WK4: Malposition/presentation, obstructed labour, fetal surveillance intro, perineal trauma and episiotomy

Question 1

Define malposition.

Answer 1

the occiput is directed towards the posterior of the maternal pelvis.
- There is only ONE malposition= occipito- posterior position (OP)

Question 2

Define malpresentation and list some malpresentations.

Answer 2

Malpresentation: any presentation of the fetus other than the vertex (SOB).
Including;
- breech
- shoulder presentation
- face (SMB)
- brow (SMV)
- sinciput (12.5cm- straight on/OF)

Question 3

What can cause malposition and what are the outcomes?

Answer 3

Cause: unknown, but may be associated with android shaped pelvis or anthropoid shaped pelvis
- Approximately 10-20% of all births – most end with normal birth
= is a vertex presents with occiput to the posterior/at back of pelvis instead of anterior
- Fetal head is deflexed so larger diameter of fetal skull presents

Associated with long more difficult labours as OP position often causes;
- constant intense back pain
- incoordinate contractions (coupling)
- some women have an uncontrollable urge to push prior to full dilation

Question 4

What are the mechanisms of labour for an OP baby?

Answer 4

• Has a longer circle of rotation
• From ROP to ROT
• ROT to ROA
• Head changes to AP/vertical diameter
  (just a longer rotation phase )

1. Descent and flexion
   - Long rotation - ROP - OA
   - Birth as for anterior position
2. Descent and slight flexion
   - Rotation initially from ROP-ROT
   - Deep Transverse Arrest at level of the ischial spines
   Unable to reach though the pelvis through to the final stage
3. Descent and deflexed head
   - Sinciput becomes denominator
   - Short rotation 45°– ROP – OP
   - Sinciput passes under pubic arch, occiput in hollow of sacrum head flexes and head born by extension

Question 4

What is it important to recognise an OP baby on palp and VE?

Answer 4

Because it can explain unusual occurrences and helps us determine out management and avoid intervention when it is unnecessary.
e.g. longer labour, coupling contractions

Question 5

What are indicators of an OP baby on abdo palp?

Answer 5

Inspection
- Saucer shaped depression at or just below the umbilibus

Palpation
- back difficult to palpate and is sometimes parallel to maternal spine, limbs felt on either side of midline,

Presentation
- Deflexed head commonly high may feel large
Lifted head with face presentation

Auscultation
- fetal heart heard in the midline, may be heard in flank on the same side as the back

Question 6

What are signs of mal position inlbaour?

Answer 6

• coupling/incoordinate contractions
• continuous back pain
• membranes rupture early due to uneven application on cervix
• VE findings= location of fontanelles, may be difficult to reach the posterior fontanelle, degree of application on cervix
• anterior fontanelle in deflexed head will be central or to front of pelvis

Question 7

How can a midwife specifically care for a women with an OP positioned baby?

Answer 7

• Will need more support due to increased length, the difficulty of front and back pain
• Physcial support; massage, heat, movement/change, water immersion.
• All four positions; baby to fall forward and not be on back causing pain
• leaning forward position to encourage baby to move around
• Ensure adequate nutrition and hydration and observe for signs of dehydration
• Labour is often prolonged
• Strong urge to push to assist with rotation of baby before cervix fully dilated- could recommend epidural
• Lots of support

Question 8

What are some complications of OP position?

Answer 8

• Deep transverse arrest (DTA)
  - Delay in second stage
  - VE shows sagittal suture in transverse with fontanelle at each end and increasing moulding and caput succedaneum
• Early ROM which may lead to cord prolapse as there is not equal pressure around the cervix
• prolonged labour
• urinary retention
• soft tissue trauma to mother
• premature expulsive effort
• maternal exhaustion due to long second stage because of rotation
• Rotation to anterior position by hand, forceps or vacuum needed (manual rotation)
• Increased risk of operative birth or C/S birth

Question 9

Define a face presentation and list the six positions it that can occur with a face presentation.

Answer 9

= When the head is hyper-extended, occiput of fetus is in contant with its spine and face presents- limbs flexed.

Denominator/presenting part= chin (mentum)

Six position that can occur with face presentation
- Right mento-posterior (RMP)
- Left mento-posterior (LMP)
- Right mento-transverse (RMT)
- Left mento-transverse (LMT)
- Right mento-anterior (RMA)
- Left mento-anterior (LMA)

Question 10

How is a face presentation diagnosed?

Answer 10

AN
- usually develops in labour
- hard to diagnose
- ultrasound?

Intrapartum
- and palp= may be difficult to detect, occiput may feel prominent, limbs may be palpated on side opposite to occiput
- VE= presenting part is high, soft and irregular. Orbital ridges ,eyes, nose and mouth may be felt.

Question 11

What causes a face presentation?

Answer 11

• Congenital abnormality
• Anterior obliquity of maternal uterus due to poor muscle tone
• Flat pltypelloid pelvis
• prematuity/multiple pregnancy/polyhdrramios = all lead to poor muscle tone of the uterus

Question 12

How do we manage a face presentation in labour?

Answer 12

• VE on ROM to exclude cord prolapse
• DO NOT APPLY SCALP ELECTRODE
• When face appears at vulva, extension is maintained by holding back the sinciput and allowing mentum to escape under symphysis pubis before occiput sweeps perineum
• If head does not descend, forceps / caesarean become necessary

Question 13

What are some complications of a face presentation?

Answer 13

• Obstruted labour
• Cord prolapse
• Faila swelling and bruising
• Cerebral haemorrhage
• Maternal trauma (perineal and genitial tract trauma)

Question 14

Define brow presentation and explain what causes it.

Answer 14

= Fetal head partially extended with frontal bone lying at brim; presenting diameter = 13.5 cm
- No mechanism for labour as it most often results in C/S unless it converts to face presentation
Cause: similar to those that cause other mal presentations…
- multiple gestations
- grand multiparty (associated with poor muscle tone)
- fetal malformations
- prematurity
- cephalopelvic disproportion

Question 15

How can a brow presentation be identified/diagnosed and then managed?

Answer 15

Diagnosis
- Cannot reliably be diagnosed prior to labour
- Lack of progress (usually)
- Abdominal palpation
- head high, seems unusually large & does not descend despite good contractions
- Vaginal examination
- presenting part high, may be difficult to reach, the sagittal suture may be in transverse or oblique position, anterior fontanelle and orbital ridges may be felt

Management: CS as head cant not fit through pelvis in this diameter.

Question 16

Define shoulder presentation and what may cause it.

Answer 16

= Fetus lies with its long axis across the uterus (transverse or oblique lie), shoulder presentation likely to present
*leads to obstructed labour

Causes=
Maternal:
- lax abdominal and uterine muscles
- uterine abnormality
- contracted pelvis
- uterine fibroid
- overdistended bladder

Fetal:
- preterm pregnancy
- multiple pregnancies
- polyhydramnios
- placenta praevia

Question 17

How is shoulder presentation diagnosed?

Answer 17

Abdominal palpation:
- broad uterus
- lower fundal height than expected; on pelvic and fundal palpation neither head or breech felt; firm ballottable head is found in one iliac fossa, with the softer mass in the other.

Ultrasound

Vaginal examination: may not feel presenting part, or may feel soft irregular mass

Question 17

How is shoulder presentation diagnosed?

Answer 17

Abdominal palpation:
- broad uterus
- lower fundal height than expected; on pelvic and fundal palpation neither head or breech felt; firm ballottable head is found in one iliac fossa, with the softer mass in the other.

Ultrasound

Vaginal examination: may not feel presenting part, or may feel soft irregular mass

Question 18

What are some potential complications of a shoulder presentation?

Answer 18

• Cord prolapse.
• Trauma to a prolapsed arm
• shoulder dystocia
• Obstructed labour and ruptured uterus
• Fetal hypoxia and death.

Question 19

What are some complications of brow presentation?

Answer 19

• facial odema
• skull moulding
• breathing problems (due to tracheal and laryngeal trauma)
• prolonged labour
• fetal distress
• spinal cord injuries
• permanent brain damage
• neonatal death
• Hypoxic-ischemic encephalopathy
• Cerebral palsy
• Periventricular leukomalacia
• Seizure disorders
• Developmental disabilities

Question 20

Define breech presentation and what are some positions?

Answer 20

= Occurs when the fetus lies longitudinally with buttocks in lower pole of the uterus
- Presenting diameter – bitrochanteric (10cm) and the sacrum as denominator
- Occurs in 3% of pregnancies at term (more frequent in premature gestations)

Right sacro-posterior (RSP)
Left sacro-posterior (LSP)
Right sacro-anterior (RSA)
Left sacro-anterior (LSA)
Right sacro-transverse (RST)
Left sacro-transverse (LST)

Question 21

What can cayse a breech presentation?

Answer 21

• Nulliparity
• Hx of breech birth
• Extended fetal legs
• Preterm gestation
• Multiple pregnancy
• Oligohydramnios (not enough amniotic fluid)
• Polyhydramnios (to mucb amniotic fluid)
• Fetal anomolies eg. Hydrocephaly
• Uterine abnormalities
• Placenta praevia

Question 22

What are the 3 types of breech?

Answer 22

1. complete breech
2. footling breech
3. frank breach

Question 23

Explain complete breech.

Answer 23

attitude= complete flexion
- Hips and knees both flexed and feet tucked beside the buttocks

Compatible with vaginal birth

Question 24

Explain footling breech

Answer 24

• One or both feet present
• When neither knees or hips
• Feet lower then buttocks and can slip out

Incompatable with Vaginal birth

Question 25

Explain Frank breech.

Answer 25

• Hips are flexed and well extended into the abdomen
• knees are not yet flexed

Compatible with vaginal birth

Question 26

How can breech be diagnosed?

Answer 26

AN
- palp= head at fundus
- auscultation= FHR heard above umbilicus

Intrapatrum
- abdo palp
- US
- VE
- soft, no fontanelles or sutured located
- anus may be felt
- fresh mec may be passed
- external genitalis may be felt

Question 27

How is breech presentation managed?

Answer 27

Offer External Cephallic-Version (ECV)
- offered and recommend antenatally (performed by obstetrician)
- Manual manipulation externally carried out under ultrasound
- Offered at 37-38 weeks in case emergency CS needs to occur
- Gas offered as can be uncomfortable
- Rate of success if varied; depends on practitioner, position of baby
- Baby can flip back to breech after ECV

In labour management;
- Spontaneous labour is recommended
- Exclude/watch for any signs of fetal compromise
- Complete or frank breech only recommended positions
- Continuous monitoring recommended
- Full dilatation confirmed prior to pushing
- Staff experienced in breech birth
- Attending staff must be ready with equipment for neonatal resuscitation
- Bladder emptied
- Spontaneous pushing encouraged
- No interference- ‘Hands off the breech’
‘Keep the back uppermost’
- If legs and shoulders gently disengaged only if necessary
- Next contraction shoulder blades appear, arms slip out and shoulders are born
- As birth progresses with the baby hanging the scapulae appear at the introitus
- The arms will birth spontaneously or they can be swept across the chest and out
- If birth does not progress normally, there are some obstetric manoeuvres that can be used

Question 28

What are some complications of a breech birth?

Answer 28

• Extended arms or head (if it gets startled)
• Entrapment of fetal head
• Cord prolapse increased risk as there is not equal pressure on the cervix
• Birth injury – soft tissue, fractures, Erb’s palsy, internal organs, adrenal glands, spine, hip dysplasia
• Fetal hypoxia
• Premature separation of the placenta
• Maternal trauma

Question 29

Define obstructed labour.

Answer 29

= when there is no advance of the presenting part despite the presence of strong uterine contractions.

Question 30

What causes obstructed labour?

Answer 30

= a barrier preventing descent
e.g. some malpresentations

Maternal
- Iatrogenic: IOL increased malpresentation (Malpresentation at time of IOL)
- Absolute cephalo-pelvic disproportion (common cause)
- Deep transverse arrest (head in transverse and unable to turn OB)
- Abnormalities of the reproductive tract:
- Lower segment fibroids
- Stenosisof cervix or vagina which may be caused by scarring from FGM
- Tight perineum caused by scarrig from FGM

Fetal
- Absolute cephalo pelvic disproportion (common cause)
- Deep transverse arrest (where baby is unable to rotate from OT to OA)
- Malpresentation (shoulder/brow)
- Fetal hydrocephaly (brain is producing and holding excess fluid- often incompatible with life)
- Multiple pregnancy with conjoined twins or locked twins

Question 31

Where does obstructed labour usually occur?

Answer 31

= at pelvic brim, but may occur in the cavity or outlet of the pelvis (e.g. deep transverse arrest)

Question 32

Define Cephalopelvic disproportion (CPD) and explain the types of CPD.

Answer 32

= occurs when there is mismatch between the size of the fetal head and size of the maternal pelvis, resulting in “failure to progress” in labor for mechanical reasons.

This could be due to a small pelvis and normal sized fetal head, or normal sized pelvis and large fetus

Types
1. Marginal
- Problem may be overcome in labour with either strong contractions, moulding of the fetal head and relaxation of pelvic joints
- Vaginal birth is possible if the above occurs

2. Definite
   - Pelvis is too small or abnormal shape, or the fetus is too large for the pelvis due to size or an abnormality (such as hydrocephaly)
   - Vaginal birth is not possible, C/S is indicated

Question 33

What are early and late signs of CPD (obstructed labour)?

Answer 33

Early signs include:
- Presenting part does not descend despite good contractions
- Slow cervical dilatation
- Poor application of presenting part to cervix (cervix hangs loosely)
- Early rupture of membranes
- Formation of loose elongated sac of forewaters

Late signs of CPD
- Bandl’s Ring- a ridge obliquely across abdomen
- Lower segment becomes thinner and longer
- Upper segment becomes shorter and thicker
*It happens because presenting part is well engaged on cervix and there fluid is lost.
= The fetus is in the lower uterus it becomes thin and fatigued.
= Increased likelihood to rupture

• Dehydration and ketosis
• Pyrexia/febrile and tachycardia
• Mother in constant pain
• Fetal distress (tachi or deceleration)
• Abdominal examination extremely painful particularly at level of lower uterine segment
  - Determining station difficult
• Contractions build in frequency and intensity
  - Tonic contraction (isnt going away)
• Vaginal examination difficult, presenting part may be high
  - Moulding
  - caput succedaneum (when there is a hold up of labour and swelling is coming out)
  - May be able to feel febrile
• Poor urinary output and haematuria

Question 34

What are some complications of obstructed labour?

Answer 34

• Rupture of uterus
  - causes PPH + shock
  - leads to maternal mortality
  - causes fetal hypoxia + asphyxia (leading to still birth, permanent brain damage + mec aspiration syndrome)
• increased pressure on the fetal head
  - can lead to obstetric fistulas
• Intrauterine infection from prolonged membrane rupture (increased even more with frequent VE’s)

Question 35

What is a fistula

Answer 35

When the fetal head is stuck in the pelvis for a prolonged period, portions of the cervix, vagina, rectum and bladder are trapped between fetal skull and pelvic bones= tissue is left without oxygen which causes fistulas

Circulation is impaired and oxygenation of the tissues is inadequate leading to necrosis

This forms a fistula
= leads to leakage of urine and fececes from the vagina.

Question 36

What is a uterine rupture and what are the 3 types?

Answer 36

= the tearing of the uterus.

Complete rupture
- Tear in wall of uterus with or without expulsion of fetus
- Baby can end up in abdomen
- Urgent CS

Incomplete rupture
- Involves tearing of uterine wall but not perimetrium
- Baby cant leave the uterus

Dehisence (of existing uterine scar)
- Rupture of the uterine wall but membranes remain intact
- Fetus retained inside of uterus (not expelled into peritoneal cavity)
- Happens with old CS scar

Question 37

What causes of uterine rupture?

Answer 37

Spontaneous rupture of an unscarred uterus in a primigravida woman are very rare in the developed world
- High parity (grand multi >5 or multiple babys)
- Poor use of oxytocin especially in a woman of high parity
- Use of prostaglandins in woman who has an existing uterine scar
- Obstructed labour
- Neglected labour where mother has had a previous C/S (unobserved)
*previous CS is not necessarily a risk
- Extension of severe cervical laceration as the result of trauma from an instrumental birth
- Trauma from an injury

Question 38

What are some signs of a ruptured uterus?

Answer 38

Complete rupture
- Sudden collapse of mother who complains of severe abdominal pain
- Tachycardic (which will then alter FHR)
- Fresh vaginal bleeding
- Contractions my stop and contour of abdomen alters as the fetus becomes palpable in the abdomen
- Degree and speed of maternal shock depends on the extent of rupture and associated blood loss

Incomplete rupture
- Insidious/gradual onset (may be found after birth/caesarean)
- Most commonly associated with previous C/S
- Blood loss may be scanty
- If mother becomes shocked during the third stage and it does not seem to relate to the type of birth or the amount of blood loss, incomplete rupture should be considered.

Question 39

What is the management of obstructed labour?

Answer 39

• Prevention in the first place!
  - Antenatal risk assessment
  - Careful assessment of labour progress
  **(including maternal hydration and nutrition as these can increase risk of obstruction if low/poor)
• IV Therapy
• Cross-matching in case blood is necessary
• Antibiotic therapy
• observe for signs
• Accurate observations of mother and fetus

Question 40

When is IA/intermittent auscultation indicated in labour?

Answer 40

For women in spontaneous labour with no other risk factors, no antenatal risk, not developed any intrapartum risk factors or who have no declined monitoring.

Question 41

When is IA best carried our during intrapartum?

Answer 41

Best practice in labour is to listen to FHR
Before contraction
During contraction
After contraction (most important time is directly after a contraction)
*if struggle to auscultate during contraction, auscultate while not contracting (base line) then compare that to FHR just after contraction and compare.

Question 42

What are some positives and negatives of a CTG?

Answer 42

Positives
- Continuous monitoring
- Provides real time info about how well oxygenated the fetus is.

Negatives
- Can not predict future fetal compromise
- Can not indicate previous fetal compromise

In labour, it measures;
- fetus’ response to contactions
- Tracks any changes that occur which would indicate hypoxia

Question 43

What are some indications for an antenatal CTG?

Answer 43

• Abdominal trauma
• Abnormal Doppler umbilical artery velocimetry
• Abnormal Doppler studies
• Antepartum haemorrhage (in excess of ‘show’ >/ 50ml)
• Diabetes requiring stabilisation
• Intrauterine Growth Restriction (suspected or confirmed)
• Known fetal abnormality that requires monitoring
• Maternal medical condition that constitutes a significant risk of fetal compromise
• Maternal Obstetric condition (e.g. cholestasis)
• Oligohydramnios (Amniotic fluid index (AFI) <5cm)
• Polyhydramnios (Amniotic fluid index (AFI) > 25 cm)
• PPRoM (>24 hours)
• Prolonged preganncy >/ 42 weeks
• Previously abnormal antenatal CTG
• Prior to and following attempted external cephalic version (ECV)
• Reduced fetal movements
• Rhesus isoimmunisation
• Severe hypertension or preeclampsia

Question 44

What are some intrapartum indications for CTG? (identifiable before labour begins)

Answer 44

• Abnormal antenatal CTG
• Abnormal cerebroplacental ratio ** (recommended by RANZCOG1 but remains experimental)
• Abnormal Doppler umbilical artery velocimetry
• Abnormal maternal serum screening results associated with an increased risk of poor perinatal outcome (e.g. PAPP-A <0.37 MoM) **
• Abnormal placental cord insertion (e.g. velamentous cord insertion) **
• Antepartum Haemorrhage
• Diabetes (on medication, or poorly controlled or fetal macrosomia)
• Hypertension / preeclampsia (current pregnancy)
• Intrauterine growth restriction (suspected or confirmed)
• Known fetal anomaly which requires monitoring **
• Maternal age >/42 years
• Maternal medical conditions that constitute a significant risk of fetal compromise (e.g. severe anaemia, cardiac disease, cholestasis, - hyperthyroidism, renal disease, iso-immunisation, substance abuse, vascular disease)
• Morbid obesity (BMI >/40)
• Multiple pregnancies
• Oligohydramnios or polyhydramnios
• Reduced fetal movements (within the preceding week unless investigated and FM now normal)
• Uterine scar / previous caesarean section

Question 45

What are some indications for a CTG at the onset of labour?

Answer 45

Breech presentation
Post-term pregnancy 42 weeks)
Preterm labour
Prolonged rupture of membranes ( 24 hours)

Question 46

What are some indications for a CTG that may arise during labour?

Answer 46

• Absent liquor following amniotomy
• Chorioamnionitis
• FHR abnormalities on auscultation (bradycardia, tachycardia, decelerations)
• Maternal pyrexia
• Meconium-stained or blood-stained liquor
• Prolonged active first stage labour (> 12 hours regular uterine contractions with cervical dilatation > 3 cm)
  Prolonged second stage of labour (> 1 hour active pushing)
• Regional anaesthetic (epidural or spinal) (including just before insertion)
• Uterine tachysystole, hypertonus or hyperstimulation
• Vaginal bleeding in labour ()in excess of a ‘show’ >/ 50 ml
• IOL
• epidural
• when a fetal heart rate is noticed on IA

Question 47

What are some known risk factors for perineal trauma?

Answer 47

Known risk factors for severe perineal trauma:
- Epidural
- Nulliparity
- Malposition
- Instrumental birth
- Macrosomia
- Asian ethnicity

Other possible risk factors for severe perineal trauma:
- Increased BMI
- AMA (advanced maternal age)
- IOL
- Augmentation of labour
- Prolonged second stage

Question 48

What are some strategies to reduce perineal trauma?

Answer 48

Research has demonstrated the following:
- Antenatal perineal massage
- Warm perineal compress during second stage of labour
- Restricted use of episiotomy
- Upright birth positions- the woman is free to choose
- Non-directed pushing- woman follows own urges

Other factors that can influence reduction in perineal trauma:
- Giving birth in a home-like environment or at home
- Continuous support from a midwife
- Birthing with a midwife (compared to an obstetrician)
- Having some control to the fetal head during birth e.g. water birth, women on babys head, midwife on baby heads

Question 49

What is the necessary care for perineal trauma after birth?

Answer 49

• pain relief
• regular changing of pads
• regular cleaning the area
• icing to reduce swelling

Question 50

What are some indications for an episiotomy?

Answer 50

• Hx of severe perineal trauma
• when birth needs to be expedited for non-reassuring FHR
• rigid perineum that is preventing birth from occurring and/or causing ‘button-holing’ perineal trauma
• Allow more room for instruments during instrumental birth
• Allow more room for manoeuvres if there is a shoulder dystocia

**birth should be fairly imminent

Question 51

What must be checked before cutting an episiotomy?

Answer 51

• indication
• consent

Question 52

Describe the steps to compete an episiotomy

Answer 52

1. Draw up 1% Lignocaine 10mL, use a long 21g needle
2. Insert index and middle finger of non-dominant hand into vagina behind perineum to protect presenting part
   *In between contractions
3. Insert full length of the needle centrally at the introitus (into the opening) and draw back on needle to see if there is blood (DO NOT INJECT INTO BLOOD VESSEL)
4. Inject one-third of dose whilst drawing the needle back
5. Without completely removing the needle from tissue, reposition needle and reinsert in mediolateral direction
6. Repeat process twice
7. Allow time for it to take effect (two- three contractions if possible)
   *if it was urgent the baby needs to be born but we have time to do the perineal infiltration then we can wait for baby to be born.

Episomoty technique
1. Insert the index and middle finger in between the presenting part and the perineum
2. Take the open scissors and position them between the fingers, over the area intended for the incision
3. Make a single, deliberate cut 3 to 4 cm into the perineum at the height of the contraction when the birth is imminent
4. The incision should start midline from the fourchette, and extend outwards in a mediolateral direction, avoiding the anal sphincter
5. If head isn’t born asap= apply pressure to the episiotomy between contractions with a sterile combine if there is a delay in the birth

Question 53

What are the 3 types of episiotomy?
and they advantages and disadvantages

Answer 53

Midline/median: Cut is made straight down towards anus.

Advantages;
- it does not cut through muscle
- two sides are anatomically balanced for easier repair
- less blood loss than mediolateral incision.

Major disadvantage;
can extend through the EAS and into the rectum.
*No longer recommended due to this reason.

Mediolateral: Cut begins at midline of the posterior fourchette and aimed towards ischial tuberosity to avoid the anal sphincter.

Advantage
- avoid the anal sphincter and muscles

• Right mediolateral is the recommended technique.

Disadvantage
However, the bulbospongiosus and transverse perineal muscles are cut with this incision.

Question 54

What are the different degrees of perineal trauma?

Answer 54

1st degree
– Injury to perineal skin and vaginal mucosa only

2nd degree
– Injury to perineum involving perineal muscles but not involving the anal sphincter

3rd degree
– Injury to perineum involving the anal sphincter complex
3A: Less than 50% of external anal sphincter (EAS)
thickness torn
3B: More than 50% of external anal sphincter thickness torn
3C: Both external and internal anal sphincter torn

4th degree
– Injury to perineum involving the anal sphincter complex and anal epithelium

Question 55

What are the potential complication of perineal trauma?

Answer 55

• Increased blood loss (PPH is possible from perineal trauma)
• Increased risk of infection
• Increased postnatal pain & discomfort
• Psychological
• Incontinence
• Dyspareunia
• Episiotomy may extend to 3rd /4th degree tear

Question 56

What is the role of the midwife in caring for someone with perineal trauma?

Answer 56

• examined systematically post-birth by a midwife or doctor trained and competent in the identification and classification of perineal trauma.
• The timing of the examination should not interrupt mother-infant bonding unless the woman has bleeding requiring urgent action
• Prior to suturing, where any degree of trauma requiring repair is identified, a rectal examination must be performed to exclude an anal sphincter tear. The external anal sphincter is palpated between two fingers - one in the vagina and one in the rectum.
• promote soft tissue healing with RICER
• Observation of the perineum should occur each shift until discharge, then again at home visit (public), and with woman’s consent

Need to observe for;
- Oedema
- excessive bruising
- the formation of perineal/vaginal haematoma
- infection and breakdown of suturing

• Important to remember that ALL women can experience perineal pain postnatally, even if they have not sustained perineal trauma