Perineal trauma

Question 1

When do perineal tears occur?

Answer 1

External vaginal opening too narrow to accomodate the baby

Question 2

When are perineal tears more common? /risk factors

Answer 2

First births (nulliparity)
Large babies (>4kg)
Shoulder dystocia
Asian ethnicity
Occipito-posterior postiion
Instrumental deliveries

Question 2

When are perineal tears more common? /risk factors

Answer 2

First births (nulliparity)
Large babies (>4kg)
Shoulder dystocia
Asian ethnicity
Occipito-posterior postiion
Instrumental deliveries

Question 3

Degrees of perinneal tear

Answer 3

First to fourth

Question 4

What is a first degree perinneal tear

Answer 4

Injury limited to frenulum of labia minora - where meet posteriorly and superficial skin

Question 5

Second degree perineal tear

Answer 5

Incl perineal muscles but not anal sphincter

Question 6

THird degree perineal tear

Answer 6

Incl anal sphincter but nnot affecting rectal mucosa

Question 7

Fourth degree perineal tear

Answer 7

incl rectal mucosa

Question 8

How are third degree tears subcategorised?

Answer 8

3A
3B
3C

Question 9

What is 3A perineal tear?

Answer 9

3A - <50% of external anal sphincter affeted

Question 10

3B vs 3C perineal tear

Answer 10

3B - >50% of external anal sphoncter affected
3C - extermal and internal anal sphincter affected

Question 11

When are sutures required in perineal tears?

Answer 11

Anything over first degree tears

Question 12

What tears need theatre reparing?

Answer 12

third and fourth degree

Question 13

What additional measires are taken to reduce risk of complications of tears?

Answer 13

Broad spectrum antibiotics - reduce rusk of infections
Laxatives - constipation and wound dehiscience
Physiotherapy - reduce risk and severity incontinence
Follow up - monitor for longstanding complications

Question 14

When are women offered C section after tears?

Answer 14

3rd or 4th degree tears that cause symptoms

Question 15

Short term complications after repair of tears

Answer 15

Pain
Infection
Bleeding
Wound dehiscene or wound breakdonw

Question 16

Lasting compliations of perineal tears?

Answer 16

Urinary incontinence
Anal incontinence and altered bowel habit (3rd and 4th degree)
Fistula between vagina and bowel
Sexual dysfunction and dyspareunia
Psychological and mental hekth consequences

Question 17

What is an episiotomy

Answer 17

Cutting the perineum in preparation for need for wider delivery eg instrumental with local anaesthetic

Question 18

How is an episiotomy done

Answer 18

Cut 45 degrees diagonally from opening vagina down and laterally
Avoid damaging anal sphincter
Mediolateral episiotomy

Question 19

What is perineal massage and when is it done

Answer 19

Reducing risk of perineal tears
Massaging the skin and tissues between vagina and anus - perineum
Done in a structured way from 34 weeks to stretch and prepare tissues for delivery