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10/1/2009

Postpartum Perineal Pain

Author: Frank W. Ling, MD

Editor: Tiffany A. Moore Simas, MD, MPH, Med

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The diagnosis and management of postpartum perineal pain depends on history and physical examination.  Because pain is rarely an isolated symptom, additional symptoms by history may also include bleeding, discharge, and or irritation.  Some perineal pain is common with normal postpartum physiologic changes, and is typically managed with oral pain medications and Sitz baths.

Severe pain should raise suspicion for perineal wound complications which occur in approximately 7% of women who have had an obstetric anal sphincter injury (OASIS).  Risk factors for OASIS include operative vaginal deliveries midline episiotomy, increased fetal birthweight, primiparity, Asian ethnicity, labor induction, labor augmentation, epidural anesthesia, and persistent occiput posterior position,  Risk factors for perineal wound breakdown include prolonged second stage, mediolateral episiotomy, third or fourth degree laceration, operative vaginal delivery, meconium stained fluid and lack of prior vaginal delivery.

A physical examination should be performed including thorough inspection and palpation of the perineal.  Concerning signs and laboratory evidence including fever, and significant leukocytosis with left shift, respectively.

Early postpartum fever and worsening perineal pain suggest an infected episiotomy or laceration repair.  The site typically appears erythematous and swollen, and may have purulent drainage.  Treatment includes antibiotics and possible drainage and debridement.  Mild discomfort with malodorus discharge may occur from a retained sponge, bacterial vaginosis, gonorrhea or chlamydia.

A hematoma may be evident on examination.  Small hematomas may be observed. Large hematomas may require packing, and if conservative management fails, surgical exploration.

Vulvar edema can be managed with ice packs and pain medication. 

Necrotizing fasciitis should be considered in the differential, as should bladder infection, diverticulum, hemorrhoids or anal fissures.  Scarring, suture abscess and granuloma are potential later causes of discomfort.

Dyspareunia, especially when accompanied by vaginal dryness and post-coital bleeding, may be related to vaginal atrophy due to breastfeeding and hormonal changes.  Water soluble lubricants and topical estrogen may be beneficial.  Counseling helps to reassure the patient and her partner that reduced lubrication is a temporary physiologic phenomenon.

Further Reading:

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 Apr;208(4):327.e1-6. doi: 10.1016/j.ajog.2012.12.025. Epub 2012 Dec 19.

Williams MK, Chames MC. Risk factors for the breakdown of perineal laceration repair after vaginal delivery.  Am J Obstet Gynecol. 2006 Sep;195(3):755-9.

Committee on Practice Bulletins-Obstetrics. ACOG Practice Bulletin No. 198: Prevention and Management of Obstetric Lacerations at Vaginal Delivery. Obstet Gynecol. 2018 Sep;132(3):e87-e102. doi: 10.1097/AOG.0000000000002841.

 

Initially approval October 2009; Reviewed July 2016, Revised November 2017, Reaffirmed May 2019

 

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