Perineal wound complications and breakdown

It is day 5 after a forceps delivery with a mediolateral episiotomy, and the midwife asks you to review. The woman is in tears; her pain is worse than at discharge, she cannot sit, and her dressing smells. This is moment topic lives or dies — between "reassure and review in clinic" and "examine now, with a chaperone and a speculum, and find the breakdown". Pain that is not settling after day 3 is not a complaint. It is a sign.^[3][14]

Overview and definition

Perineal wound complications cluster into three overlapping diagnoses that share risk factors and analgesia but diverge in management:^[3]

• Perineal wound infection — purulent discharge or abscess at the repair site, with or without systemic signs. The most common complication of an episiotomy or second-degree tear.^[3]
• Perineal wound dehiscence — separation of the wound edges, most usefully defined as a gap of greater than 0.5 cm, with sub-types by depth (skin-only, muscle-involving, sphincter-involving). The feared variant is breakdown of an OASIS repair.^[1][4]
• Perineal haematoma — bleeding into the perineal, paravaginal, vulval or supralevator spaces. The small ones pain; the large ones kill.

Definitions vary widely across studies, which is the first reason the reported rates vary so much — a wound discharge captured by a postal survey at 6 weeks and an abscess drained in theatre on day 4 are not the same entity. The Gommesen cohort and the systematic reviews all flag this heterogeneity.^[3][4]

References14ShowHide

1. [1]Dudley L, Kettle C, Thomas PW, Ismail KM Perineal resuturing versus expectant management following vaginal delivery complicated by a dehisced wound (PREVIEW): a pilot and feasibility randomised controlled trial BMJ Open, 2017.PMID 28188151
2. [2]Dudley LM, Kettle C, Ismail KM Secondary suturing compared to non-suturing for broken down perineal wounds following childbirth Cochrane Database Syst Rev, 2013.PMID 24065561
3. [3]Gommesen D, Nohr EA, Drue HC, et al. Obstetric perineal tears: risk factors, wound infection and dehiscence: a prospective cohort study Arch Gynecol Obstet, 2019.PMID 31004221
4. [4]Okeahialam NA, Wong KW, Thakar R, Sultan AH The incidence of wound complications following primary repair of obstetric anal sphincter injury: a systematic review and meta-analysis Am J Obstet Gynecol, 2022.PMID 35550375
5. [5]Duggal N, Mercado C, Daniels K, Bujor A, Caughey AB, El-Sayed YY Antibiotic prophylaxis for prevention of postpartum perineal wound complications: a randomized controlled trial Obstet Gynecol, 2008.PMID 18515507
6. [6]Buppasiri P, Lumbiganon P, Thinkhamrop J, Thinkhamrop B Antibiotic prophylaxis for third- and fourth-degree perineal tear during vaginal birth Cochrane Database Syst Rev, 2014.PMID 25289960
7. [7]Fernando RJ, Sultan AH, Kettle C, Radley S, Jones P, O'Brien PM Repair techniques for obstetric anal sphincter injuries: a randomized controlled trial Obstet Gynecol, 2006.PMID 16738150
8. [8]Roper JC, Amber N, Wan OYK, Thakar R, Sultan AH Review of available national guidelines for obstetric anal sphincter injury Int Urogynecol J, 2020.PMID 32789813
9. [9]Eogan M, Daly L, Behan M, O'Connell PR, O'Herlihy C Randomised clinical trial of a laxative alone versus a laxative and a bulking agent after primary repair of obstetric anal sphincter injury BJOG, 2007.PMID 17516966
10. [10]Mahony R, Behan M, O'Herlihy C, O'Connell PR Randomized, clinical trial of bowel confinement vs. laxative use after primary repair of a third-degree obstetric anal sphincter tear Dis Colon Rectum, 2004.PMID 14719145
11. [11]LaCross A, Groff M, Smaldone A Obstetric anal sphincter injury and anal incontinence following vaginal birth: a systematic review and meta-analysis J Midwifery Womens Health, 2015.PMID 25712278
12. [12]Mørch EJ, Perslev K, Wrønding T, et al. Counseling women with obstetric anal sphincter injury - Risk of recurrence and the influence of mode of second delivery on subsequent anal incontinence - A systematic review and meta-analysis Eur J Obstet Gynecol Reprod Biol, 2025.PMID 40090037
13. [13]Carter E, Hall R, Ajoku K, et al. Caesarean section and anal incontinence in women after obstetric anal sphincter injury: A systematic review and meta-analysis BJOG, 2025.PMID 38965793
14. [14]Committee on Practice Bulletins-Obstetrics ACOG Practice Bulletin No. 198: Prevention and Management of Obstetric Lacerations at Vaginal Delivery Obstet Gynecol, 2018.PMID 30134424