Lacerations of the Birth Canal Lacerations of the vagina and perineum are classified as first, second, third, or fourth

degree. First-degree lacerations involve the fourchette, perineal skin, and vaginal mucous membrane but not the underlying fascia and muscle. Second-degree lacerations involve, in addition to skin and mucous membrane, the fascia and muscles of the perineal body but not the anal sphincter (Fig. 1734). These tears usually extend upward on one or both sides of the vagina, forming an irregular triangular injury. Third-degree lacerations extend through the skin, mucous membrane, and perineal body, and involve the anal sphincter. A fourth-degree laceration extends through the rectal mucosa to expose the lumen of the rectum. Tears in the region of the urethra that may bleed profusely may also accompany this type of laceration. Figure 1734.

Deep second-degree laceration of the perineum and vagina. Because the repair of perineal tears is virtually the same as that of episiotomy incisions, albeit often less satisfactory because of irregular lines of tissue cleavage, the technique of repairing lacerations is discussed in the following section. Episiotomy and Repair In a strict sense, episiotomy is incision of the pudenda. Perineotomy is incision of the perineum. In common parlance, however, the term episiotomy often is used synonymously with perineotomy, a practice that we follow here. The incision may be made in the midline, creating a median or midline episiotomy, or it may begin in the midline but be directed laterally and downward away from the rectum, termed a mediolateral episiotomy. Purposes of Episiotomy Although still a common obstetrical procedure, the use of episiotomy has decreased remarkably over the past 25 years. Weber and Meyn (2002) used the National Hospital Discharge Survey to analyze use of episiotomy between 1979 and 1997 in the United States. Approximately 65 percent of women who gave birth vaginally in 1979 had episiotomies compared with 39 percent by 1997. Through the 1970s, it was common practice to cut an episiotomy for almost all women having their first delivery. The reasons for its popularity included substitution of a straight surgical incision, which was easier to repair, for the ragged laceration that otherwise might result. The long-held beliefs that postoperative pain is less and healing improved with an episiotomy compared with a tear, however, appeared to be incorrect (Larsson and colleagues, 1991).

Another commonly cited but unproven benefit of routine episiotomy was that it prevented pelvic relaxationthat is, cystocele, rectocele, and urinary incontinence. A number of observational studies and randomized trials showed that routine episiotomy is associated with an increased incidence of anal sphincter and rectal tears (Angioli and co-authors, 2000; Argentine Episiotomy Trial Collaborative Group, 1993; Eason and colleagues, 2000; Nager and Helliwell, 2001). Carroli and Belizan (2000) reviewed the Cochrane Pregnancy and Childbirth Group trials registry. There were six randomized trials of nearly 5000 deliveries in which routine (73-percent rate) versus restricted (28-percent rate) use of episiotomy was evaluated. There were lower rates of posterior perineal trauma, surgical repair, and healing complications in the restricted-use group. Alternatively, the incidence of anterior perineal trauma was lower in the routine-use group. Along with these findings came the realization that episiotomy did not protect the perineal body and contributed to anal sphincter incontinence by increasing the risk of third- and fourthdegree tears. Signorello and associates (2000) reported that fecal and flatus incontinence were increased four- to sixfold in women with an episiotomy compared with findings of a group delivered with an intact perineum. Even when compared with spontaneous lacerations, episiotomy tripled the risk of fecal incontinence and doubled it for flatus incontinence. Episiotomy without extension did not lower this risk. Finally, even with recognition and repair of a third-degree extension, 30 to 40 percent of women have long-term anal incontinence (Gjessing and co-workers, 1998; Poen and colleagues, 1998). It seems reasonable to conclude that episiotomy should not be performed routinely (Eason and Feldman, 2000). The procedure should be applied selectively for appropriate indications, some of which include fetal indications such as shoulder dystocia and breech delivery; forceps or vacuum extractor deliveries; occiput posterior positions; and in instances where it is obvious that failure to perform an episiotomy will result in perineal rupture. The final rule is that there is no substitute for surgical judgment and common sense. The important variables of episiotomy use include the timing of the incision, the type of incision, and techniques for repair. Timing of Episiotomy If performed unnecessarily early, bleeding from the episiotomy may be considerable during the interim between incision and delivery. If it is performed too late, lacerations will not be prevented. It is common practice to perform episiotomy when the head is visible during a contraction to a diameter of 3 to 4 cm (see Fig. 1724). When used in conjunction with forceps delivery, most practitioners perform an episiotomy after application of the blades (see Chap. 23, Traction). Midline versus Mediolateral Episiotomy The advantages and disadvantages of the two types of episiotomies are summarized in Table 17 4. Except for the important issue of third- and fourth-degree extensions, midline episiotomy is superior. Proper selection of cases can minimize this one disadvantage. In addition to a midline episiotomy, Combs and associates (1990) reported the following factors to be associated with an

increased risk of third- and fourth-degree lacerations: nulliparity, second-stage arrest of labor, persistent occiput posterior position, mid or low forceps, use of local anesthetics, and Asian race. Table 174. Midline Versus Mediolateral Episiotomy

Type of Episiotomy Characteristic Surgical repair Faulty healing Postoperative pain Anatomical results Blood loss Dyspareunia Extensions Midline Easy Rare Minimal Less Rare Mediolateral More difficult More common Common More Occasional

Excellent Occasionally faulty

Common Uncommon

It is reasonable to use a mediolateral episiotomy when a third- or fourth-degree extension is likely, but to employ the midline incision otherwise. Anthony and colleagues (1994), who presented data from the Dutch National Obstetric Database of over 43,000 deliveries, found more than a fourfold decrease in severe perineal lacerations when mediolateral episiotomy was employed compared with midline incision. Venkatesh and colleagues (1989) reported a 5-percent incidence of third- and fourth-degree perineal tears in 20,500 vaginal deliveries. About 10 percent of these 1040 primary repairs had a postoperative wound disruption, and 67 of the 101 required surgical correction. Goldaber and associates (1993) found that 21 of 390 or 5.4 percent of women with fourth-degree lacerations experienced significant morbidity. There were 7 (1.8 percent) dehiscences, 11 (2.8 percent) infections with dehiscences, and 3 (0.8 percent) infections alone. Although administration of a perioperative 2-g intravenous dose of cefazolin reduced this morbidity, it was not totally eliminated. Timing of the Episiotomy Repair The most common practice is to defer episiotomy repair until the placenta has been delivered. This policy permits undivided attention to the signs of placental separation and delivery. A further advantage is that episiotomy repair is not interrupted or disrupted by the obvious necessity of delivering the placenta, especially if manual removal must be performed. Technique There are many ways to close an episiotomy incision, but hemostasis and anatomical restoration without excessive suturing are essential for success with any method. A technique that commonly is employed is shown in Figure 1735. The suture material ordinarily used is 3-0

chromic catgut, but Grant (1989) recommends suture composed of derivatives of polyglycolic acid. A decrease in postsurgical pain is cited as the major advantage of the newer materials, despite the occasional later need to remove some of the suture from the site of repair because of pain or dyspareunia. Kettle and co-authors (2002) randomly assigned 1542 women with perineal lacerations or episiotomies to undergo continuous versus interrupted repair with rapidly absorbed polyglactin 910 (Vicryl Rapids, Ethicon) or standard polyglactin 910 sutures. The former typically is absorbed by 42 days and the latter completely absorbed by about 90 days. The continuous method was associated with less perineal pain. The rapidly absorbed material was associated with lower rates of suture removal within 3 months of delivery (3 percent removal versus 13 percent removal for rapidly absorbed versus standard polyglactin). Sanders and coworkers (2002) emphasized that women without regional analgesia can experience high levels of pain during perineal suturing. Figure 1735.

Repair of midline episiotomy. A. Chromic 2-0 or 3-0 suture is used as a continuous suture to close the vaginal mucosa and submucosa. B. After closing the vaginal incision and reapproximating the cut margins of the hymenal ring, the suture is tied and cut. Next, three or four interrupted sutures of 2-0 or 3-0 chromic are placed in the fascia and muscle of the incised perineum. C. A continuous suture is carried downward to unite the superficial fascia. D. Completion of repair. The continuous suture is carried upward as a subcuticular stitch. (An alternative method of closure of skin and subcutaneous fascia is illustrated in E.) E. Completion of repair of midline episiotomy. A few interrupted sutures of 3-0 chromic are placed through the skin and subcutaneous fascia and loosely tied. This closure avoids burying two layers of suture in the more superficial layers of the perineum. Fourth-Degree Laceration The technique of repairing a fourth-degree laceration is shown in Figure 1736. Various techniques have been recommended, but in all instances, it is essential to approximate the torn edges of the rectal mucosa with sutures placed in the muscularis approximately 0.5 cm apart. This muscular layer then is covered with a layer of fascia. Finally, the cut ends of the anal sphincter are isolated, approximated, and sutured together with three or four interrupted stitches. The remainder of the repair is the same as for an episiotomy. The overlapping technique is an alternative method to approximate the external anal sphincter. Despite promising initial results with this technique, more recent data based on a randomized controlled trial do not support that this method yields superior anatomical or functional results over the traditional end-to-end technique (Fitzpatrick and colleagues, 2000; Sultan and co-workers, 1999). Thus, more emphasis should be placed on prevention of anal sphincter lacerations. Postrepair, stool softeners should be prescribed for a week, and enemas should be avoided. Prophylactic antimicrobials should be considered, as described by Goldaber and colleagues (1993). Unfortunately, normal function is not always assured even with correct and complete surgical repair. Some women may experience

continuing fecal incontinence caused by injury to the innervation of the pelvic floor musculature (Roberts and co-workers, 1990). Figure 1736.

Layered repair of a fourth-degree perineal laceration. A. Approximation of the anorectal mucosa and submucosa in a running or interrupted fashion using fine absorbable suture such as 3-0 or 4-0 chromic or Vicryl. The superior extent of the anterior anal laceration is identified and the sutures are placed through the submucosa of the anorectum approximately 0.5 cm apart down to the anal verge. B. A second layer is placed through the rectal muscularis using 3-0 Vicryl suture in a running or interrupted fashion. This "reinforcing layer" should incorporate the torn ends of the internal anal sphincter, which is identified as the thickening of the circular smooth muscle layer at the distal 2 to 3 cm of the anal canal. It can be identified as the glistening white fibrous structure lying between the anal canal submucosa and the fibers of the external anal sphincter (EAS). In many cases, the internal sphincter retracts laterally and must be sought and retrieved for repair. C. The disrupted ends of the striated EAS muscle and capsule are then identified and grasped with Allis clamps. The torn ends of the EAS often retract laterally in an asymmetrical fashion as shown. D. Traditional end-to-end approximation of the EAS. Four to six simple interrupted 2-0 or 3-0 Vicryl sutures are placed at the 3, 6, 9, and 12 o'clock positions through the EAS muscle and its connective tissue capsule. The sutures through the inferior and posterior portions of the sphincter should be placed first and tied last to facilitate this part of the repair. The remainder of the repair is similar to that described for a midline episiotomy in Figure 1735. Pain after Episiotomy Application of ice packs tends to reduce swelling and allay discomfort. Minassian and colleagues (2002) randomly assigned 200 women to receive 5-percent lidocaine ointment versus placebo for relief of postpartum perineal pain. Topical application of lidocaine ointment was not effective in relieving episiotomy or perineal laceration discomfort. Analgesics such as codeine give considerable relief. Because pain may be a signal of a large vulvar, paravaginal, or ischiorectal hematoma or perineal cellulitis, it is essential to examine these sites carefully if pain is severe or persistent. Management of these complications is discussed in Chapter 35. Signorello and co-workers (2001) surveyed 615 women 6 months postpartum to determine the impact of perineal trauma on sexual functioning. Women whose newborns were delivered over an intact perineum reported the best outcomes in this regard.