1. REPAIR OF OBSTETRIC LACERATIONS Dr. Pamela Berger

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

3. Anatomy

4. External genitalia

5. Muscular structures

6. Bulbocavernosus

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. 1 st degree  Involve the perineal skin and vaginal mucosa but not the underlying fascia and muscle  May not require repair

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

11. 2 nd degree

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

13. 4 th degree  Extend through the rectal mucosa

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

15. Recognition of Grade 3 tear

16. Risk factors for 3 rd & 4 th degree tears  Maternal  Primiparity  Previous 3 rd or 4 th degree tear  Infant factors:  Birth weight >4000 g  Occiput posterior presentation  Delivery  Midline episiotomy  Prolonged second stage  Forceps > vacuum  Epidural  Shoulder dystocia

17. 3 rd & 4 th degree tears  Overall rate is 4 to 6.6%  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. 3 rd /4 th 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 laxatives (PEG 3350)  Sitz baths  Pelvic Floor Physiotherapy  Once discomfort improves

20. Approach to repair

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

22. Copyright © 2012 McGraw-Hill Medical. All rights reserved. 1. Identify landmarks!

23. 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. 2. Vaginal repair

24. 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 3. The mysterious “crown stitch”

25. 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. 4. Perineal body

26. 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. 5. Perineal skin

28. Labial and periurethral tears

29.  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

30. High vaginal tears

31.  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

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

33. Episiotomy

34. 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 17% in 2007

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

36. 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

37. Episiotomy types 1. Midline 2. Modified median (inverted T) 3. J-shaped 4. Mediolateral 5. Lateral 6. Radical lateral

38. Midline vs Mediolateral epistiotomy Easier to repair Better healing Less pain Less blood loss Less dyspareunia Less extensions Less 3 rd & 4 th degree tears Can safely make a larger incision

39. Prevention of Perineal Trauma

40. 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 6 Harvey MA, Pierce M. Obstetrical anal sphincter injuries (OASIS): prevention, recognition and repair. JOGC 2015; 37(12):1131–1148

41. What works  Antenatal perineal massage 1, 2  Nulliparous patients, starting at 35 wks  Perineal massage at time of delivery 6  Restrictive use of episiotomy 1,2,3  Delayed pushing in nullips with epidural 2  Controlled delivery of head 2,4,6  “Spontaneous” pushing 2  Birth position: lateral, sitting or on all fours 2,5  Warm compresses (less 3 rd /4 th degree tears) 1,3,6

42. What doesn’t work  Birth position: lateral, upright or on all fours 3,6  Warm compresses (less 3 rd /4 th degree tears) 2  “Hands on” (compared to “hands off”) 1  Intrapartum perineal massage 3  Antepartum perineal massage 6  “Spontaneous” pushing 6  Water birth 6  Delayed pushing in women with an epidural 6

43. What might work  Intrapartum perineal massage 1  Spontaneous pushing 3  Water birth… 1

44. Post-partum issues

45. Wound infection or break-down  Fortunately uncommon  Area swollen, erythematous, purulent exudate  Open wound, debride, irrigate  Abx only if cellulitis  Early vs delayed repair

46. 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

47. 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

48. 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

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

50. Questions?