[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);

Purpose of Perineal Repair

  • 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

Assessment of Perineal Trauma

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

Classification of perineal trauma QIS (2008)

1st

Injury to skin only

2nd

Injury to perineum involving perineal muscles but not the anal sphincter

3rd

Injury involving the anal sphincter

3a

<50% of external sphincter torn

3b

>50% of external sphincter torn

3c

internal sphincter torn

4th

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.

Identification of Anal Sphincter Trauma

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.

Principles of Perineal Repair

  • 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.

Analgesia prior to suturing

  • 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.

Suture material

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).

Method of repair

  • 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).

Prior to commencing Perineal Repair

  1. Fully explain the procedure to the woman and gain verbal consent to carry out Perineal repair;
  2. Ensure the woman is in a comfortable position with good exposure of the vaginal trauma.
  3. Check equipment - swabs; sutures; sharps; instruments with an assistant;
  4. Ensure adequate analgesia;
  5. 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;
  6. 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.

Suturing the vaginal wall

  • 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).

Suturing the muscle layer

  • 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).

Suturing the skin

  • 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).

Immediate postnatal care of the perineum

  • 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).
References

National Institute for Health and Clinical Excellence (2007) Intrapartum Care: Management and delivery of care to women in labour. NICE: London.

Royal College of Obstetricians and Gynaecologists. (2004) Methods and materials used in perineal repair. Green-top Guideline No.23. RCOG: London.

Thakar & Sultan (2008) 

Sultan & Kettle (2007)

Quality Improvement Scotland (2008) Perineal Repair after Childbirth. NHS: Glasgow.

Last reviewed: 06 February 2018

Next review: 31 January 2022

Author(s): P De Freitas; F Hendry

Approved By: Obstetric Governance Group

Document Id: 616