For reduction of infectious morbidity associated with anal sphincter lacerations, a single dose of antibiotic at the time of repair is recommended by the American College of Obstetricians and Gynecologists (20 16c). his practice is supported by evidence (Buppasiri, 2014; Duggal, 2008; Lewicky-Gaupp, 2015; Stock, 2013). A single dose of a secondgeneration cephalosporin is suitable, or clindamycin for penicillin-allergic women. With OASIS, postoperatively, stool softeners are prescribed for a week, and enemas and suppositories are avoided.
Unfortunately, normal function is not always ensured even with correct and complete surgical repair. Some women may experience continuing fecal incontinence caused by injury to the innervation of the pelvic Boor musculature (Roberts, 1990).
FIGURE 27-18 A. Suturing of the anorectal mucosa begins above the laceration apex using a continuous, non locking method with finegauge absorbable suture such as 3-0 or 4-0 chromic gut or polyglactin 910. Sutures are placed through the anorectal submucosa approximately 0.5 cm apart down to the anal verge. B. A second reinforcing layer uses 3-0 delayed-absorbable suture in a continuous, nonlocking fashion. This incorporate the torn ends of the internal anal sphincter (lAS), which can be identified as the glistening white fibrous structure lying between the anal canal submucosa and the fibers of the external anal sphincter. In many cases, the lAS retracts laterally and must be sought and retrieved for repair. (Reproduced with permission from Kenton K, Mueller M: Episiotomy and obstetric anal sphincter lacerations. In Yeomans ER, Hofman BL, Gilstrap LC III, et al (eds): Cunningham and Gilstrap's Operative Obstetrics, 3rd ed. New York, McGraw-Hili Education, 201o7.)
Initially, locally applied ice packs help reduce swelling and allay discomfort (de Souza Bosco Paiva, 2016). In subsequent days, warm sitz baths aid comfort and hygiene. Additionally, a small squirt botde of warm water can cleanse the site after voiding or stooling. For pain, topical application of 5-percent lidocaine ointment was not efective in relieving episiotomy or perineal laceration discomfort in one randomized trial (Minassian, 2002). Oral analgesics containing codeine provide considerable relie. For lesser degree of discomfort, NSAID tablets can be given.
Because pain may signal a large vulvar, paravaginal, or ischiorectal fossa hematoma or perineal cellulitis, these sites should be examined carefully if pain is severe or persistent. Management of these complications is discussed in Chapters 37 and 41 (pp. 674 and 764). In addition to pain, urinary retention may complicate episiotomy recovery (Mulder, 2012, 2016). Its management is described in Chapter 36 (p. 660).
For those with second-degree lacerations or anal sphincter tears, intercourse is usually proscribed until after the irst puerperal visit at 6 weeks. Compared with women with intact perineum, those with perineal trauma show higher rates of delayed intercourse at 3 and 6 months, but not at 1 year (McDonald, 2015; Rldestad, 2008; Signorello, 2001).
Abdel-Aleem H, Singata M, Abdel-Aleem M, et al: Uterine massage to reduce postpartum hemorrhage after vaginal delivery. Int ] Gynaecol Obstet 111(1):32,r2010 Acker DB, Sachs BP, Friedman EA: Risk factors for shoulder dystocia. Obstet