Post-operative care of higher order tears
- Prophylactic single dose intravenous antibiotics (2nd generation cephalosporin, e.g., cefotetan or cefoxitin) should be administered for the reduction of perineal wound complications following the repair of obstetrical anal sphincter injury.
- Laxatives (e.g., lactulose) should be prescribed following the primary repair of obstetrical anal sphincter injury as they are associated with earlier and less painful first bowel motions and earlier discharge from hospital. Constipating agents and bulking agents are not recommended.
Clinical Pearl: A dose of IV Ancef and PO Flagyl can be used if there is no access to cefotetan or cefoxitin.
- Non-steroidal anti-inflammatories and acetaminophen are the first-line analgesics. Opioids should only be used with caution. Constipation should be avoided by using a laxative or stool softener.
- Obstetrical anal sphincter injuries are associated with an increased risk of postpartum urinary retention.
- Women with anal incontinence following obstetrical anal sphincter injury should be referred for pelvic floor physiotherapy.
Clinical Pearl: Rectal medications should be avoided in patients with higher order tears.
Generalized post-perineal repair care
- Apply ice packs to help reduce swelling and discomfort
- Recommend using a small squirt bottle of warm water to cleanse the site after voiding and stooling
- Over subsequent days, warm sitz baths help with comfort and hygiene
- Oral analgesics:
- Acetaminophen and NSAIDs can be given to help reduce discomfort and swelling
- Examine for signs of hematomas or cellulitis if pain is severe or persistent
- For tears that are second degree or greater, recommend delaying intercourse until after the 6 week postpartum visit
- For tears involving the anal sphincter, prescribe stool softeners/gentle laxatives for a week
Clinical Pearl: If an episiotomy or perineal tear wound dehisces and is not infected, it can often be followed expectantly and heal by secondary intent. However, if the defect is large or infected, it will require surgical debridement and closure.