Complete perineal tear

complete perineal tear, deficient perineum, anal sphincter, episiotomy, old perineal tear, perineal muscle, obstetric trauma, labour, vaginal delivery.

1. complete perineal tear By Magdy Abdelrahman mohamed Lecturer of OB/GYN 2016

2. Anatomy of the perineal body: It is a pyramidal shaped area between the lower vagina and the anal canal and the lower end of the rectum.

3. Etiology: (A) Lack of elasticity of the perineal tissue: Rigidity of the perineum in primipara particularly elderly. Excessive scarring of the perineum (due to previous operation) Friability of the perineum due to edema.

4. B) Over-stretching of the perineum: Bad Management of normal labor by allowing extension of the head before crowning. Large sized head or shoulder girdle. Malpresentation e.g. delivery as face to pubis or delivery of the aftercoming head in breech presentation. Forceps delivery especially on primipara . Contracted outlet with narrow subpubic angle.

5. (C) Rapid stretching of the perineum: Precipitate labor. Rapid forceps extraction.

6. Degrees: 1st degree: Involve the fourchette , perineal skin and the posterior vaginal wall. 2nd degree: Involve the above structures as well as the muscles of the perineal body but doesn't involve the external anal sphincter. (1st and 2nd degrees are called incomplete perineal tear) 3rd degree: Involves the above structure as well as the external anal sphincter. 4th degree: it includes the anterior wall of the anal canal or rectum.

7. Old complete perineal tear Symptoms: Incontinence either complete faecal incontinence or only for flatus & liqued stool. Examination. Differentiate between 3 rd & 4 th degree. Exclude rectovaginal fistula.

8. Treatment Timing: Ideally 3 m after labour . ? P re-operative preparation. Any vaginal infection should be treated. Intestinal preparation. (Intestinal antiseptics & repeated enema).

9. Treatment Operative technique. H- shaped incision in the perineum. The vagina separated from the rectum. The torn end of external sphincter identified. Closure of anal mucosa. Suturing the external sphincters (overlapping sphinceroplasty or end to end anastmosis ).

10. Post-operative care The perineal wound is kept dry and clean by washing the perineum with antiseptic solution after every micturition or defecation. Role of 3 for 9 day. Good antibiotics. No sexual intercourse for 2 m. Subsequent deliveries better by CS.