Perineal Trauma Assessment and Repair CPG

Introduction

Classification of perineal trauma

• Described as being either small, medium or large depending on extent of incision.
  
  

Procedure

Aims

• Adequate haemostasis and obliteration of "dead space" to reduce the risk of developing a haematoma / infection / wound breakdown.

• 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.

Anaesthesia

• Lignocaine 1% is infiltrated as local anaesthesia to the perineum. A maximum amount of 3mg/kg (eg 20 ml in a 70 kg woman) may be administered within a one-hour period.
• Where an epidural or spinal anaesthetic is in situ additional perineal anaesthesia may be required.

Perineal repair

• Treat as a surgical procedure.
• 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:

• 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.

• ONLY an X-Ray detectable tampon is to be introduced into the vagina. This should be attached to a blunt-ended towel clip.
• 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 Suite Progress Notes full details of the extent of the trauma and the repair undertaken. Record any medications or additional interventions.

• Link to Procedure / Guidelines: Perineal Repair: Procedure.
  

Current clinical evidence

• Absorbable synthetic sutures (Vicryl, Vicryl Rapide, Dexon) 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 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.

References