1.4 - Perineal Care In Labour

Question 1

What are the 4 classifications of perineal tear?

Answer 1

• 1st degree - injury to skin only
• 2nd degree - injury to perineum involving perineal muscles
• 3rd degree - Injury to perineum involving anal sphincter
• 4th degree - Injury to perineum involving the anal sphincter complex and anal/rectal epithelium

Question 2

Management for the different types of tears?

Answer 2

1st degree - conservative Mx, may not require suturing

2nd degree - Suturing by experienced midwife

3rd/4th degree - Repair by senior clinician in theatre with analgesia. After op, use broad-spectrum antibiotics and laxatives

Question 3

techniques for reducing perineal trauma

Answer 3

• Perineal massage
• warm compresses
• perineal management

Question 4

Describe the evidence based strategies to prevent perineal trauma and improve maternal comfort in 2nd stage

Answer 4

Hands off

• no clear difference in the incidence of intact perineum
• Episiotomy were more frequent in the hands on group

Warm Compresses

• did not have any clear effect on the incidence of intact peri
• unable to ascertain benefit or increase or decrease 1st degree tear
• however seen a degree in 3rd the 4th tears

Massage

• Perineal massage saw an increase of intact peri
• the group experience fewer 3rd and 4th degree tears

Ritgen manoeuvre

Ritgen´s maneuver means that the fetal chin is reached for between the anus and the coccyx and pulled anteriorly, while using the fingers of the other hand on the fetal occiput to control speed of delivery and keep flexion of the fetal neck.

• less likely to have a first degree tear
• more likely to have a second degree tear
• one study reported did not have an effects on incidence of 3rd and 4th tear

Question 5

Describe the types of perineal trauma including the tissue layers that are involved

Answer 5

• 1st degree - injury to skin only
• 2nd degree - injury to perineum involving perineal muscles
• 3rd degree - Injury to perineum involving anal sphincter
• 4th degree - Injury to perineum involving the anal sphincter complex and anal/rectal epithelium

Question 6

Perineal trauma

Most common n which presentation of fetal head

Answer 6

Occipitoposterior

Question 7

https://www.kemh.health.wa.gov.au/~/media/HSPs/NMHS/Hospitals/WNHS/Documents/Clinical-guidelines/Obs-Gyn-Guidelines/Perineal-Care-And-Repair.pdf?thn=0

Question 8

How to perform an episiotomy

Answer 8

• medical indicated use of an incision to expedite delivery
• analgesia on board
• high of a contraction when fetal heads is crowning
• visualised the line of the episiotomy
• 60 degrees from the anal sphincter
• insert two fingers into the vagina
• protecting the fetal head
• injection lignocaine 45 - 60 degrees for 4 to 5 centimetres at the same ski depth
• aspirate the syringe to confirm that a blood vessel has not been cannulated
• while withdrawing the syringe continuously inject approx 3ml of local anaesthetic
• apply pressure to the episiotomy between contractions with a sterile combine

Question 9

• Describe the anatomy and physiology of the pelvic floor

Question 10

• Describe the five (5) elements of the Perineal Protection Bundle

Question 11

• Describe the role of the midwife during the second stage of labour in relation to perineal care

Question 12

• Why is it important for the accoucheur to support the perineum in the second stage of labour?

Question 13

• What are the potential outcomes if the perineum is not protected at this time?

Question 14

• What information and discussion should the midwife have with the woman in preparation for the second stage of labour?

Question 15

• Describe the indications for infiltration and episiotomy of the perineum during second stage

Question 16

• Explain the midwifery role in education, informed consent and decision making when performing infiltration and episiotomy of the perineum

Question 17

• Describe the midwifery role post procedure, what are the perineal care considerations

Question 18

• What is the evidence around routine episiotomy?