Intrapartum Care: Perineal Tears & Post-partum haemorrhage Flashcards
What is a perineal tear?
Where the vaginal opening is too narrow to accommodate the baby.
This leads to the skin and tissues in that area tearing as the baby’s head passes.
Risk factors for perineal tears?
1) primigravida (first births)
2) large babies (>4 kg)
3) precipitate labour (i.e. very rapid)
4) shoulder dystocia
5) forceps delivery
What are the 4 classifications of a perineal tear?
First degree
Second degree
Third degree
Fourth degree
What does a first degree perineal tear involve?
- Injury limited to the frenulum of the labia minora (where they meet posteriorly) and superficial skin.
- No muscle involvement
- Does not require any repair
What does a second degree perineal tear involve?
Injury to the perineal muscle, but NOT involving the anal sphincter.
Require suturing on the ward by a suitably experienced midwife or clinician.
What does a third degree perineal tear involve?
Injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS) but does NOT affect the rectal mucosa.
3a: less than 50% of EAS thickness torn
3b: more than 50% of EAS thickness torn
3c: IAS torn
What does repair of a 3rd degree perineal tear involve?
require repair in theatre by a suitably trained clinician
What does a fourth degree perineal tear involve?
Injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa.
How can 3rd degree perineal tears be further categorised?
3A - less than 50% of the external anal sphincter affected
3B - more than 50% of the external anal sphincter affected
3C - external and internal anal sphincter affected
What additional measures re taken to reduce the risk of complications in perineal tears?
1) Broad spectrum Abx: to reduce risk of infection
2) Laxatives: to reduce risk of constipation and wound dehiscence
3) Physiotherapy: to reduce the risk and severity of incontinence
4) Followup: to monitor for longstanding complications
When would a woman with a perineal tear be ffered an elective caesarean section in subsequent pregnancies?
Women that are symptomatic after third or fourth-degree tears
Short term complications of perineal tears?
- pain
- infection
- bleeding
- would dehiscence or wound breakdown
What are some long term complications of perineal tears?
1) urinary incontinence
2) anal incontinence and altered bowel habit (3rd and 4th degree tears)
3) fistula between vagina and bowel (rare)
4) sexual dysfunction and dyspareunia (painful sex)
5) psychological & mental health consequences
What is an episiotomy?
An episiotomy is where the obstetrician or midwife cuts the perineum before the baby is delivered.
When may an episiotomy be performed?
This is done in anticipation of needing additional room for delivery of the baby (e.g. before forceps delivery).
What anaesthetic is an episiotomy performed under?
Local
How is an episiotomy done?
A cut is made at around 45 degrees diagonally, from the opening of the vagina downwards and laterally, to avoid damaging the anal sphincter.
This is called a mediolateral episiotomy.
The cut is sutured after delivery.
What is one method for reducing the risk of perineal tears?
Perineal massage
What does a perineal massage involve?
It involves massaging the skin and tissues between the vagina and anus (perineum).
This is done in a structured way from 34 weeks onwards to stretch and prepare the tissues for delivery.
What is the 3rd stage of labour?
from the completed birth of the baby to the delivery of the placenta
What are the 2 options for the 3rd stage of labour?
1) physiological management
2) active management
What is physiological management of the 3rd stage of labour?
Where the placenta is delivered by maternal effort without medications or cord traction.
What is active management of the 3rd stage of labour?
Where the midwife or doctor assist in delivering of the placenta.
1) IM oxytocin to help uterus contract
2) Careful traction to the umbilical cord to guide the placenta out of the uterus and vagina
What drug is given for active management of the 3rd stage of labour involve?
IM oxytocin
Benefits vs disadvantages of active management of 3rd stage of labour?
Benefit:
- shortens the 3rd stage
- reduces risk of bleeding
Disadvantages:
- N&V
Who is active management of 3rd stage of labour offered to?
All women to reduce risk of postpartum haemorrhage.
Main benefit of active 3rd stage of labour?
Reduced risk of postpartum haemorrhage.
In what 2 scenarios is active management of 3rd stage of labour initiated?
1) haemorrhage
2) more than a 60-minute delay in delivery of the placenta (prolonged third stage)
When is IM oxytocin given in active management of 3rd stage of labour?
After delivery of baby
Steps in active management of 3rd stage of labour
1) IM dose of oxytocin after delivery of baby
2) The cord is clamped and cut within 5 minutes of birth.
3) The abdomen is palpated to assess for a uterine contraction before delivery of the placenta.
4) Controlled cord traction is carefully applied during uterine contractions to help deliver the placenta, stopping if there is resistance
5) At the same time the other hand presses the uterus upwards (in the opposite direction) to prevent uterine prolapse.
6) After delivery the uterus is massaged until it is contracted and firm.
7) The placenta is examined to ensure it is complete and no tissue remains in the uterus.
When should cord be clamped after delivery?
Within 5 minutes of birth BUT there should be a delay of 1 – 3 minutes between delivery of the baby and clamping of the cord to allow blood to flow to the baby (unless the baby needs resuscitation).
What is postpartum haemorrhage (PPH)?
Bleeding after delivery of the baby and placenta.
What is the most common cause of significant obstetric haemorrhage?
PPH
What is PPH defined as?
The loss of :
- 500ml blood after a vaginal delivery
- 1000ml blood after a caesarean section
PPH can be classified into minor and major.
What defines a minor PPH?
<1000ml blood loss
What defines a major PPH?
> 1000ml blood loss
Major PPH can be further sub-classified as:
a) moderate
b) severe
What blood loss defines each?
a) mod: 1000-2000ml blood loss
b) severe: >2000ml blood loss
PPH can be categorised as primary and secondary.
Define 1ary PPH
Bleeding within 24 hours of birth
Define 2ary PPH
From 24 hours to 12 weeks after birth
What are the 4 major causes of 1ary PPH? (4 T’s)?
T - Tone (uterine atony - the most common cause)
T - Trauma (e.g. a perineal tear)
T - Tissue (retained placenta)
T - Thrombin (bleeding disorder)