1. REPAIR OF OBSTETRIC LACERATIONS
Dr. Pamela Berger

2. Overview Review of anatomy Classification of perineal lacerations
3rd/4th degree tears
Approach to repair
Prevention of perinal lacerations
Episiotomy
Post-partum issues

3. Anatomy

4. External genitalia
Most critical area of ext genitalia is the distance from vestibular fossa to anus: perineal body, avg length 3-4cm in non-pregnant
++variation, expansion occurs as head begins to emerge

5. Muscular structures Superficial compartment
is bounded deeply by the perineal membrane and superficially by Colles fascia. It is a closed compartment, and infection or bleeding within it remains contained. The anterior triangle contains several important structures that include the ischiocavernosus, bulbocavernosus, and superficial transverse perineal muscles; Bartholin glands; vestibular bulbs; clitoral body and crura; and branches of the pudendal vessels and nerve
Posterior triangle contains the ischiorectal fossa, anal canal, anal sphincter complex, and branches of the internal pudendal vessels and pudendal nerve

7. Perineal body Function Anchors the anorectum Anchors the vagina
Helps maintains urinary and fecal continence
Prevents expansion of the urogenital hiatus
Provides a physical barrier between the vagina and rectum

8. Classification of lacerations

9. 1st degree
Involve the perineal skin and vaginal mucosa but not the underlying fascia and muscle
May not require repair
These included periurethral lacerations, which may bleed profusely.
These tears usually extend upward on one or both sides of the vagina, forming an irregular triangular injury

10. 2nd degree
Involve, in addition, the fascia and muscles of the perineal body but not the anal sphincter
Most common type

11. 2nd degree
-2nd degree + tear of clitoris

12. 3rd degree
Extend farther to involve the anal sphincter

13. 4th degree
Extend through the rectal mucosa

14. 3rd & 4th degree lacerations
Recognition is key...

15. Recognition of Grade 3 tear
3a: partial tear of the external anal sphincter involving less than 50% thickness
3b: greater than 50% tear of the external anal sphincter
3c: internal sphincter is torn

16. Risk factors for 3rd & 4th degree tears
Midline episiotomy
Nulliparity
Previous 3rd/4th degree tear
Prolonged second-stage
Persistent occiput posterior position
Forceps > vacuum
? Use of local anesthetics (including epidural)

17. 3rd & 4th degree tears
Many are not recognized and repaired  leads to fecal/flatal incontinence
Need high index of suspicion
Recognition is key!
Always do a rectal exam after repairing a tear
Consider OB consult for repair

18. 3rd/4th degree tears: Management Post-Repair
Explain to patient
Prophylactic antibiotics
Reduced early wound complications
Analgesia
NSAIDs/Acetaminophen ± narcotics, ice packs
Epimorph if epidural
Bowel Management
Dietary advice and stool softeners
Sitz baths
Pelvic Floor Physiotherapy
Once discomfort improves

19. Approach to repair

20. Tools Exposure Anesthetic Suturing instruments Suture Light
Patient positioning
Sponges
Retractors
Anesthetic
Epidural or local
Suturing instruments
Needle driver, forceps, scissors
Suture
Polysorb (Vicryl), PDS

21. Copyright © 2012 McGraw-Hill Medical. All rights reserved.
Repair of midline episiotomy. A. Disruption of the hymenal ring and bulbocavernosus and superficial transverse perineal muscle are seen within the diamond-shaped incision following episiotomy.
Copyright © 2012 McGraw-Hill Medical. All rights reserved.

22. Copyright © 2012 McGraw-Hill Medical. All rights reserved.
Absorbable 2-0 or 3-0 suture is used for continuous closure of the vaginal mucosa and submucosa.
Care should be taken to identify and incorporate the apex of the tear in the repair.
If the apex of the tear extends out of the field of vision, a suture can be placed below the apex and the suture tail used as a purchase to pull the apex into view.
Copyright © 2012 McGraw-Hill Medical. All rights reserved.

23. Copyright © 2012 McGraw-Hill Medical. All rights reserved.
After closing the vaginal incision and reapproximating the cut margins of the hymenal ring, the needle and suture are positioned to close the perineal incision.
The suture placed in the bulbocavernosus muscle is often called the "crown" stitch. 1 2
Copyright © 2012 McGraw-Hill Medical. All rights reserved.

24. Copyright © 2012 McGraw-Hill Medical. All rights reserved.
The perineal body and bulbocavernosus muscle can be reapproximated with intermittent or continuous sutures.
The advantage of an intermittent technique is that if one suture breaks, there are others to hold the repair in place.
Copyright © 2012 McGraw-Hill Medical. All rights reserved.

25. Copyright © 2012 McGraw-Hill Medical. All rights reserved.
The continuous suture is then carried upward as a subcuticular stitch. The final knot is tied proximally to the hymenal ring.
Copyright © 2012 McGraw-Hill Medical. All rights reserved.

26. Here we see the original perineal laceration, then after the vaginal repair and then after the perineum has bee repaired. Note the interrupted skin sutures to provide additional support and reduce tension on the swollen tissues

27. Labial and periurethral tears
-3rd degree with labial tear

28. Labial and periurethral tears
Catheterize if anywhere near urethra
Localize urethra (catheter) to prevent suturing through urethra, can remove catheter after repair
If through entire thickness of labia, suture each side separately
Usually superficial - due to stretching
If only bleeding  apply pressure
Minimal stitching (figure of 8 or interrupted sutures)
Sitz baths
Push fluids or peri-bottle to dilute urine
Can consider Monsel’s solution (ferric subsulfate) if only bleeding

29. High vaginal tears -high vaginal tear
(from ACOG bulletin

30. High vaginal tears Often deep and extensive Ensure not bilateral
Exposure is key
retractors
assistant
vaginal sponges
May need deep sutures
Control bleeding to prevent hematomas
Ensure apposition
Repair each tear to introitus then join to other tears

31. Approach to repair—3rd & 4th degree
Indication for consult to Ob/Gyn

32. Episiotomy

33. Historical use of episiotomy
Used to be routine, thought to:
Result in less pain
Prevent pelvic floor complications (prolapse, incontinence)
Protect perineal body
ALL of these assumptions were proven incorrect
Only advantage is ease of repair
In Canada episiotomy rate fell from 37% in to 20% in 2004

34. Disadvantages of episiotomy
Increased risk 3rd and 4th degree tears (midline episiotomy)
Increased risk of fecal incontinence
Increased risk of ≥2nd degree tear in 2nd delivery
More post-partum pain
More complications with healing (mediolateral episiotomy)

35. Indications for episiotomy
Need to expedite delivery
Shoulder dystocia
Forceps/vacuum
OP position
“Instances in which failure to perform an episiotomy will result in perineal rupture”
But NONE of these requires routine use of episiotomy
Timing is important
Timing: Too early  blood loss
Too late  fails to prevent laceration
Wait until head is visible

36. Types of episiotomy Easier to repair Better healing Less pain
Less blood loss
Less dyspareunia
Less extensions
Less 3rd & 4th degree tears
Can safely make a larger incision

37. Prevention of Perineal Trauma

38. Aasheim V, Nilsen ABV, Lukasse M, Reinar LM
Aasheim V, Nilsen ABV, Lukasse M, Reinar LM. Perineal techniques during the second stage of labour for reducing perineal trauma. Cochrane Database of Systematic Reviews 2011, Issue 12. Art. No.: CD DOI: / CD pub2.
Albers L, Borders N. Minimizing genital tract trauma and related pain following spontaneous vaginal birth. Journal of Midwifery and Women’s Health 2007; 52 (3):
Renfrew MJ, Hannah W, Albers L, Floyd E. Practices that minimize trauma to the genital tract in childbirth: a systematic review of the literature. Birth 2008; 25 (3):
Albers L, Sedler KD, Bedrick EJ, Teaf D, Peralta P. Factors related to genital trauma in normal spontaneous vaginal births. Birth 2006; 33 (2):
Soong B, Barnes M. Maternal position at midwife-attended birth and perineal trauma: is there an association?. Birth 2005; 32 (3):

39. What works Antenatal perineal massage starting at 35 wks1, 2
Nulliparous patients
Restrictive use of episiotomy1,2,3
Delayed pushing in nullips with epidural2
Controlled delivery of head between contractions2,4
“Spontaneous” pushing2
Birth position: lateral, sitting or on all fours2,5
Warm compresses (less 3rd/4th degree tears) 1,3
-perineal massage: xlast 6 wks of pregnancy for 4 min, 3-4x/wk or 10 min daily (daily works better)
-spontaneous pushing = non-directed, multiple short pushes, no sustained breath holding; as compared to Valsalva or directed pushing = forceful bearing down, sustained breath-holding –Valsalva pushing leads to shorter 2nd stage but may have reduced oxygenation in fetus
-lateral/all 4s as compared to supine or lithotomy

40. What doesn’t work Birth position: lateral, upright or on all fours3
Warm compresses (less 3rd/4th degree tears) 2
“Hands on” (compared to “hands off”) 1
Intrapartum perineal massage3

41. What might work Intrapartum perineal massage1 Spontaneous pushing3
Water birth…1

42. Post-partum issues

43. Wound infection or break-down
Fortunately uncommon
Area swollen, erythematous, purulent exudate
Open wound, debride, irrigate
Abx only if cellulitis
Early vs delayed repair
-early repair = within 2 weeks, after period of aggressive wound care (irrigation, debridement), once wound covered with pink granulation tissue; better results, faster healing

44. Granulation tissue If small can touch with silver nitrate
If bigger may need to cut off then apply silver nitrate to the base
May need more than one treatment

45. Sexual dysfunction
50-80% of women resume sexual activity by 6 weeks, 90% by 12 weeks
Decreased libido
Fatigue, pain, concern re: healing, caring for a newborn…
Worse initially if breastfeeding
Dyspareunia
50% at 2 months, most resolve with time

46. Sexual dysfunction Vaginal dryness Post-partum depression
Estrogen is low post-partum (especially if breastfeeding)
Lubricant for intercourse, may need PV estrogen
Post-partum depression
Depression & antidepressants affect sexual function
Concerns about another pregnancy

47. Post-partum issues
Always take the time to examine a patient who is complaining of discomfort at the 6 week PP visit

48. Questions?