WEEK 4B - Severe Perineal Trauma Flashcards
Risk factors for severe perineal trauma
- Primiparity (reduced perineal stretching capacity)
- Increased maternal age (decreased tissue elasticity)
- Previous severe perineal tear
- Short perineum (less than 2.5cm)
- Macrosomia
- Fetal malposition
- Shoulder dystocia
- Instrumental delivery (forceps especially)
- Prolonged second stage
- Precipitous labour
Evidence-based risk reduction strategies (calm, controlled birth)
Utilising mainly observation to determine if a woman is in second stage labour, not bound by time limits or requirements to perform unnecessary vaginal examinations
Speaking quietly and patiently
Dark room, warm, comfortable, minimal people coming in
Building trust between the midwife and the woman can reduce feelings of panic and facilitate a sense of control
Supporting the woman to be in control - eye contact, concentrate on their voice and modelling the breathing style that helps slow birth of the baby’s head
Evidence-based risk reduction strategies (position & techniques in early second stage)
Position is important - all fours, lateral, squatting, movement
Observing the perineum - being able to see the perineum clearly as the head descends
Techniques used - warm compress to soften and help the perineum stretch,
Evidence-based risk reduction strategies (hands on or off)
A combination of hands off when the woman is in early labour, hands poised when crowning, and hands on when head is being birthed / baby is being birthed too quickly
Holding head and perineum to control and prevent precipitate birth
Evidence-based risk reduction strategies (slow, blow and breathe baby out)
Emphasising the importance of birthing the head slowly
Asking the woman to breathe rather than push for the contractions surrounding the period of crowning
Female genital mutilation
any procedure that removes partly or totally, the external female genitalia.
In African countries, the incidence of FGM is extremely high (100% in Somalia and Sudan)
FGM 1 (Synonym Sunna)
Incision or removal of the hood of the clitoris, or removal of the clitoris
Main acute complication is hemorrhage infection and surgical shock may also occur
Few long-term complications
FGM 2 (Excision)
Most common form of mutilation (approx. 70-80% of cases in Africa)
Removal of the clitoris, together with excision of part of the labia
Acute complications involve haemorrhage, sepsis, shock, tetanus, urinary retention
Surgical errors may result in vesico-caginal fistula
Increased risk of pelvic infection
FGM 3 (Infibulation, Pharonic Circumcision)
Removal of the clitoris and variable amounts of the labia. Raw edges are then sewn across the midline to produce a fibrous barrier so only a small posterior aperture is left for the passage of urine and menstrual products
Short term complications include haemorrhage, sepsis, surgical shock, and urinary retention
Mortality up to 10%
Long term complications include recurrent UTI and vaginal infection, coital problems and apareunia, psychosexual complications, infertility, difficulty in pregnancy management
FGM 4
Unclassed mutilations including pricking, cutting, scraping, piercing and burning the genital area
Serious long-term complications
FGM Presentations in Western Culture
Non-pregnant women who needed reversal in order to consummate their marriages
Women who became pregnant with an intact circumcision
Women with gynaecological complaints where reversal of the circumcision was needed to facilitate investigation
Often caesarean section is carried out, but this can cause resentment mainly among the Somali community who knew it was not needed
Identifying FGM & information sharing
The midwife should ask about a woman’s FGM status in a private, non-judgemental, and culturally sensitive manner
During routine assessments, the midwife might notice signs such as scarring, narrowing of the vaginal opening, or other physical markers of FGM
Gather obstetric and gynaecological history, including questions on FGM, ideally during the first antenatal visit - approach with cultural sensitivity and ensure privacy and comfort
Educate the woman about potential physical and emotional consequences of FGM, as well as their rights regarding childbirth and healthcare options
Supportive communication for women who have undergone FGM, create a safe space to express their concerns and emotions and understand this can be sensitive and traumatic.
Build trust
Referral to counselling or support services
Third degree perineal tear
injury to the perineum involving the anal sphincter complex
Grade 3a tear - less than 50% of external anal sphincter thickness torn (striation is visible)
Grade 3b tear - more than 50% of external anal sphincter thickness torn
Grade 3c tear - both external and internal anal sphincter torn
Fourth degree perineal tear
injury to perineum involving the anal sphincter complex (external and internal) and anorectal mucosa
Perineal tear discussion points & reducing risk during pregnancy, labour, and birth
Perineal tears are common and most heal well without complications . Third and fourth degree tears are less common (around 3%). Women’s preference for birth, what can be done to reduce risk. Assessments and examinations to expect after birth
Perineal self-massage or by partner after 34 weeks of pregnancy
Pelvic floor muscle training
Applying warm compress on perineal distention
Flowing the fetal head at crowning and the birth of the shoulders
Perineal massage during second stage
Indications for consideration of an episiotomy
- High likelihood of a third or fourth degree tear
- Shoulder dystocia
- A need for accelerated birth of a compromised fetus
- A history of FGM
First degree tearing (heal)
Typically heals well without sutures or with minimal repair, discomfort lasts a few days
Mild pain, localised swelling, minimal bleeding
Second degree tear (heal)
Requires suturing, healing takes several weeks
Pain and discomfort with sitting, urination and defecation
Infection, wound breakdown, dyspareunia, prolonged perineal discomfort
Third degree tear (heal)
Requires surgical repair by an experienced obstetrician
Healing takes months with significant perineal pain and discomfort
Anal incontinence, perineal pain, infection, breakdown of repair, psychological distress, increased risk of recurrence in future births
Fourth degree tear (heal)
Requires immediate surgical repair in an operating theater, prolonged recovery with specialised postnatal care
Higher risk of anal incontinence, fistula formation, chronic pain, wound, psychological impact, may discourage future vaginal deliveries
Postnatal management of severe perineal trauma
Give the woman opportunity to discuss her recent experience and ask questions
Ensure the woman is given information about her medicines, how to care for her injury at home, what to expect while recovering, symptoms to look out for and who to contact if she has any concerns
Information about follow-up care should be provided in short and long term
Arrange an appointment with healthcare professional with experience in pelvic floor health such as a physiotherapist, psychologist, social worker
Midwife’s role in perineal repair
Soon after birth, the midwife will do an examination to check for perineal tears
The midwife will place a finger inside the rectum and carefully feel for any damaged tissues & buttonhole tear
Third and fourth degree tears will be double confirmed by another healthcare professional - they need to be sutured in theatre
Try to facilitate baby skin-to-skin
Stool softeners and PR analgesia
