Perineal Trauma

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Perineal Trauma Epsiotomy

• Prepared By Mrs Raheegeh AWNI

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Perineal Trauma R/t child birth

• - Lacerations
• -Most acute injuries or laceration of the
  perineum, vagina, uterus and their supportive
  tissues occur during child birth.
• - Laceration if not repair lead to genitourinary
  and sexual problem (pelvic relaxation, uterine
  prolapse, cystocele, rectocele, dyspareunia,
  urinary and anaL bowel dysfunction).

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CONT.

• Immediate repair
• Promotes healing
• Limits residual damage
• Decreases the possibility of infection

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CONT.

• - Primary health care provider
• continue to inspect the perineum
• carefully and evaluate lochia to
• identify any missed damage during
• the early postpartum period.

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Perineal Lacerations

• Degree of laceration
• 1. First degree laceration extends
  through the skin and structures
  superficial to muscle.
• 2. Second degree Laceration extends through
  muscles of the perineal body

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CONT.

• 3. Third degree Laceration continues
  through the anal sphincter muscle.
• 4. Fourth degree Laceration involves the
  anterior rectal wall.

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CONT.

• - Special attention must be paid to third
  and fourth stage laceration so that woman retains
  fecal continence.
• - Measures are taken to promote soft stools (e.g.
  roughage, fluid, activity, and stool softeners)
  to increase comfort and healing.

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CONT.

• - Antimicrobial therapy may be used
• - Enemas and suppositories are
• contraindication

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Vaginal Urethral laceration

• - Vaginal laceration occur in
• conjunction with perineal laceration
• - Vaginal laceration tend to extend
• up the lateral walls and if deep enough involve
  the levator ani muscle.

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CONT.

• - Vaginal vault laceration may be
• circular and result from forceps
• rotation especially in the
• cephalopelvic disproportion, rapid
• fetal decent.

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Cervical Injuries

• - Occur when the cervix retracts over the
  advancing fetal head.
• - This laceration occur at the angles of the
  external os, most are shallow, bleeding is
  minimal.

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CONT.

• - Cervical injuries when extend to vaginal vault
  or beyond it into the lower uterine segment
  serious bleeding may occur.
• - Cervix laceration can have adverse effect on
  future pregnancies and child birth.

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Evidence

• -The highest rate of trauma have consistently
  been observed in first births or operative
  vaginal deliveries (forceps or vacuum
  extraction).
• -Rate of trauma appear to increase with infant
  birth weight, maternal weight gain in pregnancy,
  and fetal malposition.
• - Use of episiotomy increases serious trauma to
  genital tract, especially third and fourth degree
  laceration.
• Leah L .Reduction Genital Tract Trauma at Birth.
  2003.

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Episiotomy

• - Is an incision in the perineum to
• enlarge the vaginal outlet.

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Timing of Episiotomy

• If performed unnecessarily early, bleeding from
  the episiotomy may be considerable during the
  interim between incision and delivery.
• If it is performed too late, lacerations will
  not be prevented. It is common practice to
  perform episiotomy when the head is visible
  during a contraction to a diameter of 3 to 4 cm.

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• When used in conjunction with forceps delivery,
  most practitioners perform an episiotomy after
  application of the blades.

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Episiotomy

• - Indication
• 1. Facilitates vacuum or forceps
  assisted birth
• 2. Fetal distress
• 3. Facilitates the birth of large baby
• 4. Premature baby

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Type of episiotomy

• 1. Median -Is most commonly used
• - It is effective
• -Easily repaired
• -Least painful
• - Midline episiotomy are associated with a higher
  incidence of third and fourth degree of
  laceration.

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Type of episiotomy

• 2. Mediolateral Is used in operative births when
  need for posterior extension.
• - Fourth degree laceration may be prevented,
  third degree may occur.
• - Blood loss is greater, painful, difficult
  repair than midline.

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Risk Factor associated with perineal trauma

• 1.Nulliparity
• 2. Maternal position
• 3. Pelvic inadequacy
• 3. Fetal malpresentation and position 4. Large
  baby
• 5. Use of instruments to facilitate birth

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CONT.

• 6. Prolong second stage of labor
• 7. Fetal distress
• 8. Rapid labor

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Evidence

• - Episiotomy should not be used unless indicated
  . Measures should be taken to avoid perineal
  trauma during labor to establish bonding early
  between mother and infant to minimize perineal
  discomfort after birth.
• Karacam Z. Effects of episiotomy on bonding and
  mothers health. 2003

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Timing of the Episiotomy Repair

• The most common practice is to defer episiotomy
  repair until the placenta has been delivered.
• This policy permits undivided attention to the
  signs of placental separation and delivery.
• A further advantage is that episiotomy repair is
  not interrupted or disrupted by the obvious
  necessity of delivering the placenta, especially
  if manual removal must be performed.

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Technique

• There are many ways to close an episiotomy
  incision, but hemostasis and anatomical
  restoration without excessive suturing are
  essential for success with any method.
• A technique that commonly is employed . The
  suture material ordinarily used is 3-0 chromic
  catgut, but Grant (1989) recommends suture
  composed of derivatives of polyglycolic acid.
  rates of suture removal within 3 months of
  delivery (3 percent removal versus 13 percent
  removal for rapidly absorbed versus standard
  polyglactin).

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• Sanders and co-workers (2002) emphasized that
  women without regional analgesia can experience
  high levels of pain during perineal suturing.
• A decrease in postsurgical pain is cited as the
  major advantage of the newer materials, despite
  the occasional later need to remove some of the
  suture from the site of repair because of pain or
  dyspareunia.

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Perineal management

• - Warm compress
• - Massage
• - Kegels exercises in the prenatal and
  postpartum periods
• - Good nutrition, hygienic measures
• - As advocates, encourage women to use
  alternative birthing positions and use
  spontaneous bearing down effort.

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• Thank you