2. Influencing factors St rategies t o pre vent / minimize perineum
traum a during labour
Influencing factors
Antenatal perineal massage but not perineal massage during the second stage of labour
Use of warm perineal compresses during the second stage of labour
Restricted use of episiotomy
Upright birth positions – freedom of w oman to choose
Non-directed pushing (w oman using her ow n urges to bear dow n w ithout coaching from the midw ife or doctor)

3. Definition of perineal trauma
Perineal trauma may occur spontaneously during vaginal birth or when a surgical incision (episiotomy) is intentionally made to facilitate birth. It is possible to have an episiotomy and a spontaneous tear (e.g. extension of an episiotomy).
Anterior perineal trauma is defined as injury to the labia, anterior vaginal wall, urethra or clitoris. Posterior perineal trauma is defined as any injury to the posterior vaginal wall or perineal muscles and may include disruption of the anal sphincters.

4. Classification of perineal trauma First degree
Injury to perineal skin only
Second degree
Injury to perineum involving perineal muscles but not involving the anal sphincter
Third degree
Injury to perineum involving the anal sphincter complex:
3a: Less than 50% of external anal sphincter (EAS) thickness torn
Effacement mean that the cervix merge into the uterine segment

5. 3b: More than 50% of external anal
sphincter thickness torn
3c: Both external anal sphincter and internal anal sphincter (IAS) torn
Fourth degree
Injury to perineum involving the anal sphincter complex and anal epithelium
Isolated button hole injury of rectum
Injury to the rectal mucosa w ithout injury to the anal sphincters

7. What is episiotomy
What is episiotomy

8. Episiotomy (why???????)
episiotomy is protective against more severe perineal lacerations has not been substantiated (Carroli and Mignini 2009), and therefore the use of ‘prophylactic’ episiotomy is no longer recommended.
However, there are still valid reasons to perform an episiotomy. A variety of episiotomy techniques are described in the literature (Kalis et al 2012), but two types of episiotomy are most frequently used:

9. what are the Indication for episiotomy
reduction of trauma
shortening the second stage of labora
recommended in the event of fetal distress
shoulder dystocia “soft-tissue dystocia”
Before forceps application, Vacuum (operative delivery)
if a significant spontaneous laceration appears
Breech delivery
Non reassuring CTG
Indication for episiotomy
reduction of trauma to the fetal head, particularly in vulnerable premature infants. Another proposed advantage is shortening the second stage of labor, thereby providing respite for mother and baby from the exhaustive work of delivery. It is presumed that a shorter second stage will result in less infant hypoxia, less sepsis, and less maternal infection as well as the de facto benefit of “getting it over with.”
Another argument in favor of episiotomy is concern over integrity of the pelvic floor. Prolonged labors and large infants are known to be risk factors for subsequent disorders of pelvic floor anatomy and function. By providing greater outlet dispensability without stretching, it is felt that innervation and anatomic relationships might be better preserved.
Episiotomy is often recommended in the event of fetal distress and shoulder dystocia to deliver the infant more rapidly. The term “soft-tissue dystocia” was coined to encompass the notion that the perineal body may impede labor progress to a measurable and on occasion detrimental degree. Relief of this dystocia by episiotomy allows for prompt delivery of the infant.
Lastly, episiotomy is considered to be indicated if a significant spontaneous laceration appears otherwise unavoidable, which includes most cases in which forceps are used. Some include use of a vacuum extractor as carrying higher potential for laceration, and would consider an episiotomy to be of benefit. One of the common exhortations of residents in the mid-1980s was “a cut is faster to repair than a tear!”
Each of these indications has some indirect evidence in support of its value. In the studies cited in the next section, each has been considered as an “indicated” use of episiotomy, in contradistinction to the procedure's “routine” use. It bears comment, however, that no single indication has had the support of a prospective, randomized controlled trial with regard to measurable change in outcome based on providing or withholding the intervention.

10. Shoulder dystocia

11. Before forceps application

12. When you should do episiotomy ???
Just at crowning

13. Types of episiotomy

14. Midline episiotomy: Advantages of the midline episiotomy are that it does not cut through muscle, the two sides of the incised area are anatomically balanced, making surgical repair easier, and blood loss is less than with mediolateral episiotomy. A major drawback is that extension through the external anal sphincter and into the rectum can occur. For this reason midline episiotomy is not recommended in the UK.

15. Mediolateral episiotomy: The right mediolateral episiotomy is the technique approved for use by midwives in the UK. The incision is made starting at the midline of the posterior fourchette and aimed towards the ischial tuberosity to avoid the anal sphincter. In addition to the skin and subcutaneous tissues, the bulbospongiosus and the transverse perineal muscles are cut.

16. Compare between the 2 types

17. What is perineal trauma
a perineal tear is a spontaneous (unintended) laceration of the skin and other soft tissue structures which, in women, separate the vagina from the anus.
When it happen
Happen during vaginal childbirth
Does it require treatment??
The majority are superficial and require no treatment, but severe tears can cause significant bleeding, long-term pain or dysfunction need repair.

18. Diagnosis of perineal trauma
Following every vaginal birth a assessment should be performed to exclude genital trauma.
explain to the woman what you plan to do and why. offer inhalational analgesia and ensure that if there is pre-existing epidural analgesia, it is effective.
There must be good lighting.
woman should be positioned so that genital structures can be seen clearly.
Ex. a comfortable position, i.e. lithotomy
, clear explanation should be provided to the woman in a sensitive manner.  

19. Who will do the repair doctor or midwife
The midwife or doctor who cared for you while you gave birth will usually do your stitches too. If they are inexperienced they may ask a colleague to do the repair, or to supervise them while they do it themselves.
A third or fourth degree tear will always be repaired by an experienced obstetrician.

20. Training
Throughout the centuries, midwives have received very formal training in the art of perineal suturing.
In June 1967, midwives working in the United Kingdom were permitted by the Central Midwives Board (CMB), to perform episiotomies, but they were not allowed to suture perineal trauma.
In June 1970 the Chairman of the CMB issued a statement that midwives who were working in ‘remote areas overseas’ may be authorized by the doctor concerned to repair episiotomies, but the final responsibility lay with the doctor.
It was not until 1983, however, that perineal repair was included in the midwifery curriculum in the UK, when the European Community Midwives Directives came into force and the CMB issued the statement that midwives may undertake repair of the perineum provided they received the necessary instruction and are deemed competent to undertake the procedure.
Tohill and Kefle (2013) have provided evidence-based guidelines for midwives on how to suture correctly.

21. How we could Prevent tear from happening
Several techniques are used to reduce the risk of tearing.
Antenatal digital perineal massage is often advocated
‘Hands on’ techniques employed by midwives, in which the foetal head is guided through the vagina at a controlled rate have been widely advocated
Waterbirth and labouring in water are popular for several reasons, and it has been suggested that by softening the perineum they might reduce the rate of tearing.

23. How are they repaired?
First and second degree tears are repaired using either an epidural if the mother already has one, or local anaesthetic, which is injected prior to the stitches being inserted.
This local anaesthetic will take away the sensation of pain, but not touch.
The vagina is repaired first, then the perineum is repaired, starting with the deepest muscles and finishing with the skin. Most people now use a ‘sub-cuticular’ stitch to the skin, which means there are no knots on the outside.

26. Importance of anorectal examination
 Informed consent must be obtained for a vaginal and rectal examination. If the digital assessment is restricted because of pain, adequate analgesia must be given prior to examination. Following inspection of the genitalia, the labia should be parted and a vaginal examination performed to establish the full extent of the vaginal tear. When multiple or deep tears are present it is best to examine and repair in the supported lithotomy position, as previously stated.

27. A rectal examination should then be performed to exclude anal sphincter trauma. Every woman should have a rectal examination prior to suturing in order to avoid missing isolated tears such as a ‘bufon hole’ of the rectal mucosa (NICE 2007). Furthermore, a third- or fourth-degree tear may be present beneath apparently intact perineal skin, rectal examination in order to exclude obstetric anal sphincter injuries (OASIS) following every vaginal birth. Following diagnosis of the tear it should be graded according to the recommended classification as delineated earlier in.
Figure 15.2 shows a partial tear along the external anal sphincter which would have been missed if a rectal examination was not performed.

28. In order to diagnose OASIS, clear visualization is necessary and the injury should be confirmed by palpation. By inserting the gloved index finger in the anal canal and the thumb in the vagina, the anal sphincter can be palpated by performing a pill-rolling motion.
If there is still uncertainty, the woman should be asked to contract her anal sphincter (in the absence of an epidural) and if the anal sphincter is disrupted, there will be a distinct gap felt anteriorly.
If the perineal skin is intact there will be an absence of wrinkling on the perianal skin anteriorly. This may not be evident under regional or general anaesthesia. As the external anal sphincter (EAS) is normally in a state of tonic contraction, disruption results in retraction of the sphincter ends.  

29. Basic principles prior to repairing perineal trauma
Repair of perineal trauma
Basic principles prior to repairing perineal trauma

30. The skills and knowledge of the operator are important factors in achieving a successful repair. Ideally the repair should be conducted in a timely manner.
The woman should be referred to a more experienced healthcare professional if uncertainty exists as to the nature or extent of trauma sustained.

31. Having fully informed the woman why a detailed examination is required and to gain her consent, an initial systematic assessment of the perineal trauma must be performed including a sensitive rectal examination to exclude any trauma.
In order to reduce maternal morbidity, repair of the perineum should be undertaken as soon as possible to minimize the risk of bleeding and oedema.
Perineal trauma should be repaired using aseptic techniques.

32. A repair undertaken on a non-cooperative woman, due to pain, is likely to result in a poor repair.
Ensure that the wound is adequately anaesthetized prior to commencing the repair. It is recommended that 10–20 ml of lidocaine 1% (maximum dose 3 mg/kg) is injected evenly into the perineal wound.
If the woman has an epidural it may be ‘topped- up’ instead of injecting local anaesthetic.
An indwelling catheter should be inserted for at least 12 hours to avoid urinary retention.

33. Degree of tears
first degree (involving the perineal skin only),
second degree (involving the perineal muscles and skin)
third degree (injury to the anal sphincter complex - 3a = < 50% of the external anal sphincter torn; 3b = > 50% of the external anal sphincter torn; 3c = injury to the external and internal anal sphincter)
fourth degree (injury to the perineum involving the anal sphincter complex and anal epithelium)

34. First-degree tears and labial lacerations
Women should be advised that, in the case of first-degree trauma, the wound should be sutured in order to improve healing, unless the skin edges are well opposed (NICE 2007).
Labial lacerations are usually very superficial but may be very painful. Some practitioners do not recommend suturing, but if the trauma is bilateral the lacerations can sometimes adhere together over the urethra and the woman may present with voiding difficulties.

35. Episiotomy and second-degree tears
Although the repair of these tears was previously carried out using the interrupted technique, the continuous suturing technique for perineal skin closure has been shown to be associated with less short-term pain.
Moreover, if the continuous technique is used for all layers (vagina, perineal muscles and skin), the reduction in pain is even greater .

36. The perineal muscles should be repaired using absorbable polyglactin material which is available in standard and rapidly absorbable forms.
A recent Cochrane review has shown that there are few differences in short-term and long-term pain, between standard and rapidly absorbing synthetic sutures, but more women need standard sutures to be removed (Kettle et al 2010).

37. Technique for perineal repair
Technique is important, as is the suturing material used  
Suturing the vagina (Fig. 15.7a)
Using 2/0 absorbable polyglactin 910 material (Vicryl rapide®), the first stitch is inserted above the apex of the vaginal skin laceration to secure any bleeding points.
The vaginal laceration is closed using a loose, continuous, non-locking technique ensuring that each stitch is inserted not more than 1 cm apart to avoid vaginal narrowing.

38. Continuous suturing technique for mediolateral episiotomy (Kettle and Fenner 2007): (a) loose continuous non-locking stitch to the vaginal wall; (b) loose, continuous non-locking stitch to the perineal muscle; (c) closure of skin using a loose subcutaneous stitch.

39. Suturing the muscle layer
The muscle layer is then approximated aher assessing the depth of the trauma and the perineal muscles (deep and superficial) are approximated with continuous non-locking stitches. If the trauma is deep, two layers of continuous stitches can be inserted through the perineal muscles.

40. Suturing the perineal skin
To suture the perineal skin the needle is brought out at the inferior end of the wound, just under the skin surface. The skin sutures are placed below the skin surface in the subcutaneous tissue, thus avoiding the profusion of nerve endings.
A vaginal examination is carried out to ensure that the vagina is not narrowed and a rectal examination carried out to ensure that sutures have not been inadvertently placed through the anorectal epithelium.

41. Obstetric anal sphincter injuries (OASIS) The quoted rate of OASIS is 1% of all vaginal births (RCOG 2007), although a more recent analysis reveals the rate to be 3.2% in consultant-led units (unpublished data). However, ‘occult’ OASIS (i.e. defects in the anal sphincter detected only by anal endosonography) has been identified in 33% of primiparous women following vaginal birth (Sultan et al 1993).
The most plausible explanation for what was previously believed to be an ‘occult’ OASIS is either an injury that has been missed, recognized but not reported, or, wrongly classified as a second-degree tear (Sultan and Thakar 2007).

42. Technique for OASIS repair
In the presence of a fourth-degree tear, the torn anorectal epithelium is sutured with a continuous 3/0 Vicryl suture. When torn (Grade 3c tear/fourth-degree), the internal anal sphincter tends to retract and can be identified lateral to the torn anal epithelium. It should be repaired with mafress sutures using 3-0 PDS (Polydioxanone) or modern braided sutures such as 2/0 Vicryl (polyglactin – Vicryl®).
To repair a torn external anal sphincter, the ends are grasped using Allis forceps and the muscle is mobilized. When the EAS is only partially torn (Grade 3a and some 3b) then an end-to-end repair should be performed using two or three mafress sutures

43. Basic principles after repair of perineal tears  
complete haemostasis should be achieved.
A rectal and vaginal examination should be performed to confirm adequate repair.
to ensure that no other tears have been missed.
Confirm that all tampons (if used) or swabs have been removed.
Detailed notes should be made of the findings and repair.
An accurate detailed account of the repair should be documented in the woman's case notes.
woman is given a full explanation of the injury sustained and contact details if she has any problems during the postnatal period
women should be advised that the prognosis following EAS repair is good, with 60–80% being asymptomatic at 12 months.

44. Postoperative care after OASIS
Broad-spectrum antibiotics should be given intraoperatively (intravenously) and continued orally for 3 days.
Severe perineal discomfort, particularly following instrumental delivery, is a known cause of urinary retention, and following regional anaesthesia it can take up to 12 hours before bladder sensation returns.
spontaneous voiding occurs at least every 3–4 hours without undue over distension of the bladder.
The degree of pain following perineal trauma is related to the extent of the injury and OASIS is frequently associated with other more extensive injuries, such as paravaginal tears.
rectal analgesia such as diclofenac is effective in reducing pain from perineal trauma within the first 24 hours after birth.

45. Postoperative care after OASIS
In women who had a repair of a fourth-degree tear diclofenac should be administered orally as insertion of suppositories may be uncomfortable and there is a theoretical risk of poor healing associated with local anti-inflammatory agents.
It is of utmost importance that constipation is avoided as passage of constipated stool or indeed faecal impaction may disrupt the repair.
Stool softeners (Lactulose) should be prescribed for the first 10–14 days postpartum.
It is recommended that women with OASIS be contacted by a healthcare provider 24 or 48 hours a her hospital discharge to ensure bowel evacuation has occurred

46. Follow-up
All women who sustain OASIS should be assessed by a senior obstetrician at 6–12 weeks
In the clinic a genital examination is performed looking specifically for scarring, residual granulation tissue and tenderness.
The women are assessed by the physiotherapists and advised to continue pelvic floor exercises while others with minimal sphincter contractility may need electrical nerve stimulation.
Any incontinence of stool or flatus should also be reported. Under such circumstances referral to a specialist gynaecologist or colorectal surgeon for endoanal ultrasound and manometry should be considered (RCOG 2007).

47. Medicolegal considerations
Although a third- or fourth-degree tear is seldom to be found,.
It is essential that a rectal examination is performed before and after any perineal repair and findings must be carefully documented in the notes.
Delay in repairing in theatre, poor note-keeping, repair by untrained personnel, poor lighting and inadequate exposure, inadequate anaesthesia, failure to recognize extent of the tear, use of wrong suture material, forgoten swab in the vagina, deviation from recommended safe practice, failure to inform and counsel the woman, failure to inform the general practitioner, inappropriate follow-up and advice regarding subsequent pregnancy are common issues raised many times.