Clinical Edge

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Prevention of Obstetric Lacerations After Delivery

Obstet Gynecol; 2016 Jul; ACOG Committee on Practice Bulletins

The American College of Obstetricians and Gynecologists’ (ACOG) Committee on Practice Bulletins—Obstetrics has issued a practice bulletin for the prevention and management of obstetric lacerations at vaginal delivery. The bulletin provides evidence-based guidelines for the prevention, identification, and repair of obstetric lacerations and for episiotomy. Among the Level A recommendations and conclusions:

• Because application of warm perineal compresses during pushing reduces the incidence of third-degree and fourth-degree lacerations, obstetrician–gynecologists and other obstetric care providers can apply warm compresses to the perineum during pushing to reduce the risk of perineal trauma.

• Restrictive episiotomy use is recommended over routine episiotomy.

• For full-thickness external anal sphincter lacerations, end-to-end repair or overlap repair is acceptable.

• A single dose of antibiotic at the time of repair is recommended in the setting of OASIS.

Level B recommendations include:

• Perineal massage during the second stage of labor may help reduce third-degree and fourth-degree lacerations.

• If there is need for episiotomy, mediolateral episiotomy may be preferred over midline episiotomy because of the association of midline episiotomy with increased risk of injury to the anal sphincter complex; however, limited data suggest mediolateral episiotomy may be associated with an increased likelihood of perineal pain and dyspareunia.

• Either standard suture or adhesive glue may be used to repair a hemostatic first-degree laceration or the perineal skin of a second-degree laceration.

• Continuous suturing of a second-degree laceration is preferred over interrupted suturing.


Prevention and management of obstetric lacerations at vaginal delivery. Practice Bulletin No. 165. American College of Obstetricians and Gynecologists. Obstet Gynecol. 2016;128:e1–15.