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Labour > Perineal Trauma > Flashcards

Perineal Trauma Flashcards

1
Q

What are antenatal risk factors for OASIS injury?

A

Asian ethnicity, RR 2.3
Nulliparity, RR 7
BW > 4kg, RR 2.3
Short perineal length <=2.5 cm

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2
Q

What are intrapartum risk factors for OASIS injury?

A

Prolonged second stage, RR 1.5-2 (depending on how prolonged)
OP position, RR 2.4
Instrumental delivery

Shoulder dystocia, RR 1.9

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3
Q

Use of ____ is recommended for 10/7 following the repair of an OASI injury

A

Stool softeners

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4
Q

If a woman suffers an OASI injury in her first pregnancy, what is the risk of suffering from one in subsequent pregnancies?

A

5-7%

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5
Q

What are the risks of subsequent vaginal delivery after OASI?

A

17% women develop worsening faecal symptoms after a second vaginal delivery

This seemed to occur if there had been faecal incontinence beyond 3 months but resolution by 6 months after the index delivery

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6
Q

How is a 4th degree perineal tear repaired?

A

Anorectal mucosa: interrupted sutures with the knot tied within the anal canal. 3/0 Vicryl
IAS: interrupted or mattress sutures WITHOUT overlapping. 3/0 PDS Monofilament OR 2/0 Vicryl
EAS: Either overlapping or end-to-end can be used with equivalent outcomes (no difference in outcomes in a Cochrane Review) 3/0 PDS Monofilament OR 2/0 Vicryl

Figure of 8 sutures should be avoided as they can cause tissue ischaemia

RCOG Guideline

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7
Q

12 months after EAS repair (OASI), how many women are asymptomatic?

A

60-80%

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8
Q

What is the description of a Grade 1 perineal injury

A

Perineal skin and/or vaginal mucosa

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9
Q

What is the description of a Grade 2 perineal injury

A

Perineal muscles

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10
Q

What is the description of a Grade 3a perineal injury

A

<50% external anal sphincter thickness

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11
Q

What is the description of a Grade 3b perineal injury

A

> 50% external anal sphincter thickness

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12
Q

What is the description of a Grade 3c perineal injury

A

Internal anal sphincter

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13
Q

What is the description of a Grade 4 perineal injury

A

Anorectal mucosa

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14
Q

What is the description of a rectal buttonhole tear?

A

Affects anorectal mucosa but the internal anal sphincter is intact.

NB: If not recognised correctly, can result in a Rectovaginal fistula

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15
Q

When does a mediolateral episiotomy have a protective effect against OASIS injuries?

A

In the context of instrumental deliveries

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16
Q

What are the four steps to perineal protection

A
  1. Left hand slowing down the delivery of the head
  2. Right hand protecting the perineum
  3. Mother not pushing when the head is crowning
  4. Think about episiotomy

I.e. HANDS ON

17
Q

What were the Cochrane findings, of the review looking at warm compresses and the rate of OASI injury?

A

Warm compresses reduced the rate of OASI injury

18
Q

What is the definition of anal incontinence?

A

Involuntary loss of flatus / faeces affecting quality of life

RCOG

19
Q

What type of muscle does the IAS consist of?

Is it under voluntary or involuntary control?

A

Smooth muscle
Circular
Involuntary control (autonomic: myenteric and gut wall complexes)

20
Q

What type of muscle does the EAS consist of?

Is it under voluntary or involuntary control?

A

Striated
Skeletal muscle
Voluntary control

21
Q

Which nerve innervates the EAS?

A

Pudendal nerve

Nerve roots S2-4

22
Q

What three muscles make up the levator ani?

A

Puborectalis
Iliococcygeous
Pubococcygeous

23
Q

What is the “normal” length of the perineal body?

A

2.5cm (RCOG)

Average (median) 3.9 according to OASIS course

24
Q

What is the definition of anal urgency?

A

Inability to defer defecation for more than 15 minutes

25
Q

What were the findings of the Cochrane Review looking at continuous vs interrupted suturing techniques for repair of epis / 2nd degree tears?

A

Continuous suturing techniques associated with less

  • short term pain
  • need for analgesia
  • suture removal
26
Q

What was the finding of the Cochrane Review looking at Antibiotic prophylaxis for 3rd and 4th degree tears

A

Suggest that prophylactic antibiotics help to prevent perineal wound complications
Loss to follow up was high so caution required

27
Q

Which sphincter is responsible for most of the anal tone?

A

Internal anal sphincter

70-80%

28
Q

What is the length of the total anal sphincter complex?

A

2.5cm

29
Q

What is anal continence maintained by?

A

Rectum: provides compliance and sensation
Ano-rectal angle
IAS: passive barrier to leakage
EAS: physic contractions
Anal mucosal folds / cushions: provide pads to completely close anus, 15% resting tone

30
Q

What is the incidence of OASI?

A

3%

31
Q

What % of repaired OASI have residual EAS defects?

A

20-35%

32
Q

What muscles are cut with a mediolateral episiotomy?

A

Transverse perineal muscles

Bulbocavernosus muscles

Labour (12 decks)

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