Perineal Repair Flashcards
what are the 6 layers of tissue of the pelvic floor?
*Pelvic peritoneum
*Visceral layer of fascia thickened to form pelvic ligaments which support the uterus
*Deep muscles encased in facia
*Superficial muscles encased in facia
*Subcutaneous fat
*skin
What is the structure and function of the pelvic floor?
*Its muscles are arranged in two layers: superficial and deep
*It supports and maintains the anatomical position of the internal female reproductive organs
*It provides voluntary muscle control for micturition and defecation (pooing)
*It facilitates birth by resisting decent of presenting part, forcing rotation, allowing birth to happen
what are the superficial muscles?
ischiocavernosus, bulbcavernosus (bulbospongiosus in the second diagram) and transverse perineal muscles, the external anal sphincter and external urethral meatus (or sphincter).
what are the deep muscle layer?
deep muscle layer (called the levator ani) provide strength and are made up of three pairs of muscles: pubococcygeus, iliococcygeus, ischiococctgeus (coccygeus in the second diagram).
Pelvic floor damage can have many consequences on the lower urinary tract?
*Urinary incontinence
*Urgency and frequency
*Slow or intermittent stream and straining
*Feeling of incomplete emptying
what is the Pelvic floor damage can have many consequences on the bowel?
*Obstructed defecation
*Functional constipation
*Faecal incontinence
*Rectal/anal prolapse
what is the Pelvic floor damage can have many consequences on the vaginal?
*Pelvic organ prolapse
what is the Pelvic floor damage can have many consequences on pain?
*Chronic pelvic pain
*Pelvic pain syndrome
what is the Pelvic floor damage can have many consequences on sexual function?
*Dyspareunia (painful sexual intercourse)
*Orgasmic dysfunction
what is the vestibule?
The vestibule is the part of the vulva between the labia minora into which the urinary meatus and vaginal opening open. It is almost like “the wall” between the 2 labial minora.
what is the fourchette?
The fourchette. This is a very important landmark in perineal repair. It marks the end of the vaginal wall suturing and where you should start the suturing of the muscle.
what is the labia minora?
It is a very important landmark in perineal repair. Labial tears or grazes are common and it is a very sensitive area.
Labial tears or grazes are common and it is a very sensitive area. The labia minora joins at the clitorial hood, but the hood (also known as prepuce) is the skin that covers the head of the clitoris
what is the perineal body?
is the space directly between the end of the vulva and the anus. It is where the perineal muscles are located. If you do not repair this correctly, it can lead to multiple pelvic floor problems.
what is the hymenal remnants?
They are visible at both sides of the introitus. They are like small “flaps” of tissue, like extra skin in the area. However, you do not need to bring these together when suturing. It is part of the tissue that remains after the hymen broke. It will help you locate when you are reaching the vaginal opening and almost at the fourchette.
what are the landmarks in the process of perineal repair?
- Locate the apex of the tear (where the tear starts)
- Suture the vagina wall until you reach the hymenal remnants.
- By approximating edges of the vaginal opening, you form the fourchette. This marks the end of your vaginal wall suturing.
- Then, repair the muscles to form the perineal body
- Repair the skin.
Apex of the tear - hymenal remnants - fourchette - perineal body (muscles) - skin
summary of performing a perineal repair?
- Identify the level of trauma and what muscles are involved.
- Get the anchor stitch 1 cm above the apex (first stitch)
- Then a continuous stitch down the vaginal wall up until where your hymenal remnants are.
- At this point you want to bring the hymenal remnants together but not sutured.
- If they hymenal remnants align then you have done the posterior wall correctly.
- Second part - perineal muscles which is another continuous stitch. You might need to do two layers to get the skin together.
- Once you get to the bottom you then do sub particular back up to the hymenal remnants. Unless the women has very frail tissue.
what is a first degree tear?
affecting the external skin or vaginal wall, but with intact perineal muscles
what is a second degree tear?
ffecting perineal muscles but not the anal sphincter
what is a third degree tear?
affecting the anal sphincter complex, with two types
what is a 3A tear?
less than 50% of the external anal sphincter is torn
what is a 3B tear?
more than 50% of the external anal sphincter is torn
what is a 3C tear?
when both internal and external anal sphincter are torn
what is a fourth degree tear?
the anal sphincter is completely torn, affecting the anal epithelium too
what are episiotomy indications?
Episiotomy should only be performed under very restricted situations, and always after gaining the woman´s consent and ensuring adequate analgesia is in place.
Episiotomy indications are:
* Instrumental birth
* To expedite birth due to fetal distress (only if head crowning)
when is the ritgen manoeuvre practiced?
the hands are placed in the perineum from the moment the head is crowning (when the size of head visible is similar to the palm of your hand).
how is the ritgen manoeuvre performed?
dominant hand is placed in the perineum, with the thumb and index applying gentle traction on both sides of the perineum, not on the fourchette.
Your other hand is placed on the head, to slow down the extension of the head in an attempt to prevent trauma in the anterior part of the vulva.
how do you perform an episiotomy?
- To insert the local anaesthetics you should vision the line of the episiotomy.
- insert two fingers into the vaginal to protect fetal head.
- Using the syringe insert the needle at the fourchette 4-5 cm deep.
- Pull back on the syringe to ensure you get no blood flashback
- As you withdraw the needle insert the anaesthetic
- Before fully withdrawing the needle, either side of the initial infiltration insert the rest of the anaesthetic. Making it more effective.
- The medial lateral technique is recommended, which is at an angle of 60 degrees away from the midline. Anything less may cut through anal.
how do you apply a warm compress?
ds
what is perineal massage?
Women are recommended to start this from 34-35 weeks, but keep in mind that this should NOT be performed by the midwife during the second stage of labour. Please note that only water-based lubricants are recommended. There are lots of oils and products in the market for perineal massage, but we do not have enough evidence to support those claims.
what are the 2 main suturing techniques?
- Continous non-locking for vaginal wall and muscle layer
Continous subcutaneous for the skin
what are the two type of knots used in suturing?
- At the apex, using a surgical square knot
At the end, using an Aberdeen knot
what is first degree tear disruption of?
perineal skin or lining of the vagina
what is second degree tear disruption of?
perineal skin or lining of vagina
perineal muscles