needs to be improved regardless of the mode employed and resources should be invested in surgical training of obstetricians in obstetric anal sphincter injury.
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Immediate pain management
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Pain following perineal trauma can be severe and persist into the postpartum period. It will inhibit normal daily activities such as walking, sitting and micturition and can influence bonding with the newborn baby. Therapeutic ultrasound, antiseptics and non-pharmacological applications such as ice packs, cooling gel pads and baths are all commonly employed.17 Treatment options for perineal pain include traditional oral analgesia and the use of rectal non-steroidal agents. Topical analgesia, such as lidocaine gel, obviates any systemic absorption but there is little evidence to support its efficacy.18
Rectal diclofenac is an effective method of analgesia that significantly reduces pain on sitting, walking and defaecation within the first 48 hours after delivery. Although there is little sustained effect after 48 hours, the relief provided, particularly on defaecation, makes it a primary choice of pain relief for obstetric anal sphincter and other perineal injuries.19
Delayed and painful defaecation can lead to considerable discomfort and distress for the woman. Stool softeners prevent faecal impaction and possible damage to the recently repaired sphincter. Laxative use in the immediate postpartum period leads to a significantly earlier and less painful first bowel motion following a third- or fourth-degree tear and an earlier discharge for the woman.20
Puerperal haematoma is an uncommon complication of childbirth but has the potential for serious morbidity. Prevention using good surgical technique, with attention to haemostasis in the repair of lacerations and episiotomies, should limit the occurrence of this complication. It is not entirely avoidable and should be suspected early in a woman complaining of acute increasing perineal discomfort post delivery. Treatment includes correcting hypovolaemia and intervening with active surgical management if the haematoma is large or expanding.
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Prevention and treatment of infection
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There is no randomised controlled evidence examining the issue of peri- and postoperative antibiotic use in the management of obstetric anal sphincter injury. A recent Cochrane review21 found insufficient data to support a policy of routine prophylactic antibiotics in fourth-degree tears, although it was suggested that a randomised controlled trial is needed. Third- and, particularly, fourth-degree tears can become contaminated with bacteria from the rectum. This significantly increases the chance of perineal wound infection, which, in turn, leads to a higher risk of wound breakdown, fistula formation and anal incontinence. Given the severity of these potential sequelae, it is prudent to prescribe both aerobic and anaerobic cover following primary repair.9 Evidence does not exist to support routine antibiotic use after first and second-degree tears.
Postpartum episiotomy dehiscence is a rare complication following vaginal delivery. Risk factors include the occurrence of a third- or fourth-degree tear, operative vaginal delivery and the presence of meconium.22 Recognition of infection is important and investigations should be made to rule out occult rectal injury that could be the source of infection. Opinion is mixed as to the best management. In a 2004 study Uyger et al.23 concluded that early repair of perineal wound dehiscence is a safe option provided there is adequate preoperative preparation with wound cleaning and intravenous antibiotics. A more commonly employed management regimen is to allow the wound to heal by secondary intention with frequent wound packing and dressing.
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Postpartum urinary difficulties
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Urinary retention
The incidence of postpartum urinary retention depends on the definition used. Voiding dysfunction symptoms such as hesitancy, difficulty passing urine, slow or intermittent stream, straining to void and a sense of incomplete emptying are common. Using the definition of no spontaneous voiding within 6 hours of delivery, Kermans et al.24 reported postpartum urinary retention in 2.1% of women following vaginal delivery and 3.2% of women delivered by caesarean section. Factors felt to be important in its occurrence include instrumental delivery, a prolonged second stage of labour and regional analgesia.
There is no consensus of opinion regarding the diagnostic criteria for postpartum urinary retention and, therefore, the optimum management for voiding dysfunction remains controversial. Conservative measures likely to stimulate spontaneous micturition, such as ambulation, privacy and a warm bath, should be employed initially. If such measures do not work, catheterisation is needed. If the residual volume is greater than 1 000 ml, it is likely that repeat catheterisation will be required in 20% of cases.25 There is little data to indicate whether repeated bladder catheterisation is preferred to inserting an indwelling catheter in women who are persistently unable to void for more than 24 hours.
Only 0.05% of women are still unable to void 3 days after delivery; leaving a Foley catheter in place for a further 2 weeks may be the best option as it allows the woman to go home with a leg bag.26 The vast majority of voiding difficulties resolve during this period.
Stress incontinence
Postpartum urinary incontinence is a common sequela of vaginal delivery. Its causation is multifactorial, although large babies and instrumental delivery are felt to be the main causes. Women who have the most marked symptoms postnatally appear to have a predisposition to urinary incontinence and often have symptoms antenatally. Although women's perceptions and reporting of symptoms and definitions vary, particularly in the early postpartum period, 8–20% of women suffer postnatal stress incontinence.27 Women who have symptoms that persist for 3 months postnatally are particularly likely to have long-lasting symptoms, with 92% remaining incontinent at 5 years.28 Continence promotion programmes delivered to women at risk can help to reduce the incidence of long-term urinary incontinence.29
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Long-term management of obstetric anal sphincter injury
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Assessment
Assessment of women who complain of altered continence following delivery should ideally be performed in a clinic dedicated to the comprehensive investigation of perineal problems. A routine postnatal review of all women who sustain a third- or fourth-degree tear is advisable because of the high risk of residual anal sphincter dysfunction. This assessment can be carried out from 6 weeks postnatally, after perineal healing and uterine involution have occurred.
Direct questioning using a detailed bowel function questionnaire is essential, as symptoms are rarely volunteered. A continence score can then be calculated to permit the easy interpretation of the severity of symptoms and their resolution with time. A scoring system has the advantage of enabling a comparative assessment of the benefits of subsequent treatment. Faecal urgency is an important consideration. This symptom can be very disabling, impacting considerably on lifestyle: inability to defer defaecation for longer than 5 minutes is significant.
Clinical examination may reveal signs suggestive of sphincter injury or neuropathy such as perineal soiling, absence of cutaneous anal reflex, scarring or rectovaginal fistula. While rectal examination may provide an approximate estimate of the integrity of the anal sphincter and perineal body, further assessment with anal manometry and endoanal ultrasound is needed. Electromyography (EMG) may be warranted if pudendal neuropathy is suspected.
Manometry
By providing a pressure profile of the anal canal, manometry assesses sphincter tone and contractile function.30,31 Three resting and three anal canal squeeze pressure readings are obtained to calculate the mean maximum resting and squeeze pressures, reflecting internal and external anal sphincter activity, respectively (Figure 1).
Endoanal ultrasound
A high resolution rotating endoprobe can provide a clear image of internal and external anal sphincter integrity (Figure 2).32 Three-dimensional ultrasonographic imaging has recently been developed but is not yet widely available. In selected women with complex injury or suspected rectovaginal fistula, magnetic resonance imaging (MRI) provides valuable additional anatomical information.
Pudendal nerve assessment
Concentric needle EMG of the external anal sphincter, with pudendal nerve conduction assessment using the clitoral–anal reflex, allows evaluation of the full length of the pudendal nerve. The assessment of neural integrity is an essential prerequisite to secondary anal sphincter repair, which is compromised by an irreversible pudendal neuropathy.
Treatment
Conservative
Because postpartum incontinence symptoms are often transient, dietary advice will help many women with a minor degree of faecal incontinence.33 A low residue diet reduces the fluidity of the stool, which can then be controlled more easily. Antidiarrhoeal medication, such as codeine phosphate or loperamide, can reduce faecal urgency and is also useful for those with neurogenic injury.34
Physiotherapy
Physiotherapy has provided the mainstay of treatment for postpartum faecal incontinence for many years. Pelvic floor exercises involving standard Kegel techniques at regular intervals throughout the day have proved beneficial in relieving symptoms of soiling. Conventional sensory biofeedback therapy combines Kegel exercises with a sensory feedback signal using either a perineometer or vaginal cones. This technique has been shown to improve faecal continence symptoms subjectively, although manometry pressures may not alter significantly.35 Augmented biofeedback constitutes a combination of conventional biofeedback with electrical stimulation using an endoanal probe to initiate and coordinate voluntary contraction of the pelvic floor muscles; it entails electrical stimulation of the sphincter muscle combined with audiovisual EMG feedback (Figure 3). This treatment is frequently employed in women who are resistant to standard physiotherapy and where demyelinating pudendal nerve injury is present to maintain sphincter muscle bulk during the neurological recovery period. It can also increase residual muscle tone as an adjunct to secondary surgical sphincter repair in women with significant muscle damage.36
Despite its widespread use, there is a paucity of data demonstrating the long-term benefits of biofeedback, either alone or with augmentation.37,38 Further work is required to define the efficacy of these treatments.
Surgical treatment
Women with persistent faecal incontinence symptoms as a consequence of large anal sphincter defects should be assessed by a colorectal surgeon with a view to delayed overlapping anal sphincter repair. This procedure offers an improved functional outcome in more than 80% of women.39 Other surgical options for severe or recurrent faecal incontinence include formation of an end colostomy, gracilis muscle transposition and artificial sphincter implantation, all of which represent major surgical undertakings. Results have been mixed and they should only be considered after standard treatments have proved unsuccessful. Collagen implantation into the anal mucosa and trans-sphincteric injection of silicone biomaterial are also still under evaluation. There is a growing body of evidence to suggest that sacral nerve stimulation may successfully restore bowel continence in some women with endoanal ultrasound evidence of defects in the external anal sphincter, thereby avoiding the need for secondary anal sphincter repair with a defunctioning colostomy.40
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Dyspareunia
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Dyspareunia can be defined as any pain that occurs during sexual intercourse. It affects a significant number of women following childbirth: approximately 30% at 3 months.7 As a symptom it is under-reported and rarely volunteered. Direct questioning is required to elucidate the extent of the symptom. In time, superficial dyspareunia can lead to apareunia and, consequently, to significant relationship difficulties. Nevertheless, there is a dearth of research regarding treatment of this problem. Clinical examination may reveal a thin band of scar tissue lying close to the introitus corresponding to the site of maximum tenderness. Perineal massage with tea tree or almond oil may help to accelerate the softening of the tissue. The use of a topical analgesic gel with perineal massage or during intercourse may also help. Injection into the site of maximum tenderness of a combination of corticosteroid, local anaesthetic and hyaluronidase represents another treatment option, although there is no strong evidence to support its efficacy. On occasions, a minor vaginoplasty (Fenton's procedure) may be required to alleviate persistent symptoms.
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Summary
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Perineal damage following vaginal delivery is a topic that has gained increased attention in recent years, not least because of better understanding of its sequelae. Faecal incontinence represents a distressing social affliction and vaginal delivery is now recognised as the principal cause. Obstetricians are best placed to minimise suffering and should have an awareness of the causes, symptoms, appropriate investigations and treatment options available. Wherever possible, women should be evaluated in a specialised clinic that has developed a close liaison with physiotherapy, dietetic and colorectal advisers. Dyspareunia is an under-reported symptom that may be present in a significant proportion of the postnatal population. Direct questioning is required to identify it and appropriate action must be taken where it is present.
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References
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TOP
Abstract
Introduction
