Management of Episiotomies and perineal tears .pptx

Lecture notes on episiotomies and perineal tears

1. EPISIOTOMIES AND PERINEAL TEARS By PROF. ISRAEL JEREMIAH Department of Obstetrics and Gynaecology, NDU.

2. EPISIOTOMY Episiotomy is a surgical incision of the perineum aimed at increasing the diameter of the vaginal introitus (vulval outlet) during childbirth. Benefits Prevention of perineal lacerations. Prevention of prolonged and overstretching of the perineum which later predisposes to prolapse and stress incontinence. Minimising compression and decompression of the head which predisposes to intracranial haemorrhage. Disadvantages Blood loss Perineal pain Dyspareunia

3. Indications (A) Maternal Whenever there are vaginal manipulations needed such as in breech deliveries shoulder dystocia. Forceps delivery Vacuum extraction Old perineal scar about to rupture. Prolonged second stage due to rigid perineum. Vulval oedema. Previous pelvic floor or perineal surgery When bearing down effort is a risk to the mother Heart disease Severe pre-eclampsia/eclampsia

4. (B) Foetal Large sized baby. Preterm baby (reduction of pressure on the foetal skull). Direct occipito -posterior position. Breech delivery. Foetal distress to expedite delivery.

5. Types Median (midline) episiotomy (common in USA). Mediolateral episiotomy (commonly used in our labour ward) J-shaped episiotomy (not commonly used) Lateral episiotomy (not commonly used)

6. Median episiotomy A midline incision from the fourchette through the perineal body, but not including the external anal sphincter. Advantages It is the easier to perform and to repair. It does not cut through the belly of the muscle. Associated with less blood loss. The wound heals quicker. Less pain and discomfort in the puerperium. Reduced incidence of dyspareunia. Better cosmetic appearance. Disadvantages: Its inadvertent extension will injure the external anal sphincter and rectum (third and fourth degree perineal tears). As a result many practitioners avoid this technique.

7. Mediolateral episiotomy The incision starts from the midline of the fourchette and aimed diagonally in the direction of the ischial tuberosity to avoid the anal sphincter. Incision may be made on the right or left depending on the operator’s preference. Advantages Extension to the anal sphincter is less common. Suitable for instrumental vaginal delivery. Incision can be extended to the ischiorectal fossa if necessary. Disadvantages Difficult to perform and to repair (tissue apposition is poor). More blood loss. More pain and discomfort in the puerperium, More dyspareunia later on. Increased incidence of wound dehiscence. Poor cosmetic appearance.

8. Procedure Anaesthesia Local infiltration, pudendal nerve block are commonly used. Anaesthetise early to provide sufficient time for effect.  Infiltrate about 10ml of 0.5% lignocaine solution beneath the vaginal mucosa and perineal skin and muscle. ! Avoid intravenous injection of lignocaine as the woman may suffer seizure or even death. Timing Episiotomy is performed when the head crowns (visible at the introitus and does not recede) during uterine contraction. This also applies when the ventouse is used. If forceps will be used, episiotomy is done just before its application. Early incision increases blood loss while late incision leads to excessive stretching of the perineum.

9. Incision: The index and middle fingers of one hand is introduced between the presenting part and the proposed site of perineal incision to protect the presenting part and support the tissues that will be incised. The incision is usually 3-5 cm in length including the posterior vaginal wall, forchette , perineal muscles and perineal skin (Fig.). A single cut is advised to avoid zig-zag incision line.

10. REPAIR OF EPISIOTOMY Principles of repair Suture as soon as possible following delivery to reduce bleeding and risk of infection. Check equipment and count swabs prior to commencing the procedure and count again following completion of the repair. Good lighting is essential. Ensure good anatomical alignment of the wound and give consideration to cosmetic results. Rectal examination after completing the repair will ensure that suture material has not been accidentally inserted through the rectal mucosa. It is important that absorbable sutures be used for closure. Polyglycolic sutures are preferred to chromic catgut for their tensile strength, non-allergenic properties and lower probability of infectious complications. Chromic catgut is an acceptable alternative.

11. Procedure Provide emotional support and encouragement. Put the woman in the lithotomy position. Use local infiltration with lignocaine. If necessary, use a pudendal block. Carefully examine the vagina, perineum and cervix. Apply antiseptic solution to the area around the tear Aspirate (pull back on the plunger) to be sure that no vessel has been penetrated. If blood is returned in the syringe with aspiration, remove the needle. Recheck the position carefully and try again. Never inject if blood is aspirated.

12. At the conclusion of the set of injections, wait 2 minutes and then pinch the area with forceps. If the woman feels the pinch, wait 2 more minutes and then retest. The exposure and difficulty with seeing the edges of the vaginal skin due to bleeding from above can be overcome by placing a vaginal swab with a tail that comes outside the introitus above the inscicion . Care should be exercised to remove this swab after completion of the repair. Repair the vaginal mucosa using interrupted 2-0 suture.

13. Start the repair about 1 cm above the apex (top) of the episiotomy as descending branches of vaginal arteries may be retracted. This helps to stop any bleeding. Continue the suture to the level of the vaginal opening; At the opening of the vagina, bring together the cut edges of the vaginal opening. Bring the needle under the vaginal opening and out through the incision and tie. Repair the perineal muscles using interrupted 2-0 suture. If the wound is deep, place a second layer of the same stitch to close the space. Repair the skin using interrupted (or subcuticular) 2-0 sutures starting at the vaginal opening.

14. Do not tie the sutures tightly (may cause oedema and pain)  A vaginal examination should confirm good approximation of the cut edges and good haemostasis . If the wound was deep, perform a rectal examination. Make sure no stitches are in the rectum.  Before cleaning and placing a pad against the vagina an instrument, needle and swabs count should be carried out. Detailed documentation should include estimated blood loss and post repair care should include sufficient instructions for pain relief including appropriate analgesics

15. POST-PROCEDURE CARE Ampicillin 500 mg 6 hourly for 5 days orally.  Metronidazole 400 mg 8 hourly for 5 days orally. Twice daily Sitz’s baths for one week. Note: Routine antibiotic prophylaxis may not be necessary. Advice perineal hygiene.

16. Complications of episiotomy Immediate Bleeding Pain Haematoma formation Late Infection Wound breakdown (usually due to poor technique and infection). Scarring Dyspareunia Fistula formation Endometriosis of the scar.

17. PERINEAL TEARS Perineal lacerations may occur with normal or instrumental vaginal delivery. Vulval and anterior vaginal tears do occur with vaginal delivery but posterior vaginal tear associated with perineal injury is more common and occurs with the delivery of the head and at times with the shoulders.

18. Classification First degree: involves vaginal and perineal skin. Second degree: involves the perineal muscle. Third degree: involves injury to anal sphincter and is subdivided based on the degree of involvement. 3a is when less than half (50%) the thickness of the external anal sphincter is involved. 3b is a full thickness external anal sphincter involvement. 3c is when both the external and internal sphincter get involved. Fourth degree tear is when the tear damages the sphincter and involves the anal/rectal mucosa. Anterior perineal trauma is defined as any injury to the labia, anterior vagina, urethra or clitoris and is associated with less morbidity.

19. REPAIR OF FIRST AND SECOND DEGREE TEARS Most first degree tears close spontaneously without sutures. Some may require one or two interrupted stitches. The repair of first and second degree tears is the same as for repair of episiotomy.

20. REPAIR OF THIRD AND FOURTH DEGREE PERINEAL TEARS Note: The woman may suffer loss of control of bowel movements and gas if a torn anal sphincter is not repaired correctly. If a tear in the rectum is not repaired, the woman can suffer from infection and rectovaginal fistula (passage of stool through the vagina). Principles of repair Should be performed in the delivery room of or theatre with good lighting and correct equipment. Provide emotional support and encouragement. Place patient in the lithotomy position. Use a pudendal block or ketamine. If all edges of the tear can be seen, the repair can be done using local infiltration with lignocaine (see above) or pethidine and diazepam IV slowly. Examine the vagina, cervix, perineum and rectum.

21. To see if the anal sphincter is torn: Place a gloved finger in the anus and lift slightly; Identify the sphincter, or lack of it; Feel the surface of the rectum and look carefully for a tear. Change to clean, high-level disinfected gloves. Apply antiseptic solution to the tear and remove any faecal material, if present. Anaesthetise early to provide sufficient time for effect If the sphincter is torn and rectal/anal mucosa is intact (third degree tear), Grasp each end of the sphincter with an Allis clamp (the sphincter retracts when torn). The sphincter is strong and will not tear when pulling with the clamp; Repair the sphincter with two or three interrupted stitches of 2-0 suture. Continue the rest of the repair as in episiotomy repair.

22. Fourth degree tear Repair the rectum using interrupted 3-0 or 4-0 polyglycolic acid sutures ( vicryl , dexon ) 0.5 cm apart to bring together the mucosa.  Remember: Place the suture through the muscularis (not all the way through the mucosa). Cover the muscularis layer by bringing together the fascial layer with interrupted sutures; Apply antiseptic solution to the area again. Repair the sphincter as described above. Examine the anus with a gloved finger to ensure the correct repair of the rectum and sphincter. Then change to clean, high-level disinfected gloves. Repair the vaginal mucosa, perineal muscles and skin.

23. POST-PROCEDURE CARE Ampicillin 500 mg 6 hourly for 5 days orally. Metronidazole 200 mg 8 hourly for 5 days orally. Twice daily Sitz’s baths for one week. Follow up closely for signs of wound infection. Avoid rectal examinations for 2 weeks. Give stool softener by mouth for 1 or 2 weeks, if possible. Enemas are not helpful.

24. MANAGEMENT OF NEGLECTED CASES OF PERINEAL TEARS A perineal tear is commonly contaminated with faecal material. If closure is delayed for more than 12 hours, infection is inevitable. Delayed primary closure is indicated in such cases. For first and second degree tears, leave the wound open. For third and fourth degree tears, close the rectal mucosa with some supporting tissue and approximate the fascia of the anal sphincter with 2 or 3 interrupted sutures. Close the muscle and vaginal mucosa and the perineal skin 6 days later.

25. COMPLICATIONS Complication Treatment Haematoma Small haematomas may be treated conservatively. Otherwise incise and drain. Give antibiotics. Infection Give antibiotics. Faecal incontinrnce If incontinence persists, reconstructive surgery after 3 months. Rectovaginal fistula Reconstructive surgery after 3 months

26. SUMMARY There is no evidence to support routine episiotomy – a tear may be less painful than an episiotomy and may also heal better. Right or left mediolateral episiotomy is preferred to a midline episiotomy. Perineal damage may affect sexual function. Third and fourth degree tears need to be repaired by experienced clinicians.

27. Thank you!