[43] Perineal Tear

Question 1

What is a perineal tear?

Answer 1

A laceration of the skin and other soft tissues which separate the vagina from the anus in women

Question 2

What is the most common cause of perineal tear?

Answer 2

Childbirth

Question 3

How common is perineal tear as an obstetric injury?

Answer 3

The most common

Question 4

What % of women who have a vaginal delivery will have some degree of perineal trauma?

Answer 4

85%

Question 5

What is the rate of 3rd/4th degree perineal tear in primips having normal vaginalis delivery?

Answer 5

4%

Question 6

What is the rate of 3rd/4th degree perineal tear in primips having instrumental delivery?

Answer 6

6.9%

Question 7

What is the rate of 3rd/4th degree perineal tear in multips having spontaneous vaginal delivery?

Answer 7

1.5%

Question 8

What is the rate of 3rd/4th degree perineal tear in multips having instrumental delivery?

Answer 8

2.5%

Question 9

Why is vaginal delivery likely to cause perineal trauma?

Answer 9

The head of a term fetus is much larger than the birth canal

Question 10

How does the fetal head cause perineal tear?

Answer 10

The soft tissues are stretched and compressed causing tearing

Question 11

What are the risk factors for 3rd/4th degree perineal tear?

Answer 11

• First baby
• Large baby (>4kg)
• Long second stage of labour
• Shoulder dystocia
• Operative vaginal delivery

Question 12

What are the classifications of perineal tear?

Answer 12

1st - 4th degree

Question 13

What is a 1st degree perineal tear?

Answer 13

Laceration is limited to fourchette and superficial perineal skin or vaginal mucosa

Question 14

What is a second degree perineal tear?

Answer 14

Laceration extends to perineal muscles and fascia but not anal sphincter

Question 15

What is a 3rd degree perineal tear?

Answer 15

Fourchette, perineal skin, vaginal mucosa, muscles and anal sphincter are torn

Question 16

What can a third degree perineal tear be further subdivided into?

Answer 16

• 3a
• 3b
• 3c

Question 17

What is a 3a perineal tear?

Answer 17

Partial tear of external anal sphincter involving <50% thickness

Question 18

What is a 3b perineal tear?

Answer 18

> 50% of external anal sphincter is torn

Question 19

What is 3c perineal tear?

Answer 19

Internal sphincter is torn

Question 20

What is a 4th degree perineal tear?

Answer 20

Rectal mucosa is torn

Question 21

What initial management should all perineal tears receive?

Answer 21

Adequate analgesia

Question 22

How can adequate analgesia be given for perineal tear?

Answer 22

Topping up epidural or infiltration with local anaesthetic

Question 23

How are 1st degree perineal tears usually managed?

Answer 23

Usually resolve quickly without treatment

Question 24

What treatment do 2nd degree perineal tears normally require?

Answer 24

Stitches

Question 25

What management do 3rd and 4th degree perineal tears require?

Answer 25

Repair in the operating theatre by an experienced obstetric surgeon

Question 26

How is the perineum repaired following a 3rd or 4th degree perineal tear?

Answer 26

Dissolvable stitches placed between the vagina and anus and underneath the skin

Question 27

What after care are patients given following a 3rd/4th degree perineal tear?

Answer 27

- Antibiotics - Laxatives - Pain relief

Question 28

What wound care advice should women be given following perineal repair?

Answer 28

- Keep area clean - If open, smelly, painful or bleeding seek medical attention - Normal to feel sore for 2-3 weeks - Urination can sting - Eat and drink plenty - Bowel control may not be as good for a few days - Can have sex when stitches have healed

Question 29

How can perineal tear be prevented?

Answer 29

- Daily perineal massage from 35 weeks - Manual perineal protection - ‘Hands on techniques’

Question 30

What is annual perineal protection?

Answer 30

HCP supports the perineum as the baby is being born and may reduce risk of 3rd or 4th degree tears

Question 31

What is a ‘hands on technique’ in delivery?

Answer 31

Fetal head is guided through the vagina at a controlled rate

Question 32

What are the complications of a 1st/2nd degree perineal tear?

Answer 32

Rarely any

Question 33

What % of people who have a 3rd/4th degree perineal tear are asymptomatic after 12 months?

Answer 33

60-80%

Question 34

What are the potential complications of 3rd/4th degree perineal tear?

Answer 34

- Faecal incontinence - Chronic perineal pain - Dyspareunia - Infection - May aggravate PND