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Postpartum perineal care and management of complications

Postpartum perineal care and management of complications
Authors:
Lori R Berkowitz, MD, MBA
Caroline E Foust-Wright, MD, MBA
Section Editors:
Linda Brubaker, MD, FACOG
Charles J Lockwood, MD, MHCM
Deputy Editor:
Kristen Eckler, MD, FACOG
Literature review current through: Jul 2022. | This topic last updated: Jul 19, 2022.

INTRODUCTION — This topic presents information on routine postpartum perineal care as well as evaluation and management of delivery-related perineal complications. Despite the importance of postpartum perineal care, there is little evidence to guide management; the information in this topic is based largely on our clinical experience.

In our experience, common postpartum perineal issues include pain control, hygiene, prevention of constipation, and resumption of sexual activity. Clinicians should be able to evaluate less common symptoms, such as severe pain, bulge or mass, or abnormal discharge, including fecal leakage.

Related topics that are presented separately include:

(See "Repair of perineal and other lacerations associated with childbirth".)

(See "Delayed surgical management of the disrupted anal sphincter".)

(See "Fecal and anal incontinence associated with pregnancy and childbirth: Counseling, evaluation, and management".)

In this topic, when discussing study results, we will use the terms "woman/en" or "patient(s)" as they are used in the studies presented. However, we encourage the reader to consider the specific counseling and treatment needs of transmasculine and gender diverse individuals.

DEFINITION — Clinicians often refer to the area between the vagina and anus as the "perineum"; however, anatomically, the perineum is the entirety of the pelvic outlet inferior to the pelvic floor (figure 1). The area between the vagina and anus is more aptly termed "the perineal body." The anatomy of the perineum is reviewed in detail separately. (See "Surgical female pelvic anatomy: Uterus and related structures" and "Surgical female urogenital anatomy" and "Surgical female urogenital anatomy", section on 'Perineum'.)

INITIAL APPROACH — We take the following approach to perineal care for all individuals undergoing vaginal delivery.

Education — Ideally, preliminary education about postpartum care is begun during prenatal visits to help patients understand typical changes that will occur during childbirth and recovery [1]. Once postpartum, we educate each patient about the nature of her perineal laceration or incision (ie, episiotomy), if any; measures for hygiene and comfort; predicted outcomes; and warning signs. We discuss that perineal pain and swelling are common for the first 7 to 10 days, and then typically improve. The duration of symptoms vary for each person and are impacted by clinical circumstances. For example, second-degree obstetric lacerations or episiotomies typically heal by the third postpartum week; those with third- or fourth-degree lacerations may require four to six weeks. Education and appropriate reassurance, in the absence of concerning symptoms, are important in this period.

Concerns frequently raised by patients include:

Fear of suture removal – Many patients believe that if they have perineal sutures, the stitches will need to be removed. This anticipated suture removal can cause significant anxiety and distress. We educate patients that the perineal sutures are self-absorbing and that no further procedures are typically required

Fear of bowel movement – Understandably, many patients are afraid that passing a bowel movement will damage the repair, be exquisitely painful, or both. We address this concern with information on pain management and prevention of constipation. (See 'Constipation prevention' below.)

Fear of sexual activity – Many patients are concerned that their vaginal introitus is permanently narrowed or that vaginal intercourse will be difficult or painful after obstetric laceration or episiotomy repair. We discuss that this fear is extremely common and reassure them that despite the initial pain, edema, and bruising they may experience following birth, these changes typically heal well. We discuss that they should be able to resume vaginal sexual function by approximately six weeks postpartum (depending on the status of the perineum). Individuals who are unable to resume predelivery sexual activity by three months postpartum should be evaluated. (See 'Resumption of sexual activity' below.)

Hygiene — Following vaginal delivery, menstrual pads, squirt bottles, and sitz baths are commonly recommended for perineal care. There are no data to guide sequence or duration of these interventions.

Menstrual pads – We and others advise use of unscented menstrual pads that are changed frequently when soiled [2].

Cold packs – Cold packs made of ice or other cold source can be placed on top of the menstrual pad. We advise patients to apply ice to the perineum for 24 hours, with warm water soaks to start thereafter. This approach can be modified based on the individual's feedback; if ice feels better, then the patient continues with ice packs for an additional 24 hours prior to initiating warm water soaks. In addition, some patients find both ice packs and sitz baths helpful and alternate treatments.

Squirt bottle for perineal care and urination – The squirt bottle is used to irrigate the perineum with warm water during urination, which can help reduce external dysuria, stinging, or discomfort. We advise patients to spray the perineum while urinating for as long as it improves comfort.

Sitz bath for perineal care and pain reduction – A sitz bath, a warm shallow bath that bathes the perineum and buttocks, is commonly used to clean the perineum and to reduce pain and swelling, although data are limited. For sitz baths, we recommend each episode be of approximately five minutes in duration, for a frequency of four times daily, or after any bowel movement (particularly emphasized in patients who have had anal sphincter lacerations). We instruct patients to ensure that the vaginal and rectal areas, including any sutures, are fully placed in the water. Of note, there are conflicting data on the optimal water temperature for pain reduction; those who find cold water more soothing are encouraged to use it [3,4]. Some clinicians advise adding Epsom salt (one-half cup salt to 1 gallon water) to the bath, although at least one study did not report a difference in perineal pain with its use [5]. We do not routinely recommend this, due to lack of evidence for efficacy. As it does not appear to be harmful, it can be done based on provider or patient preference.

Pain management — Comfort measures include topical treatments (eg, cold or warm packs), topical anesthetics, and oral analgesics. The choice of treatments is chosen on an individual basis and generally initiated in a stepwise approach [6]. As there are data associating perineal pain with postpartum depressive symptoms, efforts should be made to keep patients reasonably comfortable and ongoing or atypical pain should be evaluated [2,7].

Topical treatments Topical treatments available to reduce perineal pain include ice packs or other cooling agents and witch hazel pads (ie, hamamelis water). We suggest applying crushed ice to the painful perineal area for 10 to 20 minutes at a time as needed. We recommend using an ice pack or bag of crushed ice and then wrapping it in a cloth such as a hand towel. Direct ice (ice or crushed ice in a plastic bag without wrapping) applied to the skin for longer periods has not been studied and may actually be harmful. In a meta-analysis of 10 trials comparing localized cooling treatments with no treatment or other forms of treatment (eg, gel pads with compression, witch hazel, warm baths), self-reported individuals treated with ice packs reported decreased pain at 24 to 72 hours after birth compared with no treatment (risk ratio 0.61, 95% CI 0.41-0.91, one study) [8]. No impact on healing was reported. In a subsequent trial of 50 self-reported individuals with perineal pain following episiotomy, those treated with crushed ice to the perineum for 20 minutes reported improved pain relief compared with those who received routine care [9]. There was a direct correlation between the temperature reduction in the affected tissue and the pain relief experienced. As an alternate to crushed ice, frozen menstrual pads provide a convenient and less messy form of cryotherapy. These can be presoaked in water and then frozen to provide longer lasting cooling. Two subsequent trials reported reductions in postpartum pain scores, compared with usual care, after application of cold gel packs to the perineum for 10 to 20 minutes, which was sustained for up to two hours in one of the trials [10,11].

Topical witch hazel pads are often advised for perineal pain reduction. However, no trials comparing them with placebo are currently available. As they do not appear to be harmful, they can be combined with other treatments as desired.

Topical anestheticsBenzocaine spray is often offered to patients after vaginal birth to reduce perineal pain, although a meta-analysis of eight trials reported no difference in pain relief with other topical anesthetics (not including benzocaine) compared with placebo [12]. Additional limitations of this meta-analysis included short follow-up and limited assessment of patient satisfaction. One advantage of benzocaine spray is that it does not require touch for application. Some brands also contain skin moisturizers (aloe and lanolin) and menthol, which creates a cooling sensation. We have found this product helpful in reducing perineal discomfort, including the stinging sensation associated with perineal stretching, even if no laceration occurred. Anecdotally, benzocaine spray appears to reduce the discomfort associated with hemorrhoids as well.

Oral analgesics Oral analgesics most commonly used include nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen [6]. For patients with extensive vaginal or periurethral lacerations, underlying chronic pain syndromes, or obstetric anal sphincter injuries (OASIS), pain regimens that include short-term opioid analgesia can be required to achieve pain relief.

NSAIDs are our first choice for perineal pain relief, unless an individual has a specific contraindication. In a meta-analysis of 28 trials comparing NSAID (13 different agents) with either placebo or acetaminophen for early postpartum perineal pain, adequate pain relief at four hours was nearly twice as likely with the NSAID compared with placebo and nearly 50 percent more likely for the NSAID compared with acetaminophen [13]. Individuals treated with an NSAID were also less likely to need additional pain medication at four and six hours compared with those who received placebo. Maternal adverse effects were minor (eg, dizziness, headache, moderate epigastralgia) and not different from placebo treatment. Neonatal adverse effects were not studied. We suggest oral ibuprofen 600 mg every six hours as needed for pain relief during the first postpartum week. The maximum recommended dose of ibuprofen for individuals with normal renal function is 2400 mg in 24 hours. (See "NSAIDs: Therapeutic use and variability of response in adults", section on 'Issues in the therapeutic use of NSAIDs'.)

Acetaminophen is our second-line agent for perineal pain relief based on the above meta-analysis and a different meta-analysis demonstrating improved pain relief with acetaminophen compared with placebo [13,14]. We suggest 650 mg every 6 hours as needed, not to exceed 3250 mg per 24 hours, for pain beyond that controlled with the scheduled ibuprofen (ie, we prescribe acetaminophen in addition to the ibuprofen for those who require additional pain relief). While there are no direct comparisons of the dose effect for postpartum perineal discomfort, adequate analgesic effect has been demonstrated with the 500 to 650 mg dose [14]. (See "NSAIDs: Therapeutic use and variability of response in adults", section on 'Issues in the therapeutic use of NSAIDs'.)

Aspirin is our third-line agent for postpartum perineal pain based on a meta-analysis of 17 trials including over 1100 self-reported individuals that found a single dose of aspirin, compared with placebo, reduced perineal pain for individuals with episiotomy [15]. As breastfeeding persons were not included in the trials, the impact of aspirin on lactation or the neonate could not be assessed.

Opioid analgesics are rarely needed and should be prescribed only if the patient has not achieved adequate pain relief with the above topical and oral treatments [6]. When opioids are used, we prescribe no more than seven days of non-extended release medications. Patients whose pain is inadequately controlled or worsening should undergo further evaluation to assess for infection or other causes of heightened pain. Patients are counseled about the risk of worsened constipation with opioid treatment, which could worsen perineal pain, and drowsiness. The potential risk of addiction is reviewed as well, although this risk is reduced with short-duration treatment.

Herbal and complementary therapies – Additional treatment options for perineal pain include therapeutic ultrasound and plant-based ointments. In a meta-analysis of four trials comparing ultrasound, with or without pulsed electromagnetic therapy, with placebo, there was insufficient evidence to support use of ultrasound [16]. In a different trial, use of topical Achillea millefolium (ie, arrowroot, yarrow, or yarrow root) or Hypericum perforatum (ie, St. John's wort) ointments was associated with decreased perineal postpartum pain. However, more data are needed on efficacy and safety before routinely prescribing these agents as other proven options are available [17].

Skin glue for wound closure – Two small studies comparing surgical glue with suture for closure of obstetric lacerations reported reduced pain and similar complication rates with glue use [18,19].

Constipation prevention — Constipation during pregnancy and postpartum is common and is believed to result from smooth muscle relaxation caused by progesterone and other hormones [20,21]. Postpartum, this effect may continue for days to weeks. Following delivery, we treat to optimize stool consistency. Maintaining soft bowel movements that can be passed without straining helps avoid pain with defecation and prevent disruption of perineal and rectal sutures. (See "Maternal adaptations to pregnancy: Gastrointestinal tract" and "Maternal adaptations to pregnancy: Gastrointestinal tract", section on 'Bowel, rectum, anus'.)

Supporting data – The optimal treatment is not known. General recommendations for postpartum constipation prevention typically include eating a high-fiber diet and drinking plenty of water, but these may not be adequate in the postpartum setting. Additional treatment options include fiber supplements, stool softeners, and/or laxatives. A meta-analysis of five trials including 1208 postpartum persons compared postpartum laxative use with either placebo or laxative and fiber bulking agent [22]. None of the trials included any educational or behavioral interventions and the only trial that included a stool-bulking agent was focused on patients with OASIS [22]. Laxative use decreased time to bowel movement and increased frequency of bowel movements, but also increased frequency of diarrhea and fecal incontinence [22]. The four trials comparing laxative with placebo did not assess pain with defecation or straining with bowel movements, but the trial that compared laxative with laxative plus fiber bulking agent reported no difference in pain on defecation. Impact of constipation on surgical repair breakdown rates is not known.

Step-wise approach – In discussing constipation prevention with postpartum patients, prepregnancy and antenatal bowel habits are reviewed. For example, we inquire about any prior diarrhea-prone irritable bowel symptoms or other gastrointestinal disorders. In the absence of clinical evidence to guide care and in the absence of underlying gastrointestinal disease, we recommend treating routine postpartum individuals with scheduled doses of an oral bulk forming laxative (fiber), and then progress through a step-wise treatment plan until the patient is able to pass a soft bowel movement every two to three days (table 1). We allow two to three days to determine if a treatment is effective or if the next agent in the list needs to be added. We typically advocate continuing the prior medications and adding the next agent in the list, rather than discontinuing the prior agent and moving on to the next. The order of agents is driven in part by the ease of use by the patient. Historically, scheduled stool softeners (commercial name Colace) have been utilized as a first-line intervention to prevent constipation in this patient population. This is a surfactant agent, which lowers the surface tension of stool and allows water to enter more easily. There is little evidence to support the use of this, and a systematic review suggested it was less effective than fiber supplement [23]. A detailed review of these treatments is presented separately. (See "Management of chronic constipation in adults" and "Management of chronic constipation in adults", section on 'Initial management'.)

Our treatment regimen – While there are many agents and combinations that can be used to prevent or treat constipation, we prescribe the following drugs, in an additive and stepwise fashion, until constipation is resolved:

Oral bulk forming laxatives, such as psyllium seed (eg, Metamucil), methylcellulose (eg, Citrucel), calcium polycarbophil (eg, FiberCon), and wheat dextrin (eg, Benefiber). One dose as directed on the packaging daily.

Oral powdered polyethylene glycol (eg, MiraLAX) 17 g. Start with one daily dose and progress up to three times a day as needed.

Oral senna 8.6 mg sennosides/tablet. Two tablets are taken nightly. Dose is decreased if diarrhea or abdominal cramping occurs.

Oral magnesium hydroxide (eg, Milk of Magnesia) 400 mg/5 mL: 30 to 60 mL/day once daily at bedtime or in divided doses two times daily.

Oral magnesium citrate 1.745 g/30 mL (296 mL) taken as one bottle daily.

Limited role of rectal medication – To ensure that patients with third- and fourth-degree lacerations are not inappropriately advised to use a rectal medication, we prefer a standard protocol with oral agents that is appropriate for all postpartum persons and avoids the use of rectal agents. While patients who have not sustained a third- or fourth-degree laceration are candidates for rectal suppositories or enemas if desired, we typically do not recommend them, mainly because they are uncomfortable to use.

Resumption of sexual activity — There are no evidence-based guidelines regarding the postpartum resumption of predelivery sexual activity. Generally accepted criteria for resuming predelivery sexual activity include a fully healed perineum, emotional readiness, and use of contraception for heterosexual couples. We suggest that nothing be placed in the vagina for six weeks; by six weeks postpartum, lochia and vaginal discharge have typically ceased, perineal lacerations have healed, and sutures have resorbed. The postpartum visit typically occurs within the first six weeks and allows evaluation of the perineum and discussion of contraception needs.

SYMPTOMS REQUIRING EVALUATION — Patients with any atypical perineal complaint, including severe pain, perineal bulge or mass, abnormal discharge (eg, green vaginal or rectal discharge) should have further evaluation, preferably on the same day if possible [2].

Severe pain — Individuals reporting severe, persisting, or worsening pain should be evaluated for infection, separation, and hematoma, or other less common complications.

Infection — Extreme or worsening pain, particularly if associated with fever or general malaise, often indicates infection. While perineal infections generally occur during the first week after delivery, individuals can present with symptoms two or three weeks later. Infection can be limited to the laceration or expand as cellulitis, an abscess, or, in extreme cases, necrotizing fasciitis [24,25]. Infection or an abscess can track into the ischiorectal fossa and present as buttock pain. The obstetric laceration repair can be intact or disrupted by the infection. (See 'Separation' below.)

Patients with symptoms concerning for infection should undergo detailed, directed physical examination. Examination findings suggestive of perineal infection include erythema of the surrounding skin, shiny or tense skin, drainage, and edema. We recommend that patients with these findings undergo perineal exploration, possible debridement, and possible abscess drainage. We attempt to do as much as possible in the outpatient office setting to minimize disruption to mother-infant bonding. However, individuals with extreme pain may benefit from performing the examination with sedation or anesthesia (regional or general) as indicated.

Once perineal infection is identified, we take the following approach:

If there are signs of abscess or a soft-tissue infection, we initiate systemic oral antibiotics. (See "Acute cellulitis and erysipelas in adults: Treatment".)

If an abscess is identified, we open the repair and drain the abscess. In an office setting, opening and drainage are preceded by adequate local anesthesia (topical or injectable). Following removal of a portion of the sutures, the abscess cavity should be thoroughly irrigated. Some patients with a bulging abscess may tolerate having the sutures cut and the abscess drained without local anesthesia because abscess drainage releases the pressure that was causing the pain.

If the infection appears to be in the deeper portion of a repair, an incision into the surrounding tissues, drainage, tissue debridement, and packing can be indicated. For small abscesses, this can either be performed in the office or in the operating room. For larger abscesses or if there are any concerns about the depth/extent of infection, we prefer to incise and drain the repair in an operating room where appropriate analgesia/anesthesia options and instruments are available and adequate exploration can be achieved.

We evaluate patients who appear systemically ill and have evidence of deep tissue infection for necrotizing deep tissue infections. If there is a significant concern for possible necrotizing infection and imaging is not rapidly available, proceeding directly to the operating room for surgical exploration is the prudent and recommended course of action as a delay in treatment of this rare but life-threatening complication can be catastrophic for the patient. If imaging can be done expeditiously, we find that images can provide additional information regarding the extent of tissue involvement, help identify the amount of debridement that may be necessary, and indicate the potential need for additional surgical assistance. (See "Necrotizing soft tissue infections" and "Surgical management of necrotizing soft tissue infections".)

Separation — Separation of a repaired perineal laceration or episiotomy, also described as breakdown or dehiscence, refers to the disruption of a sutured repair. The separation can be partial or complete. Although separation can occur in the absence of infection, infection is more commonly present. Studies suggest that 10 to 14 days following vaginal delivery is the peak time for separation [26]. Individuals at highest risk of a separation are those who have sustained a third- or fourth-degree laceration. Patients with separation typically present with increased pain or burning, with abnormal discharge, or, less commonly, after experiencing a "popping" sensation.

For those with separation and infection, the repair is further opened and the patient is managed as described above until the infection has resolved (see 'Infection' above). For individuals with separation but no infection, we take the following approach:

First- or second-degree lacerations – Patients with separation of first- or second-degree lacerations can be managed expectantly, to heal by secondary intention, or have the open laceration repaired. As the limited available data suggest equal outcomes, we discuss the risks and benefits of each and elicit the individual's preference in choosing the management plan. Some people prefer to heal by secondary intention because this approach avoids the stress of surgical debridement and secondary repair. Others prefer to have the laceration closed directly. In our clinical experience, most patients with first- or second-degree perineal injuries do well with expectant management. (See "Repair of perineal and other lacerations associated with childbirth" and "Repair of perineal and other lacerations associated with childbirth", section on 'Secondary repair of episiotomy breakdown'.)

Comparison of suturing versus secondary intention – In a meta-analysis of two trials totaling 52 self-reported women that compared secondary suturing with non-suturing, there was no difference in healing at four weeks or dyspareunia rates at two and six months [27]. Although more individuals in the suturing group had resumed intercourse by two months, there was no difference at six months. No data on pain or patient satisfaction were reported.

Timing of healing with secondary intention – One review of 55 self-reports from females with perineal dehiscence (all types of obstetric lacerations) observed that wounds took an average of 3 weeks to heal and nearly 70 percent healed in ≤4 weeks [28].

Third- or fourth-degree lacerations – Patients with separation of third- or fourth-degree laceration repairs are typically treated with antibiotics, undergo operative tissue debridement until healthy tissue is present, and then receive a secondary repair. We believe this approach minimizes the risk of fistula formation and increases the likelihood of a successful repair, although supporting data are limited, particularly around choice of antibiotics. We typically use a first-generation cephalosporin unless there is evidence that more broad coverage is required (eg, large volume of fecal contamination of laceration). (See "Repair of perineal and other lacerations associated with childbirth", section on 'Secondary repair of episiotomy breakdown'.)

Aseptic technique during the initial repair is key to prevent subsequent separation. In one trial, application of povidone-iodine powder to the perineum during episiotomy repair was associated with decreased incidence of separation in the treated group compared with the standard care group (separation rates 3.5 versus 13.5 percent) [26]. Although the body of evidence is limited, the 2007 National Institute for Health and Clinical Excellence guidelines as well as the Royal College of Obstetricians and Gynaecologists recommend using aseptic techniques during perineal repair [29,30]. Unless a contraindication exists, we routinely use liquid betadine or chlorhexidine with a saline irrigation to cleanse the perineum prior to suturing. In the event of an allergy to these agents, we recommend use of baby shampoo mixed with water or saline irrigation. Repair of obstetric lacerations or episiotomy is discussed elsewhere. (See "Repair of perineal and other lacerations associated with childbirth".)

Granulation tissue often appears pink or reddened, with a tissue overgrowth or papillary appearance; granulation tissue can develop in the area of perineal repair, which should not be confused with an infection or breakdown. Expectant observation is generally sufficient, unless the granulation tissue is painful, bleeding, or otherwise bothersome to the patient. We treat symptomatic granulation tissues with either application of silver nitrate (small areas) or simple excision in the office.

Bulge or mass — Common causes of abnormal bulges or tissue in postpartum individuals include hemorrhoids (including thrombosed or prolapsed hemorrhoids), hematomas, and uterovaginal prolapse, in particular anterior wall bulge. These can be diagnosed during physical examination. Briefly, hemorrhoids appear as purplish masses protruding from the anus (picture 1 and picture 2). Hemorrhoids are typically treated with conservative management, but thrombosed hemorrhoids can require incision and drainage. In uterovaginal prolapse, the cervix or vaginal wall is visualized in the lower half of the vaginal canal or protruding out of the vagina (picture 3).

Individuals with prolapse can be fit with a pessary to provide support and reduce any associated pelvic ache or burning. Such prolapse will usually improve as they recover from the delivery, although they may be at higher likelihood of later development of pelvic floor support defects.

Presenting symptoms, diagnosis, and management of these entities is discussed in detail in the following topics:

(See "Hemorrhoids: Clinical manifestations and diagnosis".)

(See "Home and office treatment of symptomatic hemorrhoids".)

(See "Management of hematomas incurred as a result of obstetric delivery".)

(See "Pelvic organ prolapse in females: Epidemiology, risk factors, clinical manifestations, and management".)

Hematoma — Postpartum hematomas, particularly of the vagina and vulva, can expand rapidly and be exquisitely painful. These typically occur within 24 hours of delivery. Patients commonly note rapid development of a severely painful bulge in the vagina, vulva, and/or perineum. Physical examination confirms a vulvar or perineal bulge covered by skin with underlying purplish discoloration [31]. Evaluation and management of vulvar hematomas is presented separately. (See "Management of hematomas incurred as a result of obstetric delivery".)

Abnormal discharge — Abnormal postpartum discharge includes fluid that is purulent or green, foul-smelling, urine-like, stool-stained, or increasing in volume. For comparison, normal postpartum vaginal discharge (ie, lochia) can last for up to eight weeks, typically changes from red/brown to a watery yellow-white, and gradually decreases in volume. We discuss normal discharge and recommend further evaluation if they experience abnormal discharge. While these somewhat vague descriptions may result in the evaluation of individuals who are healing appropriately, we believe fewer people with complications are missed with this approach. (See "Overview of the postpartum period: Normal physiology and routine maternal care", section on 'Lochia'.)

Causes of abnormal discharge include a retained sponge, draining abscess, fistula, or incontinence. While individuals with a perineal abscess tend to present with perineal pain and/or fever within the first week following delivery, a draining abscess can be perceived as abnormal discharge. Both vesicovaginal and rectovaginal fistulas can present days to months following delivery. Any person with a sudden increase in urine loss, constant and/or brown discharge, or vaginal discharge only when she also has diarrhea should prompt evaluation. New onset stress urinary incontinence postpartum typically presents within the first few days following delivery and generally improves slowly. Fecal incontinence from a sphincter laceration or an undiagnosed buttonhole injury in the mucosa above the sphincter may present immediately or following the first episode of soft stool.

Presenting symptoms, diagnosis, and management of these entities is discussed in detail in the following topics:

(See "Perianal and perirectal abscess".)

(See "Rectovaginal and anovaginal fistulas".)

(See "Female urinary incontinence: Evaluation".)

(See "Fecal incontinence in adults: Etiology and evaluation".)

PHYSICAL EXAMINATION — Individuals suspected of having a perineal complication require a pelvic examination, despite concomitant pain, tissue edema, and patient anxiety. A discussion of the components of the pelvic examination is presented separately. (See "The gynecologic history and pelvic examination", section on 'Pelvic examination'.)

Generally, we perform the initial evaluation in the office. Topical lidocaine jelly can be applied to the perineum to reduce examination-related discomfort. Superficial inspection of the labia and perineum can identify erythema suggestive of infection, a distal abscess, or superficial cellulitis. For individuals with symptoms or examination findings concerning for abscess, hematoma, or separation, digital vaginal examination is performed with a single examination finger to minimize patient discomfort. If a speculum examination is indicated, we use the smallest speculum that provides adequate visualization and separate the speculum to use only the posterior blade to retract the obstructing tissue.

If the patient is unable to tolerate the examination, we proceed with an examination under anesthesia. While such an examination is typically performed in an operating room, some labor and delivery units have the ability to provide intravenous conscious sedation outside of the operating room. (See "Procedural sedation in adults outside the operating room".)

POST-DISCHARGE CARE — The optimal post-discharge care of individuals with obstetrics lacerations is not known. We take the following approach:

First- or second-degree perineal lacerations or episiotomy – At least one society advises an interaction between patient and maternal care provider occurs during the first three weeks after delivery [1]. Whether performed in person or virtually, this visit can be useful to assess for any concerns of the patient, physical or otherwise. We advise clinicians to ask the patient about concerns with healing, pain, and incontinence of urine and/or feces; subsequent evaluation and specialty referral can be made as needed.

Third- or fourth-degree perineal lacerations – We advise more frequent follow-up for individuals with third- or fourth-degree obstetric lacerations to ensure early detection of any developing complications. We generally schedule these individuals for an outpatient visit and examination one to two weeks following hospital discharge and then continue to see them every one to two weeks until the repair has completely healed. Patients who may benefit from weekly visits include those with medical risk factors for poor wound healing (eg, those with diabetes, immunosuppression, other comorbidities, or smokers), individuals with extensive repairs, and individuals who find perineal care challenging (eg, limited social support or intellectual capabilities). For patients who are unable to visit weekly, an alternate option can be evaluation by a visiting nurse or similar service.

LONG-TERM ISSUES — Following initial perineal healing, patients may present with new pelvic floor issues.

Perineal pain or dyspareunia — Prolonged postpartum perineal pain and dyspareunia are relatively common. In a questionnaire study, 8 percent of self-reported women noted persistent perineal pain at one year following vaginal delivery [32]. In a retrospective study comparing the degree of obstetric perineal laceration and sexual function in primiparous individuals, approximately 20 percent reported dyspareunia at six months after delivery [33]. Episiotomy did not increase the risk of postpartum dyspareunia relative to same degree of spontaneous laceration [33]. Factors associated with increased risk of postpartum dyspareunia include operative vaginal delivery (both forceps and vacuum) and third- and fourth-degree obstetric lacerations [33-36]. Perineal pain is associated with depressive symptoms, in addition to negatively impacting quality of life and sexual activity [7].

Although supporting data are limited, initial treatment options include topical estrogen therapy and pelvic floor muscle therapy (PFMT). For patients with dyspareunia and hypoestrogenism, typically related to breastfeeding, the authors prescribe topical estrogen cream, 1 gram twice weekly applied to the vagina and perineum, without a ramp-up period [37]. Individuals with persistent perineal pain or dyspareunia at three months postpartum may benefit from PFMT for symptom reduction, although the data are conflicting [38,39]. We do not universally request early referrals for PFMT in postpartum individuals to reduce the likelihood of development of postpartum pain or dyspareunia. If these symptoms are reported following their six week postpartum visit, we will offer a referral for PFMT at that time [38-40].

For individuals with refractory perineal pain or dyspareunia who have not responded to PFMT, revision perineoplasty is a treatment option. In a study of nine postpartum women with persistent perineal dyspareunia and anatomic distortion (ie, scarring), there was a significant reduction in perineal pain and increase in coital frequency and satisfaction following perineal revision [41]. However, as repeat surgery can also increase scarring and resultant pain, revision perineoplasty is reserved for individuals with persistent, severe symptoms that are isolated to the obstetric scar.

While transcutaneous electrical nerve stimulation and therapeutic ultrasound therapy have been used to treat postpartum perineal pain and dyspareunia, we do not prescribe them as the body of evidence is limited. One small trial of transcutaneous electrical nerve stimulation (TENS) therapy reported decreased dyspareunia with treatment, but no control group was included for comparison [42]. In a meta-analysis of four trials comparing therapeutic ultrasound with placebo, women in two trials were more likely to report perineal pain reduction with treatment and women in one trial were less likely to report dyspareunia [16]. However, because no other measured outcomes reached significance and the overall quality of the trials was variable, the authors concluded that there was insufficient evidence to assess therapeutic ultrasound as a treatment for postpartum perineal pain or dyspareunia.

Incontinence or pelvic organ prolapse — Although the available data are limited, we suggest postpartum PFMT for individuals with incontinence (urinary or anal) and/or pelvic organ prolapse that remains symptomatic three months after delivery. PFMT appears to improve postpartum urinary and anal incontinence symptoms at 1 year, but not in the long-term (6 to 12 years) [38,39,43]. PFMT has been demonstrated to improve pelvic organ prolapse severity and symptoms in older individuals, although the impact on persons who are immediately postpartum is not known [44]. We routinely recommend Kegel exercises to postpartum people who have symptoms of either incontinence or prolapse, although do not recommend it universally to asymptomatic individuals. During pelvic examination, it is helpful to assess muscular strength and ensure appropriate Kegel performance.

Poorly healed perineum — Some patients will present months after delivery with bothersome perineal anatomic changes or defects despite having fully healed obstetric perineal lacerations. These may include an open (widened) introitus and thin perineal body, which typically result from detachment of the bulbocavernosus and superficial transverse perineal muscles. One trial comparing the impact of surgical correction with pelvic floor physical therapy for patients with residual symptoms following second-degree injuries reported greater improvement in all measured domains with surgical correction (71 versus 11 percent) [45]. Measurements of improvement included the Patient Global Impression of Improvement, Pelvic Floor Distress Inventory, the Pelvic Floor Impact Questionnaire, the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire, and the Hospital Anxiety and Depression Scale. Thus, for patients who are at least six months from delivery with perineal symptoms relating to their prior obstetric laceration, the authors offer surgical correction, although patients who desire a trial of pelvic floor physical therapy may reasonably do so. The offer of surgical repair is balanced with counseling regarding timing of subsequent pregnancies. Surgical correction is not advised for patients who desire to conceive in the short term; repair is generally delayed until the completion of childbearing or possibly performed at the time of a subsequent delivery. If the patient is undecided or planning on a moderate to extended delay of childbearing, the authors will offer surgical correction.

SPECIAL POPULATIONS

Obstetric anal sphincter injury — Individuals with an obstetric anal sphincter injury (OASIS; ie, a third- or fourth-degree obstetric laceration) appear to be at increased risk of infection and separation compared with those with lesser lacerations [46-48]. In a prospective cohort study of nearly 270 self-reported women, operative vaginal delivery was the main risk factor for separation following OASIS [46]. As evidence-based interventions that prevent complications are not known, we advise frequent postpartum follow-up of individuals with OASIS to identify complications early and initiate treatment to reduce sequelae. Discussions of management of third- and fourth-degree lacerations and delayed anal sphincter repair are presented elsewhere. (See "Repair of perineal and other lacerations associated with childbirth", section on 'Secondary repair of episiotomy breakdown' and "Delayed surgical management of the disrupted anal sphincter".)

Female genital cutting (circumcision) — Individuals with prior female genital cutting have unique perineal challenges during labor, delivery, and recovery. The management of these individuals is presented in detail in separately. (See "Female genital cutting".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Postpartum care".)

SUMMARY AND RECOMMENDATIONS

Definition of perineum – Anatomically, the perineum is the entirety of the pelvic outlet inferior to the pelvic floor (figure 1). (See 'Definition' above.)

Routine postpartum perineal care – As the optimal approach to postpartum care is not known, we take the approach below and tailor the specific plan based on the patient's history.

Patient education – For all individuals who have a vaginal delivery, we discuss perineal healing and hygiene, pain management, prevention of constipation, and resumption of sexual activity. As the data are limited, the optimal strategies for these efforts are not known. (See 'Initial approach' above.)

First- or second-degree perineal lacerations or episiotomy – These patients typically have one visit (in-person or virtual) during the first three weeks after delivery. We address any patient concerns and ask about healing, pain, and incontinence of urine and/or feces. Subsequent evaluation and specialty referral can be made as needed. (See 'Post-discharge care' above.)

Third- or fourth-degree perineal lacerations – We advise more frequent follow-up for individuals with third- or fourth-degree obstetric lacerations to ensure early detection of any developing complications. We generally schedule these patients for an outpatient visit and examination one to two weeks following hospital discharge and then continue to see them every one to two weeks until the repair has completely healed. (See 'Post-discharge care' above.)

Symptoms for evaluation – Patients with any atypical perineal complaint, including severe pain, perineal bulge or mass, abnormal discharge (eg, green vaginal or rectal discharge) should undergo focused evaluation. (See 'Symptoms requiring evaluation' above.)

Excessive or atypical pain – Individuals reporting severe, persisting, or worsening pain should be evaluated for infection, separation, and hematoma, or other less common complications. (See 'Severe pain' above.)

Bulge symptoms – Common causes of abnormal bulges or tissue in postpartum individuals include hemorrhoids (including thrombosed or prolapsed hemorrhoids), hematomas, and uterine prolapse. These diagnoses are confirmed with physical examination. (See 'Bulge or mass' above.)

Discharge – Abnormal postpartum discharge includes fluid that is purulent or green, foul-smelling, urine-like, stool-stained, or increasing in volume. Causes of abnormal discharge include a draining abscess, fistula, or incontinence. (See 'Abnormal discharge' above.)

Physical examination – Patients suspected of having a perineal complication require a pelvic examination, which can be challenging in a patient who has recently delivered vaginally because of pain, tissue edema, and patient anxiety. We perform the initial examination in the office. Individuals who are unable to tolerate an office examination are evaluated under anesthesia. Individuals who have office findings requiring treatment beyond what can comfortably be tolerated in the office setting (debridement or repair) should be evaluated in a surgical setting. (See 'Physical examination' above.)

Long-term issues – Long-term issues include persistent perineal pain and incontinence of urine, feces, or both. Pelvic floor muscle training appears to reduce symptoms. (See 'Long-term issues' above.)

Unique populations – Individuals with obstetric anal sphincter lacerations or female genital cutting can have additional care needs. (See 'Special populations' above.)

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