After every vaginal delivery, the perineum, vagina, and cervix should be carefully examined.[3] A digital rectal examination should be done with any severe laceration to assess the integrity and tone of the anal sphincter.[3][4]

Most perineal lacerations are sutured, but there is limited evidence to support this practice for first and second-degree lacerations.[4] First degree lacerations that are hemostatic and do not distort the natural anatomy do not need to be repaired. If repair is desired, suture or adhesive skin glue can be used if the laceration is hemostatic.[4] A trial comparing skin adhesive and suture for first degree lacerations found that the total repair time was shorter and overall patient pain scores were lower in the adhesive group.[4] It can be left to the surgeon’s discretion to use suture or adhesive for hemostatic first-degree lacerations.  

When repairing second-degree lacerations, continuous or running suture should be used over interrupted suturing to decrease post-partum pain and the possibility of the patient requiring suture removal.[4][9] Suture is used to reapproximate the vaginal mucosa to the level of the hymen.  Once the hymen is restored attention is turned to the perineal body and submucosal region. After these areas are properly closed, the skin is reapproximated.[4][9]

Third- and fourth-degree lacerations are repaired in a stepwise fashion. In a fourth-degree laceration, the rectal mucosa is reapproximated starting at 1 cm above the apex of the laceration. Care is taken to not penetrate through the rectal mucosa. The anal sphincter is then reapproximated with attention paid to include the fascial sheath of the muscle with the repair. The internal anal sphincter should be repaired separately from the external anal sphincter when possible.[5] Once the rectal mucosa and anal sphincter are repaired, the remaining portion of the laceration is closed in the same fashion as a second-degree tear.[9]

A single dose of a second-generation cephalosporin can be given after any OASIS repair to decrease the patient’s risk of infection and wound breakdown.[3][4][3]

Care after any perineal laceration repair, but especially after an OASIS injury, should include pain management, laxatives or stool softeners to avoid constipation and monitoring for signs of urinary retention.[3][4][5][4][3]

The most common complication of a perineal laceration is bleeding. Most bleeding can be quickly controlled with pressure and surgical repair.[4] However, hematoma formation can lead to large amounts of blood loss in a very short time. 

Beyond bleeding, immediate complications also include pain and suturing time leading to delayed mother-child bonding.[2] There is also a risk of infection and wound break down with any vaginal repair. Infection can delay wound healing and lead to wound dehiscence.[4]

Long term complications include pain, urinary or anal incontinence, and delayed return to sexual intercourse due to dyspareunia.[1][3] These symptoms are worse in women who had an episiotomy compared to those who were allowed to tear naturally.[2] Flatal incontinence can persist for years after an OASIS.[3] Quality of life can be greatly affected by the severity of a perineal laceration and the long term urinary, flatal or fecal incontinence that may follow. 

Approximately 25% of women who suffer from an OASIS injury will experience wound dehiscence in the first six weeks post-partum and 20% will suffer from a wound infection. Rectovaginal and/or rectoperineal fistulas may develop in women who had an unidentified or poorly healed OASIS injuries.[4]

The time it takes a woman to return to normal sexual function after perineal trauma varies but has been correlated to the severity of the laceration. The more severe the laceration, the longer the return to normal sexual function.[10]

Perineal trauma can have long term effects on a woman's life and well being. Multiple studies have found that some women who experience severe perineal lacerations suffer long term psychological trauma and social isolation.[10] Women may be embarrassed by their symptoms and therefore do not discuss them with their health care providers. Practicing clinicians must take care to properly diagnose and repair lacerations in childbirth as well as address concerns in the post-partum period.

Multiple strategies have been proposed for the prevention of perineal trauma at the time of vaginal delivery. There is no consensus on the best ways to prevent or reduce the severity of lacerations.[2] 

Perineal massage has been shown to decrease the incidence of lacerations requiring suture, although the reduction was minor.[4] Additional studies have shown a decrease in third- and fourth-degree lacerations when massage was performed during the second stage of labor, however, there is no consistently proven benefit.[2][4] Massage may promote perineal relaxation, increasing perineal blood flow, and stretching the vaginal tissue prior to delivery, leading to less severe lacerations. This relaxation may decrease the number of episiotomies cut.[1][11]  Massage can be started after 34 weeks and be performed daily until delivery.[1][2]

Perineal support or a “hands-on” approach, can be protective of the perineum and decrease the severity of perineal lacerations at the time of delivery.[2] However, studies are conflicting on the significant benefit to this measure.[12]  

Delayed or immediate pushing after a woman reached ten centimeters of dilation showed no difference in the incidence of perineal lacerations. However, there was a higher incidence of delivery with intact perineum in women who delivered in the lateral position with delayed pushing compared to immediate pushing in the lithotomy position.[4]  

Warm compresses can be used during the second stage of labor to decrease the risk of third- and fourth-degree lacerations.[4] Warm compresses and perineal massage are the only intervention shown to decrease the frequency of third- or fourth-degree lacerations.[3]

Post-partum care providers must ensure they are addressing and validating any concerns a woman may have about her perineal trauma experienced during childbirth. A woman's physical and psychological health should be discussed. Severe perineal trauma can have long term effects on a woman's sexuality, overall wellbeing, and relationship with her partner.[10]

Women who have suffered an OASIS injury in a previous pregnancy need to be counseled about the risk of recurrence of injury with subsequent pregnancies. Elective cesarean section can be discussed as an option, but the low risk of another OASIS injury should be carefully weighed against the risk of cesarean delivery.[3][4] Women with a history of an OASIS injury who are currently asymptomatic and show no symptoms of sphincter injury can be encouraged to have a vaginal delivery.[4]

The health care team should be prepared and willing to ask about and treat any complications a woman may have after childbirth. Some women feel embarrassed and ashamed about the problems they encounter and will not bring up concerns to their care providers.[10] By asking questions at the post-partum visit and understanding the details of her delivery and any perineal trauma encountered, care providers can provide complete and compassionate care for their patients.