Perineal Trauma And Repair

Question 1

What are the percentage of perineal trauma for primions and Multips?

Answer 1

Primips 90%
Multips 70 %

Question 2

What does a second degree tear effect?

Answer 2

Superficial transverse perineal muscle
Bulbocavernosus muscle

Question 3

What does a third degree additionally effect?

Answer 3

External anal sphincter

Question 4

What does the 4th degree additionally effect

Answer 4

In eternal anal sphincter
Rectal mucosa

Question 5

What is the definition of a first degree tear according to RCOG ‘15

Answer 5

Injury to perineal skin and or vaginal mucosa

Question 6

What is the definition of a Second degree tear according to RCOG ‘15

Answer 6

Injury to perineum involving perineal muscles but not involving the anal sphincter.

Question 7

What is the definition of a third degree tear according to RCOG ‘15

Answer 7

Injury to perineum involving the anal sphincter complex.

Question 8

What is the definition of a 3a degree tear according to RCOG ‘15

Answer 8

Less than 50% of external anal sphincter (EAS) thickness torn.

Question 9

What is the definition of a 3b degree tear according to RCOG ‘15

Answer 9

More than 50% of EAS thickness torn.

Question 10

What is the definition of a f3c degree tear according to RCOG ‘15

Answer 10

Both EAS and internal anal sphincter (IAS) torn.

Question 11

What are the holistic effects of having tear repair

Answer 11

Increase perinatal MH
Can effect sexual health and family planning (feeling)

Question 12

What is the definition of a fourth degree tear according to RCOG ‘15

Answer 12

Injury to perineum involving the anal sphincter complex (EAS + IAS) and anorectal mucosa.

Question 13

What are some risk factors for having a tear?

Answer 13

Asian ethnicity
Instrumental birth
Primiparity
Foetal birth weight >4kg
Shoulder dystocia
Prolonged second stage
Malposition
Age
Tissue type
Nutritional type
Position.

Question 14

What is meant by an episiotomy?

Answer 14

A surgical incision on the perineum made to increase the diameter of the vulval outlet (and likely expedite birth)
The fourchette, perineum and perineal body are involved ( the same as a second degree tear).

Question 15

What are epicissors-60 used for

Answer 15

Surgical scissors used for episiotomy and a designated to achieve a medico lateral cut at 60 degrees to the perineal midline to minimise the risk of obstetric anal sphincter injuries.

Question 16

What is the midwife role to assessing tear?

Answer 16

Following the 3rd stage of labour
Assessment of perineum-skin/muscle
Assessment of vaginal wall
Assessment of the anal sphincter

Question 17

Equipment needed for perineal repair

Answer 17

Sterile gloves
Swabs
Water (and receptacle)
Analgesia?
Inco sheet
Light
Lubricant? (For anal examination)
Lithotony?

Question 18

What is the aim of perineal repair?

Answer 18

Haemostatisis
Minimise bleeding
Reduce risk of infection
Assist healing through primary intention and correct anatomical alignment
Maintaining overall integrity of the pelvic floor.

Question 19

How do you prepare the woman for perineal repair?

Answer 19

Clear explanation and rationale of plan and procedures
Test and confirm analgesia is sufficient before proceeding
Position the woman so she is comfortable
Clear visual access to identify extent of trauma and structures involved
Identifying the apex and bleeding vessels
Rectal examination to exclude damage to the external and internal anal sphincter
Explanation of findings and procedures undertaken.

Question 20

What are the basic surgical skills needed for perineal repair?

Answer 20

Types of surgical instruments
Handling of instruments
Positioning and guarding the needle
Surgeons square knot
Insertion of continuous subcutaneous sutures
The Aberdeen knot.

Question 21

Instruments needed for repair?

Answer 21

Needle holder
Dissecting forceps
Scissors
Suture material

Question 22

What are the basic principles for handling surgical instruments?

Answer 22

Safety
Economy of movement
Relaxed handling
Avoid awkward movement.

Question 23

What should the position of the needle be?

Answer 23

Last 1/3 of the needle (the part closest to thread)
At the right angle to the curve of the needle
Grasp the needle securely
Backhand or forehand position to the left or right of the holder

Question 24

What is meant by the guarding of the needle and how is this done?

Answer 24

Rotate teh needle backwards
Length and tip of the needle lie towards the centre of the needle holder
Ensure sharp tip is protected.

Question 25

What is the first stage of the surgeons square knot?

Answer 25

• Instruments Positioned in the ‘V’ shape of the suture material
• Wrap the left hand twice around the forceps in clockwise dirction
• Short end of material on the right-hand side with the forceps
• Pull it tight, crossing the hands
• Make sure it lies flat

Question 26

What is the second stage of the surgeons square knot?

Answer 26

• Keep the Instrument in the
‘V’ shape of the suture material
• Reverse the direction of the suture material
• Wrap the right-hand once around the forceps in anti-clockwise direction
• Short end of the material on the left-hand side with the forceps
• Pull it tight

Question 27

What is the third stage of the surgeons square knot?

Answer 27

Keep within the V shape
Change the direction of the suture material around the forceps clockwise
Position if the hands
Pull it tight
Short end of material is cut for and anchor knot. Or both ends if it’s in for a single interrupted stitch.

Question 28

How to you perform an insertion of continuous subcutaneous sutures?

Answer 28

-Start at the lower end of the wound to the enteroitus
* Each new stitch should enter directly opposite the exit of the previous stitch
* If not, this may cause ‘puckering’ or unevenness of the final wound closure
* Use dissecting forceps to the skin edge and gently retract the skin to facilitate visualisation of the subcutaneous tissue
* Take bites of subcutaneous tissue with the needle exiting under the skin edge
* Your movement should follow the curve of the needle
* Draw tightly together

Question 29

What is the first stage of the Aberdeen knot?

Answer 29

• Hymenal remnant emerge on lefthand side of the wound
• Then Insert on the right side of wound exiting on left side
• Leave a small loop

Question 30

What is the second stage of the Aberdeen knot?

Answer 30

*Pull the suture material through in a see saw manor
* Pulling on the lower thread to close the loop
* Leave a small loop
* Repeat three times
* Ensure the third knot is placed flat on the tissue

Question 31

What is the third stage of the Aberdeen knot?

Answer 31

• Needle can be pulled through the loop
• Guard the needle
• Pull the suture material tight
• Cut the end 0.5cm to1cm away from the knot.

Question 32

What are the steps to the continuous technique?

Answer 32

*Examining the perineum
* Infiltrating the local anaesthetic
* Using the correct suturing material
* Surgeons square knot
* Repair of Vaginal Trauma
* Re-approximating the perineal muscles
* Skin Closure
* Securing the repair – Aberdeen knot.

Question 33

what should we do for postnatal perineal care?

Answer 33

Postnatal perineal examination
Postnatal advice
Documentation

Question 34

What are the points when giving post-surgical advice?

Answer 34

Care and hygiene
Diet and Hydration
Pelvic floor exercises
Analgesia
Sexual Intercourse

Question 35

What needs documenting after perineal repair?

Answer 35

• Documentation of consent (NMC, 2015)
• Description or pictorial diagram of tear
• Analgesia used
• Method technique of suturing
• Materials used
• Correct count of needle and swabs
• Per rectum (PR) and Per vagina (PV) examination
• Estimated blood loss (EBL)
• Name and designation of midwife undertaking the repair

Question 36

What is important post examination to do?

Answer 36

Counting swabs
After care information
Debrief
Documentation/Datix