Can there be long term problems?

Possible complications in the immediate postnatal period

Perineal pain

Infection

Wound dehiscence – partial or complete

Adhesions

Areas of overgranulated tissue

Postnatal depression - interruption to breastfeeding and disruption of bonding

Possible longer term complications

Dysparaeunia (painful sexual intercourse)

Psychosexual problems – altered body image/embarrassment

Nerve pain

Urinary dysfunction

Incontinence of faeces and/or flatus

Pelvic organ prolapse

Fear of repeat vaginal birth

What are the complications of childbirth related perineal trauma?

Fear of perineal injury requiring stitches and worry about infection and wound breakdown is a priority concern for women, worldwide (supporting evidence - 7,8). In addition to infection, complications, such as adhesions and/or areas of over-granulated tissue may arise and lead to longer term complications

Infection

There is wide variation in reported rates of wound infections, with estimates ranging from 0.1% to 40.1%, and a retrospective audit by Johnson et al (2012) suggesting an infection or complications of sutured CRPT will occur in 10% of women (supporting evidence - 9). In the UK, the lack of integration of community, primary and secondary care information technology systems make it difficult to capture such data accurately.

If an infection is suspected - due to the presence of excessive discoloured and/or offensive smelling exudate (fluid that leaks from cells following damage) rather than normal yellow exudate, abscess, erythema (swelling) or cellulitis - wound swabs to identify causative organisms should be taken and broad based antibiotics commenced in line with local guidelines.

Wound dehiscence (breakdown)

Wound dehiscence, either partial or complete, is frequently reported to be a result of infection. In the UK, current practice is ‘expectant management’ (allowing the wound to heal naturally) with antibiotic cover (supporting evidence - 10). However, some clinicians recommend secondary suturing once infection is excluded or treated. Regardless of the management option chosen, and to avoid the risk of systemic it is vital that women with perineal infection are reviewed urgently, have their wound assessed, relevant microbiological swabs taken, prescribed appropriate antibiotics if required and regularly monitored throughout the healing process. Ongoing observation should be by either the general practitioner or midwife in the primary care setting or by referral to a specialised perineal clinic that some hospitals provide for both short and long term perineal complications.

Excessive granulation tissue formation

Some perineal may develop excessive granulation tissue formation (overhealed tissue). Women commonly complain of what is perceived to be a skin tag that bleeds easily on touch and excessive discharge. In the majority of cases, this can be easily managed using silver nitrate in an outpatient setting. Rarely, it requires surgical excision or cauterisation under anaesthetic. In contrast, excessive scar tissue formation or poor alignment of tissues in the initial repair might require additional reconstructive surgery in the form of modified Fenton’s procedure, perineal refashioning or perineorrhaphy (supporting evidence - 11).

What is the impact of childbirth related perineal trauma on sexual function?

In women who have sustained perineal trauma during childbirth, perineal pain, associated dyspareunia and impaired sexual drive can continue for up to six months and in some women for up to three years post childbirth (supporting evidence - 12, 15).

Women often wait for review by the GP prior to commencing sexual intercourse for reassurance that it is safe to do so and that all trauma has fully healed. The majority of women do not find any significant changes to sexual function and desire (supporting evidence - 13,14).