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The Perineal Debate

Antibiotic prophylaxis improved outcomes of repair for obstetric lacerations, which were more likely to occur after prior episiotomies.

Perineal laceration is a relatively frequent consequence of vaginal delivery, particularly when episiotomy — one of the more common surgical procedures in the U.S. — has been performed. Such trauma is associated with risk for infection and, during subsequent deliveries, recurrent perineal tearing. Can we better manage and prevent obstetric lacerations?

To address the issue of postpartum perineal wound infection, Dr. Duggal’s group conducted a prospective, randomized trial to evaluate prophylactic second-generation cephalosporins or clindamycin compared with placebo, all given intravenously at the time of repair of third-degree (extending into the capsule and muscle of the anal sphincter) or fourth-degree (extending into the rectal mucosa) perineal tears. At 2 weeks postpartum, 107 patients were evaluated for perineal wound complications (defined by abscess, purulent discharge, or breakdown of the repair site). Of 49 patients who received antibiotics, 8% developed perineal wound complications compared with 24% of 58 women who received placebo (P=0.037).

In an observational study, Dr. Alperin and colleagues evaluated retrospectively whether episiotomy performed at first vaginal delivery increased risk for spontaneous perineal tearing during the next vaginal delivery. Among 6052 women with consecutive deliveries at the same hospital, the rate of episiotomy at first deliveries was 48%. At second deliveries, third- or fourth-degree perineal laceration occurred in 5% of women who had undergone prior episiotomies and in 2% of women without prior episiotomies (P<0.001).

Comment: Antibiotic use is not the standard of care for women who sustain third- or fourth-degree obstetric lacerations. Should it be? Dr. Duggal and colleagues noted that the perineal wound complication rate in their study was much higher than they would have predicted. Also, such wound complications are not definitively associated with subsequent incontinence, fistulas, or sexual dysfunction (although this seems plausible). Last, the findings in this patient population might not be generally applicable. Nevertheless, an editorialist — despite reservations about liberal use of antibiotics — suggests that we should consider adopting this strategy for appropriate patients with third- and fourth-degree tears.

The editorialist also cites a Practice Bulletin (Obstet Gynecol 2006; 107:956) in which the American College of Obstetricians and Gynecologists concluded that routine episiotomy has no identified benefits. The findings of Dr. Alperin’s group only reinforce the pivotal query: "Why have clinicians hesitated to discontinue routine use of an intervention that has no proven benefit and that has significant complications?" Overall, the evidence-based medicine arising from these two studies might help us to alter our long-held beliefs and change our approach to managing later stages of labor.

— Ann J. Davis, MD

Published in Journal Watch Women's Health July 24, 2008

Citation(s):

Duggal N et al. Antibiotic prophylaxis for prevention of postpartum perineal wound complications: A randomized controlled trial. Obstet Gynecol 2008 Jun; 111:1268.

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• Medline abstract (Free)

Alperin M et al. Episiotomy and increase in the risk of obstetric laceration in a subsequent vaginal delivery. Obstet Gynecol 2008 Jun; 111:1274.

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• Medline abstract (Free)

Chescheir NC. Great expense for uncertain benefit. Obstet Gynecol 2008 Jun; 111:1264.

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• Medline abstract (Free)