Introduction
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Genital tract trauma can occur spontaneously during a vaginal birth, or during an assisted vaginal birth, or by surgical incision (episiotomy).
Assessment of genital tract trauma includes undertaking an examination for potential injury to the labia, vagina, urethra, clitoris, perineal muscle and anal sphincter The focus of the examiner should not only be on the perineal body.
It is important for the examiner to be aware of the direct relationship between the extent and complexity of the genital tract trauma sustained during the birth and the likelihood of subsequent pain and functional impairment in the post partum period.
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Classification of perineal trauma
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A. Spontaneous perineal trauma
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1st degree: involves the skin of the fourchette, hymen, labia, vaginal epithelium
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2nd degree: involves the pelvic floor, perineal muscle, vaginal muscle (but not the anal sphincter)
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3rd degree: involves the anal sphincter complex (EAS and IAS)
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 | 3a: Less than 50% of the EAS thickness torn
| 3b: More than 50% of the EAS thickness torn
| 3c: IAS torn
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4th degree: involves complete disruption of external and internal anal sphincter and anal epithelium
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B. Episiotomy
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Described as being either small, medium or large, depending on the extent of the incision.
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Assessment of perineal trauma
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Prior to assessing the extent of the perineal trauma the midwife/ medical officer will:
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- explain to the woman what they plan to do and why and obtain verbal consent
- assist the the woman into a comfortable position for the examination
- offer inhalational analgesia during the examination
- ensure good lighting so that the genital structure can be seen clearly
- undertake a systematic examination to assess genital tract trauma in a gentle manner as soon as practicable after the birth
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| - commence the examination anteriorly, examine the peri-urethral area and descend laterally to include the labia and vaginal walls
- continue posteriorly to include the vaginal vault, posterior vaginal floor and perineum
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- once the genital trauma is identified it should be repaired by a competent practitioner
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- any uncertainty about the nature or extent of the trauma should result in the woman being referred to a more experienced practitioner.
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Risk factors for third degree trauma
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Be aware of the factors that precipitate obstetric anal sphincter injury. These include:
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- baby larger than 4kg
- malposition/ malpresentation at birth
- nulliparity/ birth position
- induction of labour
- epidural anaesthesia/ analgesia
- prolonged second stage of labour <1 hour
- assisted birth (e.g. forceps or Ventouse)
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- midline episiotomy
- other suggested predisposing factors may include ethnicity, maternal nutritional status, maternal age (very young or older mothers) inability to communicate with mother.
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Recognition of third degree trauma
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- on visual examination, the lack of 'puckering' around the anterior aspect of the anus may be suggestive of anal sphincter injury
- the clinician should undertake a digital examination to establish if perineal trauma reaches the anal margin
- if third degree trauma is suspected a digital rectal examination should be undertaken by the clinician, and the woman is asked to squeeze her rectum. If the external anal sphincter is damaged the separated ends may be seen to retract backwards.
- the tear should be confirmed by palpating the muscle bulk of the anal sphincter between the index finger in the anus and the thumb over the vaginal tear ('pill rolling action').
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Note: Regional analgesia may affect muscle power in the perineum.
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The repair of third and fourth degree perineal trauma should only be undertaken by an experienced registrar with a consultant in the operating theatre with adequate lighting, anaesthesia and equipment. Refer to CPG Management of 3rd and 4th degree tears.
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Procedure
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Aims
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- adequate haemostasis and obliteration of 'dead space' to reduce the risk of developing a haematoma / infection / wound breakdown
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- skin stitched not too tightly, minimal use of knots, least amount of suture materials used: all are reported to contribute to a reduction in postpartum perineal pain.
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Anaesthesia
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- lignocaine 1% is infiltrated as local anaesthesia to the perineum. A maximum amount of 3mg/kg (e.g. 20mL in a 70kg woman) may be administered within a one-hour period.
- where an epidural or spinal anaesthetic is in situ additional perineal anaesthesia may be required.
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Perineal repair
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Tthis is a surgical procedure that requires adherence to infection control and safe practice guidelines:
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- standard infection control procedures are to be respected.
- all equipment is to be accounted for by the doctor or midwife undertaking the procedure and the midwife providing assistance. this equipment includes:
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| - hypodermic needles
- suture needles
- suture packs with radio-opaque thread
- tampon with radio-opaque thread
- instruments
- yellow kidney dish- to receive contaminated 'sharps'
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- a count of all instruments, packs, tampon and needles used for the repair should be conducted at the beginning and the end of the procedure with any additions being recorded throughout
- if it becomes necessary to replace the assisting midwife during the procedure a count of the equipment should also occur.
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If there is any discrepancy in the count refer to Perineal Repair: Safe practice procedure for management guidelines.
The count must be documented and signed by both parties on the count sheet on the back of the partogram.
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- ONLY an X-Ray detectable tampon is to be introduced into the vagina. This should be attached to a blunt-ended towel clip.
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- appose all tissues correctly by identifying and aligning the following anatomical landmarks: apex of tear, hymenal remnants, and fourchette. Eliminate the 'dead' space within the wound.
- repair the perineal wound in layers as per guidelines
- both a vaginal examination and a rectal examination must be performed at the completion of the procedure
- describe and record in the Birth Centre Progress Notes full details of the extent of the trauma and the repair undertaken. Record any medications or additional interventions.
- observe and record amount of blood loss occurring during procedure.
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Refer to Perineal Repair: Safe practice procedure.
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Current clinical evidence
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Absorbable synthetic sutures (polyglactin 910) for repair of 1st and 2nd degree trauma and episiotomies are associated with less perineal discomfort and analgesic use within 10 days of birth and significantly reduced dyspareunia at 12 months postpartum when compared with catgut sutures. For simple repairs rapidly absorbed Vicryl Rapide is the material of choice as it loses half its tensile strength in 10 days and is absorbed over approximately 40 days.
A continuous sub-cuticular repair of the perineal skin or a two stage perineal repair are reported as reducing perineal pain in the 10 days after birth.
Non-suturing of perineal skin in 1st and 2nd degree tears and episiotomies is said to significantly reduce dyspareunia 3 months after birth.
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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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