Perineal Laceration Repair•Avoid episiotomy and operative vaginal delivery •Identification of...
Transcript of Perineal Laceration Repair•Avoid episiotomy and operative vaginal delivery •Identification of...
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Perineal Laceration Repair
Todd Shaffer, MD, Professor and Program Director, University of Missouri Kansas City Family Medicine
Residency Program, Kansas City
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ACTIVITY DISCLAIMER
The material presented here is being made available by the American Academy of Family Physicians for educational purposes only. This material is not intended to represent the only, nor necessarily best, methods or procedures appropriate for the medical situations discussed. Rather, it is intended to present an approach, view, statement, or opinion of the faculty, which may be helpful to others who face similar situations.
The AAFP disclaims any and all liability for injury or other damages resulting to any individual using this material and for all claims that might arise out of the use of the techniques demonstrated therein by such individuals, whether these claims shall be asserted by a physician or any other person. Every effort has been made to ensure the accuracy of the data presented here. Physicians may care to check specific details such as drug doses and contraindications, etc., in standard sources prior to clinical application. This material might contain recommendations/guidelines developed by other organizations. Please note that although these guidelines might be included, this does not necessarily imply the endorsement by the AAFP.
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Objectives
1. Classify perineal lacerations as
first, second, third or fourth
degree tears.
2. Demonstrate proficiency in
suturing tears to the perineal
skin, muscles and vaginal
tissues.
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Citation
Written permission has been received to use
the following slides from the Advanced Life
Support in Obstetrics (ALSO®) Provider
Course Syllabus. The American Academy of
Family Physicians owns the ALSO Program
and it’s copyright.
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History
• Reference to laceration repair dates back to Hippocrates
• Incidence of lacerations was increasing but has stabilized
Parallels the use of episiotomy
• Repair technique has been fine tuned using an evidence based approach
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Associated Factors I
• Episiotomy
midline > mediolateral
• Delivery with stirrups
delivery table, lithotomy position
• Operative delivery
forceps > vacuum
• Increasing birth weight
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Associated Factors II
• Prolonged 2nd stage of labor
• Nulliparity
• OT or OP positions
• Anesthesia - local and epidural
• Younger age
• Use of oxytocin
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Body of Clitoris
Urethral Orifice
Ischiocavernosus
Bulbocavernosus
Perineal Membrane
Superficial Transverse Perineal Muscle
External Anal Sphincter
Levator Ani
Glans of Clitoris
Crus of Clitoris
Bulb of Vestibule
Hymen
Greater Vestibular Gland
Central Tendon of Perineum
Anus
Gluteus Maximus
Coccyx
Anatomy of
Perineum
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Classification of Lacerations
Degree of laceration
Description
First degree Superficial laceration of the vaginal mucosa or perineal body
Second degree Laceration of the vaginal mucosa and/or perineal skin and deeper subcutaneous tissues
Third degree
Incomplete
Second degree laceration with laceration of the capsule and part (but not all) of the external anal sphincter muscle
complete As above with complete laceration of the external anal sphincter muscle
Fourth degree Laceration of the rectal mucosa
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Prevention
• Avoid operative delivery
• Vacuum if needed
• Avoid episiotomy
• Antenatal perineal massage
• Lateral birth position
• Perineal warm packs during 2nd stage
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Prior to Repair
• Evaluate laceration
• Prepare equipment
• Instruments
• Sutures
• Call for assistance
• Provide
Analgesia
Lighting
Visualization
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Equipment
• Sponges
• Vaginal pack
• Irrigation
• 2 Allis clamps
• Needle holder
• Sharp tooth tissue forceps
• Sutures Polyglycolic acid
derivative
2-0 & 3-0
• Local anesthesia
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Anesthesia
• Provide perineal analgesia
• Local vs. pudendal vs. regional vs. inhalation
• Anesthetics:
Lidocaine
Bupivacaine
Chloroprocaine
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Ilioinguinal and genitofemoral nerve
Pudendal Nerve
Dorsal nerve of clitoris
Labial nerve
Inferior rectal nerve
Perineal branch posterior femoral cutaneous nerve
Coccygeal and last sacral nerve
Innervation of Perineum
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Ilioinguinal nerve
Genital branch genitofemoral nerve
Perineal branch posterior femoral cutaneous nerve
Dorsal nerve of clitoris
Labial nerve
Ischial spine
Pudendal nerve
Inferior hemorrhoidal nerve
Sacrospinous ligament
Pudendal Block
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Rectal Mucosa
• Identify apex
• Begin closure above apex
• Close with running or interrupted 3-0 polyglycolic suture
• Transmucosal sutures not recommended
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Internal Anal Sphincter Closure
• Identify the internal anal sphincter
Longitudinal fibromuscular layer
Between the rectal mucosa and the external anal sphincter
• Close with running locked 3-0 polyglycolic suture
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Rectovaginal Septum
• Goal:
Decreased dead space
strengthened septum
• Reapproximate rectovaginal fascia
• Run 2-0 polyglycolic suture
• Repair may occur before or after external anal sphincter
• Avoid entry into rectal lumen
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External Anal Sphincter
• End-to-end traditional
Taught as primary method in ALSO
• Overlap a newer technique
• Some heterogeneity in the evidence but the end-to-end technique seems to have better continence outcomes
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External Anal Sphincter: end-to-end
• Identify ends of sphincter
• Grasp with Allis clamps
• Reapproximate with at least four 2-0 polyglycolic sutures
• Don’t strangulate
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External Anal Sphincter: overlap
• Similar to end-to-end
• Grasp with Allis clamps
• Reapproximate with at least four 2-0 polyglycolic sutures
• Overlap muscle as shown
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Vagina
• Begin above apex
• Use polyglycolic suture
• Close to hymeneal ring
• Suture placed deep enough to repair rectovaginal septum but not into rectal lumen
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Perineal muscles
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Perineal Body
• New suture, or continue with vaginal suture
• Assess defect
• Close in 1 or 2 layers
• Place “crown stitch” and complete closure
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Repair of perineal body muscles: Bulbocavernosis (bulbospongiosis)
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Perineum Skin
• Continue stitch as a subcuticular closure
• Transepithelial stitches not recommended due to increased pain
• Leaving skin unsutured is an option if minimal gap after muscles repaired
• Complete closure by bringing suture into vagina for tying
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Evaluation of Surgical Repair
• Assure correct sponge, instrument count
• Vaginal exam to assess repair, look for other lacerations
• Rectal exam for:
• Palpable defects
• Intact rectal sphincter
• “Squeeze my finger”
• Consider need to revise repair if problems noted, but may not be beneficial in case of suture in rectal lumen
• Prepare operative note
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The Complicated Repair
• Lateral and multidirectional extensions
• Hemorrhage
• Pain
• Consider:
• Additional anesthesia or regional anesthesia
• Additional assistance
• Consultation
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Complications
• Infection
• Dehiscence
• Hematoma
• Rectovaginal fistula
• Rectocutaneous fistula
• Perineal abscess
• Anal incontinence
• Dyspareunia
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Etiology of Complications I
• Infection
• Hematoma
• Poor tissue approximation
• Obesity
• Poor perineal hygiene
• Malnutrition
• Anemia
• Constipation
• Blunt or penetrating trauma
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Etiology of Complications II
• Forceful coitus
• Cigarette smoking
• Inflammatory bowel disease
• Connective tissue disease
• Prior pelvic radiation
• Hematologic disease
• Endometriosis
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Summary
• Avoid episiotomy and operative vaginal delivery
• Identification of depth of laceration and anatomy is essential
• Ensure adequate lighting
• Provide hemostasis and good approximation of tissue planes
• Examine repair and rectum
• Stay vigilant for post-op infection and treat judiciously
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