Episiotomy and perineal tears

Question 1

When should tears be repaired?

Answer 1

Ideally as soon as possible (within 1hr), but mother should be given bonding time with her baby (endorphins from pregnancy give temporary pain relief)

Question 2

What tears can occur as a result of childbirth?

Answer 2

Perineal - Classified according to degree of damage
Labial - common and very painful, but heal quickly; suturing only required if both labia torn and there is a risk of the two fusing

Question 3

What are the degrees of perineal tearing?

Answer 3

First degree - superficial, no damage to muscle; suture unless skin folds well apposed to aid healing
Second degree - involve perineal muscle; repair similar to that of episiotomy
Third degree - damage to anal sphincter
3a - up to 50% of external anal sphincter
3b - greater than 50% of EAC torn
3c - both internal and external sphincters (longitudinal fibres) torn
Fourth degree - damage to anal muscles and tearing of rectal mucosa

Question 4

How are perineal tears repaired?

Answer 4

3rd/4th degree repaired by experienced surgeon, under GA, with intraoperative abx cover
Rectal mucosa repaired first using absorbable suture (apex to mucocutaneous junction)
Muscle interposed
Vaginal mucosa sutured
Internal anal sphincter repaired with interrupted sutures
Overlap and repair severed ends of external anal sphincter
Finally repair skin

Question 5

What is recommended post-op following tears?

Answer 5

(abx prophylaxis for 3rd/4th degree)
High fibre diet/lactulose to avoid constipation for first 10d
Pelvic floor exercise with physio for 6-12w
Follow-up with O&G consultant 6-12w (esp if pain/incontinence, possible referral to GI/gynae for endoanal US/manometry)

Question 6

What is an episiotomy?

Answer 6

Enlargement of vaginal outlet

Question 7

Why are episiotomies performed?

Answer 7

Hasten birth of distressed baby
Instrumental birth
Breech
Prevention of 3rd degree tear (anal tearing not reduced by more episiotomy in normal delivery)

Question 8

How common are episiotomies?

Answer 8

12% England

50% USA

Question 9

What tissues are incised in an episiotomy?

Answer 9

Vaginal epithelium
Perineal skin
Bulbocavernous muscle
Superficial and deep transverse perineal muscles
In large episiotomies, the following may be affected:
-External anal sphincter
-Levator ani
-Ischiorectal fat partially exposed

Question 10

How is an episiotomy performed?

Answer 10

Hold perineal skin away from presenting part of foetus (2 fingers in vagina)
Infiltrate target area with lidocaine 1%
Keeping fingers in introitus, cut mediolaterally toward ischial tuberosity, starting in midline (6 o’clock) to avoid Bartholin’s glands

Question 11

How is an episiotomy performed?

Answer 11

Use resorbable suture e.g. polyglactin 910
In lithotomy position
Repair vaginal epithelium first, from apex to wound edges (using continuous non-locked stitches 1cm apart)
Repair muscles with continuous non-locked technique to obliterate dead space
Close skin with subcuticular stitch
Perform rectal exam to ensure mucosa has not been perforated

Question 12

What problems are associated with episiotomy?

Answer 12

Bleeding
Infection
Breakdown
Haematoma formation
Superficial dyspareunia
Introitus too small (esp if labia minora involved in skin bridge)

Question 13

What can be used for comfort following repair of episiotmy?

Answer 13

Ice packs
Salt baths
Hair dryer to dry perineum
Rectal diclofenac

Question 14

How many women suffer perineal damage (episiotomy or tear)?

Answer 14

60%