Perineal Repair

Last updated 03.11.12

 

Definition

-  Repair of perineal trauma secondary to delivery +/- episiotomy

 

Features

-  Aim for

-  Obliteration of dead space & haemostasis

-  +/- Repair of external &/or internal anal sphincter (3rd or 4th degree)

-  Skin not to be stitched too tightly

-  As oedema settle tissues shrink

-  Minimal use of knots & suture material

-  1st & 2nd degree tears can be repaired on the ward

-  3rd & 4th degree tears should be repaired in theatre

-  Only urgency for time is if bleeding

-  Reasonable to wait for daytime hours if dependant on theatre

 

Equipment

-  Lighting

-  Sterile drape x2

-  Strile gloves  +/- Gown

-  +/- mask & visor

-  LA: Lidocaine 1%

-  20ml syrine

-  21G & 23G needles

-  Chlorhexadine w Cetrimide

-  2-0 Vicryl rapide w 36mm taper cut needle

-  +/- 2-0 Vicryl

-  +/- 2-0 PDSII

-  Packs w radio-opaque thread

-  Suture pack: scissors, forceps, needle holder

-  +/- Weitlaner retractor

-  PR analgesia

-  +/- Paracetamol 1g suppository

-  +/- Diclofenac 100mg suppository

 

Procedure

-  Assessment of tear

-  Explanation + consent

-  Ensure placenta complete & no PPH

-  Analgesia

-  Inhalational analgesia: Nitrous

-  May have existing Epidural

-  Positioning in lithotomy

-  Lighting

-  +/- Mask/visor, scrub/hand hygeine, gown & glove

-  Count instruments

-  Preparation/clean area with Chlorhexidine

-  Drape under backside +/- over abdo

-  Thorough examination (may require LA)

-  Determine degree of tear (perineal trauma)

-  Ensure no PPH

-  Apply Lidocaine LA into tissues

-  Max 3mg/kg (20ml in 70kg woman) in 1 hr

-   May include amount used for Episiotomy

-   Ensure not in vessel via withdrawal (area highly vascularised)

-  If 3rd or 4th degree

-  Repair in theatre under GA or regional (Spinal/Epidural)

-   With assistant

-  May require muscle relaxant to access retracted ends of muscles

-  Single dose of IV Abx at time of repair: Metronidazole 500mg, Cephazolin 2g

-  Sequence for 3rd & 4th Degree

-  Repair in separate layers

-  Repair anal epithelium/rectal mucosa

-   2.0 Vicryl if interrupted

-   OR 2.0 PDS II if continuous

-   Knots tied in lumen of anus

-  Internal anal sphincter (IAS) with 2.0 PDS II

-   End to end or overlap technique

-  External anal sphincter (EAS) with 2.0 PDS II

-   End to end for 3a or 3b (<50% effected)

-   Overlap technique for 3c or 4

-   Avoid figure eight sutures unless for haemostasis

-  Make sure knots are well buried to avoid knot migration & pain

-  Repair remainder of wound as per 2nd degree tear

 

3rd 4th Degree Tears

 

-  Sequence for 1st & 2nd Degree

-  Repair wound in layers

-   Vaginal wall

-  Perineal muscles

-  Perineal skin & subcutaneous tissue

-  Anchor stitch at apex of perineal tear

-   Approx 0.5cm+ distal to furthest extent of tear

-   Assits in haemostasis by constricting supplying vessles to wound

-  Run continuous stitch towards hymenal remnant

-   0.5 to 0.75 ccm from edge of tear

-   Close dead space

-  Sequence depends of operator & location of tear & tissues

-  Lock suture deep to hymenal remnant after taking deep bite down

-   Tie with loop from bite

-   One end to remain to close wound later

-   Once end to continue stitch

-   One end cut short

-  Continue suture to close muscle layer with deep bites

-   +/- 2 layers as needed

-  Stitch to exit at apex of inferior extent of tear

-  Run subcuticular stitch anteriorly to vagina

-  Tie stitch to remnant from previous knot

-  PV exam

-  Check stitch tension

-  Ensure haemostasis

-  Ensure vagina admits 2+ fingers

-  PR exam: ensure no stitches have penetrated into rectum, insert analgesia

-  Paracetamol 500mg x2

-  Diclofenac 50-100mg (ensure no Asthma)

-  +/- Misoprostol as indicated (PPH)

-  Clean area

-  Palpate uterine fundus: ensure well contracted

-  Count

-  Dispose of sharps

-  Document

-  Consent

-  Count pre & post: packs, needles, instruments

-  Analgesia: Epidural, amount of Lidocaine

-  Degree of tear

-  Suture material

-  Procedure

-  Haemostasis

-  PV + PR exams

-  Medications given

-  EBL

 

Post Op

-  +/- ice to perineum

-  For 20min every 3-4hrs over 48-72hrs

-  Analgesia

-  Paracetamol

-  PO NSAIDs

-  If 3rd/4th degree avoid suppositories (to avoid damaging sutures)

-  Avoid constipation

-  Adequate fluid intake

-  +/- Laxatives (esp if 3rd or 4th degree)

-  Sutures

-  Vicryl rapide half tensile strength in 10 days, absorbed over 40 days

-  3rd or 4th degree tears

-  Abx

-   PO Cephalexin 500mg PO QID 4-10/7 + Metronidazole 400mg PO TDS 4-10/7

-   OR IV Cephazolin single stat dose at time of repair

-  Lactulose 10mls BD for 7-10/7 +/- Fybogel

-  Low residue diet for 7/7

-  F/U at 12/52 with O&G or General Surgeon

-   Monitor for knot migration

-   Determine anal incontinence or leakage

-   Confirm physio & ongoing exercises

-   Review perineum

-   Assess for dysparaenia +/- oestrogen cream

-   +/- endoanal US

-  Physio

-  D/W pt & consultant re mode of delivery for next delivery

-   Risk of anal incontinence or worse S/S

-   No evidence to support routine episiotomies

-  Wound care

-  Keep clean & dry

-  Monitor for infection

-  R/V by LMO at 4-6/52 if 1st or 2nd degree tears or episiotomies

-  R/V by O&G/General Surgeon if 3rd or 4th degree tears

-  +/- Physio

-  Day 3+

-  Pelvic floor exercises

-  Esp if 3rd/4th degree

-  +/- sexual abstinence for 6/52

 

 

 

References

 

RWH CPG: Perineal Trauma: Assessment & Repair 2012

RCOG Greentop N. 29: Third & Fourth Degree Perineal Tears, Management, 01/03/2007

American Family PHysician: Repair of Obstetric Perineal Lacerations