Abstract
The majority of the women in the UK who deliver a baby vaginally sustain perineal trauma that requires suturing. GPs are frequently consulted by women regarding perineal health after delivery, either with specific concerns or opportunistically at the 6–8 week routine postnatal check. The aim of this article is to explore the common presentations and underlying pathologies of postpartum perineal problems, their management in primary care and when to refer. We also aim to emphasise the need for a holistic approach and to consider where perineal problems fit into the broader picture of postnatal health.
The GP curriculum and postnatal perineal problems
Recognise common signs and symptoms of, and know how to manage, gynaecological disease; be the first port of call for pregnancy, eating disorders and other conditions confined to or more common in women, involving other members of the healthcare team as appropriate Recognise and intervene immediately when patients present with a gynaecological or obstetric emergency Understand the impact of other illness, in both the patient and her family, on the presentation and management of women’s health problems Discuss the psychosocial component of women’s health and the need, in some cases, to provide women patients with additional emotional and organisational support
The scope of the problem
Perineal trauma after vaginal delivery is extremely common. Up to 85% of women will suffer perineal trauma and at least 70% of these will require suturing after delivery (McCandlish et al., 1998). There are numerous risk factors for trauma, but the most clinically significant are: nulliparity, Asian ethnicity, macrosomia (infant weight greater than 4 kg) and instrumental delivery, especially forceps. A recent prospective telephone audit carried out at 21 days postnatal found that some 13% of women had contacted their GP or hospital and been prescribed antibiotics for perineal concerns (Johnson, Thakar, & Sultan, 2012).
Types of perineal trauma and repair
There is a broad spectrum of genital tract trauma that can be sustained during childbirth. Most commonly, trauma is found posteriorly involving the posterior vaginal wall, perineal muscles, and skin between the vagina and anus. The severity of trauma in this location is categorised using a standard classification system (see Box 1 and Fig. 1).
Common types of perineal trauma. Classification of perineal trauma.
Obstetric trauma may also commonly occur anteriorly to the vagina and include labial tears, peri-uretheral tears and tears that are the result of female genital mutilation including its reversal (deinfibulation). Episiotomies, providing they have not extended to include the anal sphincter are a form of second-degree tear.
All tears are usually sutured with the exception of first-degree tears that are not bleeding and labial tears unless bleeding or bilateral. The most common type of suture used is Vicryl Rapide, an absorbable suture that starts to fall off of skin surfaces 7–10 days after repair with complete absorption by 42 days.
Women who sustain third- or fourth-degree tears are usually discharged with a week’s supply of prophylactic broad-spectrum antibiotics in addition to stool softeners, and should be followed up in secondary care. There is a significant risk of anal incontinence, especially with the more extensive third- and fourth-degree tears, so these patients should be seen in a dedicated perineal clinic. This is often a combined clinic with both obstetricians and colorectal surgeons. By reviewing patients’ residual symptoms and undertaking endo-anal ultrasound, those who may benefit from secondary repair of the anal sphincter complex can be identified. This review also provides a good opportunity for debriefing and discussion regarding future deliveries.
Routine perineal care
Women should be reassured that perineal tears usually heal well, without any complications and with minimal long-term morbidity. The most important advice is to keep the wound clean and dry, to avoid applying any skin products to the area, to practice good hand hygiene and regularly change maternity pads. At each postnatal visit, either with GP or midwife, an enquiry about whether the mother has any concerns about healing should be made. If concerns are raised, then clinical assessment should be offered. Analgesia can be provided with topical cold compresses, oral paracetamol and/or non-steroidal drugs if required. All women should be advised to report any concerns about healing, particularly infective symptoms to a healthcare professional as soon as possible (National Institute for Health and Care Excellence (NICE), 2006). If passing urine is uncomfortable or painful, the woman can be advised to try voiding in the shower or bath to dilute the urine and reduce irritation, however, urinary tract infection should also be excluded.
Postnatal complications
There are a number of perineal complications after delivery that a woman may present with to primary care. These complications may co-exist and a proportion of women will present with no significant pathology, but rather seeking reassurance about a tear that is healing normally. In contrast, it is also important to remember that many women may be embarrassed about discussing their perineal concerns and may need to be asked directly about healing or symptoms.
Infection
Infection may present with increasing perineal pain, erythema, bleeding, offensive vaginal discharge, dehiscence of the wound or symptoms of systemic infection. Any woman complaining of these symptoms should be assessed as a matter of urgency, as genital tract sepsis can spread extremely rapidly.
As with any intimate examination, it is essential to offer the patient a chaperone. Systematic assessment of the wound should be undertaken including careful inspection of the external skin surface noting any erythema, purulent discharge or offensive smell, and any suggestion of abscess or collection. The labia should be gently parted and any internal component to the tear also carefully examined. It is not usually necessary to attempt speculum examination unless concerned about endometritis and taking a high vaginal swab. The wound should be swabbed and empirical broad-spectrum antibiotics commenced.
In the last confidential enquiry into maternal deaths from genital tract sepsis, the most commonly isolated organism in the women who died was group A Streptococcus (MBRRACE-UK, 2014). Other postnatal organisms isolated from wound swabs include coliforms and anaerobic bacteria. If empirical treatment is required, then it is important to follow your local antibiotic formulary and/or speak to a microbiologist to help guide treatment. Co-amoxiclav is a reasonable option, as it provides excellent cover against most of the likely organisms (especially group A Streptococcus), however, many areas have restricted its use due to antibiotic resistance. For those with penicillin allergy, clindamycin is a good alternative (with excellent group A Streptococcus cover) although it provides little gram-negative cover (Centre for Maternal and Child Enquries, 2011).
Occasionally, perineal infection may spread very quickly and result in overwhelming sepsis. There are case reports of death from necrotising fasciitis post-delivery and the latest confidential enquiry (MBRRACE-UK, 2014) highlighted, in particular, the rapidity with which Group A Streptococcal infection may become fatal. GPs have a vital role in the recognition of Group A Streptococcal infection as they may be aware of other family members who have recently been treated for Group A Streptococcal pharyngitis (Centre for Maternal and Child Enquries, 2011).
Symptoms and signs of sepsis warranting urgent hospital referral.
Most patients will be systemically well and managed in the community with oral antibiotics. Signs and symptoms of spreading infection should be explained to the patient with clear advice when to seek medical help and a review date set to ensure resolution of the infection and review of the swab results.
For patients whose symptoms do not resolve after an initial course of antibiotics, a further course of antibiotics should be considered, depending on the initial swab results. If the initial swab results are culture-negative then antibiotics should be stopped and a repeat swab obtained to guide further management, unless there are concerns about spreading infection requiring intravenous antibiotics.
Dehiscence
Wound dehiscence after perineal repair is relatively uncommon, with rates of up to 4.6% reported depending on degree of initial trauma (Ramin & Gilstrap, 1994). Dehiscence may be partial, with some degree of skin gaping but with the muscle layer underneath intact, or full thickness breakdown of the wound. The most common cause of dehiscence is infection preventing healing of the opposed edges, resulting in separation as the sutures dissolve. Dehiscence may also occur in a wound in the absence of infection if it has not been sutured correctly initially or if a knot comes loose. Recognising that infection is the most common cause of perineal dehiscence, the primary treatment is with oral antibiotics to clear the area of infection and promote healing by secondary intention.
There is significant controversy over the role of re-suturing versus conservative management. Current practice in the UK tends to favour healing by secondary intention. Women can be reassured that even with a fully dehisced wound, healing will occur spontaneously once infection is treated, often with a good cosmetic result, although complete healing may take several weeks or even months. If the woman is not satisfied with the final result cosmetically or suffers persistent dyspareunia, then referral to secondary care for consideration of a corrective procedure (Fenton’s procedure or perineal refashioning) is appropriate.
Currently, some clinicians advocate re-suturing once infection has been treated and the wound edges debrided. This approach carries the risk of recurrent infection, especially when re-suturing occurs in the presence of active infection, and wound breakdown (Webb, Sherburn, & Ismail, 2014). The theoretical advantages of re-suturing are reduced healing times, improved cosmetic appearance, reduced need for further procedures and a reduction in psychological morbidity. The latest Cochrane review found insufficient evidence to support or refute re-suturing in this context and further randomised control trials are underway to investigate this further (Dudley, Kettle, & Ismail, 2013). Women should therefore be advised that it is unlikely that immediate secondary repair will be undertaken.
Granulation tissue
Primary or secondary healing may result in the formation of excess granulation tissue. This tends to present as a later consequence of perineal trauma, often weeks to months after delivery. It may present with a tender nodule that bleeds on contact or produces discharge in the area where the trauma occurred. Women can be reassured that this is usually very easily treated with topical silver nitrate, which can be carefully applied in the community or gynaecology clinic. If this fails then excision under anaesthesia is curative (Webb et al., 2014).
Haematoma
Haematomas usually develop in the first few hours to days after delivery and are therefore most likely to be seen by GPs following rapid discharge from hospital or a homebirth. The blood supply around the time of childbirth is very rich and haematomas may occur spontaneously or if tissues are not adequately approximated and excessive dead space is left during repair, thus allowing blood to accumulate. The connective tissues around the perineum are very loose and can allow a very large quantity of blood to collect resulting in anaemia or haemodynamic instability. The patient will usually present with worsening pain, which may be out-of-proportion to what is visible externally. In addition, there may be symptoms of anaemia or difficulty in passing urine. Analgesia is paramount to allow adequate assessment. If a haematoma is suspected then referral to secondary care should be made, as blood transfusion and surgical drainage may be required, however, haematomas are often managed conservatively by monitoring both pain and haemoglobin levels. Antibiotics are prescribed to prevent secondary infection.
Patients with a known haematoma may present to the GP after hospital discharge. If treated conservatively it may take some weeks for full resolution. This is either by absorption or by spontaneous drainage as a result of wound breakdown.
Knot migration
Most tears are sutured at the time of delivery with a soft, undyed, absorbable poly-filament suture, which causes very little irritation to the surrounding skin. If the tear involved the external anal sphincter, this is usually repaired with a much more rigid monofilament suture taking a lot longer to be absorbed. The knots are buried under the skin, but occasionally these knots or other suture material may migrate and appear within or next to the skin wound causing a great deal of irritation, as they are so much harder than the usual suture material. The patient can be reassured that the stitches will eventually be reabsorbed; however, if there is considerable discomfort, referral to secondary care for stitch removal is warranted.
Fistula
This is one of the most-feared complications of childbirth and is thankfully rare within the UK. In the context of perineal trauma, the most likely form is rectovaginal fistulation. This can be as a result of wound breakdown after repair or an initial failure to diagnose and repair the trauma correctly. It usually presents with foul-smelling offensive vaginal discharge or even the passage of faecal material per vagina. Small fistulas may resolve with antibiotics and conservative management, but all should be seen and followed up in secondary care. Larger fistulas will require surgical correction at specialist centres.
Long-term prognosis
Patients should be reassured that the long-term prognosis for most perineal trauma is excellent, although perineal pain and dyspareunia may continue for up to 6 months and occasionally up to 3 years after delivery (Webb et al., 2014). A large study in Sweden found that sustaining vaginal trauma during childbirth increased the length of time until first sexual intercourse after delivery and that this delay was longer with increasingly severe trauma. However, by 1 year, there was no difference between women with trauma and those without (Radestad, Olsson, Niseen, & Rubertsson, 2008).
Practicing holistically
Although women may initially present with a perineal complaint, it is important to see this in the much broader context of biopsychosexual postnatal health and to take the opportunity to address any issues holistically. Figure 2 shows the interconnected web of postnatal health and many of the concerns that the patient may be facing but not volunteering.
The interconnected web of postnatal health.
Concerns about perineal healing may be part of wider anxiety over physical changes in the puerperium. This may include worries about weight, stretch marks, breast changes and hair loss. This is often intimately connected with the return of sexual activity after vaginal delivery when there may be considerable apprehension about pain and discomfort, concerns about her body appearance in the eyes of her partner and anxiety about contraception. It is important to reassure women that discomfort during sexual intercourse after perineal trauma is normal and usually settles within a few months.
Breastfeeding usually provides a sustained period of amenorrhoea, due to suppression of the hypothalamic–pituitary–gonadal axis. As a result, there may be a significant period of hypo-oestrogenism, resulting in some menopausal symptoms. This may present with symptomatic vaginal dryness and may cause narrowing of the introitus, interfering with the return of sexual function. Women can usually be reassured that these symptoms will settle with time as oestrogen levels return to normal, but some will require treatment. Initially, this is with lubricant or vaginal moisturisers; however, if these fail to resolve symptoms adequately, then topical oestrogen cream may be required.
Women presenting postnatally with perineal problems should be asked opportunistically about other symptoms they may not otherwise volunteer, for example, urinary or faecal incontinence and advice about pelvic floor exercises given. The opportunity should also be taken to enquire about symptoms of postnatal depression and the occurrence of domestic violence, the risk of which is significantly higher during pregnancy and the postnatal period.
Key points
Most women who deliver vaginally will sustain some degree of vaginal trauma, the majority will be sutured and most heal without any problems at all Women may present to their GP with a variety of problems, the commonest being infection and wound breakdown. This can usually be managed in the community with antibiotics and reassurance Even in the context of complete wound breakdown, the eventual cosmetic result is often extremely good, however, complete healing may take months Although rare, overwhelming sepsis can develop from postnatal perineal infection, therefore careful clinical assessment is mandatory and if concerned, urgent referral to secondary care is needed Concerns about perineal healing are a small part of the ‘iceberg’ of postnatal health problems and active screening for postnatal depression and domestic violence should be considered