Perineal Trauma (Perineal Tears, Episiotomy)

Last updated 03.11.12

 

Definition

-  Female genital tract trauma during vaginal birth +/- w assisted delivery or by surgical incision (episiotomy)

 

Features

-  Effective repair reduces subsequent pain & functional impairment

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

-  3rd & 4th degree require repair by experienced practitioner in OT

-  Overall risk of anal sphincter (third or fourth degree tear) injury 1% vaginal deliveries

 

Classification

-  Spontaneous perineal trauma

-  1st Degree: skin of fourchette, hymen, labia, vaginal epithelium

-  2nd Degree: + pelvic floor, perineal m., vaginal m. (not anal sphincter)

-  3rd Degree: involves anal sphincter complex (EAS, IAS)

-   3a: <50% of EAS

-   3b: >50% EAS

-   3c: IAS torn

-  4th Degree: complete disruption of EAS + IAS + anal epithelium

-  Episiotomy

 

Assessment

-  Inhalational analgesia: Nitrous

-  Adequate lighting

-  Lithotomy position

-  Systematic examination

-  Anterior, periurethral area, laterally to labia & vaginal walls

-  Posterior incl vaginal vault, floor & perineum

-  If uncertain about degree of tear seek experienced help

-  3rd Degree+

-  Lack of puckering around anterior aspect of anus

-  PR exam + squeeze

 

Perineal Tear

 

Risk Factors

-  Baby >4kg

-  Malposition/malpresentation at birth: breech, persistant OP..

-  Primiparous

-  IOL

-  Epidural

-  Active second stage labour >1hr

-  Assisted delivery (forceps..)

-  Midline episiotomy

-  For 3rd Degree Tears

-  Baby >4kg 2%

-  Persistant OP 3%

-  Primparous 4%

-  IOL 2%

-  Epidural 2%

-  Prolonged second stage labour >1hr 4%

-  Shoulder dystocia 4%

-  Midline episiotomy

-  Forceps 7%

 

Mx

-  Perineal repair

-  +/- in OT if 3rd or 4th degree

-  +/- Mx of PPH

 

 

 

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 (inl Pic)