European Journal of Obstetrics & Gynecology and Reproductive Biology 254 (2020) 69–73

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European Journal of Obstetrics & Gynecology and

Reproductive Biology
journal homepage: www.elsevier.com/locate/ejogrb

Full length article

Early re-suturing of dehisced obstetric perineal wounds: A 13-year

experience
NA Okeahialama , R Thakara,b , H Kleprlikovaa,c, A Taithongchaia , AH Sultana,d,*
a
Croydon University Hospital, London UK
b
Honorary Senior Lecturer St George’s University of London, UK
c
Department of General Anthropology, Faculty of Humanities, Charles University in Prague, Czech Republic
d
Honorary Reader St. George’s University of London, UK

A R T I C L E I N F O A B S T R A C T

Article history: Objectives: To describe post-operative outcomes following early re-suturing of obstetric perineal wound
Received 24 July 2020 dehiscence.
Received in revised form 4 September 2020 Study Design: This was a retrospective series of 72 women who underwent re- suturing of a dehisced
Accepted 7 September 2020
perineal wound at a tertiary urogynaecology department during a 13-year period (December 2006 -
December 2019).
Keywords: Results: Seventy-two women with complete perineal wound dehiscence opted for secondary re-suturing.
Childbirth related perineal trauma
Other accompanying symptoms included purulent discharge from the wound (22.2 %), perineal pain
Wound dehiscence
Perineal wound infection
(23.6 %) and both purulent discharge and pain (26.4 %). The median time taken for the wound to heal
Re-suturing of perineal wounds completely following re-suturing was 28 days (IQR 14.0-52.0); 49.2 % had healed completely by four
weeks, 63.5 % by six weeks and 76.2 % by eight weeks. The median number of out-patient follow-up
appointments required was 2 (IQR 1.0-3.0). No post-operative complications were experienced in 63.6 %
of women, one complication occurred in 25.8 % and two complications in 10.6 %. Complications included
skin dehiscence (33.3 %), granuloma (33.3 %), scar tissue (17.6 %), perineal pain (5.9 %) and sinus formation
(5.9 %). Of the women who developed two complications, four developed skin dehiscence with
granulation tissue and one had skin sinus formation. One developed granulation tissue with perineal
pain. All complications were managed conservatively in an outpatient setting or surgically under local
anaesthetic, without further complication. There was no significant difference (p = 0.443) in complication
rates between the group (n = 10) with dehisced wounds with signs of wound infection (purulent
discharge or the presence of both purulent discharge and pain) pre-operatively versus the group (n = 14)
without signs of infection.
Conclusions: This study demonstrates the positive outcomes of early re-suturing of perineal wound
dehiscence with faster healing, reduced follow-up requirements and few major complications. It
provides information to clinicians who are uncertain about the effects of early re-suturing of perineal
wounds which can be used to help counsel mothers with wound dehiscence on their management
options.
Crown Copyright © 2020 Published by Elsevier B.V. All rights reserved.

Introduction infection [2,3]. However, the true prevalence of the two

complications is unknown, with the reported incidence of wound
Perineal injury following childbirth can result in complications dehiscence and infection ranging between 0.1 %–23.6 % and 0.2
such as wound infection and dehiscence [1]. These are associated %–24.6 % respectively [4].
with significant peripartum morbidity and prolonged post-natal Early re-suturing has been defined as the repair of a dehisced
recovery [2,3]. Perineal wound dehiscence usually occurs in the perineal wound within 14 days after vaginal delivery [5]. This
first 7–14 days following delivery and is commonly associated with management is currently offered by some clinicians. Traditionally,
the popular approach was to delay re-suturing of dehisced perineal
wounds (up to three months) to allow for tissue re-vascularisation
and resolution of infection and inflammation [5–8]. However, it is
* Corresponding author at: Croydon University Hospital, 530 London Rd,
Thornton Heath CR7 7YE, 020 84013969, UK. postulated that the current condition of the tissues is most
E-mail address: [email protected] (A. Sultan). important for a successful secondary repair, irrespective of the

https://doi.org/10.1016/j.ejogrb.2020.09.013
0301-2115/Crown Copyright © 2020 Published by Elsevier B.V. All rights reserved.
70 N.A. Okeahialam et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 254 (2020) 69–73

time to repair interval [9]. At present, there is no agreed best given. The women were made aware of the lack of evidence of one
practice recommendation for the management of perineal wound method of management being superior to the other.
dehiscence due to a lack of robust evidence comparing expectant Women who opted for conservative management were given
management (healing by secondary intention with antibiotic oral antibiotics, perineal hygiene advice and offered a further
cover) and early re-suturing [10]. Published data to date is limited, follow-up in 2–3 weeks with a contact telephone number if any
reporting outcomes in a small number of participants [6,7,11–14]. additional concerns were to arise, for example, symptoms of
These studies support early re-suturing; reporting post-operative infection. Those who consented to surgical management were re-
success rates (complete wound closure with no complication) in admitted into hospital and placed onto an emergency operating list
over 90 % [6,12], earlier resumption of sexual intercourse [14] and a to be performed by the Urogynaecology consultant or registrar. If
trend toward shorter healing times in comparison to wounds there was any evidence of wound infection then the patient was
managed expectantly [13]. Significant complications such as admitted for intravenous antibiotics and regular wound irrigation,
complete wound dehiscence, infection and recto-vaginal fistula with a plan for re-suturing once the wound was deemed clean.
occurred solely in women with risk factors such as obstetric anal
sphincter injury (OASI), chronic disease and those taking Surgical technique
immunosuppressive therapy [6,11,12]. A pilot study designed to
demonstrate feasibility, showed significant differences in healing All secondary wound closures were performed using a standard
times and maternal satisfaction, favouring re-suturing. However, surgical procedure protocol under general anaesthetic. The featured
given the small sample size and nature of the study, these results video demonstrates the surgical steps necessary to re-suturing a
should be interpreted with caution; only 26 % of the potentially dehisced obstetric perineal wound (Supplementary content).
eligible women were recruited as most women opted for re- In the lithotomy position, the perineal area and vagina were
suturing rather than participating in the randomised controlled cleansed using an aseptic technique with a sterile swab saturated
trial (RCT). This small sample size may offer an imprecise with povidone-iodine antiseptic solution (or chlorhexidine gluco-
treatment effect size and so undermine the reliability of its results nate 4 % for women with iodine sensitivity). Sterile drapes were
[15]. Despite this, there is wide variation in practice with regard to then applied. A per rectal examination was performed to confirm
perineal wound dehiscence management. In the UK, expectant sphincter integrity and all old sutures were removed and
management is generally advised, however perineal wound discarded. The perineal wound was irrigated with a 50:50 dilution
dehiscence can take up to 16 weeks to heal when managed of 3 % hydrogen peroxide and 0.9 % sodium chloride and debrided
expectantly and during this time the patient will require regular using a brush and curette. Once fresh tissue with bleeding points
review [3,16]. Thereby resulting in a longer period of maternal were exposed, the margins of the broken-down perineal and
morbidity [10,16]. Therefore, some clinicians recommend that vaginal skin were excised.
early re-suturing should be attempted following the exclusion or Perineal repair was completed in three layers after checking
treatment of concurrent infection [6,7,12,16]. alignment and apposition of the perineal skin. Initially the vaginal
The aim of this study was to describe post-operative outcomes mucosa was closed with a continuous, non-locking suture using
following early re-suturing of perineal wound dehiscence. 2 0 Vicryl (polydiaxone) suture material from the vaginal apex to
the hymenal remnants. Following this, the perineal muscles were
Materials and methods dissected away from the skin as necessary to release tension and
then sutured continuously in one or two layers with 1 0 Vicryl,
This was a retrospective series of 72 women who underwent re- closing all the dead space. Skin closure was then completed with
suturing of a dehisced perineal wound at a tertiary urogynaecology interrupted 2 0 Vicryl mattress sutures (Fig. 1).
department during a 13-year period (December 2006 - December Vaginal and per rectal examinations were performed at the end
2019). of the procedure, ensuring that the vaginal introitus admitted at
All women with perineal wound dehiscence were reviewed in a least two fingerbreadths and that no sutures had penetrated the
dedicated perineal clinic either by a specialist midwife, urogy- rectal mucosa.
naecology registrar or consultant. Dehiscence was defined as All women were discharged the same day and followed-up in
separation of both the perineal skin and muscle layer. Appropriate the perineal clinic one week after the procedure and discharged
counselling on management options, including conservative from outpatient clinic once the wound was deemed to have healed
(healing by secondary intention) or surgical (re-suturing), were and symptoms resolved.

Fig. 1. Images showing dehiscence following an episiotomy repair (A) The wound edges of the broken-down perineal skin have been excised. Allis forceps are being used to
grasp the vaginal skin to check anatomical apposition and alignment. (B) The perineum after interrupted mattress sutures were inserted for skin closure, ensuring the wound
is not under tension as swelling may occur post-operatively.
 N.A. Okeahialam et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 254 (2020) 69–73 71

Statistical analysis Table 2

Delivery Details.

The data was analysed using SPSS version 26.0.0.0. Descriptive N = 72 N (%)
analysis of the electronic patient records data was undertaken. Parity1 59(81.9)
Nominal data is presented as number (N) and percent. For Parity2 9(12.5)
continuous data, the median and interquartile range (IQR) were Parity>2 1(1.4)
Parity unknown 3(4.2)
calculated. The relationship between categorical variables was
assessed using the Fisher’s Exact Test. A p-value <0.05 was Mode of delivery
considered statistically significant. SVD 24(33.3)
Forceps 15(20.8)
Results Ventouse 19(26.4)
Ventouse + Forceps 7(9.7)
Vaginal Breech 1(1.4)
During the study period (December 2006- December 2019), 72 Unknown 6(8.3)
women underwent re-suturing following complete dehiscence of
their perineal wound. Most women were primiparous and the Episiotomy
Yes 62(86.1)
median age was 29 years (IQR 25-33). The majority of wounds that
No 9(12.5)
were re-sutured were episiotomies (59.7 %). Four women had a Unknown 1(1.4)
history of OASI. These women had dehiscence of the perineal
muscle layer, but on examination their primary anal sphincter Perineal trauma type
repair remained intact. No woman who had a perineal wound Episiotomy only 43(59.7)
Second degree tear 24(33.3)
infection developed an extension and disruption of an intact anal
OASIa
sphincter. Further patient characteristics and relevant delivery 3a 0(0)
details of those who underwent re-suturing are described in 3b 3(4.2)
Tables 1 and 2. 3c 1(1.4)
Of the 72 women with perineal wound dehiscence, other 4th 0(0)
Unknown 1(1.4)
accompanying symptoms included purulent discharge from the
wound (22.2 %), perineal pain (23.6 %) and both purulent discharge BMI- Body Mass Index.
SVD- Spontaneous Vaginal Delivery.
and pain (26.4 %). Diagnosis of infection was based on the presence
OASI- Obstetric Anal Sphincter Injury.
of purulent discharge or the presence of both purulent discharge a
These women had wound breakdown of their perineal trauma, however on
and pain (n = 33). The median time from delivery to re-suturing examination their primary anal sphincter repair remained intact.
was 11 days (IQR 9-14) and number of out-patient follow -up
appointments was 2 (IQR 1-3). Nine women were lost to follow-up,
of these, six did not attend any follow-up appointments. The
wound completely healed at a median of 28 days (IQR 14-52). By
Table 3
four weeks, 49.2 % of wounds had healed completely, by six weeks
Time taken for wound to heal following re-suturing.
63.5 % and by eight weeks 76.2 % had healed (Table 3).
Forty-two women (63.6 %) experienced no post-operative N = 63a 4 weeks 6 weeks 8 weeks >8 weeks
complications. One complication was experienced in 17(25.8 %) Time to Healing 31(49.2) 40(63.5) 48(76.2) 63(100)
and two complications in 7(10.6 %). In those experiencing one N (%)
complication, this included skin dehiscence (33.3 %), granuloma a
Nine women did not attend all of their follow up appointments until the wound
(33.3 %), scar tissue (17.6 %), perineal pain (5.9 %) and sinus had healed and so were removed from analysis.
formation (5.9 %). In those with two complications, four developed
skin dehiscence and granulation tissue, one developed skin
dehiscence and sinus formation and in one had granulation tissue
and perineal pain. Additionally, one woman, concurrently being
Table 4
treated for tuberculosis, formed an inter-sphincteric collection
Wound healing outcomes following re-suturing.
with intact external and internal anal sphincters on endoanal
ultrasound (Table 4). There was no significant difference (p = Median (IQR)
0.443) in complication rates between the group (n = 10) with Time from delivery to re-suturing in days (N= 72) 11(9.0 14.0)
dehisced wounds and signs of wound infection (purulent discharge Number of follow up appointments (N = 66a ) 2(1.0 3.0)
Time from re-suturing to wound healed in days (N = 63b) 28(14.0 52.0)
or the presence of both purulent discharge and pain) pre-
Complications (N = 66a ) N (%)
operatively versus the group (n = 14) without signs of infection. No complications 42(63.6)
One complication (N=17) 17(25.8)
Table 1 Skin dehiscence 6(33.3)
Patient characteristics. Granulation tissue 6(33.3)
Posterior fourchette scar/adhesions 3(17.6)
N = 72 Median (IQR) Sinus 1(5.9)
Age (years) 29(25 33) Perineal pain 1(5.9)
BMI (kg/m [2]) 24.2(21.6 25.9) Two complications (N=7) 7(10.6)
Skin dehiscence + granulation tissue 4(57.1)
Ethnicity N (%) Skin dehiscence + sinus 1(14.3)
White British 35(48.6) Skin dehiscence + wound infection/collection 1(14.3)
Asian Indian/Pakistani/other Asianbackground 21(29.2) Granulation tissue + perineal pain 1(14.3)
Black African/Caribbean 6(8.3) a
Any otherethnic group 6(8.3) Six women did not attend any follow up appointments and so were removed
Unknown 4(5.6) from analysis.
b
Nine women did not attend all of their follow up appointments until the wound
BMI- Body Mass Index. had healed and so were removed from analysis.
72 N.A. Okeahialam et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 254 (2020) 69–73

All complications were managed conservatively in an outpatient management. Analysis of these additional complications following
setting or surgically under local anaesthetic without further re-suturing is relevant as they can prolong the healing process,
complication. thereby increasing the number of outpatient appointments,
potentially influencing the woman’s management decision.
Discussion The limitations in this study include the relatively small
sample size and the retrospective design which may introduce
The aim of this study was to present the post-operative bias. However, given that this is not a common condition, 72 is a
outcomes of women undergoing secondary re-suturing of a sizeable number. This study will be of interest to clinicians who
dehisced perineal wound following review in a dedicated perineal are uncertain about the effects of early re-suturing of perineal
clinic. To the best of our knowledge, based on a literature search, wounds. We acknowledge that 91.7 % returned for follow-up. We
this is the largest study describing outcomes following early re- do not have long term outcomes such as sexual dysfunction as our
suturing of perineal wound dehiscence. cohort were discharged once the wound had healed. Therefore,
Wound dehiscence is often described to occur concomitantly outcomes such a resumption of sexual intercourse and dyspar-
with infection [16,17]. In the retrospective analysis of outcomes eunia at three to six months were not addressed [10]. Another
following re-suturing of dehisced perineal tears by Ramin et al. limitation is that, this study describes outcomes of those women
[12] 79 % of wounds also exhibited signs of infection. It is therefore who underwent early secondary repair of the perineum and
not surprising that the common additional presenting complaints therefore comparison to women who were managed expectantly
in our patients were purulent wound discharge and perineal pain. cannot be made. We do not have outcomes such as healing time
Also, we found that, the majority of re-sutured wounds occurred and complications in those perineal wounds managed expec-
following an episiotomy (59.7 %). This concurs with a recent study tantly in our unit. However, it is possible that clinicians and
showing that episiotomy is associated with an approximately two- patients were more likely to opt for healing by secondary
fold increase in wound infection and a three-fold increase in intention for lesser degrees of dehiscence and re-suturing
wound dehiscence [18]. preferred for those with a large dehiscence as they were
The average time taken from delivery to wound dehiscence perceived to take much longer to heal with associated pain.
presentation is reported to be between five to six days and the Ideally a prospective, multi-centre study comparing re-suturing
average time taken from wound dehiscence presentation to re- with healing by secondary intention is required. This would allow
suturing is three to seven days [7,12]. In our study, the median time full evaluation of the treatment effects of both management
from initial repair to re-suturing was 11 days. Re-suturing of options. When such an RCT was previously performed by Dudley
perineal wound dehiscence in the immediate puerperium has been et al. [15] it faced challenges in terms of recruitment due to
described to decrease maternal morbidity by improving sexual patient and clinician treatment preferences, with a small number
function and minimising the risk of cloacal-like defect formation. of potentially eligible women being recruited. Nevertheless, this
Additionally, early re-suturing may potentially reduce the need for study showed a significant improvement in wound healing at two
future major perineal revision procedures, longer hospital inpa- weeks and better patient satisfaction at three months following
tient stay, and litigation; overall, reducing the economic burden to perineal re-suturing. Due to the small sample size of this pilot
the health service [8]. The median time taken for the re-sutured study, reliable conclusions cannot be drawn. It is unlikely that a
perineal wound to heal completely in our study was 28 days and definitive study will ever be completed due to the nature of a
76.2 % of women had a completely healed wound within eight complete perineal wound dehiscence, whereby women and
weeks. It is reported that dehisced perineal wounds managed clinicians will be more likely to favour re-suturing as opposed
surgically are 20-times more likely to heal within four weeks, in to expectant management. A nested qualitative study from this
comparison to those managed expectantly [15]. Also, another small RCT showed women with complete wound dehiscence who were
RCT of infected episiotomies showed that women who underwent managed expectantly were more likely to feel in the long-term
re-suturing experienced shorter healing times than those managed that their perineum has not returned to “normal” [3]. In the same
expectantly [13]. study, women managed expectantly expressed they would have
In terms of complications following re-suturing, there was no preferred surgical treatment. One reason given was the extended
difference in complication rates in wounds with signs of wound healing process they faced. By contrast, the reported experiences
infection in comparison to those with no signs. This is likely of women undergoing perineal re-suturing were very positive [3].
attributed to the pre-operative preparation of infected wounds As the perineum is in close proximity to the anorectum,
including intravenous antibiotics and regular wound irrigation techniques to minimise infection risk and hence dehiscence also
until the wound objectively appeared clean. Skin dehiscence was need to be explored. The prophylactic antibiotics in the prevention
the most common complication, occurring in 19.7 % of women. of infection after operative vaginal delivery (ANODE) RCT showed
This was managed conservatively and healing was by secondary that prophylactic administration of a broad-spectrum antibiotic
intention. Rates in the literature concur with this and are reported following an instrumental delivery significantly reduced the risk of
to range between 14.3 %–21.7 % [6,7,11]. Granuloma formation was superficial perineal infection by 47 % and deep infection by 54 %.
another commonly experienced complication and was managed Also, the risk of perineal wound dehiscence and perineal pain was
with silver nitrate. Other complications such as scar tissue significantly reduced at six weeks post-partum by 48 % and 16 %
formation, required surgical division under local anaesthetic, respectively [20]. Another recent RCT, has shown that the use of 3 %
and the formation of small uncomplicated sinuses did not require copper impregnated sanitary towels in women with perineal
surgical treatment. Perineal pain resolved with the use of 5 % trauma following vaginal delivery reduced the rate of superficial
topical lidocaine hydrochloride ointment and in the woman who perineal wound infection by 77.8 % and deep infection by 85.3 %
formed an inter-sphincteric collection, her diagnosis of tuberculo- [21].
sis may have been a factor contributing to her poor wound healing
due to the chronic systemic inflammatory state associated with Conclusion
Mycobacterium Tuberculosis [19]. As she did not develop an abscess,
she was managed conservatively. Overall however, the post- In the absence of an adequately powered RCT, we feel that this
surgical complication rate was low. To date, no study has reported study demonstrates the positive outcome of early re-suturing of
these other early post-surgical complications and their perineal wound dehiscence, due to a potentially shorter healing
 N.A. Okeahialam et al. / European Journal of Obstetrics & Gynecology and Reproductive Biology 254 (2020) 69–73 73

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