What is the treatment approach for a patient with a vaginal tear?

Treatment of Vaginal Tears

For minor first-degree vaginal tears, use tissue adhesive rather than sutures as it provides superior pain control and faster recovery; for deeper tears (second-degree and above), perform immediate surgical repair with absorbable sutures under appropriate anesthesia, and administer prophylactic antibiotics for third- and fourth-degree tears to prevent wound infection. 1, 2, 3

Initial Assessment and Stabilization

Hemodynamic Evaluation

• Assess for hemodynamic instability immediately - vaginal tears can cause significant blood loss requiring packed red blood cell transfusion 1
• Median time from bleeding onset to hospital admission in case series was 12 hours (range 2-24 hours), but hemodynamically unstable patients require immediate intervention 1
• One study found 5% of patients with postcoital vaginal injuries required blood transfusion 1

Identify Tear Location and Severity

• Common tear locations include:
  • Vaginal fornix (45% of cases) 1
  • Mid-vagina (20% of cases) 1
  • Hymenal ring or posterior fourchette (30% of cases) 1
  • Longitudinal vaginal septum (5% of cases) 1
• Examine for extension into rectum (rectovaginal tear) or anal sphincter involvement (third/fourth-degree) 2, 4

Treatment Algorithm by Tear Severity

First-Degree Tears (Skin Only)

• Use tissue adhesive (skin glue) as first-line treatment rather than conventional suturing 3
• Tissue adhesive provides significantly lower pain scores at rest, sitting, walking, and micturition during the first postpartum week 3
• Time to become pain-free is significantly shorter with adhesive (3.18 days vs 8.65 days with sutures, p<0.001) 3
• Wound gaping occurs rarely (only 2 patients in one study) 3
• Tissue adhesive is particularly useful in out-of-hospital settings such as home births or midwifery-led centers 3

Second-Degree and Deeper Tears

• Perform surgical repair with absorbable sutures under appropriate anesthesia 1
• Median time from admission to surgery should be approximately 56 minutes (range 15-540 minutes) 1
• Ensure hemodynamic stability before proceeding to repair 1

Third- and Fourth-Degree Tears (Anal Sphincter/Rectal Involvement)

• Administer prophylactic antibiotics to prevent perineal wound infection 2
• Use single-dose, second-generation cephalosporin (cefotetan or cefoxitin 1g IV) 2
• Prophylactic antibiotics reduce perineal wound complications from 24.1% to 8.2% (RR 0.34,95% CI 0.12-0.96) 2
• Third- and fourth-degree tears have significantly increased risk of bacterial contamination from rectum 2
• These tears occur in 1-8% of vaginal births, with higher rates after forceps delivery (28%) and midline episiotomies 2

Extensive Rectovaginal Tears

• Perform primary surgical repair with diverting colostomy for extensive tears with wide communication between vagina and rectum 4
• These injuries are extremely rare but potentially serious, requiring prompt identification to avoid delayed treatment and poor outcomes 4

Critical Pitfalls to Avoid

• Do not delay evaluation and treatment - prompt assessment is essential as vaginal tears may involve significant blood loss 1
• Do not miss rectal involvement - failure to identify rectovaginal extension can lead to delayed treatment and poor outcomes 4
• Do not assume minor trauma - even consensual intercourse can rarely cause serious injuries requiring surgical intervention 1, 4
• Do not skip antibiotic prophylaxis for third/fourth-degree tears - bacterial contamination risk is significantly elevated 2

Post-Repair Management

• Provide psychosexual assessment and support to both patient and partner once hemodynamically stable 1
• Schedule follow-up at two weeks postpartum to assess for wound complications including disruption and purulent discharge 2
• Monitor for wound gaping, particularly in the first week after repair 3