- To control bleeding
- To prevent infection
- To assist the wound to heal by primary intention – healing is usually rapid and scarring is minimal providing there is no infection or excessive bleeding/haematoma
[CG] Episiotomy, Perineal Repair, Obstetrics
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- All women who have had a vaginal delivery must undergo a systematic examination of the vagina, perineum and rectum to assess the extent of damage prior to perineal repair.
- This should be performed in the immediate period following birth.
- Following all vaginal deliveries a rectal examination must be undertaken to ensure identification of 3rd & 4th degree tears also referred to as Obstetric Anal Sphincter Injuries (OASI).
- Thakar & Sultan (2008) & Sultan & Kettle (2007)
- (NICE 2007) & QIS (2008);
Prior to assessing perineal trauma midwives must:
- Provide a full explanation
- Gain informed verbal consent
- Ensure adequate analgesia
- Ensure adequate lighting
- Ensure a comfortable, sustainable position
Injury to skin only
Injury to perineum involving perineal muscles but not the anal sphincter
Injury involving the anal sphincter
<50% of external sphincter torn
>50% of external sphincter torn
internal sphincter torn
Injury to anal sphincter and anal/rectal epithelium
Practitioners should only leave trauma unsutured when it is the woman’s explicit wishes and this must be documented in case notes.
Prior to carrying out a rectal examination the procedure and reason for the examination should be explained and verbal consent gained.
- On visual examination, the absence of ‘puckering’ around the anterior aspect of the anus may suggest OASIS trauma;
- Insert index finger into rectum and thumb into vagina and perform a “pill-rolling” motion to palpate the anal sphincter;
- When the sphincter is disrupted you feel a distinct “gap” anteriorly;
- If the technique is inconclusive ask the woman to contract her anal sphincter while your fingers are still in situ;
- The internal anal sphincter (IAS) is paler in appearance, similar to the flesh of raw fish, whilst the external anal sphincter (EAS) is a deep red, similar to raw red meat.
- Medical opinion (middle grade or above) should be sought if examination suggests a 3rd or 4th degree tear or if any uncertainty about the nature or extent of the trauma.
- Midwives or doctors undertaking perineal repair should be trained in the procedure.
- The extent of the perineal trauma should be evaluated by examining the vagina and perineum. A rectal examination should be performed as part of the assessment to exclude OASI injury;
- Suturing should commence ideally 30-60min following delivery of 3rd stage as the repair will be less painful and the risk of infection is reduced. NB Water birth – delay for 1 hour
- Handle tissues gently using non-toothed forceps;
- Ensure good anatomical restoration and alignment to facilitate healing;
- Ensure haemostasis between each layer and close all dead space to avoid haematomas developing
- Sutures should approximate not strangulate the tissues. Ensure knots are tied securely but not too bulky;
- PR after completion to ensure no suture material has accidentally been inserted into the rectal mucosa.
- Ensure adequate analgesia prior to repair
- If the woman has had an epidural ensure it provides adequate pain relief.
- The perineum is infiltrated using Lidocaine 1% .
- The maximum safe dose should be calculated - 3mg/kg of 1% lidocaine using a recent weight.
20 mls 1% lidocaine is the maximum dose administered by midwives.
The use of No 2/0 Vicryl Rapide with a 35mm tapercut needle should be used. It is associated with a significant reduction in:
- perineal pain and subequent analgesic use;
- less dehiscence;
RCOG (2004); QIS (2008) & NICE (2007).
- Modified Fleming technique should be used.
- This technique is associated with less short term pain compared with the traditional interrupted method NICE (2007) & QIS (2008).
- Fully explain the procedure to the woman and gain verbal consent to carry out Perineal repair;
- Ensure the woman is in a comfortable position with good exposure of the vaginal trauma.
- Check equipment - swabs; sutures; sharps; instruments with an assistant;
- Ensure adequate analgesia;
- Thoroughly examine the vagina and perineum to establish the extent of the trauma and identify the apex. If there is any doubt regarding the extent of the trauma – ASK FOR HELP;
- Insert a tampon, if necessary to provide a clear view and secure the tail with an artery forceps; ensure you have adequate light to carry out the repair.
- Confirm local anaesthetic is working prior to commencing suturing
- Consider inserting a tampon to provide a clear view of the apex of the tear.
- Identify the apex and insert the anchoring suture 0.5cm above the apex to allow for haemostasis of any small vessels, which may have retracted beyond this point
- Repair the vaginal wall using a loose, continuous, non-locked stitch with approx 0.5cm between each stitch
- Continue to suture from apex to introitus; ensuring sutures are not placed in the hymenal remnants
- Place the needle under the fourchette and emerge in the centre of the perineal muscle NICE (2007) & QIS (2008).
- Check the depth of the trauma
- Repair the perineal muscles in one or two layers with the same loose, continuous, non-locked stitch
- Ensure the muscle edges are apposed carefully leaving no dead space
- Visualise the needle between sides to prevent stitches being inserted into the rectal mucosa
- On completion of the muscle layer, the skin should align so that they can be brought together without tension NICE (2007) & QIS (2008).
- Reposition the needle and commence suturing the skin from the apex of the wound
- Stitches are placed below the surface of the skin, the point of the needle should be repositioned between each side (a side-to-side technique)
- Continue the sub cuticular stitch until the proximal end of the wound is reached
- Sweep the needle behind the fourchette back into the vagina. Pick up a small amount of vaginal tissue to tie off the stitch, knot, bury and tie off. Alternatively, the Aberdeen knot can be used NICE (2007) & QIS (2008).
- Inspect the repair to ensure haemostasis has been achieved. NB – “Less is more” – only carry out the required amount of suturing to achieve haemostasis – an excessive amount of sutures causes severe perineal morbidity
- Remove tampon
- Perform PR to ensure no sutures have been accidentally inserted through the rectal mucosa
- Analgesia – Diclofenic 100mg PR if no contraindications
- Remove legs from lithotomy and ensure comfort
- All swabs, sharps and instruments should be accounted for and discarded safely
- Debrief and advise regarding perineal hygiene, pelvic floor exercises
- Document the repair and any difficulty during suturing i.e. friable tissue in case note.
- Sign prescription for local anaesthetic and analgesia (PGD) NICE (2007) & QIS (2008).