repair of obstetric lacerations dr. pamela berger

REPAIR OF OBSTETRIC LACERATIONS

Dr. Pamela Berger

Overview

Review of anatomy Classification of perineal lacerations

3rd/4th degree tears Approach to repair Prevention of perinal lacerations Episiotomy Post-partum issues

Anatomy

External genitalia

Muscular structures

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

Classification of lacerations

1st degree

Involve the perineal skin and vaginal mucosa but not the underlying fascia and muscle

May not require repair

2nd degree

Involve, in addition, the fascia and muscles of the perineal body but not the anal sphincter

Most common type

2nd degree

3rd degree

Extend farther to involve the anal sphincter

4th degree

Extend through the rectal mucosa

3rd & 4th degree lacerations

Recognition is key...

Recognition of Grade 3 tear

Risk factors for 3rd & 4th degree tears Midline episiotomy Nulliparity Previous 3rd/4th degree tear Prolonged second-stage Persistent occiput posterior position Forceps > vacuum

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

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

Approach to repair

Tools

Exposure Light Patient positioning Sponges Retractors

Anesthetic Epidural or local

Suturing instruments Needle driver, forceps, scissors

Suture Polysorb (Vicryl), PDS

Copyright © 2012 McGraw-Hill Medical. All rights reserved.

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.

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.

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.

The continuous suture is then carried upward as a subcuticular stitch. The final knot is tied proximally to the hymenal ring.

Labial and periurethral tears

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

High vaginal tears

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

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

Episiotomy

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

1993 to 20% in 2004

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)

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

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

Prevention of Perineal Trauma

1 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.: CD006672. DOI: 10.1002/14651858.CD006672.pub2.

2 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): 246-253

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): 143-160

4 Albers L, Sedler KD, Bedrick EJ, Teaf D, Peralta P. Factors related to genital trauma in normal spontaneous vaginal births. Birth 2006; 33 (2): 94-100

5 Soong B, Barnes M. Maternal position at midwife-attended birth and perineal trauma: is there an association?. Birth 2005; 32 (3): 164-169

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

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

What might work

Intrapartum perineal massage1

Spontaneous pushing3

Water birth…1

Post-partum issues

Wound infection or break-down Fortunately uncommon Area swollen, erythematous, purulent

exudate Open wound, debride, irrigate Abx only if cellulitis Early vs delayed repair

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

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

Sexual dysfunction

Vaginal dryness 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

Post-partum issues

Always take the time to examine a patient who is complaining of discomfort at the 6 week PP visit

Questions?