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 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

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

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 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

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

2nd degree -2nd degree + tear of clitoris

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 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

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)

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 Anesthetic Suturing instruments Suture 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. 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.

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.

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.

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.

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.

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

Labial and periurethral tears -3rd degree with labial tear

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

High vaginal tears -high vaginal tear (from ACOG bulletin http://www.obgyndo.com/resources/Rotating-Residents/intern-ACOG-Bulletin-Episiotomy-and-Repair.pdf)

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 Timing: Too early  blood loss Too late  fails to prevent laceration Wait until head is visible

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

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.: CD006672. DOI: 10.1002/14651858.CD006672.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): 246-253 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 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 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 -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

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 -early repair = within 2 weeks, after period of aggressive wound care (irrigation, debridement), once wound covered with pink granulation tissue; better results, faster healing

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 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

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

Questions?