17:57, 09/12/2021 Postpartum perineal care and management of complications - UpToDate

Authors: Lori R Berkowitz, MD, Caroline E Foust-Wright, MD, MBA

Section Editors: Linda Brubaker, MD, FACOG, Charles J Lockwood, MD, MHCM
Deputy Editor: Kristen Eckler, MD, FACOG

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Nov 2021. | This topic last updated: Sep 09, 2021.

INTRODUCTION

This topic presents information on routine postpartum perineal care as well as evaluation and
management of delivery-related perineal complications. Despite the importance of
postpartum perineal care, there is little evidence to guide management; the information in
this topic is based largely on our clinical experience.

In our experience, common postpartum perineal issues include pain control, hygiene,
prevention of constipation, and resumption of sexual activity. Clinicians should be able to
evaluate less common symptoms, such as severe pain, bulge or mass, or abnormal discharge,
including fecal leakage.

Related topics that are presented separately include:

● (See "Repair of perineal and other lacerations associated with childbirth".)

● (See "Delayed surgical management of the disrupted anal sphincter".)
● (See "Fecal and anal incontinence associated with pregnancy and childbirth: Counseling,
evaluation, and management".)

DEFINITION

Clinicians often refer to the area between the vagina and anus as the "perineum"; however,
anatomically, the perineum is the entirety of the pelvic outlet inferior to the pelvic floor (
figure 1). The area between the vagina and anus is more aptly termed "the perineal body."
The anatomy of the perineum is reviewed in detail separately. (See "Surgical female pelvic
anatomy: Uterus and related structures" and "Surgical female urogenital anatomy" and
"Surgical female urogenital anatomy", section on 'Perineum'.)

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INITIAL APPROACH

We take the following approach to perineal care for all women undergoing vaginal delivery.

Education — Ideally, preliminary education about postpartum care is begun during prenatal

visits to help women understand typical changes that will occur during childbirth and recovery
[1]. Once postpartum, we educate each woman about the nature of her perineal laceration or
incision (ie, episiotomy), if any; measures for hygiene and comfort; predicted outcomes; and
warning signs. We discuss that perineal pain and swelling are common for the first 7 to 10
days, and then typically improve. The duration of an individual woman's experience may vary
depending on clinical circumstances. For example, second-degree obstetric lacerations or
episiotomies typically heal by the third postpartum week; women with third- or fourth-degree
lacerations may require four to six weeks. Education and appropriate reassurance, in the
absence of concerning symptoms, are important in this period.

Concerns frequently raised by patients include:

● Fear of suture removal – Many women understand that they have perineal sutures,
which they assume will need to be removed. This anticipated suture removal can cause
significant anxiety and distress. We educate women that the perineal sutures are self-
absorbing and that no further procedures are typically required.

● Fear of bowel movement – Understandably, many women are afraid that passing a
bowel movement will damage the repair, be exquisitely painful, or both. We address this
concern with information on pain management and prevention of constipation. (See
'Constipation prevention' below.)

● Fear of sexual activity – Many women are concerned that their vaginal introitus is
permanently narrowed or that vaginal intercourse will be difficult or painful after
obstetric laceration or episiotomy repair. We discuss that this fear is extremely common
and reassure women that despite the initial pain, edema, and bruising they may
experience following birth, these changes typically heal well. We educate women that
they should be able to resume vaginal sexual function by approximately six weeks
postpartum (depending on the status of the perineum). Women who are unable to
resume predelivery sexual activity by three months postpartum should be evaluated.
(See 'Resumption of sexual activity' below.)

Hygiene — Following vaginal delivery, a squirt bottle and sitz bath are commonly
recommended for perineal care. There are no data to guide sequence or duration of these

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interventions. We recommend that the woman use the squirt bottle any time she voids for as
long as it improves comfort and applies ice to the perineum for 24 hours, with warm water
soaks to start thereafter. This approach can be modified based on the woman's feedback; if
ice feels better, then we have her to continue with ice packs for an additional 24 hours prior to
initiating warm water soaks. In addition, some women find both ice packs and sitz baths
helpful and alternate treatments. (See 'Pain management' below.)

The squirt bottle is used to irrigate the perineum with warm water during urination, which can
help reduce external dysuria, stinging, or discomfort. A sitz bath, a warm shallow bath that
bathes the perineum and buttocks, is commonly used to clean the perineum and to reduce
pain and swelling, although data are limited. For sitz baths, we recommend each episode be
of approximately five minutes in duration, for a frequency of four times daily, or after any
bowel movement (particularly emphasized in women who have had anal sphincter
lacerations). We instruct patients to ensure that the vaginal and rectal areas, including any
sutures, are fully placed in the water. Of note, there are conflicting data on the optimal water
temperature for pain reduction; women who find cold water more soothing are encouraged
to use it [2,3]. Some clinicians advise adding Epsom salt (one-half cup salt to 1 gallon water) to
the bath, although at least one study did not report a difference in perineal pain with its use
[4]. We do not routinely recommend this, due to lack of evidence for efficacy. As it does not
appear to be harmful, it can be done based on provider or patient preference.

Pain management — Comfort measures include topical treatments (eg, cold or warm packs),
topical anesthetics, and oral analgesics. The choice of treatments is chosen on an individual
basis and generally initiated in a stepwise approach [5].

● Topical treatments – Topical treatments available to reduce perineal pain include ice
packs or other cooling agents and witch hazel pads (ie, hamamelis water). We suggest
applying crushed ice to the painful perineal area for 10 to 20 minutes at a time as
needed. We recommend using an ice pack or bag of crushed ice and then wrapping it in
a cloth such as a hand towel. Direct ice (ice or crushed ice in a plastic bag without
wrapping) applied to the skin for longer periods has not been studied and may actually
be harmful. In a meta-analysis of 10 trials comparing localized cooling treatments with
no treatment or other forms of treatment (eg, gel pads with compression, witch hazel,
warm baths), women treated with ice packs reported decreased pain at 24 to 72 hours
after birth compared with no treatment (risk ratio 0.61, 95% CI 0.41-0.91, one study) [6].
No impact on healing was reported. In a subsequent trial of 50 women with perineal
pain following episiotomy, women treated with crushed ice to the perineum for 20
minutes reported improved pain relief compared with women who received routine care

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[7]. There was a direct correlation between the temperature reduction in the affected
tissue and the pain relief experienced. As an alternate to crushed ice, frozen menstrual
pads provide a convenient and less messy form of cryotherapy. These can be presoaked
in water and then frozen to provide longer lasting cooling. Two subsequent trials
reported reductions in postpartum pain scores, compared with usual care, after
application of cold gel packs to the perineum for 10 to 20 minutes, which was sustained
for up to two hours in one of the trials [8,9].

Topical witch hazel pads are often advised for perineal pain reduction. However, no trials
comparing them with placebo are currently available. As they do not appear to be
harmful, they can be combined with other treatments as desired.

● Topical anesthetics – Benzocaine spray is often offered to patients after vaginal birth to
reduce perineal pain, although a meta-analysis of eight trials reported no difference in
pain relief with other topical anesthetics (not including benzocaine) compared with
placebo [10]. Additional limitations of this meta-analysis included short follow-up and
limited assessment of patient satisfaction. One advantage of benzocaine spray is that it
does not require touch for application. Some brands also contain skin moisturizers (aloe
and lanolin) and menthol, which creates a cooling sensation. We have found this product
helpful in reducing perineal discomfort, including the stinging sensation associated with
perineal stretching, even if no laceration occurred. Anecdotally, benzocaine spray
appears to reduce the discomfort associated with hemorrhoids as well.

● Oral analgesics – Oral analgesics most commonly used include nonsteroidal anti-
inflammatory drugs (NSAIDs) and acetaminophen [5]. For women with extensive vaginal
or periurethral lacerations, underlying chronic pain syndromes, or obstetric anal
sphincter injuries (OASIS), pain regimens that include short-term opioid analgesia can be
required to achieve pain relief.

• NSAIDs are our first choice for perineal pain relief, unless an individual woman has a
specific contraindication. In a meta-analysis of 28 trials comparing NSAID (13
different agents) with either placebo or acetaminophen for early postpartum perineal
pain, adequate pain relief at four hours was nearly twice as likely with the NSAID
compared with placebo and nearly 50 percent more likely for the NSAID compared
with acetaminophen [11]. Women treated with an NSAID were also less likely to need
additional pain medication at four and six hours compared with women who received
placebo. Maternal adverse effects were minor (eg, dizziness, headache, moderate
epigastralgia) and not different from placebo treatment. Neonatal adverse effects
were not studied. We suggest oral ibuprofen 600 mg every six hours as needed for
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pain relief during the first postpartum week. The maximum recommended dose of
ibuprofen for women with normal renal function is 2400 mg in 24 hours. (See
"NSAIDs: Therapeutic use and variability of response in adults", section on 'Issues in
the therapeutic use of NSAIDs'.)

• Acetaminophen is our second-line agent for perineal pain relief based on the above
meta-analysis and a different meta-analysis demonstrating improved pain relief with
acetaminophen compared with placebo [11,12]. We suggest 650 mg every 6 hours as
needed, not to exceed 3250 mg per 24 hours, for pain beyond that controlled with
the scheduled ibuprofen (ie, we prescribe acetaminophen in addition to the ibuprofen
for women who require additional pain relief). While there are no direct comparisons
of the dose effect for postpartum perineal discomfort, adequate analgesic effect has
been demonstrated with the 500 to 650 mg dose [12]. (See "NSAIDs: Therapeutic use
and variability of response in adults", section on 'Issues in the therapeutic use of
NSAIDs'.)

• Aspirin is our third-line agent for postpartum perineal pain based on a meta-analysis
of 17 trials including over 1100 women that found a single dose of aspirin, compared
with placebo, reduced perineal pain for women with episiotomy [13]. As
breastfeeding women were not included in the trials, the impact of aspirin on
lactation or the neonate could not be assessed.

• Opioid analgesics are rarely needed and should be prescribed only if the patient has
not achieved adequate pain relief with the above topical and oral treatments [5].
When opioids are used, we prescribe no more than seven days of non-extended
release medications. Patients whose pain is inadequately controlled or worsening
should undergo further evaluation to assess for infection or other causes of
heightened pain. Patients are counseled about the risk of worsened constipation with
opioid treatment, which could worsen perineal pain, and drowsiness. The potential
risk of addiction is reviewed as well, although this risk is reduced with short-duration
treatment.

● Herbal and complementary therapies – Additional treatment options for perineal pain
include therapeutic ultrasound and plant-based ointments. In a meta-analysis of four
trials comparing ultrasound, with or without pulsed electromagnetic therapy, with
placebo, there was insufficient evidence to support use of ultrasound [14]. In a different
trial, use of topical Achillea millefolium (ie, arrowroot, yarrow, or yarrow root) or
Hypericum perforatum (ie, St. John's wort) ointments was associated with decreased

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perineal postpartum pain. However, more data are needed on efficacy and safety before
routinely prescribing these agents as other proven options are available [15].

● Skin glue for wound closure – Two small studies comparing surgical glue with suture
for closure of obstetric lacerations reported reduced pain and similar complication rates
with glue use [16,17].

Constipation prevention — Constipation during pregnancy and postpartum is common and

is believed to result from smooth muscle relaxation caused by progesterone and other
hormones [18,19]. Postpartum, this effect may continue for days to weeks. Following delivery,
we treat women to optimize stool consistency. Maintaining soft bowel movements that can be
passed without straining helps avoid pain with defecation, prevent disruption of perineal and
rectal sutures. (See "Maternal adaptations to pregnancy: Gastrointestinal tract" and "Maternal
adaptations to pregnancy: Gastrointestinal tract", section on 'Bowel, rectum, anus'.)

The optimal treatment is not known. General recommendations for postpartum constipation
prevention typically include eating a high-fiber diet and drinking plenty of water, but these
may not be adequate in the postpartum setting. Additional treatment options include fiber
supplements, stool softeners, and/or laxatives. A meta-analysis of five trials including 1208
postpartum women compared postpartum laxative use with either placebo or laxative and
fiber bulking agent [20]. None of the trials included any educational or behavioral
interventions and the only trial that included a stool-bulking agent was focused on women
with OASIS [20]. Laxative use decreased time to bowel movement and increased frequency of
bowel movements, but also increased frequency of diarrhea and fecal incontinence [20]. The
four trials comparing laxative with placebo did not assess pain with defecation or straining
with bowel movements, but the trial that compared laxative with laxative plus fiber bulking
agent reported no difference in pain on defecation. Impact of constipation on surgical repair
breakdown rates is not known.

In discussing constipation prevention with postpartum women, prepregnancy and antenatal

bowel habits are reviewed. For example, we inquire about any prior diarrhea-prone irritable
bowel symptoms or other gastrointestinal disorders. In the absence of clinical evidence to
guide care and in the absence of underlying gastrointestinal disease, we typically treat routine
postpartum women with scheduled doses of stool softeners, and then progress through a
step-wise treatment plan until the woman is able to pass a soft bowel movement every two to
three days ( table 1). We allow three days to determine if a treatment is effective or if the
next agent in the list needs to be added. We typically advocate continuing the prior
medications and adding the next agent in the list, rather than discontinuing the prior agent
and moving on to the next. The order of agents is driven in part by the ease of use by the
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patient. A detailed review of these treatments is presented separately. (See "Management of

chronic constipation in adults" and "Management of chronic constipation in adults", section
on 'Initial management'.)

While there are many agents and combinations that can be used to prevent or treat
constipation, we prescribe the following drugs, in an additive and stepwise fashion, until
constipation is resolved:

● Oral docusate sodium (commercial name Colace) 100 mg three times daily.

● Oral senna 8.6 mg sennosides/tablet. Two tablets are taken nightly. Dose is decreased if
diarrhea or abdominal cramping occurs.

● Oral bulk forming laxatives, such as psyllium seed (eg, Metamucil), methylcellulose (eg,
Citrucel), calcium polycarbophil (eg, FiberCon), and wheat dextrin (eg, Benefiber). One
dose as directed on the packaging daily.

● Oral powdered polyethylene glycol (eg, MiraLAX) 17 g. Start with one daily dose and
progress up to three times a day as needed.

● Oral magnesium hydroxide (eg, Milk of Magnesia) 400 mg/5 mL: 30 to 60 mL/day once
daily at bedtime or in divided doses two times daily.

● Oral magnesium citrate 1.745 g/30 mL (296 mL) taken as one bottle daily.

To ensure that women with third- and fourth-degree lacerations are not inappropriately
advised to use a rectal medication, we prefer a standard protocol with oral agents that is
appropriate for all women and avoids the use of rectal agents. While women who have not
sustained a third- or fourth-degree laceration are candidates for rectal suppositories or
enemas if desired, we typically do not recommend them, mainly because they are
uncomfortable to use.

Resumption of sexual activity — There are no evidence-based guidelines regarding the

postpartum resumption of predelivery sexual activity. Generally accepted criteria for resuming
predelivery sexual activity include a fully healed perineum, emotional readiness, and use of
contraception for heterosexual couples. We suggest that nothing be placed in the vagina for
six weeks; by six weeks postpartum, lochia and vaginal discharge have typically ceased,
perineal lacerations have healed, and sutures have resorbed. The postpartum visit typically
occurs within the first six weeks and allows evaluation of the perineum and discussion of
contraception needs.

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SYMPTOMS REQUIRING EVALUATION

Women with any atypical perineal complaint, including severe pain, perineal bulge or mass,
abnormal discharge (eg, green vaginal or rectal discharge) should have further evaluation.

Severe pain — Women reporting severe, persisting, or worsening pain should be evaluated

for infection, separation, and hematoma, or other less common complications.

Infection — Extreme or worsening pain, particularly if associated with fever or general

malaise, often indicates infection. While perineal infections generally occur during the first
week after delivery, women can present with symptoms two or three weeks later. Infection
can be limited to the laceration or expand as cellulitis, an abscess, or, in extreme cases,
necrotizing fasciitis [21,22]. Infection or an abscess can track into the ischiorectal fossa and
present as buttock pain. The obstetric laceration repair can be intact or disrupted by the
infection. (See 'Separation' below.)

Women with symptoms concerning for infection should undergo detailed, directed physical
examination. Examination findings suggestive of perineal infection include erythema of the
surrounding skin, shiny or tense skin, drainage, and edema. We recommend that women with
these findings undergo perineal exploration, possible debridement, and possible abscess
drainage. We attempt to do as much as possible in the outpatient office setting to minimize
disruption to mother-infant bonding. However, women with extreme pain may benefit from
performing the examination with sedation or anesthesia (regional or general) as indicated.

Once perineal infection is identified, we take the following approach:

● If there are signs of abscess or a soft-tissue infection, we initiate systemic oral

antibiotics. (See "Cellulitis and skin abscess in adults: Treatment", section on 'Clinical
approach'.)

● If an abscess is identified, we open the repair and drain the abscess. In an office setting,
opening and drainage are preceded by adequate local anesthesia (topical or injectable).
Following removal of a portion of the sutures, the abscess cavity should be thoroughly
irrigated. Some women with a bulging abscess may tolerate having the sutures cut and
the abscess drained without local anesthesia because abscess drainage releases the
pressure that was causing the pain.

● If the infection appears to be in the deeper portion of a repair, an incision into the
surrounding tissues, drainage, tissue debridement, and packing can be indicated. For

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small abscesses, this can either be performed in the office or in the operating room. For
larger abscesses or if there are any concerns about the depth/extent of infection, we
prefer to incise and drain the repair in an operating room where appropriate
analgesia/anesthesia options and instruments are available and adequate exploration
can be achieved.

● We evaluate women who appear systemically ill and have evidence of deep tissue
infection for necrotizing deep tissue infections. If there is a significant concern for
possible necrotizing infection and imaging is not rapidly available, proceeding directly to
the operating room for surgical exploration is the prudent and recommended course of
action as a delay in treatment of this rare but life-threatening complication can be
catastrophic for the patient. If imaging can be done expeditiously, we find that images
can provide additional information regarding the extent of tissue involvement, help
identify the amount of debridement that may be necessary, and indicate the potential
need for additional surgical assistance. (See "Necrotizing soft tissue infections" and
"Surgical management of necrotizing soft tissue infections".)

Separation — Separation of a repaired perineal laceration or episiotomy, also described as

breakdown or dehiscence, refers to the disruption of a sutured repair. The separation can be
partial or complete. Although separation can occur in the absence of infection, infection is
more commonly present. Studies suggest that 10 to 14 days following vaginal delivery is the
peak time for separation [23]. Women at highest risk of a separation are those who have
sustained a third- or fourth-degree laceration. Women with separation typically present with
increased pain or burning, with abnormal discharge, or, less commonly, after experiencing a
"popping" sensation.

For women with separation and infection, the repair is further opened and the patient is
managed as described above until the infection has resolved (see 'Infection' above). For
women with separation but no infection, we take the following approach:

● Women with separation of first- or second-degree lacerations can be managed

expectantly, to heal by secondary intention, or have the open laceration repaired. In a
meta-analysis of two trials totaling 52 women that compared secondary suturing with
non-suturing, there was no difference in healing at four weeks or dyspareunia rates at
two and six months [24]. Although more women in the suturing group had resumed
intercourse by two months, there was no difference at six months. No data on pain or
patient satisfaction were reported. In our clinical experience, most women with first- or
second-degree perineal injuries do well with expectant management. As limited
available data suggest equal outcomes, we discuss the risks and benefits of each and
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elicit the woman's preference in choosing the management plan. Some women prefer to
heal by secondary intention because this approach avoids the stress of surgical
debridement and secondary repair. Other women prefer to have the laceration closed
directly. (See "Repair of perineal and other lacerations associated with childbirth" and
"Repair of perineal and other lacerations associated with childbirth", section on
'Secondary repair of episiotomy breakdown'.)

● Women with separation of third- or fourth-degree laceration repairs are typically treated
with antibiotics, undergo operative tissue debridement until healthy tissue is present,
and then receive a secondary repair. We believe this approach minimizes the risk of
fistula formation and increases the likelihood of a successful repair, although supporting
data are limited, particularly around choice of antibiotics. We typically use a first-
generation cephalosporin unless there is evidence that more broad coverage is required
(eg, fecal contamination of laceration). (See "Repair of perineal and other lacerations
associated with childbirth", section on 'Secondary repair of episiotomy breakdown'.)

Aseptic technique during the initial repair is key to prevent subsequent separation. In one
trial, application of povidone-iodine powder to the perineum during episiotomy repair was
associated with decreased incidence of separation in the treated group compared with the
standard care group (separation rates 3.5 versus 13.5 percent) [23]. Although the body of
evidence is limited, the 2007 National Institute for Health and Clinical Excellence guidelines as
well as the Royal College of Obstetricians and Gynaecologists recommend using aseptic
techniques during perineal repair [25,26]. Unless a contraindication exists, we routinely use
liquid betadine and saline irrigation to cleanse the perineum prior to suturing. In the event of
an allergy to betadine, we recommend use of baby shampoo mixed with water or saline
irrigation. Repair of obstetric lacerations or episiotomy is discussed elsewhere. (See "Repair of
perineal and other lacerations associated with childbirth".)

Granulation tissue often appears pink or reddened, with a tissue overgrowth or papillary
appearance; granulation tissue can develop in the area of perineal repair, which should not be
confused with an infection or breakdown. Expectant observation is generally sufficient, unless
the granulation tissue is painful, bleeding, or otherwise bothersome to the woman. We treat
symptomatic granulation tissues with either application of silver nitrate (small areas) or simple
excision in the office.

Bulge or mass — Common causes of abnormal bulges or tissue in postpartum women

include hemorrhoids (including thrombosed or prolapsed hemorrhoids), hematomas, and
uterovaginal prolapse, in particular anterior wall bulge. These can be diagnosed during
physical examination. Briefly, hemorrhoids appear as purplish masses protruding from the
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anus ( picture 1 and picture 2). Hemorrhoids are typically treated with conservative
management, but thrombosed hemorrhoids can require incision and drainage. In
uterovaginal prolapse, the cervix or vaginal wall is visualized in the lower half of the vaginal
canal or protruding out of the vagina ( picture 3).

Women with prolapse can be fit with a pessary to provide support and reduce any associated
pelvic ache or burning. Such prolapse will usually improve as they recover from the delivery,
although they may be at higher likelihood of later development of pelvic floor support defects.

Presenting symptoms, diagnosis, and management of these entities is discussed in detail in

the following topics:

● (See "Hemorrhoids: Clinical manifestations and diagnosis".)

● (See "Home and office treatment of symptomatic hemorrhoids".)
● (See "Management of hematomas incurred as a result of obstetric delivery".)
● (See "Pelvic organ prolapse in women: Epidemiology, risk factors, clinical manifestations,
and management".)

Hematoma — Postpartum hematomas, particularly of the vagina and vulva, can expand

rapidly and be exquisitely painful. These typically occur within 24 hours of delivery. Women
commonly note rapid development of a severely painful bulge in the vagina, vulva, and/or
perineum. Physical examination confirms a vulvar or perineal bulge covered by skin with
underlying purplish discoloration [27]. Evaluation and management of vulvar hematomas is
presented separately. (See "Management of hematomas incurred as a result of obstetric
delivery".)

Abnormal discharge — Abnormal postpartum discharge includes fluid that is purulent or

green, foul-smelling, urine-like, stool-stained, or increasing in volume. For comparison,
normal postpartum vaginal discharge (ie, lochia) can last for up to eight weeks, typically
changes from red/brown to a watery yellow-white, and gradually decreases in volume. We
educate women about normal discharge and recommend further evaluation if they
experience abnormal discharge. While these somewhat vague descriptions may result in the
evaluation of women who are healing appropriately, we believe fewer women with
complications are missed with this approach. (See "Overview of the postpartum period:
Normal physiology and routine maternal care", section on 'Lochia'.)

Causes of abnormal discharge include a retained sponge, draining abscess, fistula, or

incontinence. While women with a perineal abscess tend to present with perineal pain and/or
fever within the first week following delivery, a draining abscess can be perceived as abnormal
discharge. Both vesicovaginal and rectovaginal fistulas can present days to months following
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delivery. Any woman with a sudden increase in urine loss, constant and/or brown discharge,
or vaginal discharge only when she also has diarrhea should prompt evaluation. New onset
stress urinary incontinence postpartum typically presents within the first few days following
delivery and generally improves slowly. Fecal incontinence from a sphincter laceration or an
undiagnosed buttonhole injury in the mucosa above the sphincter may present immediately
or following the first episode of soft stool.

Presenting symptoms, diagnosis, and management of these entities is discussed in detail in

the following topics:

● (See "Perianal and perirectal abscess".)

● (See "Rectovaginal and anovaginal fistulas".)
● (See "Evaluation of females with urinary incontinence".)
● (See "Fecal incontinence in adults: Etiology and evaluation".)

PHYSICAL EXAMINATION

Women suspected of having a perineal complication require a pelvic examination, despite

concomitant pain, tissue edema, and patient anxiety. A discussion of the components of the
pelvic examination is presented separately. (See "The gynecologic history and pelvic
examination", section on 'Pelvic examination'.)

Generally, we perform the initial evaluation in the office. Topical lidocaine jelly can be applied
to the perineum to reduce examination-related discomfort. Superficial inspection of the labia
and perineum can identify erythema suggestive of infection, a distal abscess, or superficial
cellulitis. For women with symptoms or examination findings concerning for abscess,
hematoma, or separation, digital vaginal examination is performed with a single examination
finger to minimize patient discomfort. If a speculum examination is indicated, we use the
smallest speculum that provides adequate visualization and separate the speculum to use
only the posterior blade to retract the obstructing tissue.

If the woman is unable to tolerate the examination, we proceed with an examination under
anesthesia. While such an examination is typically performed in an operating room, some
labor and delivery units have the ability to provide intravenous conscious sedation outside of
the operating room. (See "Procedural sedation in adults outside the operating room".)

POST-DISCHARGE CARE

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The optimal post-discharge care of women with first- or second-degree perineal lacerations or
episiotomy is not known; we typically see these women at six weeks postpartum. In the
interim, patients are instructed to report concerning symptoms, specifically vaginal discharge
that appears purulent, fevers, or increasing pain in the perineum.

We advise more frequent follow-up for women with third- or fourth-degree obstetric
lacerations to ensure early detection of any developing complications. We generally schedule
these women for an outpatient visit and examination one to two weeks following hospital
discharge and then continue to see them every one to two weeks until the repair has
completely healed. Women who may benefit from weekly visits include those with medical risk
factors for poor wound healing (eg, women with diabetes, immunosuppression, other
comorbidities, or smokers), women with extensive repairs, and women who find perineal care
challenging (eg, limited social support or intellectual capabilities). For women who are unable
to visit weekly, an alternate option can be evaluation by a visiting nurse or similar service.

LONG-TERM ISSUES

Following initial perineal healing, patients may present with new pelvic floor issues.

Perineal pain or dyspareunia — Prolonged postpartum perineal pain and dyspareunia are

relatively common. In a questionnaire study, 8 percent of women reported persistent perineal
pain at one year following vaginal delivery [28]. In a retrospective study comparing the degree
of obstetric perineal laceration and sexual function in primiparous women, approximately 20
percent reported dyspareunia at six months after delivery [29]. Episiotomy did not increase
the risk of postpartum dyspareunia relative to same degree of spontaneous laceration [29].
Factors associated with increased risk of postpartum dyspareunia include operative vaginal
delivery (both forceps and vacuum) and third- and fourth-degree obstetric lacerations [29-32].

Although supporting data are limited, initial treatment options include topical estrogen
therapy and pelvic floor muscle therapy (PFMT). For patients with dyspareunia and
hypoestrogenism, typically related to breastfeeding, the authors prescribe topical estrogen
cream, 1 gram twice weekly applied to the vagina and perineum, without a ramp-up period
[33]. Women with persistent perineal pain or dyspareunia at three months postpartum may
benefit from PFMT for symptom reduction, although the data are conflicting [34,35]. We do
not universally request early referrals for PFMT in postpartum women to reduce the likelihood
of development of postpartum pain or dyspareunia. If these symptoms are reported following
their six week postpartum visit, we will offer a referral for PFMT at that time [34-36].

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For women with refractory perineal pain or dyspareunia who have not responded to PFMT,
revision perineoplasty is a treatment option. In a study of nine women with persistent
perineal dyspareunia and anatomic distortion (ie, scarring), there was a significant reduction
in perineal pain and increase in coital frequency and satisfaction following perineal revision
[37]. However, as repeat surgery can also increase scarring and resultant pain, revision
perineoplasty is reserved for women with persistent, severe symptoms that are isolated to the
obstetric scar.

While transcutaneous electrical nerve stimulation and therapeutic ultrasound therapy have
been used to treat postpartum perineal pain and dyspareunia, we do not prescribe them as
the body of evidence is limited. One small trial of transcutaneous electrical nerve stimulation
(TENS) therapy reported decreased dyspareunia with treatment, but no control group was
included for comparison [38]. In a meta-analysis of four trials comparing therapeutic
ultrasound with placebo, women in two trials were more likely to report perineal pain
reduction with treatment and women in one trial were less likely to report dyspareunia [14].
However, because no other measured outcomes reached significance and the overall quality
of the trials was variable, the authors concluded that there was insufficient evidence to assess
therapeutic ultrasound as a treatment for postpartum perineal pain or dyspareunia.

Incontinence or pelvic organ prolapse — Although the available data are limited, we

suggest postpartum PFMT for women with incontinence (urinary or anal) and/or pelvic organ
prolapse that remains symptomatic three months after delivery. PFMT appears to improve
postpartum urinary and anal incontinence symptoms at 1 year, but not in the long-term (6 to
12 years) [34,35,39]. PFMT has been demonstrated to improve pelvic organ prolapse severity
and symptoms in older women, although the impact on women who are immediately
postpartum is not known [40]. We routinely recommend Kegel exercises to postpartum
women who have symptoms of either incontinence or prolapse, although do not recommend
it universally to asymptomatic women. During pelvic examination, it is helpful to assess
muscular strength and ensure appropriate Kegel performance.

Poorly healed perineum — Some patients will present months after delivery with
bothersome perineal anatomic changes or defects despite having fully healed obstetric
perineal lacerations. These may include an open (widened) introitus and thin perineal body,
which typically result from detachment of the bulbocavernosus and superficial transverse
perineal muscles. One trial comparing the impact of surgical correction with pelvic floor
physical therapy for patients with residual symptoms following second-degree injuries
reported greater improvement in all measured domains with surgical correction (71 versus 11
percent) [41]. Measurements of improvement included the Patient Global Impression of

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Improvement, Pelvic Floor Distress Inventory, the Pelvic Floor Impact Questionnaire, the Pelvic
Organ Prolapse/Urinary Incontinence Sexual Questionnaire, and the Hospital Anxiety and
Depression Scale. Thus, for patients who are at least six months from delivery with perineal
symptoms relating to their prior obstetric laceration, the authors offer surgical correction,
although patients who desire a trial of pelvic floor physical therapy may reasonably do so. The
offer of surgical repair is balanced with counseling regarding timing of subsequent
pregnancies. Surgical correction is not advised for patients who desire to conceive in the short
term; repair is generally delayed until the completion of childbearing or possibly performed at
the time of a subsequent delivery. If the patient is undecided or planning on a moderate to
extended delay of childbearing, the authors will offer surgical correction.

SPECIAL POPULATIONS

Obstetric anal sphincter injury — Women with an obstetric anal sphincter injury (OASIS; ie,
a third- or fourth-degree obstetric laceration) appear to be at increased risk of infection and
separation compared with women with lesser lacerations [42-44]. In a prospective cohort
study of nearly 270 women, operative vaginal delivery was the main risk factor for separation
following OASIS [42]. As evidence-based interventions that prevent complications are not
known, we advise frequent postpartum follow-up of women with OASIS in order to identify
complications early and initiate treatment to reduce sequelae. Discussions of management of
third- and fourth-degree lacerations and delayed anal sphincter repair are presented
elsewhere. (See "Repair of perineal and other lacerations associated with childbirth", section
on 'Secondary repair of episiotomy breakdown' and "Delayed surgical management of the
disrupted anal sphincter".)

Female genital cutting (circumcision) — Women with female genital cutting have unique
perineal challenges during labor, delivery, and recovery. The management of these women is
presented in detail in separately. (See "Female genital cutting (circumcision)".)

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected countries and regions
around the world are provided separately. (See "Society guideline links: Postpartum care".)

SUMMARY AND RECOMMENDATIONS

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● Anatomically, the perineum is the entirety of the pelvic outlet inferior to the pelvic floor (
figure 1). (See 'Definition' above.)

● For all women who have a vaginal delivery, we discuss perineal healing and hygiene,
pain management, prevention of constipation, and resumption of sexual activity. As the
data are limited, the optimal strategies for these efforts are not known. (See 'Initial
approach' above.)

● Women with any atypical perineal complaint, including severe pain, perineal bulge or
mass, abnormal discharge (eg, green vaginal or rectal discharge) should undergo
focused evaluation. (See 'Symptoms requiring evaluation' above.)

● Common causes of abnormal bulges or tissue in postpartum women include

hemorrhoids (including thrombosed or prolapsed hemorrhoids), hematomas, and
uterine prolapse. These diagnoses are confirmed with physical examination. (See 'Bulge
or mass' above.)

● Abnormal postpartum discharge includes fluid that is purulent or green, foul-smelling,

urine-like, stool-stained, or increasing in volume. Causes of abnormal discharge include
a draining abscess, fistula, or incontinence. (See 'Abnormal discharge' above.)

● Women suspected of having a perineal complication require a pelvic examination, which

can be challenging in a woman who has recently delivered vaginally because of pain,
tissue edema, and patient anxiety. We perform the initial examination in the office.
Women who are unable to tolerate an office examination are evaluated under
anesthesia. Women who have office findings requiring treatment beyond what can
comfortably be tolerated in the office setting (debridement or repair) should be
evaluated in a surgical setting. (See 'Physical examination' above.)

● The optimal post-discharge care of women with perineal wounds or complications is not
known. We typically see women with perineal trauma that does not involve the anal
sphincter at six weeks postpartum. As women with obstetric anal sphincter injury (OASIS;
ie, a third- or fourth-degree obstetric laceration) have a higher risk of separation, these
women are seen more frequently after discharge in order to identify complications early
and initiate treatment to reduce sequelae. (See 'Post-discharge care' above.)

● Long-term issues include persistent perineal pain and incontinence of urine, feces, or
both. Pelvic floor muscle training appears to reduce symptoms. (See 'Long-term issues'
above.)

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● Women with obstetric anal sphincter lacerations or female genital cutting can have
additional care needs. (See 'Special populations' above.)

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REFERENCES
1. American College of Obstetricians and Gynecologists’ Committee on Obstetric Practice,
Association of Women’s Health, Obstetric and Neonatal Nurses. Committee Opinion No.
666: Optimizing Postpartum Care. Obstet Gynecol 2016; 127:e187.

2. Hill PD. Effects of heat and cold on the perineum after episiotomy/laceration. J Obstet
Gynecol Neonatal Nurs 1989; 18:124.

3. Ramler D, Roberts J. A comparison of cold and warm sitz baths for relief of postpartum
perineal pain. J Obstet Gynecol Neonatal Nurs 1986; 15:471.

4. Sleep J, Grant A. Effects of salt and Savlon bath concentrate post-partum. Nurs Times
1988; 84:55.

5. Pharmacologic Stepwise Multimodal Approach for Postpartum Pain Management: ACOG

Clinical Consensus No. 1. Obstet Gynecol 2021; 138:507.

6. East CE, Begg L, Henshall NE, et al. Local cooling for relieving pain from perineal trauma
sustained during childbirth. Cochrane Database Syst Rev 2012; :CD006304.

7. Beleza AC, Ferreira CH, Driusso P, et al. Effect of cryotherapy on relief of perineal pain
after vaginal childbirth with episiotomy: a randomized and controlled clinical trial.
Physiotherapy 2016.

8. Senol DK, Aslan E. The Effects of Cold Application to the Perineum on Pain Relief After
Vaginal Birth. Asian Nurs Res (Korean Soc Nurs Sci) 2017; 11:276.

9. Francisco AA, De Oliveira SMJV, Steen M, et al. Ice pack induced perineal analgesia after
spontaneous vaginal birth: Randomized controlled trial. Women Birth 2018; 31:e334.

10. Hedayati H, Parsons J, Crowther CA. Topically applied anaesthetics for treating perineal
pain after childbirth. Cochrane Database Syst Rev 2005; :CD004223.

https://www.uptodate.com/contents/postpartum-perineal-care-and-management-of-complications?search=care postpartrum&source=search_result&… 17/21

17:57, 09/12/2021 Postpartum perineal care and management of complications - UpToDate

11. Wuytack F, Smith V, Cleary BJ. Oral non-steroidal anti-inflammatory drugs (single dose)
for perineal pain in the early postpartum period. Cochrane Database Syst Rev 2016;
7:CD011352.

12. Chou D, Abalos E, Gyte GM, Gülmezoglu AM. Paracetamol/acetaminophen (single

administration) for perineal pain in the early postpartum period. Cochrane Database Syst
Rev 2013; :CD008407.

13. Shepherd E, Grivell RM. Aspirin (single dose) for perineal pain in the early postpartum
period. Cochrane Database Syst Rev 2020; 7:CD012129.

14. Hay-Smith EJ. Therapeutic ultrasound for postpartum perineal pain and dyspareunia.
Cochrane Database Syst Rev 2000; :CD000495.

15. Hajhashemi M, Ghanbari Z, Movahedi M, et al. The effect of Achillea millefolium and
Hypericum perforatum ointments on episiotomy wound healing in primiparous women.
J Matern Fetal Neonatal Med 2017; :1.

16. Swenson CW, Low LK, Kowalk KM, Fenner DE. Randomized Trial of 3 Techniques of
Perineal Skin Closure During Second-Degree Perineal Laceration Repair. J Midwifery
Womens Health 2019; 64:567.

17. Mota R, Costa F, Amaral A, et al. Skin adhesive versus subcuticular suture for perineal
skin repair after episiotomy--a randomized controlled trial. Acta Obstet Gynecol Scand
2009; 88:660.

18. Wald A, Van Thiel DH, Hoechstetter L, et al. Effect of pregnancy on gastrointestinal
transit. Dig Dis Sci 1982; 27:1015.

19. Lawson M, Kern F Jr, Everson GT. Gastrointestinal transit time in human pregnancy:
prolongation in the second and third trimesters followed by postpartum normalization.
Gastroenterology 1985; 89:996.

20. Turawa EB, Musekiwa A, Rohwer AC. Interventions for preventing postpartum
constipation. Cochrane Database Syst Rev 2015; :CD011625.

21. Almarzouqi F, Grieb G, Klink C, et al. Fatal Necrotizing Fasciitis following Episiotomy. Case
Rep Surg 2015; 2015:562810.

22. Lynch CM, Pinelli DM, Cruse CW, et al. Maternal death from postpartum necrotizing
fasciitis arising in an episiotomy: a case report. Infect Dis Obstet Gynecol 1997; 5:341.

https://www.uptodate.com/contents/postpartum-perineal-care-and-management-of-complications?search=care postpartrum&source=search_result&… 18/21

17:57, 09/12/2021 Postpartum perineal care and management of complications - UpToDate

23. Ruparelia BA, Robson P, Iqbal I, Johnson IR. Use of povidone-iodine in post-delivery
perineal repairs: A prospective trial. Journal of Obstetrics & Gynaecology 1990; 10:202.

24. Dudley LM, Kettle C, Ismail KM. Secondary suturing compared to non-suturing for
broken down perineal wounds following childbirth. Cochrane Database Syst Rev 2013;
:CD008977.

25. National Collaborating Centre for Women's and Children's Health (UK). Intrapartum Care:
Care of Healthy Women and Their Babies During Childbirth, RCOG Press, London 2007.

26. Royal College of Obstetricians and Gynaecologists. Green-top guideline 27. In: The Mana
gement of Third and Fourth-degree Perineal Tears, RCOG, London 2007.

27. Zahn CM, Yeomans ER. Postpartum hemorrhage: placenta accreta, uterine inversion, and
puerperal hematomas. Clin Obstet Gynecol 1990; 33:422.

28. Kainu JP, Halmesmäki E, Korttila KT, Sarvela PJ. Persistent Pain After Cesarean Delivery
and Vaginal Delivery: A Prospective Cohort Study. Anesth Analg 2016; 123:1535.

29. Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning and its
relationship to perineal trauma: a retrospective cohort study of primiparous women. Am
J Obstet Gynecol 2001; 184:881.

30. Leeman L, Rogers R, Borders N, et al. The Effect of Perineal Lacerations on Pelvic Floor
Function and Anatomy at 6 Months Postpartum in a Prospective Cohort of Nulliparous
Women. Birth 2016; 43:293.

31. Fodstad K, Staff AC, Laine K. Sexual activity and dyspareunia the first year postpartum in
relation to degree of perineal trauma. Int Urogynecol J 2016; 27:1513.

32. Sayed Ahmed WA, Kishk EA, Farhan RI, Khamees RE. Female sexual function following
different degrees of perineal tears. Int Urogynecol J 2016.

33. Rosen NO, Pukall C. Comparing the Prevalence, Risk Factors, and Repercussions of
Postpartum Genito-Pelvic Pain and Dyspareunia. Sex Med Rev 2016; 4:126.

34. Deffieux X, Vieillefosse S, Billecocq S, et al. [Postpartum pelvic floor muscle training and
abdominal rehabilitation: Guidelines]. J Gynecol Obstet Biol Reprod (Paris) 2015; 44:1141.

35. Battut A, Nizard J. [Impact of pelvic floor muscle training on prevention of perineal pain
and dyspareunia in postpartum]. Prog Urol 2016; 26:237.

https://www.uptodate.com/contents/postpartum-perineal-care-and-management-of-complications?search=care postpartrum&source=search_result&… 19/21

17:57, 09/12/2021 Postpartum perineal care and management of complications - UpToDate

36. Kolberg Tennfjord M, Hilde G, Staer-Jensen J, et al. Effect of postpartum pelvic floor
muscle training on vaginal symptoms and sexual dysfunction-secondary analysis of a
randomised trial. BJOG 2016; 123:634.

37. Woodward AP, Matthews CA. Outcomes of revision perineoplasty for persistent
postpartum dyspareunia. Female Pelvic Med Reconstr Surg 2010; 16:135.

38. Dionisi B, Senatori R. Effect of transcutaneous electrical nerve stimulation on the

postpartum dyspareunia treatment. J Obstet Gynaecol Res 2011; 37:750.

39. Mathé M, Valancogne G, Atallah A, et al. Early pelvic floor muscle training after
obstetrical anal sphincter injuries for the reduction of anal incontinence. Eur J Obstet
Gynecol Reprod Biol 2016; 199:201.

40. Li C, Gong Y, Wang B. The efficacy of pelvic floor muscle training for pelvic organ
prolapse: a systematic review and meta-analysis. Int Urogynecol J 2016; 27:981.

41. Bergman I, Westergren Söderberg M, Ek M. Perineorrhaphy Compared With Pelvic Floor

Muscle Therapy in Women With Late Consequences of a Poorly Healed Second-Degree
Perineal Tear: A Randomized Controlled Trial. Obstet Gynecol 2020; 135:341.

42. Lewicky-Gaupp C, Leader-Cramer A, Johnson LL, et al. Wound complications after

obstetric anal sphincter injuries. Obstet Gynecol 2015; 125:1088.

43. Williams MK, Chames MC. Risk factors for the breakdown of perineal laceration repair
after vaginal delivery. Am J Obstet Gynecol 2006; 195:755.

44. Stock L, Basham E, Gossett DR, Lewicky-Gaupp C. Factors associated with wound
complications in women with obstetric anal sphincter injuries (OASIS). Am J Obstet
Gynecol 2013; 208:327.e1.

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