Management of Postpartum Perineal Laceration Breakdown

Objectives: To describe management strategies of postpartum perineal laceration breakdown

Methods: This is a systematic review including studies that reported on characteristics and outcomes of patients who underwent surgical management of postpartum perineal laceration breakdown. Studies included were from 1990 to 2023 and included observational and experimental study designs.

Results: 10 studies of patients with postpartum perineal laceration breakdown were included in this review. Timing of reoperation/surgical revision of postpartum perineal laceration breakdown ranged from 1 to 60 days postpartum. The majority of studies reported on characteristics and outcomes of patients who underwent early closure, which was defined differently in each study, but most commonly within two weeks of delivery. The overwhelming majority of providers performed surgical revision utilized vicryl or other braided suture versus 20% of providers utilized chromic suture. Clindamycin was the most commonly utilized preoperative antibiotic; 3 studies reported discharging patients home on 5 days of oral antibiotics while others did not comment on length of treatment. One study found no significant difference in perineal healing while breastfeeding; no studies evaluated the use of vaginal estrogen to aid in healing.

The most common risk factors for perineal wound breakdown included obstetric anal sphincter injuries (OASI), episiotomy, nulliparity, and wound infection. Three studies evaluated time to healing, noting improved healing at 2 weeks postoperatively but no established difference by 4-8 weeks; the average healing time ranged from 21-28 days. Four studies considered sexual function, reporting dyspareunia in 6.6% to 11% of patients with early repair at 6 months and 1 year after repair, with no significant difference in sexual activity by 6 months. Three studies included symptoms of anorectal dysfunction, and the average rate of fecal incontinence was 1.7% to 9% between 3 and 6 months after repair, much of which was attenuated by 9 months. Lastly, 1 study reported on odds of patient satisfaction with repair being 1.43 times higher for patients who underwent early closure vs delayed. Follow-up time ranged from as early as 1 week since repair to as late as 9 months postpartum.

Conclusions: Perineal wound breakdown is associated with various risk factors, including OASIs and infection. Management strategies should be tailored to individual patient characteristics, however, most researchers promote early intervention, utilizing absorbable braided suture, and prompt antibiotic administration. Multidisciplinary collaboration and patient education continue to remain integral components of effective management.