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Review 2007;9:164170 10.1576/toag.9.3.164.27336 www.rcog.org.uk/togonline The Obstetrician & Gynaecologist

Review Postpartum care of the

perineum
Authors Myra Fitzpatrick / Colm OHerlihy

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.
Keywords biofeedback physiotherapy / obstetric anal sphincter injury / pelvic floor
assessment / perineal trauma / vaginal delivery
Please cite this article as: Fitzpatrick M, OHerlihy C, Postpartum care of the perineum. The Obstetrician & Gynaecologist 2007;9:164170.

Author details
Myra Fitzpatrick MRCOG Colm OHerlihy FRCOG
Lecturer Professor of Obstetrics and Gynaecology
National Maternity Hospital National Maternity Hospital
Department of Obstetrics and Gynaecology Dublin, Republic of Ireland
Holles Street, Dublin 2
Republic of Ireland
Email: myrafitzpatrick@hotmail.com
(corresponding author)

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Introduction
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, 6070% 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 0.53% in Europe and
69% 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 womans
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
Immediate management of
perineal trauma
3
The RCOGs guidelines recommend suturing of first
and second-degree tears with an absorbable synthetic
2007 Royal College of Obstetricians and Gynaecologists
2007;9:164170 Review
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.1214
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.
Degree Trauma Table 1
Definition of spontaneous tears3
First Injury to the skin only
Second Injury to the perineum involving perineal muscles but not
involving the anal sphincter
Third Injury to the perineum involving the anal sphincter complex
3a: less than 50% of EAS thickness torn
3b: more than 50% of EAS thickness torn
3c: IAS torn
Fourth Injury to perineum involving the anal sphincter complex
(EAS and IAS) and anal epithelium
EAS  external anal sphincter; IAS  internal anal sphincter
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Immediate pain management
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.
Prevention and treatment
of infection
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
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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.
Postpartum urinary difficulties
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
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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 womens perceptions and reporting of
symptoms and definitions vary, particularly in the
early postpartum period, 820% 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
Long-term management of
obstetric anal sphincter injury
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
2007 Royal College of Obstetricians and Gynaecologists
2007;9:164170 Review
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
Figure 1
Anal manometry
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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

Figure 2
Endoanal ultrasound32
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
clitoralanal 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
Figure 3
Augmented biofeedback with a minor degree of faecal incontinence.33 A low
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

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sphincter, thereby avoiding the need for secondary
anal sphincter repair with a defunctioning
colostomy.40
Dyspareunia
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 (Fentons procedure) may be required
to alleviate persistent symptoms.
Summary
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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2007 Royal College of Obstetricians and Gynaecologists