PerinealRepair

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NHS FORTH VALLEY

Perineal Repair

22/07/2008Approved

1.0Version 01/07/2006Date of First Issue01/08/2010Review Date01/08/2008Date of IssueYes 28/07/2008EQIADebbie HoustonAuthor / Contact

Unit Business MeetingGroup / Committee Final Approval


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NHS Forth Valley

Consultation and Change Record

Contributing Authors: Anne Paterson and Paul Holmes

Consultation Process: Obstetric Consultants, Midwifery Managers, Midwifery TeamLeaders and Clinical Shift Co-Ordinators

Distribution: Women and Childrens Unit

Change Record

No changes Required


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All women having a vaginal delivery MUST have a systematic examination of theperineum, vagina and rectum to assess the severity of damage prior to suturing(NICE 2007)

Following all vaginal deliveries a rectal examination should be undertaken toensure that 3rd and 4th degree tears are recognised. If you are unsure of whatyou are seeing on inspection of the perineum ask for assistance from MiddleGrade Doctor. It is critical that 3rd and 4th degree tears are identified andeffectively managed

When a 3rd or 4th degree tear is diagnosed follow Management of 3rd & 4thDegree Perineal Tearprotocol

CLASSIFICATION OF PERINEAL TEARS(NICE 2007)This classification allows differentiation to be made between injuries to the external analsphincter (EAS), internal anal sphincter (IAS) and anal epithelium.

It is current Unit policy to repair any perineal trauma involving muscle tissue

Women should be advised that in the case of first-degree trauma, the woundshould be sutured in order to improve healing, unless the skin edges are wellopposed. NICE Guidelines (September 07). There is no evidence to supportleaving 2nd degree or worse unsutured.

Practitioners must be cautious about leaving trauma unsutured unless it is thewomans explicit wish; this must be documented in the case notes

PREREQUISITE FOR MIDWIVES SUTURING Midwives will have read the current protocol on perineal repair Midwives will have sound knowledge of the structure and anatomy of the

perineum Midwives have attended the perineal repair study day Midwives will have received instruction on perineal repair by an experienced

operator Midwives will be supervised until they feel confident / competent in their practice

or are deemed competent by an experienced operator

Student midwives will always be supervised

Degree TraumaFirst Injury to the skin onlySecond Injury to the perineum involving perineal muscles but not

involving the anal sphincterThird Injury to the perineum involving the anal sphincter complexFourth Injury to perineum involving the anal sphincter complex (EAS

and IAS) and anal epithelium

NHS Forth ValleyWomen & Childrens Unit

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PERINEAL REPAIR


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PURPOSE OF REPAIR

To control bleeding To prevent infection To assist the wound to heal by primary intention healing is usually rapid and

scarring is minimal providing there is no infection or excessivebleeding/haematoma

If the wound is left unsutured it will heal by secondary intention with the formationof granulation tissue, which contracts to form scar tissue.

The following are the basic principles and constitute good practice when repairing anyperineal trauma

PRINCIPLES OF REPAIR1. Check the extent of perineal trauma by thoroughly examining the vagina and

perineum to establish the extent of the trauma. A rectal examination should beperformed as part of the assessment following vaginal delivery

2. Suture as soon as possible after delivery; ideally this should be carried out within30 minutes following the third stage of labour. Repair is less painful and this alsoreduces the risk of infection

3. Ensure good anatomical restoration and alignment to encourage healing; whenaligned properly the process of wound healing begins.4. Ensure haemostasis. Suturing must achieve this in each part of the repair

otherwise haemorrhage can continue between the layers resulting in ahaematoma or post partum haemorrhage

5. Handle tissue gently using dissecting forceps6. Close all dead space; haemorrhage may occur into areas of dead space resulting

in a haematoma7. Use minimal amount of suture material. An excessive amount of sutures may well

cause severe discomfort in the puerperium and beyond. Only enough sutures toachieve haemostasis are required

8. Dont over-tighten sutures or have too loose as this may impede healing(approximate, dont strangulate)

9. Make sure knots are tied securely but are not too bulky10.Rectal examination after completing the repair will establish if any suture material

has been accidentally inserted through the rectal mucosa. Inform Middle GradeDoctor if this found on examination


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ANALGESIA DURING SUTURINGIf the woman has an epidural, ensure that it provides adequate pain relief. If it does notthen local anaesthesia should be used.

The perineum is infiltrated using Lidocaine 1% see: Patient Group Directive. The totalamount of Lidocaine 1% should not exceed 20mls, (including infiltration for episiotomy)which should provide effective analgesia for the woman.

PRIOR TO COMMENCING THE REPAIR

Place the woman in a comfortable position or if necessary use lithotomy poles. Thebaby can continue with skin-to-skin contact throughout the procedure. Support can begiven from her partner to assist this.

1. Check you have all the equipment required2. Check swabs/sutures/local anaesthesia with an assistant prior to commencing

procedure3. Thoroughly examine vagina and perineum to establish the extent of the trauma.

If more extensive than originally thought or if there is any doubt regarding theextent of trauma or structures involved ask for the assistance of Senior SisterMidwife/Middle Grade Doctor. Difficult trauma should be repaired by anexperienced operator in theatre under regional or general anaesthesia. DONTBE AFRAID TO ASK FOR ASSISTANCE

4. Insert a vaginal tampon only if necessary, to provide a clearer view. If tamponrequired press fundus, mop out vaginal vault and insert tampon, securing tail withan artery forceps

5. Ensure you have adequate light to carry out repair6. Fully explain the extent of the trauma and suturing procedure to the woman and

gain her verbal consent

SUTURE MATERIALThe use of a more rapidly absorbed synthetic suture, such as Vicryl Rapide isassociated with a significant reduction in perineal pain, analgesia used, dehiscence,resuturing and reduction in suture removal when compared with standard absorbablesynthetic material (RCOG 2007).

A suitable suture material is No 2/0 Vicryl Rapide, W9962


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METHOD OF CHOICE FOR THE REPAIR A loose, continuous non-locking suturing technique used to appose each layer (vaginaltissue, perineal muscle and skin) is associated with less short term pain compared withthe traditional interrupted method (NICE 2007)

METHOD OF REPAIR MODIFIED FLEMING TECHNIQUE

1. Confirm the local anaesthetic is working before commencing suturing2. Insert a vaginal pack, only if necessary, to provide a clearer view of the area to

be sutured (this should not be routinely done)3. Identify anatomical landmarks4. Identify the apex of the wound. Place the first stitch approximately 0.5 cm beyond

the apex to allow for haemostasis of any small vessels, which may have retractedbeyond this point

5. Repair the vaginal wall using a continuous stitch with approximately 0.5 cmbetween each bite

6. Carry out the repair from apex to the introitus; ensuring sutures are not placed inthe hymenal remnants.

7. At this point place the needle behind the exit point of the last stitch. Sweep itunder the fourchette bringing the suture material out into the perineal muscle.Alternatively, where there is a deep tear that requires the muscle to be repaired in

2 layers, repair from apex to hymenal remnants and then sweep suture behindlast stitch to repair the muscle layer8. Repair the perineal muscles in one or two layers with the same continuous stitch.

It is important to appose the muscle edges carefully and leave no dead space.Usually three or four stitches are all that is required in any one layer

9. At the distal end of the tear/episiotomy, reposition the needle in the needle holderso that it points in the opposite direction

10.Using a side-to-side technique when suturing subcutaneously (1/2 cm bites),continue until the proximal end of the wound is reached

11. Sweep the needle behind the fourchette back into the vagina. Pick up a smallamount of vaginal tissue to tie off the stitch and cut (the knot is tucked into the

vagina to minimise discomfort). Alternatively, the repair may be completed usingthe Aberdeen knot


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IMMEDIATE POST OP CARE1. Inspect the repair to check that haemostasis has been achieved. NB an

excessive amount of sutures may well cause severe discomfort in thepuerperium and beyond. Only carry out the required amount of suturing toachieve haemostasis

2. Remove the vaginal tampon, if used, and account for all instruments, swabsand needles discard of sharps safely

3. Perform rectal examination following completion of the repair to detect anysuture material which may have been accidentally inserted through the rectalmucosa

4. Diclofenic Acid 100mgs may be given PR, if no contraindications5. Remove woman's legs from lithotomy position6. Make the woman comfortable7. Document repair and sign prescription for local anaesthetic (PGD)8. Any difficulty experienced in suturing should be documented in the labour

notes, e.g. excessive bleeding, friable tissue, bruising, etc.9. Explain the extent of trauma and advise woman regarding hygiene and pain

relief associated with perineal trauma10.Document procedure in the womans notes

GUIDANCE FOR DOCUMENTATION 0F PERINEAL REPAIR

11.Date and time of repair of laceration/episiotomy12.Procedure explained and consent obtained.13.Anaesthesia achieved with ..mls of 1% Lidocaine14.Apex identified and repair carried out using Vicryl Rapide 2/0. Document

repair method used15.Haemostasis achieved16.PV and PR satisfactory17.Swabs, sutures and instruments correct18.Perineal hygiene advice given19.Sign and print name and designation

REFERENCENICE (2007) Intrapartum care: Management and delivery of care to women inlabour September 07


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August 2008: Review August 2010 or Sooner

Debbie Houston

PerinealRepair

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