What is the management for postpartum perineal dehiscence?

Management of Postpartum Perineal Dehiscence

Initial Assessment

Perform a thorough visual inspection and digital examination of the perineal wound to assess the extent of dehiscence, presence of infection (purulent discharge, erythema, edema), and involvement of deeper structures including the anal sphincter. 1, 2

• Ensure adequate lighting and proper patient positioning before examination, as inadequate visualization can lead to misclassification of injury severity 2
• Conduct a mandatory digital rectal examination to evaluate for occult anal sphincter involvement, as up to 35% of sphincter injuries are missed without rectal examination 2, 3
• If concern exists for anal sphincter compromise, perform endoanal ultrasound to assess the full extent of damage to the anal sphincter complex 1, 3

Decision Algorithm: Conservative vs. Surgical Management

The management approach depends on wound characteristics, timing, and presence of infection:

Conservative Management (Expectant/Secondary Intention Healing)

For superficial dehiscence without anal sphincter involvement and no active infection, manage conservatively with meticulous wound care, as this approach avoids the increased risk of complications such as fistula formation associated with early resuturing. 4

• Prescribe stool softeners (polyethylene glycol 4450 or mineral oil twice daily) for six weeks to achieve toothpaste consistency stools and prevent strain 1
• Recommend sitz baths twice daily to promote comfort and tissue healing 1, 3
• Provide pain control with acetaminophen and ibuprofen as primary analgesics; reserve opiates only if needed 1, 3
• Apply ice packs for additional pain relief 1
• Arrange follow-up within two weeks, ideally in a specialized postpartum perineal clinic 1, 2

Note that 30% of wounds healing by secondary intention experience delayed healing, with initial wound area, perimeter, bacterial colonization, and OASIS being associated with delayed healing. 5

Early Resuturing (Secondary Repair)

Consider early resuturing for large dehiscences, particularly those involving deeper structures or causing significant functional impairment, but recognize this increases the risk of complications including fistula formation. 4

Preoperative Preparation for Secondary Repair:

• Ensure meticulous wound care and debridement of necrotic tissue before attempting resuturing 4
• Administer prophylactic antibiotics: first-generation cephalosporin (cefazolin 2g) or second-generation cephalosporin (cefoxitin 2g); for penicillin allergy use gentamicin 5 mg/kg plus clindamycin 900 mg or metronidazole 500 mg 1
• Perform vaginal preparation with povidone-iodine or chlorhexidine gluconate if allergic to iodine 1
• Ensure regional or general anesthesia for adequate pain control and muscle relaxation 1, 3
• Place Foley catheter before initiating repair 1

Surgical Technique:

• Repair sequentially from deep to superficial structures: rectovaginal fascia, perineal body muscles, and skin 1, 2
• Use continuous non-locking subcuticular sutures rather than interrupted transcutaneous sutures, as this technique avoids damage to nerve endings and reduces pain 1, 3
• Count all surgical instruments, sponges, and sutures pre- and postoperatively 1

Management of Infected Dehiscence

For dehiscence with signs of infection (purulent discharge, erythema, significant edema), initiate broad-spectrum antibiotics and delay any resuturing until infection is cleared. 1, 6

• Administer second- or third-generation cephalosporin, or metronidazole with gentamicin (or clindamycin for penicillin allergy) for adequate coverage of vaginal and bowel flora 1
• Antibiotic administration is associated with decreased risk of wound infection (adjusted OR 0.50) and reduced dehiscence rates 1, 6
• Perform wound debridement and allow granulation tissue formation before considering secondary repair 4

Special Considerations for OASIS Dehiscence

Dehiscence involving third- or fourth-degree tears requires specialized management due to the high baseline complication rates (infection 19.8%, dehiscence 24.6%) and risk of long-term anal incontinence (29-53% flatal incontinence, 5-10% fecal incontinence). 1, 2

• Refer to a specialized postpartum perineal clinic for expert evaluation 1, 2, 3
• If resuturing is performed, repair the internal anal sphincter using end-to-end technique with mattress or interrupted sutures using 3-0 delayed absorbable suture 2
• Maintain Foley catheter until postoperative day 1, then perform voiding trial 2

Risk Factors to Monitor

Recognize that BMI >35 kg/m² increases the risk of wound infection (adjusted OR 7.66) and dehiscence (adjusted OR 3.46), while episiotomy triples the risk of infection (adjusted OR 2.97). 6

Common Pitfalls to Avoid

• Do not rush to resuture without adequate wound preparation and infection control, as this increases fistula risk 4
• Do not overlook occult anal sphincter injury, as failure to identify this leads to persistent symptoms and inadequate treatment 3
• Do not assume all persistent pain is normal healing; new tenderness warrants thorough investigation for specific pathology 3
• Do not rely solely on visual inspection; always perform digital rectal examination to detect deeper involvement 2

Emerging Therapies

Limited evidence suggests autologous platelet-rich plasma (A-PRP) may accelerate healing in refractory cases through its hemostatic, anti-inflammatory, and antimicrobial properties, though its use in gynecological injuries remains investigational 7