Perineal injury and episiotomy

1. PERINEAL INJURY AND EPISIOTOMY

2. OUTLINE OF PRESENTATION
•ANATOMY OF PERINEUM
•FIRST AND SECOND DEGREE TEAR – REPAIR
•THIRD AND FOURTH DEGREE TEAR - REPAIR

3. PERINEUM
•Diamond shaped area between the thigh
•Perineal body:
–mass of interlocking muscular, fascial, and fibrous
components lying between the vagina and anorectum
–attachment point for components of the urinary and fecal
continence mechanisms, which are commonly damaged
during vaginal childbirth
•Anterior and posterior triangle

4. Anterior triangle: superficial compartment

5. •bounded deeply by the perineal membrane and
superficially by Colles fascia
•closed compartment  infection or bleeding within it
remains contained
•Contains muscles that are cut during episiotomy:
–Bulbospongiosus
–Transverse perineal

7. Anterior triangle: deep compartment

8. Posterior triangle
•Contents:
–Ischiorectal fossa
–Anal canal
–Sphincter complex

9. ANORECTUM

11. External anal sphincter

12. Internal anal sphincter

13. CLASSIFICATION OF PERINEAL INJURY

14. RCOG GREEN TOP GUIDELINE
•Risk factors (for 3
rd
degree tear):
1.BW > 4.0 kg
2.Persistent OP position
3.Nulliparity
4.IOL
5.Epidural analgesia
6.Prolonged second stage ( > 1 hour)
7.Shoulder dystocia
8.Midline episiotomy
9.Forceps delivery

15. •Prognosis:
–Good prognosis following EAS repair
–60 - 80% asymptomatic at 12 months
–Those with symptoms: flatus incontinence or faecal urgency
–Endoanal ultrasound as part of follow-up  persistent defects
in 54–88% of women after primary repair of recognised third-
degree tears

16. •Future deliveries (for those who sustained obstetrics
anal sphincter injury):
–should be counselled about the risk of developing anal
incontinence or worsening symptoms with subsequent vaginal
delivery
–no evidence to support the role of prophylactic episiotomy in
subsequent pregnancies
–Those who are symptomatic or have abnormal endoanal
ultrasonography and/or manometry should have the option of
elective caesarean birth