Exxcellence pearls: 4th degree perineal laceration breakdown

Question 1

What is the rate of third or fourth degree perineal laceration?

Answer 1

1-8%

Question 1

What are risk factors for severe perineal laceration?

Answer 1

Forceps delivery, midline episiotomy, nulliparity, high birthweight infant, Asian race

Question 2

Describe the perineal laceration grading system.

Answer 2

First: Only through perineal skin
Second: Extends through perineal body muscles
Third: Includes external anal sphincter
Fourth: Through rectal mucosa

Question 3

How should breakdown of a fourth degree perineal laceration be managed?

Answer 3

Physical examination including rectal exam to assess the perineum for abscess, hematoma and the extent of the breakdown.
Debridement of necrotic tissue.
Delayed closure with conventional practice being repair in 3 to 4 months. Newer studies with aggressive daily debridement and antibiotics performed repair as early as 7 to 10 days following delivery.

Question 4

What is the risk of breakdown after fourth degree laceration repair?

How can this risk be minimized?

Answer 4

5%

Antibiotics at the time of repair

Question 6

What are the long-term complications of fourth-degree perineal laceration?

Answer 6

Anal incontinence, fistula formation and dyspareunia

Question 7

What are the risks with subsequent deliveries in a woman with a fourth degree perineal laceration?

Answer 7

Increased risk of sustaining another severe perineal laceration and worsening of anal incontinence symptoms.