2.2 - Severe perineal trauma - Exam

Question 1

Explain the risk factors for perineal trauma

Answer 1

• obese
• AMA
• Obestetric emergency such as shoulder dystocia
• breech birth
• primigravidas
  Individual risk factors (mother)
  ■ Women having their first vaginal birth
  ■ Women of south Asian ethnicity
  Fetal risk factors
  ■ Infants with a higher birth weight*
  Risks arising during labour and birth
  ■ Persistent occipito-posterior position
  ■ Shoulder dystocia
  ■ Prolonged second stage of labour
  ■ Instrumental vaginal birth
  ■ Epidural pain relief **
  ■ Midline episiotomy***

Question 2

Explain evidence based risk reduction strategies

Answer 2

• slowing the birth of the fetal head
• warm compress and support of the perineium
• Allows the peri to stretch in a controlled manner

Question 3

Describe the types of female genital mutilation (FGM) and the implications on vaginal birth

Question 4

Describe the midwife role in antenatal care of women who may have undergone FGM

Question 5

Pelvic floor muscles

Answer 5

1. the piriformis muscle
2. obturator inernus muscle
3. levator ani
4. coccygeal muscle

Question 6

Explore the evidence for prevention of obstetric perineal trauma described in this chapter.

Question 7

Exam: List the strategies that have robust evidence to support them

Answer 7

• hands on approach with the non dominent hand to slow the birth of the fetal head.
• encourge the woman to pant, breathe through the contractions whilst the peri is stretching
• warm compress and support of the perineium
• Allows the peri to stretch in a controlled manner

Question 8

Exam Drawing on the strategies you have listed, write a short script that outlines how you would have a conversation with a primipara who has expressed concerns about sustaining a perineal trauma (draw upon the women’s experiences in the ‘episiotomy choice paper’)

Answer 8

• Provided education and information phamplets
• discuss her concerns as she may have been misinformed
• discuss what the midwife can do during the 2nd stage ie warm compress
• controlled breathing
• discuss the risk factors
• discuss the different degrees of tears etc
• Antenatal peri massage

Question 9

Exam: The woman says she has heard it is better to have an episiotomy than it is to tear. How would you respond?

Answer 9

• Sometimes a woman’s perineum may tear as their baby comes out.
• an episiotomy can help to prevent a severe tear or speed up delivery if the baby needs to be born quickly.
• there is a need for forceps or vacuum (ventouse),
• there is a risk of a tear to the anus
• depends on the clinical picture
• blanching of the peri

Question 10

Exam: List potential risk factors for sustaining perineal trauma?

Answer 10

• obese
• AMA
• Obestetric emergency such as shoulder dystocia
• breech birth
• primigravidas
  Individual risk factors (mother)
  ■ Women having their first vaginal birth
  ■ Women of south Asian ethnicity
  Fetal risk factors
  ■ Infants with a higher birth weight*
  Risks arising during labour and birth
  ■ Persistent occipito-posterior position
  ■ Shoulder dystocia
  ■ Prolonged second stage of labour
  ■ Instrumental vaginal birth
  ■ Epidural pain relief **
  ■ Midline episiotomy*****

Question 11

Exam: Drawing on the strategies you have lisited, write a short script that outlines how you would have a conversation with a primipara who has expressed concerns about sustaining a perineal trauma (draw upon the women’s experiences in the “episiotomy choice paper)

Question 12

Exam: Third an fourth degree perineal care
Clinical standards
Techniques used by the expert midwives to preserve the perineum intact.
Refelect on what you have seen clinically, is there a robust evidence to. support these practices?
List thoses that you have seen that lack evidence to support their practice
Why do you think they are still commonly practiced

Question 13

Exam: of those strategies that dont have robus evidence, which “make sense” physiologically?
Wrtie a rational for each of these

Question 14

Exam: which episotomy type is the least likely to lead to severe perineal traume (3rd or 4th degree tear)

Answer 14

medilateral episotomy 60 degrees from the anus

Question 15

Exam: what are the indications for episiotomy

Answer 15

Instrumental delivery
fetal distress
shorten peri
should dysocia
breech

Question 16

Exam: How do you ensure you dont inject the locat anaesthetic IV?

Answer 16

draw back on the syringe to ensure no blood return

Question 17

Exam: How many areas do you infiltrate?

Answer 17

Infiltration
2.1 Using the syringe and 19 gauge needle, draw up 10mL of 1% Lignocaine. Check the medication and dosage with an assistant.
2.2 Insert two fingers into the vagina between the presenting part and the skin.
For a medio-lateral episiotomy, direct the needle at an angle of approximately 45- 60° for 4 to 5 cm at the same skin depth.
Aspirate the syringe to confirm that a blood vessel has not been cannulated.
While withdrawing the syringe, continuously inject approximately 3 mL of local anaesthetic into the area.
Leave the tip of the needle still inserted in the perineal area.
2.3 Repeat this step twice by redirecting the needle either side of the initial injection so that a fan shaped area is anaesthetised.
2.4 Withdraw the needle and apply pressure over the injection site.

Question 18

Exam: why is a medio-lateral episiotomy cut at this angle?

Answer 18

to avoid the anal sphinctor involved medline lateral episiotomy will cause unneccesary trauma to the pelvic floor

Question 19

Exam: define each of the degrees of perineal trauma

Answer 19

1st degree
2nd degree
3a degree
3b degree
3c degree
4th degree

Question 20

Exam: What are your responisbilities before beginnning a perineal assessment?

Answer 20

• obtain consent
• explain that you can stop at any given time during the examination
• check for degree of tear by PV exam
• check via PR exam this must be done for every woman whom has delivered by vagina as there may be a button hole tear that is no visable on an intact peri
  *

Question 21

Exam: What is the purpose of the rectal examination?

Answer 21

to ascertain the degree of the tear
what strutures are involved
any button hole tear not seen but must be felt

Question 22

Exam: Why is identification of the hymenal remnants and forchette important when identifying genital tract trauma?

Answer 22

to understand the landmarks of the pelvic structures

Question 23

**Exam: Which muscles are often referred to as the “pelvic sling”.
What type of tear can damage these muscles?

Answer 23

Pelvic sling - Levator ani.

Question 24

Exam: What physiological changes occur to the perineal muscles, bladder and anus during second stage

Answer 24

• perineal muscles
• During a vaginal birth:

your perineum stretches to make room for your baby
your pelvic floor muscles can help deliver your baby
Pelvic floor
ferguson reflex
pressure from the presenting part stimulates nerve receptor in the pelvic floor
neuoendorine reflex - to stimulates the expelsive of the fetus

Bladder - (anteriorly) the bladder is pushed upwards into the abdominal cavity where there is less risk of injury during fetal descent
this results is stretching and thinning of the urethra

Recum - (posteriory) the rectum becomes flattened in the sacral curve and the pressue of advance head expels any residual faecal matter

Levantori Ani muscle
dilates and thins out
are displaced laterally and the perineal body is flatened, stretch and thinned

Question 25

Exam: Which muscles are damaged in a 2nd degree tear

Answer 25

involves the perineal muscle but no involving the anal sphincter

Question 26

Exam: How do you differentiate an intact v damaged EAS?
How would you differentiate the IAS from the EAS

Answer 26

EAS
* visual inspection of the rectum
* green/blue in colour and firmer on paplation
* measures 8 - 10 cm in length

IAS
viual inspection of rectum or digital inspection
is paler pink in colour
2.5 cm in length
3.

Question 27

Exam: What is a buttonhole tear and how would you identify this

Answer 27

• a tear within the rectal muscosa and not involving the EAS or IAS
• digitial examination post vaginal delivery

Question 28

Exam: Describe the current evidence around non- suturing of 1st and 2nd degree tears. How would
you approach this discussion with a woman who is asking about the necessity to suture a
perineal tear?

Answer 28

1. With a first-degree tear if the skin edges are not well opposed, women should be advised that the wound should be sutured to improve healing.
2. In the case of second-degree tears, standard management is to offer suturing but this can be discussed with the patient in the context of the extent of the tear and bleeding.
3. discuss if better healing options to have stutures

Question 29

Exam: What is the conventional process of suturing perineal tears? What 3 layers are repaired? In
what order?

Question 30

Exam: What landmarks are used to guide the clinician as they suture?

Answer 30

fourchette, hymen

Question 31

Exam: Why has continuous repair of all layers not been widely adopted by clinicians?

Question 32

Exam: What suture materials are available for use? Which offer the best outcomes? What outcomes
are measured to come to this conclusion?

Question 33

Exam: What factors would prompt you to recommend the suturing of a first degree tear?

Answer 33

With a first-degree tear if the skin edges are not well opposed, women should be advised that the wound should be sutured to improve healing.

Question 34

Exam: What volume of local anaesthetic are you able to use and what type and concentration is
used?

Question 35

Exam: Suturing / no suturing?

Answer 35

repairs to all grade 3 & 4 tears
perienal repair is undertaken to promote healing by primary intention effective haeomostasis and minimize risk of infectoni

there is limoited evidence re benefit or harm for leaving grade 1 or 2 trauma unsutured

Question 36

Exam: Possible complications - how would you identify these? How are they managed? How
would you frame a conversation with a woman about infection prevention?

Answer 36

• infection risk
• stitches too tight
• increased pain
• ensure keep area clean and dry (do not use a hair dyer to dry the are)
• clean and then pat dry.
• wash hands before and after going to the toilet
• monitor for any increased redness, pain, discharge or generally feeling unwell report to GP or Obgyn
• Ice packs - for 10 mins every two hours
• ensure a good diet high fibre and increase H2O intact or apperients to softer bowel motions
  *

Question 37

Exam: Pain relief - what does the literature say? Does this fit with your experiences in the clinical
setting?

Answer 37

routinley adminstered
diclofenac supps 100mg post repair
regular paracetamol 1g qid
ibuprofen 400mg TDS
Tramadol 50 - 100mg orally qid prn
end ir 5mg qid prn
ice packs and cooling pack always consider
remember opoids can let to conspitation and increase pain during bowel actions and relucencts to open bowels

Question 38

Exam: Information for the woman

Question 39

Exam: Follow up care

Answer 39

All perineal tears
1. Ask about and inspect perineal healing / pain – each shift for 48 hrs
2. Postnatal care (HIPPS1):
* Hygiene- keep clean and dry.
* Ice / cold packs- first 48-72 hours for 10-20 minute intervals3
* Pelvic floor exercises
* Pain relief
* Support- at all times. Give written and verbal information on perineal care
Compression- double pad and firm underwear until swelling resolved.
3. Review by Medical Officer if signs/symptoms of infection, wound breakdown,
inadequate repair, or non-healing
4. Dysuria from labial grazes: Consider urinary alkaliniser, void in shower

3rd & 4th degree tears (See 3rd/4th Degree: Post Repair section) In addition to the above:
1. Infection prevention: Antibiotics and good hygiene
2. IDC: Insert and to remain in situ for minimum 12 hours. Refer to Bladder
Management guideline.
3. Bowel care: Laxatives, healthy diet & adequate fluid intake
4. Referrals: Physiotherapy (& consider dietitian)
5. Comfort / care: Encourage twice daily perineal showers
6. Medications: Avoid rectal suppositories & codeine
7. Follow-up:
* At KEMH Perineal Care Clinic around 12 weeks (additional follow-up organised by the clinic if required)
* Physio will organise a routine follow up at 6 weeks

Question 40

Exam: Implications for next birth

Answer 40

dependant of the degree of tear
discuss concerns with obygn or midwife next pregnancy
have a plan

Question 41

Bulbospongiosus muscle

Answer 41

muscle on each side to the clitoris, urethra and vagina

Question 42

Ischiocavernous muscle

Answer 42

attached to the ischial spines
on proximaside closest to the pelvic bones

Question 43

Superfical transerve perineal muscle

Answer 43

between the vagina and rectum ( before the perineal body)

Question 44

Levator Ani Muscle

Answer 44

between the superfical transerve perinal muscle and the muscle near the coccyx muscle
involves
pubococcygeus aka pubovisceral, pubovaginalis, puboanalis, puborectalis, iliococcygeus)

Question 45

Layer One - Urogenital Triangle

Answer 45

Bulbocavernosus
Ischiocavernosus
Superficial transverse perineal
External anal sphincter