Tears And Episiotomy Flashcards
Repair sound be completed how long after delivery?
Within 1 hour
Unless marked bleeding, should you allow the mother some bonding time with baby before examination and repair?
Yes
How are perineal tears classified?
But the degree of damage caused
What percentage of vaginal deliveries are complicated by perineal trauma?
Approximately 85% and of these, 60-70% require suturing
The majority of perineal tears are of what degree?
Majority are 1st and 2nd degree
3-4% will be 3rd/4th degree injuries
Describe a first degree tear
Superficial damage with no muscle involvement
Describe a second degree tear
Injury to the perineal muscle, but not involving the anal sphincter
Describe a third degree tear
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
Describe a fourth degree tear
Injury to perineum involving the anal sphincter complex (EAS and IAS) and rectal mucosa
What risk factors are there for perineal tears?
Primigravida Large babies >4kg Precipitant labour Shoulder dystocia Induced labour Epidural Instrumental delivery Second stage more than 1 hour
How should 3rd or 4th degree tears be managed?
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
Repair of anal sphincter injuries significantly reduces the risk of…
Ongoing flatus and stool incontinence but doesn’t alleviate it completely
Risk of mechanical injury is greatest after when?
The first vaginal delivery (4% primip vs 1% multip)
Traumatic stretching of the pudendal nerve occurs in more than what percentage of primips?
> 30% , but is mostly asymptomatic or mildly/transiently so
After repair of a tear, what should be prescribed?
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
When should follow up be arranged after tear?
Arrange 6-12 weeks post delivery to check healing and continence. If flatus/faecal incontinence occurs gene expert help
How can constipation be avoided after having a tear?
Lactulose for 10 days
High fibre diet
After a tear physio therapy should be arranged to do…
Pelvic floor exercises for 6-12 weeks
If the woman experiences pain or incontinence after having a tear, what should be done?
Refer to specialist gynaecologist or colorectal surgeon for endoanal US
Why is an episiotomy done?
To enlarge the outlet and hasten birth of a distressed baby, for instrumental or breech delivery and to try and prevent 3rd degree tears
Which tissues are incised in an episiotomy?
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
How is an episiotomy done?
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)
After repairing an episiotomy, what should be done?
Perform a rectal examination to check sutures have not penetrated the rectal mucosa
What problems can occur with an episiotomy?
Bleeding, infection, breakdown, haematoma
After an episiotomy what can provide effective analgesia?
Rectal diclofenac
