ACOG updates recommendations for preventing obstetric lacerations during vaginal delivery.

Clinical Pearls:

• Recommends against routine episiotomy, advises restrictive use of episiotomy
• Warm compress during pushing led to decreased incidence of third-degree and fourth-degree lacerations.
• No single birthing position helps in decreasing perineal lacerations.
• Suture material used is absorbable synthetic ones with continuous suturing.
• Full thickness external anal sphincter repair should be done end-to-end or overlap with a single dose of antibiotics at the time of repair.
• Vaginal delivery is an appropriate, safe option for women who have experienced severe obstetric lacerations during previous pregnancies unless she had anal incontinence, wound infection or repeat surgery.
• Does not recommend the routine use of endoanal ultrasonography immediately after labor to detect occult OASIS.

ACOG states that 53% to 79% of patients will have some type of lacerations during vaginal deliveries but most of them will not hamper the functional outcome.[1] Most of these are first and second degree lacerations, but third and fourth degree lacerations resulting in obstetric anal sphincter injuries (OASIS) can occur in 11% of patients.

A new practice Bulletin  “Prevention and Management of Obstetric Lacerations at Vaginal Delivery,"  was released by ACOG  on June 22, 2016 replacing  Practice Bulletin #71, “Episiotomy,” and Committee Opinion #647, “Limitations of Perineal Lacerations as an Obstetric Quality Measure.”

"The previous bulletin did not focus on the broader concept of perineal lacerations and anal sphincter injury. This was developed to be much more comprehensive and to reaffirm to physicians that episiotomy is not recommended as routine part of delivery." Said co-author Sara Cichowski. MD.

The bulletin advises obstetrics practitioner against the routine use of episiotomy to decrease perineal lacerations, instead take other measures to mitigate the risk.

A review involving 8 trials and 11,651 randomized women have concluded that warm compress on the perineum during pushing is associated with decreased incidence of perineal trauma.[2] (Level A recommendation). Perineal massage, either during first stage or during the second stage of labor, can decrease muscular resistance and reduce the likelihood of laceration. Many other trials have confirmed the benefit of perineal massage but ACOG did not recommend perineal support due to lack of sufficient information and clinical methods.

Based on clinical data ACOG recommends restrictive use of episiotomy as compared to routine use. A systemic review[3] found many benefits of restrictive use over routine use like severe perineal trauma, less suturing and fewer healing complications. Both fared equal for severe vaginal/perineal trauma, dyspareunia and urinary incontinence.

The bulletin quotes "Current data and clinical opinion suggest that there are insufficient objective evidence-based criteria to recommend episiotomy, especially routine use of episiotomy, and that clinical judgment remains the best guide for use of this procedure." [4]

National Episiotomy rates have steadily decreased since 2006, when ACOG guidelines did not recommend routine episiotomy. Data shows that in 2000, 33% of women received episiotomy which has come down to 12% in 2012.

Data on timing of giving episiotomy was sparse as also its benefit or harm in cases of shoulder dystocia or operative vaginal delivery.

Clear consensus also could not be reached on any single birthing position and delayed pushing after full dilatation leading to decreased perineal lacerations and episiotomy.  

Minor tears of anterior vaginal wall and labia can be left to heal by itself after achieving hemostasis while periurethral, periclitoral and large labial laceration with bleeding should be repaired. Clinicians are advised to use clinical judgement when it comes to repair first- or second-degree lacerations due to lack of evidence.

The choice of suture material should be continuous absorbable synthetic ones, such as polyglactin. Full thickness external anal sphincter repair should be done end-to-end or overlap with a single dose of antibiotics at the time of repair. (Level A recommendation).

ACOG also states that majority of women with obstetric anal sphincter injuries (OASIS) deliver vaginally in subsequent pregnancies. Cesarean delivery may be offered to women who with history of OASIS if she experienced anal incontinence, wound infections, repeat surgery or psychological trauma.

“Without question, a vaginal delivery is an appropriate, safe option for women who have experienced severe obstetric lacerations during previous pregnancies,” opined Sara Cichowski, MD, who co-authored the new guidelines. “However, women who have anal incontinence or who have suffered significant physical or emotional trauma as a result of previous experiences may find that a cesarean delivery is the right choice for them.”[5]

It also does not recommend the routine use of endoanal ultrasonography immediately after labor to detect occult OASIS, but advocates that a trained clinical research fellow should examine the patient before the suturing perineal tear by the attending physician. Detection of overt OASIS have a learning curve and improves with education and training.

The bulletin also provided recommendations for long term monitoring and pelvic floor exercises.

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[1] http://www.acog.org/About-ACOG/News-Room/News-Releases/2016/Ob-Gyns-Can-Prevent-and-Manage-Obstetric-Lacerations

[2] http://www.ncbi.nlm.nih.gov/pubmed/22161407

[3] http://www.ncbi.nlm.nih.gov/pubmed/19160176

[4] http://journals.lww.com/greenjournal/Abstract/2016/07000/Practice_Bulletin_No__165___Prevention_and.46.aspx

[5] http://www.acog.org/About-ACOG/News-Room/News-Releases/2016/Ob-Gyns-Can-Prevent-and-Manage-Obstetric-Lacerations