Checklist for perineal lacerations: Readers weigh in

I am not convinced that another checklist is needed, as we may end up with a cookbook approach if we aren’t careful. Just do the job correctly with a well-thought-out rationale for your approach.

Donald R. Wilson, MD
Maysville, Kentucky

A few questions about bowel preparation
I appreciate the clear-cut guidelines presented in this editorial. I have taught gynecology for 25 years at an Egyptian university. The addition of critical details to our surgical protocols will be of great help in improving outcomes. However, I have one major concern that was not mentioned in the article, and it involves bowel preparation.

Not all women undergo colon preparation and enema before coming to the labor room. Some are transferred from the emergency room or come to the hospital after home delivery. These women may have a full rectum and colon, sometimes even constipation with hard fecal matter, or they may have eaten recently.

How should these women be managed when a severe perineal laceration is present? Should the contaminated area be addressed first, followed by repair? Also, it seems to me that a full rectum and colon at the time of repair will place the sutures under undue stress, risking rupture with the patient’s first defecation.

In the past, we cleaned all areas of contamination with a povidone-iodine solution and administered a constipating regimen for 5 to 7 days postoperatively, with fluids and parenteral treatment, followed by laxatives and lactulose for 2 days before gradually incorporating a regular diet. Some physicians have proposed administering lactulose or a similar enema in the delivery room to evacuate bowel contents, followed by antisepsis, repair, and antibiotics.

I wonder how Dr. Barbieri would address this scenario?

Magdy Hassan Balaha, MD
Ahsaa, Saudi Arabia

More on the need for analgesia and anesthesia
I have a suggestion for checklists for the repair of severe perineal lacerations: Add an item mentioning the need to ensure adequate analgesia/anesthesia. Besides being kind to the patient, this step may facilitate exposure.

Also important is an environment that encourages consultation by any provider confronted with a perineal laceration of uncertain extent or unclear anatomy.

Nancy Kerr, MD, MPH
Telluride, Colorado, and Albuquerque, New Mexico

Fluids are important
When I repair fourth-degree lacerations, I use at least 1 L of normal saline in 100- to 200-cc aliquots throughout the repair.

Paul G. Crawford, MD
Shreveport, Louisiana

DR. BARBIERI RESPONDS:

We thank Dr. Kanoff, Dr. Shilkrut, Dr. Richardson, Dr. Wilson, Dr. Hassan Balaha, Dr. Kerr, and Dr. Crawford for their excellent additions to the perineal laceration checklist, all of which I support.

Dr. Richardson and Dr. Kerr specifically mention adequate analgesia/anesthesia, which is critically important to facilitate an optimal repair. Dr. Lavin mentions the repair of three sphincters: internal and external rectal sphincters and the superficial transverse perineal muscle. I am not aware that the superficial transverse perineal muscle is a classic “sphincter,” but it is important to include it in the repair of second-degree perineal lacerations.

Dr. Hassan Balaha asks about the handling of a contaminated field during repair. There are no randomized studies addressing this problem; most obstetricians will cleanse the area as well as possible and proceed with the repair. Dr. Hassan Balaha also recommends a two-step bowel regimen, involving a constipating regimen for 5 to 7 days, followed by laxatives and lactulose for 2 days BEFORE initiating a regular diet—a very interesting idea, which I will share with my colleagues. As noted in the editorial, the only clinical trial of this situation randomized women to a narcotic (constipating regimen) or a laxative regimen. The women in the laxative group reported earlier and less painful bowel movements than the women in the narcotic group.¹

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