1. Purpose
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This document provides details of the Perineal repair: safe practice procedure. The guidelines provide information to ensure that The Royal Women’s Hospital and the health professionals they employ meet their legislative and professional obligations.
This procedure details process requirements related to the Clinical Practice Guideline (CPG): Perineal Trauma: Assessment and Repair.
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2. Definitions
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Radio-opaque - swabs and tampons that contain an x-ray detectable strip. If a swab or tampon is missing at count, their presence in a body cavity can be detected by x-ray.
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Vicryl Rapide (Polyglacton 910) - a soluble suture with rapid absorption. This is the preferred suture for perineal repair as it is associated with less perineal pain in the postnatal period1,2.
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Clean birth trolley - a trolley which has been used for the birth with the used items removed, the trolley surface wiped with alcohol and a clean sterile drape applied.
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Suture trolley - a specially designated trolley set up with perineal repair equipment.
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Operator - the clinician who is performing the repair who may be either a doctor or midwife.
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Assistant - the clinician who is assisting the operator (commonly a midwife).
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3. Applicable to
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- medical and midwifery staff credentialed to conduct perineal repair
- medical and midwifery staff assisting the credentialed clinician
- medical and midwifery students under supervision
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4. Procedure
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The guiding principles of this procedure are to promote safe practice, maintain infection control principles, maintain universal precautions and reduce the risk of needle-stick injuries by:
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- minimising the risk of a retained foreign body in a maternal body cavity
- ensuring that all instruments, needles, swabs or tampons are accounted for at the beginning and end of the procedure
- safe handling and disposal of ‘sharps’ to minimize the risk of needle-stick injuries
- ensuring that a full count of all instruments, needles, swabs, packs and tampon (if used) is made at the commencement of the procedure and recorded on the partogram
- ensure that appropriate eye and skin protection are provided (goggles and gowns).
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4.1 Equipment required
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- suture packs x2 with opaque thread
- vaginal tampon with opaque thread (if required)
- green drapes x 2
- 20mL syringe and 21g or 23g needle
- 20mL lignocaine 1% (to supplement epidural anaesthesia or administer local anaesthesia)
- chlorhexidine 0.015% and Cetrimide 0.15% lotion
- adequate light source
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Choice of suture material:
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- 2.0 Vicryl Rapide on 36 mm taper or tapercut needle for a simple 3-layer repair
- 2.0 Vicryl on 36 mm tapercut needle for deep muscle layer if required
- 2.0 Vicryl Rapide on 26mm taper needle for repair of labial trauma or anterior FGM repair
- 2.0 PDS ll on 26mmm taper needle for repair of anal sphincter trauma (experienced operator only).
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4.2. Equipment count
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4.2.1 Any additional swabs, tampons, instruments or needles required during the procedure are recorded on the partogram when issued recorded on the count sheet (partogram).
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4.2.2 It is necessary to do a recount of the equipment should the assistant be replaced during the procedure.
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4.2.3 If required to improve the visibility of the area to be repaired, a radio-opaque tampon may be inserted into the vagina. It must be secured with a blunt-ended towel clip attached to the tape and clipped to the top drape.
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4.2.4 The assistant is responsible for the removal of equipment used during the procedure, including appropriate counting and disposal of SPS equipment and ensuring that the suture trolley (if used) is restocked.
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4.3 Minimising needle-stick injuries
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The operator is responsible for their own safety by ensuring that the exposed suture needle is ‘guarded’ in the needle holder when not in use.
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4.3.1 Dissecting forceps should be used to handle the needle as much as possible during the procedure to reduce the potential for ‘needle-stick’ injuries.
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4.3.2 During the repair, contaminated ‘sharps’ are placed in the sterile yellow kidney dish provided.
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4.3.3 The operator and the assistant are equally responsible for ensuring that all equipment used, including ‘sharps’, are accounted for at the end of the procedure and documented on the partogram.
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4.3.4 The operator is responsible for safe disposal of all ‘sharps’ used prior to leaving the room.
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4.4 Maintaining infection control principles
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Best practice in perineal repair requires maintenance of standard infection control precautions at all times.
The operator is expected to:
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- use protective eyewear and a plastic apron
- perform hand hygiene with 2% Chlorhexidine hand wash or Microshield hand rub before donning a sterile gown and gloves.
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4.5 Safe practice
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4.5.1 The procedure is fully explained to the woman and her verbal consent obtained. Known allergies to local anaesthetic should be identified and excluded at this time.
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4.5.2 The woman is assisted into a lithotomy position to assist visualisation of the wound. To reduce physical harm to the woman or attending staff, two staff members are required 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 supports.
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4.5.3 Once the operator has scrubbed, gloved and gowned, an initial count of equipment is performed with the assistant and documented in the partogram.
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4.5.4 The operator cleanses the perineal area with Chlorhexidine/ Cetrimide lotion.
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4.5.5 A sterile drape is placed underneath the woman’s buttocks and a second sterile drape placed over her abdomen. Care is taken to avoid contaminating the operator’s gloved hands.
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4.5.6 Prior to starting the repair, the operator assesses the genital tract in good light to visualize the apex of the vaginal wound and to determine the presence of other trauma such as obstetric anal sphincter injury that may require suturing or further consultation. A suture pack is used to remove any debris and old blood clot from the wound surface.
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4.5.7 The operator is expected to seek assistance from a more experienced clinician if the repair is beyond their capabilities.
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4.6 Conducting the repair
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Do not tie knots or pull sutures too tightly while undertaking the repair. Oedema of the tissues will develop during the first 24- 48 hours and sutures that are too tight will constrict the tissue leading to increased maternal discomfort.
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4.6.1 The wound is infiltrated with Lignocaine 1%. A maximum amount of 20 - 30mL (3mg/kg of body weight) 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.
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4.6.2 Where an epidural or spinal anaesthetic has been used, care is taken to determine if additional anaesthesia to the perineum is required.
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4.6.3 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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4.6.4 Sensation around the wound can be assessed by ‘pinching’ with dissecting forceps before commencing the 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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4.6.5 If a vaginal tampon is required to improve the visualization of vaginal trauma, consideration is given to the woman’s comfort. Obstetric cream can be used for lubrication prior to insertion. To prevent accidental retention of the tampon, the tape must be secured to a blunt ended towel clip and secured the clip to the sterile drape on the mother's abdomen.
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4.6.6 Repair the perineal wound in three layers (vaginal wall, perineal muscle, perineal skin and subcutaneous tissue) using a rapidly absorbed suture such as 2/0 Vicryl Rapide.
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4.6.7 Insert an anchor stitch 0.5cm beyond the apex of the posterior vaginal floor wound. Close the wound with a continuous suture, placing these 0.5-0.75cm from the wound edge. Endeavour to eliminate ‘dead space’.
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4.6.8 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. Where a deep muscle layer of sutures is required for approximation of the wound this should be accomplished using a longer absorbed suture e.g. 2.0 Vicryl.
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4.6.9 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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4.6.10 Match the hymenal remnants and the fourchette to achieve even approximation of the wound ensuring sutures are not placed in the hymenal remnants.
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4.6.11 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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4.6.12 The perineal skin is apposed using continuous or interrupted sutures.
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4.6.13 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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4.6.14 Conduct a count of all equipment used as per section 4.2.
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4.7 Immediate post-repair care
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Immediate care includes consideration of the woman’s comfort, pain relief requirements, perineal hygiene and standard postnatal observations.
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4.7.1 If P.R. Diclofenac 100mg is to be administered at this time, consideration is given to contraindications for administration. The alert sheet (in the woman’s medical record) is consulted and the woman is asked if she has any drug allergies or past history of asthma, bleeding disorders or a gastric ulcer. The normal checking regime for administering medicines is required.
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4.7.2 The vulva is cleansed gently and an icepack inside a sterile pad applied to the perineum with the woman’s consent. The woman is left in a comfortable position. The icepack is to be left insitu for no longer than 30 minutes to lessen the risks of ice-burns to the perineal tissue. It is recommended that ice packs be used regularly to reduce oedema and maternal discomfort.
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4.7.3 The uterine fundus is palpated to ensure it is well contracted and to expel any blood clots.
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4.7.4 Consideration is given to post-partum bladder management e.g. catheterization. If catheterization is required ensure gloves are sterile and not contaminated when inserting the catheter. Refer to CPG: Peripartum Bladder Management.
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4.7.5 Prior to leaving the room, an equipment check is conducted as per section 4.2. The check is documented and signed on the back of the partogram. The operator is responsible for ensuring that the trolley is free of 'sharps' at the completion of the procedure.
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4.7.6 The procedure is recorded in the procedure in the woman’s ‘Progress Notes’. Documentation includes:
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- the observed genital tract trauma
- the amount of Lignocaine 1% used
- the type of suture thread used
- a description of the actual repair technique
- estimated blood loss
- that haemostasis was obtained
- P.V and P.R examination was undertaken and rectal sutures excluded
- any additional interventions such as medicines, catheterisation etc.
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4.8 Procedure for discrepancy in perineal repair count
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Any discrepancy found with the count must immediately be responded to by the staff member performing the perineal repair.
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4.8.1 Equipment should not be removed from the room until a thorough search is conducted.
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4.8.2 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 be conducted before the woman is discharged from the Birth Centre.
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4.8.3 The AUM in charge of the Birth Centre 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 is informed of the event.
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4.8.4 The woman is advised of the discrepancy plus the outcome of any search for the missing items.
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4.8.5 If the discrepancy remains following the repeat count and search, it is recorded on the count sheet and in the medical record. The event and all relevant information must also be recorded on an incident report and forwarded to the CMC, Birth Centre.
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4.9 Penetration of the rectum by sutures
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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 provided to the woman.
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The removal of sutures and resuturing of the wound requires the operator to remove the contaminated gloves, perform hand hygiene and reapply sterile gloves before taking the wound down and resuturing. The set-up is renewed if contaminated with any fecal matter.
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4.10 Leaving tampons or packs in the vagina after the repair for haemostasis
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All packs or tampon deliberately left in the vagina to provide haemostasis must contain a radio-opaque thread.
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The presence of the pack or tampon is documented on the partogram, along with the planned time for removal. Verbal handovers between clinicians include this information.
Removal of the pack or tampon must be documented in the partogram or progress notes at the time of removal.
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5. Performance indicators
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I. Women and staff do not sustain injury due to the repair:
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 | a. procedure for identifying swabs/tampons counts are followed
b. equipment and swabs are not left in body cavities
c. reports of needle-stick injuries or blood splashes during perineal repair are minimal
d. reports of perineal infections are rare
e. allergies or contraindications for drugs commonly used in perineal repair are identified
f. procedures for removing rectal sutures are followed
g. procedure for identifying swabs/tampons deliberately left in-situ are followed
h. perineal repair is conducted by appropriately credentialed clinicians cognizant of their limitations.
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II. Complaints from women regarding inadequate pain relief during perineal repair are rare.
III. Documentation of the injury and repair meets the standards required of this procedure.
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6. References
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Access References (separate page): References: Perineal Trauma: Assessment and Repair.
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Evidence table
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Access Evidence table (separate page): Evidence Table: Perineal Trauma: Assessment and Repair
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Revised, updated and published:
28 August 2009
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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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