Tears And Episiotomy

Question 1

Repair sound be completed how long after delivery?

Answer 1

Within 1 hour

Question 2

Unless marked bleeding, should you allow the mother some bonding time with baby before examination and repair?

Answer 2

Yes

Question 3

How are perineal tears classified?

Answer 3

But the degree of damage caused

Question 4

What percentage of vaginal deliveries are complicated by perineal trauma?

Answer 4

Approximately 85% and of these, 60-70% require suturing

Question 5

The majority of perineal tears are of what degree?

Answer 5

Majority are 1st and 2nd degree

3-4% will be 3rd/4th degree injuries

Question 6

Describe a first degree tear

Answer 6

Superficial damage with no muscle involvement

Question 7

Describe a second degree tear

Answer 7

Injury to the perineal muscle, but not involving the anal sphincter

Question 8

Describe a third degree tear

Answer 8

Injury to perineum involving the anal sphincter complex
3a - less than 50% of external anal sphincter thickness torn
3b - more than 50% of EAS thickness torn
3c - external and internal anal sphincter torn

Question 9

Describe a fourth degree tear

Answer 9

Injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa

Question 10

What risk factors are there for perineal tears?

Answer 10

Primigravida
Large babies >4kg
Precipitant labour
Shoulder dystocia
Induced labour
Epidural 
Instrumental delivery 
Second stage more than 1 hour

Question 11

How should 3rd or 4th degree tears be managed?

Answer 11

Repair by an experienced surgeon under epidural or GA in theatre with intra operative antibiotic cover
Rectal mucosa repaired first using absorbable suture, then vaginal mucosa

Question 12

Repair of anal sphincter injuries significantly reduces the risk of…

Answer 12

Ongoing flatus and stool incontinence but doesn’t alleviate it completely

Question 13

Risk of mechanical injury is greatest after when?

Answer 13

The first vaginal delivery (4% primip vs 1% multip)

Question 14

Traumatic stretching of the pudendal nerve occurs in more than what percentage of primips?

Answer 14

> 30% , but is mostly asymptomatic or mildly/transiently so

Question 15

After repair of a tear, what should be prescribed?

Answer 15

Laxatives e.g lactulose 15ml OD or BD depending on stool softness and antibiotics - cefuroxime 500mg PO/8hours and metronidazole 400mg PO/8 hours for 7-10 days

Question 16

When should follow up be arranged after tear?

Answer 16

Arrange 6-12 weeks post delivery to check healing and continence. If flatus/faecal incontinence occurs gene expert help

Question 17

How can constipation be avoided after having a tear?

Answer 17

Lactulose for 10 days

High fibre diet

Question 18

After a tear physio therapy should be arranged to do…

Answer 18

Pelvic floor exercises for 6-12 weeks

Question 19

If the woman experiences pain or incontinence after having a tear, what should be done?

Answer 19

Refer to specialist gynaecologist or colorectal surgeon for endoanal US

Question 20

Why is an episiotomy done?

Answer 20

To enlarge the outlet and hasten birth of a distressed baby, for instrumental or breech delivery and to try and prevent 3rd degree tears

Question 21

Which tissues are incised in an episiotomy?

Answer 21

Vaginal epithelium, perineal skin, bulbocavernous muscle, superficial and deep transverse perineal muscles
With large episiotomies, the external anal sphincter or levator ani may be partially cut and ischiorectal fat exposed

Question 22

How is an episiotomy done?

Answer 22

Hold perineal skin away from presenting part of fetus - 2 fingers in vagina
Infiltrate area to be cut with local anaesthesia - 1% lidocaine
Cut mediolaterally towards ischeal tuberosity (avoiding Bartholin’s glands)

Question 23

After repairing an episiotomy, what should be done?

Answer 23

Perform a rectal examination to check sutures have not penetrated the rectal mucosa

Question 24

What problems can occur with an episiotomy?

Answer 24

Bleeding, infection, breakdown, haematoma

Question 25

After an episiotomy what can provide effective analgesia?

Answer 25

Rectal diclofenac