Perineal tears

Question 1

What are 4 risk factors for perineal tears?

Answer 1

• primigravida
• large babies
• precipitant labour
• shoulder dystocia
• forceps delivery

Question 2

Define a first degree perineal tear. What is the management?

Answer 2

superficial damage with no muscle involvement

do not require any repair

Question 3

Define second degree perineal tear. What is the management?

Answer 3

injury to the perineal muscle, but not involving the anal sphincter

require suturing on the ward by a suitably experienced midwife or clinician

Question 4

Define third degree perineal tear. What are the subtypes? What is the management?

Answer 4

injury to perineum involving the anal sphincter complex (external anal sphincter, EAS and internal anal sphincter, IAS)

• 3a: less than 50% of EAS thickness torn
• 3b: more than 50% of EAS thickness torn
• 3c: IAS torn

require repair in theatre by a suitably trained clinician

Question 5

Define fourth degree perineal tear. What is the management?

Answer 5

injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa

require repair in theatre by a suitably trained clinician

Question 6

What are the short-term and long-term complications associated with perineal tears?

Answer 6

• Pain
• Infection - BUT infections of the perineum are surprisingly uncommon considering the risk of bacterial contamination during delivery so any signs of infection must be taken seriously. Risk of NF.
• Abscess - shoudl be drained
• Spontaneous opening of the wound - should not be closed again as this is usually caused by secondary infection
• If damage to IAS/EAS - may casuse problems with continence

Question 7

What advice can be given to mothers who have had perineal tears?

Answer 7

Pain management:

• local cooling (with crushed ice, witch hazel or tap water)
• topical anaesthetics e.g. % lignocaine gel, provide short-term symptomatic relief.
• regular paracetamol - most effective
• diclofenac- rectally or orally may also be added.
• Avoid: codeine - cause constipation in the mother and drowsiness in some breastfed babies.

Prevent infection

• daily cleaning or showering using tap water only, and with frequent changing of sanitary pads.
• signs of infection (redness, pain, swelling and heat), especially with a raised temperature - admit to hospital for swabs and broad-spectrum antibiotics

Question 8

How are third and fourth degree tears managed?

Answer 8

• Repaired in theatre by trained doctor - under general or regional anaesthesia. Local anaesthesia does not allow relaxation of the sphincter enough for satisfactory repair.

Aftercare:

• Lactulose and bulking agent - 5-10 days + remain in hospital until after first bowel motion
• Broad spectrum antibiotic - 5-7 days
• MDT approach - physiotherapy may be required
• Follow up once discharged and at 6-12 weeks for full evaluation of symptoms

Question 9

How common are perineal tears?

Answer 9

Of women who have a vaginal delivery, 85% will have some degree of perineal trauma and 60–70% will require suturing