Can your patient access early secondary repair if they develop a perineal laceration wound breakdown?
The breakdown of an OASIS repair is an obstetric catastrophe with complications that can last many months and sometimes stretch into years. The best approach to a perineal laceration wound breakdown remains controversial. It is optimal if all patients with a wound breakdown can be offered an early secondary repair or healing by secondary intention, permitting the patient to select the best approach for their specific situation.
As noted by the pioneers of early repair of episiotomy dehiscence, Drs. Hankins, Haugh, Gilstrap, Ramin, and others,18-20 conventional doctrine is that an episiotomy repair dehiscence should be managed expectantly, allowing healing by secondary intention and delaying repair of the sphincters for a minimum of 3 to 4 months.21 However, many small case-series report that early secondary repair of a perineal laceration wound breakdown is possible following multiple days of wound preparation prior to the repair, good surgical technique and diligent postoperative follow-up care. One large case series reported on 72 women with complete perineal wound dehiscence who had early secondary repair.22 The median time to complete wound healing following early repair was 28 days. About 36% of the patients had one or more complications, including skin dehiscence, granuloma formation, perineal pain, and sinus formation. A pilot randomized trial reported that, compared with expectant management of a wound breakdown, early repair resulted in a shorter time to wound healing.23
Early repair of perineal wound dehiscence often involves a course of care that extends over multiple weeks. As an example, following a vaginal birth with OASIS and immediate repair, the patient is often discharged from the hospital to home on postpartum day 3. The wound breakdown often is detected between postpartum days 6 to 10. If early secondary repair is selected as the best treatment, 1 to 6 days of daily debridement of the wound is needed to prepare the wound for early secondary repair. The daily debridement required to prepare the wound for early repair is often performed in the hospital, potentially disrupting early mother-newborn bonding. Following the repair, the patient is observed in the hospital for 1 to 3 days and then discharged home with daily wound care and multiple follow-up visits to monitor wound healing. Pelvic floor physical therapy may be initiated when the wound is healed. The prolonged process required for early secondary repair may be best undertaken by a subspecialty practice.24
The surgical repair and postpartum care of OASIS continues to evolve. In your practice you should consider:
- performing a mediolateral episiotomy at a 60-degree angle to reduce the risk of OASIS in situations where there is a high risk of anal sphincter injury, such as in forceps delivery
- using one dose of a prophylactic antibiotic with extended anaerobic coverage, such as cefotetan or cefoxitin
- focus on identifying and separately repairing an internal anal sphincter injury
- using a long-lasting absorbable suture, such as PDS, to repair the internal and external anal sphincters
- ensuring that the patient with a dehiscence following an episiotomy or anal sphincter injury has access to early secondary repair. Standardizing your approach to the prevention and repair of anal sphincter injury will benefit the approximately 112,600 US women who experience OASIS each year. ●
Do you use intrapartum warm compresses to the perineum or perineal massage in your practice?
A Cochrane Database Systematic Review reported that moderate-quality evidence showed a decrease in OASIS with the use of intrapartum warm compresses to the perineum and perineal massage.1 Compared with control, intrapartum warm compresses to the perineum did not result in a reduction in first- or second-degree tears, suturing of perineal tears, or use of episiotomy. However, compared with control, intrapartum warm compresses to the perineum was associated with a reduction in OASIS (relative risk [RR], 0.46; 95% confidence interval [CI], 0.27–0.79; 1,799 women; 4 studies; moderate quality evidence; substantial heterogeneity among studies). In addition to a possible reduction in OASIS, warm compresses also may provide the laboring woman, especially those having a natural childbirth, a positive sensory experience and reinforce her perception of the thoughtfulness and caring of her clinicians.
A Cochrane Database Systematic Review reported that moderate-quality evidence showed a decrease in OASIS with the use of intrapartum warm compresses to the perineum and perineal massage.1 Compared with control, intrapartum warm compresses to the perineum did not result in a reduction in first- or second-degree tears, suturing of perineal tears, or use of episiotomy. However, compared with control, intrapartum warm compresses to the perineum was associated with a reduction in OASIS (relative risk [RR], 0.46; 95% confidence interval [CI], 0.27–0.79; 1,799 women; 4 studies; moderate quality evidence; substantial heterogeneity among studies). In addition to a possible reduction in OASIS, warm compresses also may provide the laboring woman, especially those having a natural childbirth, a positive sensory experience and reinforce her perception of the thoughtfulness and caring of her clinicians.
Compared with control, perineal massage was associated with an increase in the rate of an intact perineum (RR, 1.74; 95% CI, 1.11–2.73; 6 studies; 2,618 women; low-quality evidence; substantial heterogeneity among studies) and a decrease in OASIS (RR, 0.49; 95% CI, 0.25–0.94; 5 studies; 2,477 women; moderate quality evidence). Compared with control, perineal massage did not significantly reduce first- or second-degree tears, perineal tears requiring suturing, or the use of episiotomy (very low-quality evidence). Although perineal massage may have benefit, excessive perineal massage likely can contribute to tissue edema and epithelial trauma.
Reference
1. Aasheim V, Nilsen ABC, Reinar LM, et al. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database Syst Rev. 2017;CD006672.