Guidelines to ensure safe practice when undertaking a perineal repair.
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To be used in conjunction with the CPG: Perineal Trauma: Assessment and Repair
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AIM: To ensure safe practice by:
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a. Reduction of risk of retained foreign body
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b. Ensure all packs, needles and instruments are accounted for
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c. Safe handling and disposal of "sharps"
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- A full count of all instruments, needles and packs and tampon (if used) is to be made at the commencement of the procedure and recorded on the back of the partogram.
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- Any additions of packs or needles are to be recorded on the partogram when issued. If it becomes necessary to replace the assisting midwife during the procedure a count of the equipment being used should also be undertaken.
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- Only a radio-opaque tampon is to be inserted into the vagina. If this occurs a blunt ended towel clip is to remain attached to the tape and clipped to the top drape.
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- It is the responsibility of the person undertaking the repair and the supporting midwife to ensure that all equipment used is accounted for at the end of the procedure and documented on the partogram.
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- The person undertaking the repair should ensure that the exposed suture needle is "guarded" in the needle holder when not in use and that dissecting forceps are used to handle the needle as much as possible during the procedure to reduce the potential for "needle-stick" injuries. A sterile yellow kidney dish is provided to receive contaminated “sharps” during the repair. The operator should also ensure that all "sharps" are disposed of at completion of the procedure.
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- If a pack or tampon is deliberately left in the vagina these should contain a radio-opaque thread and be noted on the partogram, along with the time for removal. Once removed, this to is to be signed for.
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Procedure for Perineal repair
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1. To non-contaminated birth set up add:
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- sterile swabs
- suture instruments in yellow kidney dish
- suture packs (with radio-opaque thread) as required
- sterile vaginal tampon (with radio-opaque thread)if required
- green drapes X 2
- 20 ml syringe and 23G needle
- 20 ml Lignocaine 1% (To supplement epidural or administer Local Anaesthesia)
- 2.0 Vicryl Rapide on 36 mm taper or tapercut needle
- chlorhexidine 0.015% and Cetrimide 0.15% lotion
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2. Maintain standard infection control precautions at all times.
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Perform hand hygiene with 2% Chlorhexidine hand wash or Microshield hand rub before donning:
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3. Explain the procedure fully to the mother and obtain verbal consent.
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4. Place the mother in the lithotomy position to assist visualization of the wound.
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 | To reduce physical harm to the mother or attending staff, two staff members are to support and place one leg each into the lithotomy stirrups simultaneously. This is also to occur when removing the woman's legs from the stirrups.
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5. Once scrubbed, gloved and gowned perform initial count of equipment with supporting midwife.
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6. The perineal area should be swabbed down with Chlorhexidine/ cetrimide lotion and one sterile drape placed underneath the mother's buttocks and a second sterile drape placed over her abdomen without contaminating your gloved hands.
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7. Prior to starting the repair, assess the genital tract in good light to visualize the apex of the vaginal wound and to determine the presence of other trauma that may require suturing. Using the suture pack, remove any debris and old blood clot from the wound surface.
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8. Check if the mother has any known allergies to local anaesthetic. Infiltrate the wound with Lignocaine 1%. A maximum amount of 20 - 30 mls may be administered over a one hour period. This total includes any local anaesthetic used for infiltration prior to the performance of an episiotomy if it occurs within this time frame. Where an epidural or spinal anaesthetic has been used, additional anaesthesia to the perineum may be required.
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- Insert the needle into the wound edges, first from the fourchette, along the skin edges towards the anus, then from the fourchette, along the posterior vaginal wall to the apex of the wound. Before the injection of the local anaesthetic, withdraw the syringe plunger to ensure the needle has not entered a blood vessel. The local anaesthetic is injected as the needle is withdrawn. Wait 2- 3 minutes to ensure anaesthetic is effective.
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- Check sensation around the wound by "pinching" with dissecting forceps before commencing repair. If the mother is experiencing discomfort, further anaesthesia is required. It is indefensible to commence the repair without providing adequate pain relief.
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9. Assess the necessity for using a vaginal tampon to improve the visualization of vaginal trauma. Tie the tape to a blunt ended towel clip and secure the clip to the sterile drape on the mother's abdomen. Consider the mothers comfort when inserting same.
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10. Repair the perineal wound in three layers.
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a. Vaginal wound
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b. Perineal muscle (may require 1 or 2 layers)
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c. Perineal skin and subcutaneous tissue.
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- Insert an anchor stitch 0.5 cm beyond the apex of the posterior vaginal floor wound. Close the wound with a continuous suture, placing these 0.5- 0.75 cms from the wound edge. Endeavour to eliminate "dead space". Match the hymenal remnants and the fourchette to achieve even approximation of the wound. Once the vagina is repaired, the suture should be tied off at the level of the fourchette if the operator plans to use interrupted sutures to the muscle layer.
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- If a continuous suture to the muscle layer is preferred, the final suture of the vaginal layer is made into muscle at the fourchette.
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- The muscle layer is apposed in one or two layers dependent on the depth of the trauma. Interrupted or continuous sutures may be used. "Dead space" should be eliminated as much as possible to reduce the risk of infection and wound breakdown.
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- The perineal skin is apposed using continuous or interrupted sutures.
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11. At completion of the procedure a vaginal examination (P.V) should be undertaken to ensure that the vaginal introitus admits at least two fingerbreadths and ensure haemostasis of the vaginal wound. A P.R examination is then undertaken to ensure no sutures have penetrated through the vagina into the rectum.
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- If penetration of the rectum occurs, the repair must be taken down, the sutures removed, the wound resutured and the mother commenced on antibiotics. An explanation is to be provided to the mother of the event.
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- The removal of sutures and resuturing of the wound requires that the operator remove the contaminated gloves, perform hand hygiene and reapply sterile gloves before taking the wound down and resuturing. Replace the set-up if contaminated with any fecal matter.
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DO NOT forget that any tampon previously inserted into the vagina is to be removed and accounted for at the end of the procedure.
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12. Check with the mother for drug allergies and a past history of asthma or a gastric ulcer if P.R. Diclofenac 100 mgms is to be administered at this time. The normal checking regime for administering medications is required.
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- Check the uterine fundus to ensure it is well contracted and expel any blood clots.
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- Consider need for post-partum bladder management eg catheterization. If catheterization is required ensure gloves are sterile and not contaminated when inserting the catheter.
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- The vulva is cleaned gently and an icepack inside a sterile pad applied to the perineum. The mother is left in a comfortable position.
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- Check swabs, needles instruments and sutures are correct and dispose of "sharps" as per infection control procedures. Document and sign for the count on the back of the partogram. The person undertaking the repair is responsible for ensuring that the trolley is free of "sharps" at the completion of the procedure.
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13. Record the procedure in the mothers "Progress Notes". This should include the observed genital tract trauma, the strength and amount of Lignocaine 1% used and the type of suture thread used. A description of the actual repair technique is required.
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Record also, that haemostasis was obtained and a P.V and P.R was undertaken. Any additional interventions such as drugs, catheterisation etc. should also be recorded.
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Procedure for discrepancy in perineal repair count
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Any discrepancy found with the count must be immediately be responded to by the staff member performing the perineal repair.
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- No equipment should be removed from the room until a thorough search is conducted.
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- In relation to a missing pack or tampon, a vaginal examination of the patient must be undertaken. If following this procedure the item is still missing, an X-ray of the patient must conducted before the woman is discharged from the Birth Suite.
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- The AUM in charge of the Birth Suite and the NUM must be notified of the discrepancy. If the incident occurs out of hours, the AUM in charge of the shift and the After Hours Manager should be informed of the event.
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- The woman is advised of the discrepancy plus the outcome of any search for the missing items.
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- If the discrepancy remains following the repeat count and search, it must be recorded on the count sheet and in the medical record. The event and all relevant information must also be recorded on an incident report.
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References
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References: Perineal Trauma: Assessment and Repair
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Revised and published: 13 August 2007
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Royal Women's Hospital Clinical Practice Guidelines (CPGs) are intended to provide guidance to health care professionals, based on a thorough evaluation of research evidence, on the practical assessment and management of specific clinical issues or situations. The guidelines allow some flexibility on the part of the health care professional based on the needs of the specific patient for whom they are caring.
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