1. 1 Repair of Fourth-Degree Perineal Lacerations Rhonda A. Sparks, MD University of Oklahoma Family Medicine Residency Program, Oklahoma City, Oklahoma Andrea D. Beesley, PhD Mid-Continent Research for Education and Learning, Aurora, Colorado Andrew D. Jones, MD Exempla Saint Joseph Family Medicine Residency Program, Denver, Colorado

2. 2 Overview Definition of fourth-degree perineal laceration Review of relevant anatomy Description of how anatomical structures are represented in the model Description of the steps of the repair Practice repairing lacerations in the model Peer assessment

3. 3 Objectives The learner will be able to identify the structures involved in perineal lacerations using the sponge model. The learner will be able to recall and perform the steps in the repair of perineal lacerations using the sponge model and according to the task checklist.

4. 4 Fourth-Degree Laceration Cunningham et. al. (1997). Williams Obstetrics. 20 th ed. Stamford, CT: Appleton & Lange. Copyright McGraw-Hill Companies, Inc. A. Jones & A. Beesley

5. 5 The Model: Vaginal Wall Cunningham et. al. (1997). Williams Obstetrics. 20 th ed. Stamford, CT: Appleton & Lange. Copyright McGraw-Hill Companies, Inc.

6. 6 The Model: Hymenal Ring Cunningham et. al. (1997). Williams Obstetrics. 20 th ed. Stamford, CT: Appleton & Lange. Copyright McGraw-Hill Companies, Inc.

7. 7 The Model: Perineum Cunningham et. al. (1997). Williams Obstetrics. 20 th ed. Stamford, CT: Appleton & Lange. Copyright McGraw-Hill Companies, Inc.

8. 8 The Model: Rectal Sphincter Cunningham et. al. (1997). Williams Obstetrics. 20 th ed. Stamford, CT: Appleton & Lange. Copyright McGraw-Hill Companies, Inc.

9. 9 The Model: Rectal Mucosa Cunningham et. al. (1997). Williams Obstetrics. 20 th ed. Stamford, CT: Appleton & Lange. Copyright McGraw-Hill Companies, Inc.

10. 10 Procedure: Setting up Lighting 5.0-3.0 Vicryl or Chromic suture Needle driver Forceps Suture scissors Allis clamps Gilpi retractor 4x4’s 1% lidocaine Pudendal tray Needle driver Forceps Allis clamp A. Jones

11. 11 Procedure: Anesthesia Does the patient have epidural anesthesia? Consider a bolus if needed Attempt local anesthesia with 1% lidocaine without epi Pudendal anesthesia if local inadequate

12. 12 Visualize! Cunningham et. al. (1997). Williams Obstetrics. 20 th ed. Stamford, CT: Appleton & Lange. Copyright McGraw-Hill Companies, Inc.

13. 13 Reapproximate rectal mucosa Anchor suture in vertex of tear Running or interrupted stitch SUPERIOR to rectal mucosa—avoid passing suture into mucosa

14. 14 Reapproximate rectal mucosa A. Jones

15. 15 Reapproximate rectal sphincter Identify and grasp with Allis on both sides Interrupted or figure of 8 stitches in four points 1.Posterior 2.Inferior 3.Superior 4.Anterior Get the fibrous sheath while suturing

16. 16 Reapproximate rectal sphincter Clamping the rectal sphincter Completed repair A. Jones

17. 17 Reapproximate perineal and vaginal mucosa Repair vaginal sidewall to hymenal ring Deep repair from hymenal ring to anal verge Subcuticular repair from anal verge to hymenal ring

18. 18 Repair of vaginal sidewall to hymenal ring A. Jones

19. 19 Repair of perineum A. Jones

20. 20 Completed repair A. Jones

21. 21 Finishing up Check hemostasis Add interrupted sutures as needed Cleanse with warm saline

22. 22 Time for practice! Complete one practice repair while your partner holds the model Switch places Complete another repair while your partner hold the model and checks off the checklist Switch places