Perineal_Tears_Flashcards

Question 1

What are the classifications of perineal tears according to the RCOG guidelines?

Answer 1

The classifications of perineal tears according to the RCOG guidelines are first degree, second degree, third degree, and fourth degree.

Question 2

What characterizes a first-degree perineal tear?

Answer 2

A first-degree perineal tear is characterized by superficial damage with no muscle involvement.

Question 3

Do first-degree perineal tears require repair?

Answer 3

First-degree perineal tears do not require any repair.

Question 4

What characterizes a second-degree perineal tear?

Answer 4

A second-degree perineal tear is characterized by injury to the perineal muscle but not involving the anal sphincter.

Question 5

Who should repair second-degree perineal tears and where?

Answer 5

Second-degree perineal tears require suturing on the ward by a suitably experienced midwife or clinician.

Question 6

What characterizes a third-degree perineal tear?

Answer 6

A third-degree perineal tear is characterized by injury to the perineum involving the anal sphincter complex (external anal sphincter, EAS, and internal anal sphincter, IAS).

Question 7

What are the subcategories of third-degree perineal tears?

Answer 7

The subcategories of third-degree perineal tears are 3a, 3b, and 3c.

Question 8

What characterizes a 3a third-degree perineal tear?

Answer 8

A 3a third-degree perineal tear is characterized by less than 50% of EAS thickness torn.

Question 9

What characterizes a 3b third-degree perineal tear?

Answer 9

A 3b third-degree perineal tear is characterized by more than 50% of EAS thickness torn.

Question 10

What characterizes a 3c third-degree perineal tear?

Answer 10

A 3c third-degree perineal tear is characterized by the IAS being torn.

Question 11

Where should third-degree perineal tears be repaired and by whom?

Answer 11

Third-degree perineal tears require repair in theatre by a suitably trained clinician.

Question 12

What characterizes a fourth-degree perineal tear?

Answer 12

A fourth-degree perineal tear is characterized by injury to the perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa.

Question 13

Where should fourth-degree perineal tears be repaired and by whom?

Answer 13

Fourth-degree perineal tears require repair in theatre by a suitably trained clinician.

Question 14

What are the risk factors for perineal tears?

Answer 14

The risk factors for perineal tears include primigravida, large babies, precipitant labour, shoulder dystocia, and forceps delivery.

Question 15

summarise perineal tears

Answer 15

Perineal tears

The RCOG has produced guidelines suggesting the following classification of perineal tears:
first degree
superficial damage with no muscle involvement
do not require any repair
second degree
injury to the perineal muscle, but not involving the anal sphincter
require suturing on the ward by a suitably experienced midwife or clinician
third degree
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
fourth degree
injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa
require repair in theatre by a suitably trained clinician

Risk factors for perineal tears
primigravida
large babies
precipitant labour
shoulder dystocia
forceps delivery

Question 16

A 37-year-old is admitted to the hospital for delivery. She is gravida 2 para 2 and all of her previous deliveries were vaginal.

After three hours she delivers a healthy girl. The baby’s APGAR score was 9 at 1 minute and 10 at 5 and 10 minutes. On examination, the newborn looks macrosomic. As a result, the mother suffered a perineal tear during the delivery, and the midwife calls the doctor to suture it.

They notice that there is an injury to the superficial and deep transverse perineal muscles, involving the external and internal anal sphincters, with mucosal sparing.

What degree of injury does she have?

Fifth-degree
First-degree
Fourth-degree
Second-degree
Third-degree

Answer 16

Third-degree

Third degree perineal tears injury to perineum involving the anal sphincter complex (external anal sphincter and internal anal sphincter)
Important for meLess important
The correct answer is third-degree. This patient had a perineal tear, a laceration of the skin and other soft tissue structures which separate the vagina from the anus. The tear is due to the excessive strain undergone during childbirth and it is more common in first pregnancies, and as in this case, delivery of macrosomic children (usually due to undetected gestational diabetes).

Third-degree tears are defined as an injury to the perineum involving the anal sphincter complex but sparing the mucosa, as happened in this case.

Fifth-degree tears do not exist as the classification of the Royal College of Obstetricians and Gynaecologists only provides four degrees of tears.

First-degree tears involve superficial damage with no muscle involvement, but in this case, the superficial and deep transverse perineal muscles have been involved, as well as the external and internal anal sphincters, making the option incorrect.

Fourth-degree tears involve injury to the perineum involving the anal sphincter complex and rectal mucosa. They are severe lesions and require repair in theatre by a suitably trained clinician. In this case, the mucosa has been spared, making this option incorrect.

Second-degree perineal tears involve the perineal muscle but do not include the anal sphincter, which in this case has been involved making the answer incorrect.

Question 17

A 24-year-old woman had just delivered her first baby. The delivery required the midwife to perform McRobert’s manoeuvre due to shoulder dystocia. There were no other labour complications. After the delivery of the placenta, the midwife examined the patient and found a perineal tear which involved the external anal sphincter (EAS) but did not extend to the internal anal sphincter (IAS) or rectal mucosa.

What is the most appropriate next step in management?

Allow a suitably trained midwife to suture the perineal tear on the ward
Do not repair the perineal tear as it will most likely heal
Repair in theatre by a suitably trained clinician as it is a fourth degree tear
Repair in theatre by a suitably trained clinician as it is a second degree tear
Repair in theatre by a suitably trained clinician as it is a third degree tear

Answer 17

Repair in theatre by a suitably trained clinician as it is a third degree tear

Third degree perineal tears require repair in theatre by a suitably trained clinician

This patient has sustained a third degree perineal tear and requires repair in theatre by a suitably trained clinician. The tear has extended beyond the perineal mucosa and muscle, to involve the EAS but does not involve the rectal mucosa and is therefore classified as 3rd degree. Second degree tears involve the perineal muscle but do not extend into the EAS. Fourth degree tears extend beyond the IAS to involve the rectal mucosa.

It is appropriate to repair the tear in theatre, however the tear is third degree so the option repair in theatre by a suitably trained clinician as it is a fourth degree tear is incorrect.

Similarly the option repair in theatre by a suitably trained clinician as it is a second degree tear is not correct because a third degree tear is described in the scenario.

First degree tears are the only type that do not require repair so as this is a third degree tear it would not be appropriate to not repair the perineal tear as it will most likely heal.

Second degree tears can be repaired by a suitably trained midwife on the ward, but as the tear is third degree this option is not appropriate.

Question 18

A 35-year-old woman gives birth via vaginal delivery. After delivery of the placenta, she is examined on the ward. Examination reveals a small tear on the perineum with no muscle involvement.

What is the most appropriate management?

Glue on the ward
No repair required
Staples in theatre
Suture in theatre
Suture on the ward or in theatre

Answer 18

No repair required

First degree perineal tears usually do not require suturing

This woman has a first-degree perineal tear. First degree perineal tears are superficial tears to the perineum with no muscle involvement.

No repair required is the correct answer. This patient has a first-degree perineal tear. This usually does not require repair as they heal on their own.

Glue on the ward is the wrong answer. First-degree perineal tears usually do not require closure and will heal on their own. As such, this is not the appropriate management for this situation. Furthermore, sutures would be the preferred option, as glue should not be used in the perineal region. Glue should be used to close small, straight, superficial, low-tension wounds.

Staples in theatre is the wrong answer. First-degree perineal tears usually do not require repair and will heal on their own. As such, this is not the appropriate management for this situation. Furthermore, sutures would be the preferred option, as staples should not be used in the perineal region.

Suture in theatre is the wrong answer. First-degree perineal tears usually do not require suturing and will heal on their own. Therefore, this is the wrong answer. If a first-degree perineal tear did require suturing this could be done on the ward by a midwife or an appropriately trained practitioner. It is only necessary to take a woman to the theatre to repair a third or fourth-degree tear as the closure of these wounds requires regional or general anaesthesia.

Suture on the ward or in theatre is the wrong answer. First-degree perineal tears usually do not require suturing and will heal on their own. As such, this is not the appropriate management for this situation. If a first-degree perineal tear did require suturing this could be done on the ward by a midwife or an appropriately trained practitioner. It is only necessary to take a woman to theatre to repair a third or fourth-degree tear as the closure of these wounds requires regional or general anaesthesia.