Perineal Tear Flashcards
What is a perineal tear?
A laceration of the skin and other soft tissues which separate the vagina from the anus in women
What is the most common cause of perineal tear?
Childbirth
How common is perineal tear as an obstetric injury?
The most common
What % of women who have a vaginal delivery will have some degree of perineal trauma?
85%
What is the rate of 3rd/4th degree perineal tear in primips having normal vaginalis delivery?
4%
What is the rate of 3rd/4th degree perineal tear in primips having instrumental delivery?
6.9%
What is the rate of 3rd/4th degree perineal tear in multips having spontaneous vaginal delivery?
1.5%
What is the rate of 3rd/4th degree perineal tear in multips having instrumental delivery?
2.5%
Why is vaginal delivery likely to cause perineal trauma?
The head of a term fetus is much larger than the birth canal
How does the fetal head cause perineal tear?
The soft tissues are stretched and compressed causing tearing
What are the risk factors for 3rd/4th degree perineal tear?
- First baby
- Large baby (>4kg)
- Long second stage of labour
- Shoulder dystocia
- Operative vaginal delivery
What are the classifications of perineal tear?
1st - 4th degree
What is a 1st degree perineal tear?
Laceration is limited to fourchette and superficial perineal skin or vaginal mucosa
What is a second degree perineal tear?
Laceration extends to perineal muscles and fascia but not anal sphincter
What is a 3rd degree perineal tear?
Fourchette, perineal skin, vaginal mucosa, muscles and anal sphincter are torn
What can a third degree perineal tear be further subdivided into?
- 3a
- 3b
- 3c
What is a 3a perineal tear?
Partial tear of external anal sphincter involving <50% thickness
What is a 3b perineal tear?
> 50% of external anal sphincter is torn
What is 3c perineal tear?
Internal sphincter is torn
What is a 4th degree perineal tear?
Rectal mucosa is torn
What initial management should all perineal tears receive?
Adequate analgesia
How can adequate analgesia be given for perineal tear?
Topping up epidural or infiltration with local anaesthetic
How are 1st degree perineal tears usually managed?
Usually resolve quickly without treatment
What treatment do 2nd degree perineal tears normally require?
Stitches
What management do 3rd and 4th degree perineal tears require?
Repair in the operating theatre by an experienced obstetric surgeon
How is the perineum repaired following a 3rd or 4th degree perineal tear?
Dissolvable stitches placed between the vagina and anus and underneath the skin
What after care are patients given following a 3rd/4th degree perineal tear?
- Antibiotics
- Laxatives
- Pain relief
What wound care advice should women be given following perineal repair?
- Keep area clean
- If open, smelly, painful or bleeding seek medical attention
- Normal to feel sore for 2-3 weeks
- Urination can sting
- Eat and drink plenty
- Bowel control may not be as good for a few days
- Can have sex when stitches have healed
How can perineal tear be prevented?
- Daily perineal massage from 35 weeks
- Manual perineal protection
- ‘Hands on techniques’
What is annual perineal protection?
HCP supports the perineum as the baby is being born and may reduce risk of 3rd or 4th degree tears
What is a ‘hands on technique’ in delivery?
Fetal head is guided through the vagina at a controlled rate
What are the complications of a 1st/2nd degree perineal tear?
Rarely any
What % of people who have a 3rd/4th degree perineal tear are asymptomatic after 12 months?
60-80%
What are the potential complications of 3rd/4th degree perineal tear?
- Faecal incontinence
- Chronic perineal pain
- Dyspareunia
- Infection
- May aggravate PND
