repair of vaginal and perineal tears22

8/19/2019 Repair of Vaginal and Perineal Tears22

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REPAIR OF VAGINAL AND PERINEAL TEARS

Four degrees of tear can occur during delivery:

First degree Vaginal mucosa + connective tissueSecond degree Vaginal mucosa + connective tissue +

musclesThird degree Complete transection of the anal

sphincterFourth degree Rectal mucosa also involved

Repair of first and second degree tears

Most first degree tears close spontaneously without sutures.1 Use local infiltration with lidocaine. If necessary

use a pudendal !loc". #naestheti$e early to provide sufficient time for itto ta"e effect.

#s" an assistant to massage the uterus and providefundal pressure.

!Carefully e%amine the vagina perineum and cervi%&Figure '(.')*. If the tear is long and deep throughthe perineum inspect to !e sure there is no third

or fourth degree tear:• lace a gloved finger in the anus

• ,ently lift the finger and identify thesphincter

• Feel for the tone or tightness of thesphincter

• Change to clean sterile gloves.

Figure '(.')

"If the sphincter is in-ured see pages '((/ to '((0 on the repair of third and fourth degree tears.

# If the sphincter is not in-ured proceed with repair.$

Repair the vaginal mucosa using a continuous (12suture &Figure '(.'/*:

• 3tart the repair a!out ' cm a!ove the ape%&top* of the vaginal tear continuing thesuture to the level of the vaginal opening

•

#t the opening of the vagina !ring togetherthe cut edges of the vaginal

opening

• 4ring the needle under the vaginal openingand out through the perinealtear and tie.



Figure '(.'/

% Repair the perineal muscles using interrupted (12suture &Figure '(.'0*. If the tear is deep place asecond layer of the same stitch to close the space.

Figure '(.'0

&Repair the s"in using interrupted &or su!cuticular*(12 sutures starting at the vaginal opening &Figure

'(.'5*. If the tear was deep perform a rectale%amination. Ma"e sure no stitches are in therectum.

Figure '(.'5

Repair of third and fourth degree perinea' tears

6he woman may suffer loss of control over !owel movements and gas if a torn anal sphincter is notrepaired correctly. If a tear in the rectum is notrepaired the woman can suffer from infection and rectovaginal fistula.

Repair the tear in the operating roo()

1 If you cannot see all edges of the tear useregional or general anaesthesia.If you can see all edges of the tear use localinfiltration with lidocaine.

#s" an assistant to massage the uterus andprovide fundal pressure.

! 7%amine the vagina cervi% perineum and



rectum. 6o see if the anal sphincter is torn:

• lace a gloved finger in the anus and liftslightly

• Identify the sphincter or lac" of it

• Feel the surface of the rectum and loo"carefully for a tear.

" Change to sterile gloves apply antiseptic solutionto the tear and remove any faecal material ifpresent.

# Repair the rectum using interrupted 812 or 912

sutures 2. cm apart to !ring together the mucosa&Figure '(.(2*. lace the suture through themuscularis &not all the way through the mucosa*.

Figure '(.(2

$

Cover the muscularis layer !y !ringing togetherthe fascial layer with interrupted sutures.

% #pply antiseptic solution to the area fre;uently.& Repair the s"in using interrupted &or

su!cuticular* (12 sutures starting at the vaginalopening &Figure '(.'5*. If the tear was deepperform a rectal e%amination. Ma"e sure nostitches are in the rectum.

Figure '(.'5

* If the sphincter is torn grasp each end of the

sphincter with an #llis clamp &the sphincterretracts when torn*. 6he sphincter is strong and will not tear when pulling with the clamp. Repairthe sphincter with two or three interruptedstitches of (12 suture &Figure '(.('*.



Figure '(.('

1+ #pply antiseptic solution to the area again.7%amine the anus with a gloved finger to ensurethe correct repair of the rectum and sphincter.6hen change to clean sterile gloves. Repair the

vaginal mucosa perineal muscles and s"in.

Post,procedure care1 If there is a fourth degree tear give a single dose

of prophylactic anti!iotics: #mpicillin 22 mg !y mouth plusmetronida$ole 922 mg !y mouth.

Follow up closely for signs of wound infection.! #void giving enemas or rectal e%aminations for

( wee"s." ,ive stool softener !y mouth for ' wee" if

possi!le.-anage(ent of neg'ected cases

# perineal tear is always contaminated with faecal material. If closure is delayed more than '( hoursinfection is inevita!le. <elayed primary closure isindicated in such cases.

.. For first and second degree tears leave the woundopen

.. For third and fourth degree tears close the rectalmucosa with some supporting tissue andappro%imate the fascia of the anal sphincter with( or 8 sutures= close the muscle and vaginalmucosa and the perineals"in ) days later.

/o(p'icationsIf a haematoma is o!served open and drain it. If there are no signs of infection and the !leeding hasstopped the wound can !e reclosed.

If there are signs of infection open and drain the wound. Remove infected sutures and de!ride the

wound.

If the infection is mild anti!iotics are not re;uired.

If the infection is severe !ut does not involve deep tissues give a com!ination of anti!iotics:.. #mpicillin 22 mg !y mouth four times per day

for days plus metronida$ole 922 mg !y mouththree times per day for days.

If the infection is deep involves muscles and is causing necrosis &necroti$ing fasciitis* give a com!inationof anti!iotics until necrotic tissue has !een removed and the woman is fever1free for 90 hours:.. enicillin , ( million units IV every ) hours

plus gentamicin mg>"g !ody weight IV every(9 hours plus metronida$ole 22 mg IV every

0 hours.?nce the woman is fever1free for 90 hours give:.. #mpicillin 22 mg !y mouth four times per day

for days plus metronida$ole 922 mg !y mouththree times per day for days.

@ecroti$ing fasciitis re;uires wide surgical de!ridement. erform secondary closure in (9 wee"sdepending on resolution of infection.

Faecal incontinence may result from complete sphincter transection. Many women are a!le to maintaincontrol of defaecation !y the use of other perineal muscles. Ahen incontinence persists reconstructivesurgery must !e underta"en 8 months or more after delivery.

repair of vaginal and perineal tears22

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