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Appreciating Complex Midwifery Care > Perineal Trauma > Flashcards

Perineal Trauma Flashcards

1
Q

How many women ensure some degree of trauma during childbirth?

A
  • 85%

- 69% require repair

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2
Q

What is a 1st degree tear?

A

Injury to perineal skin and/or vaginal mucosa only

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3
Q

What is a 2nd degree tear?

A

Injury to perineal muscles excluding the anal sphincter

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4
Q

What is a 3rd degree tear?

A

Trauma involving the anal sphincter:
3a - <50% of external anal sphincter
3b - >50% of EAS torn
3c - both the EAS and internal anal sphincter torn

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5
Q

What is a 4th degree tear?

A

Injury to the anal sphincter complex and extends into the rectal lumen through the rectal mucosa

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6
Q

What do EAS and IAS stand for?

A

External and Internal Anal Sphincter

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7
Q

What can the anal sphincter muscle do?

A
  • Differentiate between solid, liquid and gas
  • Can tell whether the person is alone or with someone
  • Can tell whether the person is standing up or sitting down
  • Can tell whether the person has their pants on or off
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8
Q

What are the risk factors for anal sphincter injuries?

A
  • Nulliparity
  • Maternal age >25
  • Asian ethnicity
  • FGM
  • BMI <25
  • BW >4kg
  • Precipitate 2nd stage
  • Shoulder dystocia
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9
Q

What does OASI stand for?

A

Obstetric Anal Sphincter Injury

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10
Q

What are the effects of OASI?

A
  • Incontinent of flatus
  • Incontinent of faeces
  • Urgency when toileting
  • Experience pain
  • Sexual problems
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11
Q

How should OASI be managed?

A
  • Diagnose asap
  • Dedicated consultant OASI clinic appt
  • Seen as 16 weeks PN
  • Physiotherapy
  • Consistent care and advice
  • Correct medication (lactulose)
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12
Q

What are some common allegations that are made?

A
  • Failure to consider to CS
  • Failure to perform/ extend the episiotomy
  • Failure to diagnose the true extent and grade of the injury including failure to perform rectal examination
  • Inadequate post-repair management
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13
Q

What are the 3 types of episiotomy?

A 
Medial = straight down the midline from the vagina to the anus
Mediolateral = between the midline and the lateral line
Lateral = perpendicular to the midline
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14
Q

How are most episiotomies in the UK performed?

A

Mediolaterally towards the woman’s right hand side

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15
Q

What are the main indications for episiotomy?

A
  • Tight perineum causing poor progress
  • Allow more space for instrumental deliveries
  • Prevent damage during face/breech presentation
  • Shorten 2nd stage of labour for foetal distress/ maternal medical condition
  • FGM
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16
Q

What is buttonholing?

A

When the perineum is pulled so tight that holes appear; if these holes are near the anal sphincter, an episiotomy should be performed

17
Q

Why is timing important?

A

Too early = the PP will not be pressing on the perineum and will not have displaced the levator ani (deep muscles)

18
Q

What are the first 6 steps for the procedure?

A
  1. Draw up 10ml of lidocaine (0.5%) using ANTT
  2. Insert 2 fingers into the vagina behind the perineum to protect the PP
  3. Insert needle fully
  4. Draw back to ensure not in blood vessels
  5. Inject 1/3 of anaesthetic whilst withdrawing needle
  6. As introitus is reached, reposition need and re-insert
19
Q

What is the introitus?

A

The opening of the vagina

20
Q

What are the final 4 steps for the procedure?

A
  1. Allow time for lidocaine to take effect
  2. Re-insert 2 fingers into the vagina along the proposed incision line
  3. Make a single decisive cut at an angle of 45-60 during a contraction
  4. Apply control to foetal head, remove scissors, guard perineum and slowly deliver head
21
Q

What should be done if the head is not immediately delivered following an episiotomy?

A

Apply pressure to the episiotomy site between contractions to reduce bleeding

22
Q

How can perineal trauma be minimised?

A
  • Perineal massage (Myles)
  • Birthing positions (Myles)
  • Hands on
  • Warm compresses to perineum during 2nd stage (Myles)
  • Episiotomy at 60 degree angle
23
Q

What does PEACHES stand for?

A 
P = position
E = extra midwife
A = assess the perineum
C = communication
H = hands-on technique
E = episiotomy (if req.)
S = slowly
24
Q

What are the best positions for reducing the risk of perineal trauma?

A

Left lateral, kneeling or semi-recumbent

25
Q

How should the perineum be checked for trauma?

A
  • Use a bright light
  • Examine vulva from clitoris to anus (laterally paraclitoral, paraurethral, paravaginal and pararectal skin and muscles)
  • Examine in rectum
26
Q

How is a bi-digital anal sphincter assessment done?

A
  • Insert right index finger into anal canal at the same time as inserting left forefinger/ right thumb into vagina
  • Use ‘pill-rolling’ motion

Appreciating Complex Midwifery Care (14 decks)

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