Lacerations

Question 1

4 degrees of lacerations?

Answer 1

1st degree: fourchette, perineal skin and vaginal mucosa (no muscle involvement)
2nd degree: above + muscles of perineal body BUT NOT the anal sphincter
3rd degree: extends into anal sphincter
4th degree: through rectal wall (w/or w/o sphincter involvement)

Question 2

7 predisposing factors for a laceration?

Answer 2

rapid, sudden expulsion of head
posterior presentation
size of baby
instrumentation
friable maternal tissues
exaggerated lithotomy position
outlet contraction of pelvis

Question 3

7 ways to prevent lacerations?

Answer 3

slow head delivery
kegel exercises before
perineal support/counterP
head flexion of baby
good PN nutrition
warm compresses if no excess swelling
perineal massage prior

Question 4

5 reasons why it might be a good idea to suture lacerations?

Answer 4

1. makes pt more comfortable
2. restores anatomical integrity
3. decreases infxn and increases wound healing
4. decrease PP blood loss
5. restore cosmetic appearance

Question 5

topical anesthetics to use? what size syringes? what size and type of needles? what type of suture?

Answer 5

topically: lidocaine gel, cetacain
lidocaine w/or w/o EPI, bupivocaine
syringes: 3 cc and 10 cc
needles: 25, 27, 30 gauge; 0.5-1.5 inch; taper is ideal
suture: absorbable

Question 6

problems with superficial laceration closures?

Answer 6

have been shown to increase incidence of perineal pain at 3 mos post delivery

Question 7

problems with repair of 3rd/4th degree tear?

Answer 7

20-50% report anal incontinence or rectal urgency after repair

Question 8

between median vs mediolateral:
which is easier to repair?
which has less faulty healing?
which has more pain in the perineum afterwards?
which is more likely to result in dyspareunia?
which results in less blood loss?
which one is common to extend?

Answer 8

easier to repair: median
less faulty healing in median (more faulty healing in mediolateral)
mediolateral is more likely to have perineum afterwards
mediolateral is more likely to have assoc dyspareunia
median results in less blood loss
median is more likely to extend to the anal sphincter

Question 9

what are the guiding principles to cutting an episiotomy?

Answer 9

protect presenting part of the fetus
single cut is preferred over multiple cuts as these edges can become jagged
should be large enough to accomplish purpose for cutting it
cut should be timed so as to avoid lacerations and unnecessary blood loss
perineum should be bulging
delivery of presenting part should be expected to occur w/in next 2-4 contractions post episiotomy

Question 10

how to cut a median episiotomy?

Answer 10

place index and middle finger in vagina, palmar side down and facing you
separate fingers slightly and push outwardly on perineum
place blades of scissors up and down position w/perineum b/w
palpate for external anal sphincter
adjust blades to correct length
cut
sponge, observe and palpate again for anal sphincter
extend if need either externally down the perineum or intravaginally
apply pressure w/4x4 sponges to the incision

Question 11

how to perform a mediolateral episiotomy

Answer 11

same as median but start at midline perineum and cut towards ischial tuberosity
avoid bartholin’s gland and anal sphincter

Question 12

when do cervical lacerations occur?

Answer 12

most often occur dt birth through an incompletely dilated os

Question 13

with profuse hemorrhage in 3rd stage of labor what should you suspect?

Answer 13

cervical laceration

Question 14

how to care for the perineum PP?

Answer 14

ice packs immediately
wash w/peri bottle after every BM and void
homeopathy
sitz baths: garlic, warm saline water, comfrey, uva ursi, calendula
kegel exercises