The American College of Obstetricians and Gynecologists has released a new Practice Bulletin “Prevention and Management of Obstetric Lacerations at Vaginal Delivery” providing guidelines and recommendations for care providers. This new Practice Bulletin replaces a previous Practice Bulletin, “Episiotomy” from 2006 and “Limitations of Perineal Lacerations as an Obstetric Quality Measure,” a Committee Opinion released in 2015.
Lacerations during vaginal birth is both a common occurrence, 53-79% of women will sustain a laceration the document notes, and a common concern of our clients. Most lacerations, ACOG notes, are of the first-degree or second-degree. This Practice Bulletin also points out that “laceration rates vary based on patient characteristics, birth settings, and obstetric care provider practices.” Episiotomy is discussed as well.
Preventing Lacerations During Birth
A number of different perineal management interventions have been used in the antepartum period or at the time of delivery in an effort to reduce perineal trauma, including maternal perineal massage, manual perineal support, warm compresses, different birthing positions, and delayed pushing.
— “Prevention and Management of Obstetric Lacerations at Vaginal Delivery”, Practice Bulletin #165, American College of Obstetricians and Gynecologists
Perineal Massage decreases muscle resistance. In research cited in the Practice Bulletin, massage beginning at 34 weeks was found to reduce trauma that required suturing and reduce the need for episiotomy. Reduction in pain after birth was found in multiparous women who received prenatal perineal massage, but not first time mothers. During labor, perineal massage has been associated with fewer third and fourth degree lacerations.
Perineal support, where a care provider uses their hand(s) to provide manual support of perineum during pushing, is mentioned in this Practice Bulletin which notes that research supporting its effectiveness at reducing severe perineal trauma are mixed. As a result, this intervention is not listed in the summary recommendations.
Warm compresses during the second stage were associated with a reduced rate of third-degree and fourth-degree lacerations, but not first-degree or second-degree. The Practice Bulletin also states that because they “have been shown to be acceptable to women and are, therefore, reasonable to offer.”
Birth position is also not listed in the summary recommendations of this Practice Bulletin. The authors review of studies regarding birthing position is noted to have mixed results with some demonstrating that upright or lateral positions led to fewer episiotomies, less operative births but higher rates of second-degree lacerations. Studies of patients with epidurals did not demonstrate “a clear benefit of any upright position.” Lateral position combined with delayed pushing when an epidural is present has been found to reduce the risk of all types of lacerations but was not included in the summary recommendations in this Practice Bulletin.
First-degree and Second-degree Lacerations
First and second degree lacerations can either be repaired or not, at the provider’s discretion. Those which are bleeding or distort anatomy are recommended to be sutured. Should a provider elect to repair a first-degree or second-degree laceration, suturing or adhesive glue can be used. Absorbable sutures are recommended due to less pain reported in first three days after birth and less need for resuturing later.
Much of this Practice Bulletin focuses on obstetric anal sphincter injuries (OASIS) including factors that contribute to these injuries, best methods for their repair and postpartum care. While much of this information applies to the decisions and care that physicians or midwives will provide, there is information that doulas and expectant families should know:
- Risk factors: The strongest risk factors for OASIS include forceps delivery, vacuum-assisted delivery, midline episiotomy and increased fetal birth weight. Midline episiotomy, the most common type performed in the United States, is noted as a “strong,independent risk factor for third-degree or fourth-degree lacerations.” Rates of episiotomy and operative delivery are likely among the care practices referred to in this Practice Bulletin which impact the likelihood of lacerations during vaginal birth.
- Time needed for repair: The more significant and complex the injury, the more time will likely be needed for the repair. This can be distressing to families and frustrate them if the repair impacts skin-to-skin contact or the initiation of breastfeeding. Doulas can help by positioning the baby and enlisting partners to help support the baby to facilitate bonding, skin-to-skin contact and/or breastfeeding.
- Positing & Lighting for repair: The ACOG Practice Bulletin notes that adequate light and visualization are needed for evaluation, repair and closure of a laceration. This can also lend itself to an environment and immediate postpartum experience that was not in the family’s ideal scenario. Shielding the newborn’s eyes from bright light while positioning the family so they can see and focus on their baby may help reduce the impact of the repair on their bonding and first breastfeeding experience. The Practice Bulletin notes that, on average, severe injuries take up to 23 minutes to repair.
- Antibiotics: When OASIS is present, a single dose of antibiotics is recommended to prevent complications from infection. Patients who received antibiotics in labor, such as for group B strep, may not need additional antibiotics to prevent infection from a severe laceration. Without antibiotics, around 20% of women with an OASIS will develop an infection.
- Pain management: Use of ice packs has been associated with significantly less pain in first three days after birth. Pain medication can also help, but should be combined with laxatives or stool softeners.
- Constipation prevention: To prevent further injury and reduce pain, stool softeners or oral laxatives are recommended in the immediate postpartum period.
- Evaluation of wound healing: Significant to severe perineal injuries should be evaluated frequently, ACOG recommends. Letting clients know to expect more frequent and thorough exams postpartum when significant tears are present can help eliminate surprises and set expectations.
- Risk of future injury: Evidence indicates that there is an increased risk for severe perineal trauma at a future birth. ACOG also notes that the absolute risk is low at 3%. Doulas should be aware that this may be a concern for multiparous clients, particularly those who had significant pain, infection or other complications from a laceration previously. Reviewing ACOG’s suggested preventative measures and encouraging a client to discuss these with their care provider can help alleviate concerns and provide a sense of control over future injury with a subsequent vaginal birth.
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 (13).
“Prevention and Management of Obstetric Lacerations at Vaginal Delivery”, Practice Bulletin #165, American College of Obstetricians and Gynecologists
Episiotomy increases the length of lacerations, and routine use is associated with a greater risk of more severe perineal trauma. Research noted in the Practice Bulletin found that midline episiotomy combined with forceps delivery substantially increases the risk of third-degree laceration and fourth-degree laceration.
Prevention and management of obstetric lacerations at vaginal delivery. Practice Bulletin No. 165. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e1–15.
ACOG,. Ob-Gyns Can Prevent And Manage Obstetric Lacerations During Vaginal Delivery, Says New ACOG Practice Bulletin. 2016. Web. 22 Aug. 2016.
Dekker, Rebecca. “What Is The Evidence For Perineal Massage During Pregnancy To Prevent Tearing?“. Science and Sensability. N.p., 2016. Web. 23 Aug. 2016.