Perineum Repair

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Perineal Repair Page1 WACS Clinproc2.5Nov-07

SDMS ID: P2010/0488-0012.5-08WACS

Title: Perineal RepairReplaces: Episiotomy and Perineal Repair Protocol 2.5Description: Suturing of perineal lacerations and/or episiotomy

Target Audience: Midwifery and Medical Staff, Queen Victoria Maternity UnitKey Words: Suture, perineal repair, accreditation

Policy Supported: P2010/0308-001 Management of Third and Fourth Degree Tears

P2010/0488-001LGH QVMU Perineal Repair Learning Package

Purpose:Perineal repair is a surgical procedure and should only be undertaken by credentialedmedical and midwifery personnel who have undertaken additional education in repair of theperineum, or by those undergoing supervised practice.

Where the extent of the repair is beyond the skill level of an individual, assistance should besought from a more experience operator.

The repair of third and fourth degree perineal tears should only be undertaken by anexperienced registrar or consultant.

Definition:First degree tear involves fourchette, hymen, labia, skin, vaginal mucosa.Second degree tear involves the pelvic floor, perineal muscle, vaginal mucosa.

Third degree tear involves the external anal sphincter (EAS) and internal anal sphincter(IAS).

3a: less than 50% of EAS thickness torn3b: more than 50% of EAS thickness torn3c: IAS torn

Fourth degree tear involves the anal sphincter (EAS and IAS) and rectal mucosa.

EquipmentSuture packGloves and gownSuture material and needlesLocal anaesthetic 1% lignocaineSyringe 20mlNeedles 19 FG drawing up and 22FG infiltration needleAntiseptic solutionStoolLight source

LubricantSanitary pad
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Procedure

Repair of the perineal tear or episiotomy should be carried out as soon as ispracticable after the birth.

Explain the procedure to the woman prior to commencing the repair. Place the woman appropriately and ensure good lighting. Ensure the area to be suture is adequately anaesthetised by:

o offering the woman N2O & O2prior to and during preparation and infiltration of the

area oro offering the woman an epidural top up if there is one in progress.o allow time for the anaesthetic to take full effect before continuing.

Infiltrated the perineum using 1% lignocaine with the maximum dose not exceeding20ml (in accordance with the General Orders for Midwives).

Clean the perineal area with a warm antiseptic solution. Adhere to a strict aseptic technique. Insert a vaginal tampon and record its insertion. Assess the full extent of the trauma. Observe for excessive blood loss during and following the procedure.

Repair the episiotomy and /or any genital lacerations in layers ensuring correctapposition:o Insert an initial knot 1 cm beyond the apex of the vaginal wall.o Using a continuous suture, repair the vaginal epithelium first followed by perineal

muscles and finally the skin.o Ensure sutures are not over tightened, clots are removed from the wound, dead

spaces are not left behind and hymen remnants are not sutured. Remove the vaginal tampon on completion of the repair and records its removal. Perform a vaginal and rectal examination. Consider 100mg Diclofenac suppository rectally, if no known allergy and no history of

asthma. Clean the area. Apply intermittent cold therapy, eg an ice pad for up to 30 minutes, with half hourly to

hourly intervals between applications. Avoid direct application of any cooling device tothe skin.

Gently and simultaneously remove the womans legs from the lithotomy position (ifused).

Ensure the woman is clean, dry and comfortable. Instruct the woman about the nature of the injury sustained, the absorption time of the

sutures and care of the perineum. Check swabs, needles and instruments are correct and dispose of "sharps" as per

infection control procedures. Document the perineal repair in the womans notes.


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Attachments

Attachment 1 Background Information

Attachment 2 References

Performance Indicators: Evaluation of compliance with guideline to be achieved through

medical record audit annually by clinical Quality improvementMidwife WACS

Review Date: Annually verified for currency or as changes occur, andreviewed every 3 years via Policy and Procedure workinggroup coordinated by the Clinical and Quality improvementmidwife. November 2009

Stakeholders: Midwives and medical staff WACS

Developed by: Dr A Dennis Co-Director (Medical) Sue McBeath Co-Director(Nursing & Midwifery) Womens & Childrens Services

Dr A Dennis Sue McBeathCo-Director (Medical) Co-Director (Nursing & Midwifery)Womens & Childrens Services Womens & Childrens Services

Date: _________________________


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APPENDIX 1Background Information:

The use of more rapidly absorbed form of polyglactin 910 (Vicryl Rapide) for repair ofperineal trauma is associated with a significant reduction in pain and a reduction in sutureremoval when compared with standard absorbable synthetic material.

The use of a continuous subcuticular technique for the perineal skin closure is associatedwith less short-term pain than techniques employing interrupted sutures.

A loose, continuous non-locking suturing technique used to oppose each layer (vaginaltissue, perineal muscle and skin) is associated with less short-term pain compared with thetraditional interrupted method (RCOG Guideline No. 23 Methods and materials used inperineal repair 2004).

A vaginal tampon is inserted to prevent uterine blood oozing onto the wound andobscuring the area. It also reduces the risk of further trauma and bleeding which may becaused by repeated swabbing or dabbing (King Edward Memorial Hospital Guideline No. B

5. 15.1.Suturing an episiotomy/genital laceration).

Rectal analgesia can reduce pain from perineal trauma following childbirth experienced bywomen and the intensity of any pain within the first 24 hours after birth. Women use lessadditional analgesia within the first 48 hours after birth when analgesic rectal suppositoriesare used.


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APPENDIX 2

REFERENCESHedayati H, Parsons J , Crowther CA. Rectal analgesia for pain from perineal traumafollowing childbirth. Cochrane Database of Systematic Reviews 2003, Issue 3. Art. No.:CD 003931. DOI: 10.1002/14651858.CD003931.

J oanna Briggs Institute 2005 Suturing episiotomy/genital laceration. Online:http://www.joannabriggs.edu.au/cis/gu_manual_index.php

King Edward Memorial Hospital Clinical Guidelines 2003 Suturing an episiotomy/genitallaceration. Online:http://www.kemh.health.wa.gov.au/development/manuals/guidelines.htm

Kettle C, J ohanson RB. Continuous versus interrupted sutures for perineal repair.Cochrane Database of Systematic Reviews 1998, Issue 1. Art. No.: CD000947. DOI:10.1002/14651858.CD000947.

Kettle C, J ohanson RB. Absorbable synthetic versus catgut suture material for perinealrepair. Cochrane Database of Systematic Reviews 1999, Issue 4. Art. No.: CD000006.DOI: 10.1002/14651858.CD000006.

Pairman S, Pincombe J , Thorogood C, Tracy S, Midwifery preparation for practice 2006Elsevier Australia

Royal College of Obstetricians and Gynaecologist Guideline No 23 2004 Methods andmaterials used in perineal repair. Online: http://www.rcog.org.uk/index.asp?PageID=525

Royal Womens Hospital Clinical Practice Guidelines 2006 Perineal trauma: assessmentand repair. Online:http://www.rwh.org.au/rwhcpg/maternity.cfm?doc_id=4918

Royal Womens Hospital Clinical Practice Guidelines 2006 Perineal repair: procedure.Online: http://www.rwh.org.au/rwhcpg/maternity.cfm?doc_id=9407
http://www.joannabriggs.edu.au/cis/gu_manual_index.phphttp://www.joannabriggs.edu.au/cis/gu_manual_index.phphttp://www.kemh.health.wa.gov.au/development/manuals/guidelines.htmhttp://www.kemh.health.wa.gov.au/development/manuals/guidelines.htmhttp://www.rcog.org.uk/index.asp?PageID=525http://www.rcog.org.uk/index.asp?PageID=525http://www.rwh.org.au/rwhcpg/maternity.cfm?doc_id=4918http://www.rwh.org.au/rwhcpg/maternity.cfm?doc_id=4918http://www.rwh.org.au/rwhcpg/maternity.cfm?doc_id=4918http://www.rwh.org.au/rwhcpg/maternity.cfm?doc_id=9407http://www.rwh.org.au/rwhcpg/maternity.cfm?doc_id=9407http://www.rwh.org.au/rwhcpg/maternity.cfm?doc_id=9407http://www.rwh.org.au/rwhcpg/maternity.cfm?doc_id=4918http://www.rcog.org.uk/index.asp?PageID=525http://www.kemh.health.wa.gov.au/development/manuals/guidelines.htmhttp://www.joannabriggs.edu.au/cis/gu_manual_index.php

Documents

Perineum Repair