REPAIR OF OBSTETRIC LACERATIONS Dr. Pamela Berger.
-
Upload
douglas-williamson -
Category
Documents
-
view
240 -
download
8
Transcript of REPAIR OF OBSTETRIC LACERATIONS Dr. Pamela Berger.
REPAIR OF OBSTETRIC LACERATIONS
Dr. Pamela Berger
Overview
Review of anatomy Classification of perineal lacerations
3rd/4th degree tears Approach to repair Prevention of perinal lacerations Episiotomy Post-partum issues
Anatomy
External genitalia
Muscular structures
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
Classification of lacerations
1st degree
Involve the perineal skin and vaginal mucosa but not the underlying fascia and muscle
May not require repair
2nd degree
Involve, in addition, the fascia and muscles of the perineal body but not the anal sphincter
Most common type
2nd degree
3rd degree
Extend farther to involve the anal sphincter
4th degree
Extend through the rectal mucosa
3rd & 4th degree lacerations
Recognition is key...
Recognition of Grade 3 tear
Risk factors for 3rd & 4th degree tears Midline episiotomy Nulliparity Previous 3rd/4th degree tear Prolonged second-stage Persistent occiput posterior position Forceps > vacuum
3rd & 4th degree tears
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
3rd/4th 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 stool softeners
Sitz baths Pelvic Floor Physiotherapy
Once discomfort improves
Approach to repair
Tools
Exposure Light Patient positioning Sponges Retractors
Anesthetic Epidural or local
Suturing instruments Needle driver, forceps, scissors
Suture Polysorb (Vicryl), PDS
Copyright © 2012 McGraw-Hill Medical. All rights reserved.
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.
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
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.
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.
Labial and periurethral tears
Labial and periurethral tears 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
High vaginal tears
High vaginal tears
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
Approach to repair—3rd & 4th degree Indication for consult to Ob/Gyn
Episiotomy
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 20% in 2004
Disadvantages of episiotomy Increased risk 3rd and 4th degree tears
(midline episiotomy) Increased risk of fecal incontinence Increased risk of ≥2nd degree tear in 2nd
delivery More post-partum pain More complications with healing
(mediolateral episiotomy)
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
Types of episiotomy
Easier to repair
Better healing
Less pain
Less blood loss
Less dyspareunia
Less extensions
Less 3rd & 4th degree tears
Can safely make a larger incision
Prevention of Perineal Trauma
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
What works
Antenatal perineal massage starting at 35 wks1, 2
Nulliparous patients Restrictive use of episiotomy1,2,3
Delayed pushing in nullips with epidural2
Controlled delivery of head between contractions2,4
“Spontaneous” pushing2
Birth position: lateral, sitting or on all fours2,5
Warm compresses (less 3rd/4th degree tears) 1,3
What doesn’t work
Birth position: lateral, upright or on all fours3
Warm compresses (less 3rd/4th degree tears) 2
“Hands on” (compared to “hands off”) 1
Intrapartum perineal massage3
What might work
Intrapartum perineal massage1
Spontaneous pushing3
Water birth…1
Post-partum issues
Wound infection or break-down Fortunately uncommon Area swollen, erythematous, purulent
exudate Open wound, debride, irrigate Abx only if cellulitis Early vs delayed repair
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
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
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
Post-partum issues
Always take the time to examine a patient who is complaining of discomfort at the 6 week PP visit
Questions?