Episiotomy and perineal trauma

Question 1

Episiotomy indications

Answer 1

Fetal distress
Head is not passing over the perineum despite maternal effort
Large tear likely

Question 2

Classifications of perineal trauma

Answer 2

1st degree: Injury to skin only
2nd degree: Involving perineal muscles but not anal sphincter
Episiotomy: Equivalent to second degree but may extend to third/fourth
Third degree: Involving anal sphincter complex (3a 50%; 3c also internal)
Fourth degree: Involving anal sphincter and anal epithelium

Question 3

Management of 1st and 2nd degree tears and episiotomies without anal sphincter damage

Answer 3

Suture under local anaesthetic

Question 4

Risk factors for 3rd and 4th degree tears

Answer 4

Forceps delivery
Large babies
Nulliparity

Question 5

Management of 3rd and 4th degree tears

Answer 5

Repair under epidural or spinal anaesthetic in operating theatre
Antibiotics, laxatives and analgesia given
Physiotherapy assessment
Up to 30% of women have long term sequelae (urgency, incontinence of flatus, frank incontinence)