lacerations of the birth canal

Question 1

first degree

Answer 1

fourchette
perineal skin
vaginal mucosa
NOT muscle
*does not need suturing*

Question 2

second degree

Answer 2

fourchette
perineal skin
vaginal mucosa
muscle(s) of the perineal body
NOT the anal sphincter
*should be sutured*

Question 3

third degree

Answer 3

extends into the anal sphincter, can be partial

Question 4

fourth degree

Answer 4

extends through the rectal wall

with or without anal sphincter involvement

Question 5

blind fourth degree

Answer 5

into rectal wall interior to sphincter

Question 6

predisposing factors for lacerations

Answer 6

Rapid, sudden expulsion of the head
Posterior presentation – takes up more space
Size of baby
Instrumentation
Friable maternal tissues – previous tear, poor nutrition, HPV infection
Exaggerated lithotomy position
Outlet contraction of pelvis

Question 7

prevention of lacerations

Answer 7

slow head delivery
kegel exercises
perineal support/counterpressure
head flexion (only do this if you know baby is OA)
good prenatal nutrition
warm compresses if no excess swelling
perineal massage

Question 8

why suture lacerations?

Answer 8

*restore anatomical integrity*
decrease infxn
increase wound healing
decrease pp blood loss
restore cosmetic appearance

Question 9

suturing materials

Answer 9

1)Topical anesthetic - lidocaine gel, cetacaine
2)Lidocaine with or without epi 1%, bupivocaine 0.25% *this lasts longer, so when you’re starting use this so you don’t have to worry about it wearing off (don’t use epi near clitoris, if skin dog ears don’t want to cut off circ to edge of tissue)
3)Sterile gloves
4)Sterile 4x4’s
5)Sterile instruments - needle holders, forceps, hemostats, scissors, speculum, ring forceps – speculum and ring forceps are for cervical tears
6)Syringes - 3cc & 10cc – just use 10cc most of time bc lidocaine is not expensive, better to draw up to be prepared.
7)Needles - 25, 27 or 30 gauge 1/2 to 11/2 inch – use as small as you can get away with for putting in the meds, she likely won’t feel 30 going in, she’ll feel the burn of the med. Use esp small if going towards anus, lots of nerve endings there.
8)Suture - Absorbable (gut or vicryl)
Non-absorbable (silk)
Size - 2-0 for deep lacerations to vagina
4-0 for superficial lacerations or labia/clitoral tears
3-0 Good general size – will do most of your tears.
9)Needle type
Taper is ideal for vagina – don’t use a cutting needle!! ALWAYS use this for vagina/rectum etc.
Taper/cut for labia
10)Good light – Petzl or Welch Allyn headlamp – doesn’t need to be headlamp but need to have someone holding light otherwise.

Question 10

vicryl or chromic gut?

Answer 10

vicryl!
decreased wound dehiscence
less pp perineal pain
decreases the need for pp suture removal after repair of 2nd degree

Question 11

second degree repair

Answer 11

1) Visualize Laceration
2) Insert tampon or 4x4 gauze so you can visualize area without blood obstruction.
3) Visualize apex of tear – put anchor stitch ABOVE apex to grab any retracted BV (less bleeding)
4) Anesthetize
5) Infiltrate with 1% lidocaine or .25% bupivacaine – put it into skin around the tear, not into the tear itself. Put needle in, plunge in slowly as you’re withdrawing and say “burn burn burn burn burn”, redirect needle and point down towards anus. Then do again on the other side.
6) Place first suture
7) Continuous suturing to hymenal ring
8) Make sure you’re joining together Bulbocavernosus Muscle & transverse muscle
9) Crown Stitch for bulbocavernosus muscle.
10) Approximate Perineal Skin
11) Simple Interrupted stitch: she will be more uncomfortable after and looks poor. But will do.
12) Perineal Skin Repair
13) Note superficial extension to anal skin
14) Superficial skin closure: skin sutures have been shown to increase the incidence of perineal pain at three months after delivery. Therefore a running subcuticular stitch is best choice – hides it all and is less itchy than interrupted transcutaneous sutures.

Question 12

recent studies have demonstrated a 20-50% incidence of what two sequelae after repair of 3rd/4th degree tears?

Answer 12

anal incontinence

rectal urgency

Question 13

two ways to repair an external sphincter tear

Answer 13

end to end
overlapping repair (may give more integrity)

Question 14

indications for episiotomy

Answer 14

-Delay due to rigid perineum or disproportion between fetus and vaginal orifice
-Fetal distress – are willing to sacrifice maternal tissue, need to look at mom’s anatomy (if have short perineum have increased risk for serious tears), prolapsed cord in second stage.
-To facilitate vaginal or intrauterine manipulation
Application of vacuum
Resolution of shoulder dystocia
-Preterm baby (under 4 lbs) to avoid intracranial damage (not for out-of-hospital)

Question 15

median episiotomy

Answer 15

Easier to repair
Faulty healing is rare
Less pain in puerperium
Dyspareunia less likely
Anatomical restoration consistent
Less blood loss

Question 16

mediolateral episiotomy

Answer 16

More difficult to repair, best left for surgeons
Faulty healing more common
Pain in 1/3 cases in the puerperium
Dyspareunia more likely
Faulty repair in 10% of cases
Greater blood loss
3rd degree extension 1%

Question 17

guiding principles of episiotomy

Answer 17

*Protect the presenting part of the fetus from injury
A single cut in any direction is far preferable to repeated snipping because the latter will leave jagged edges – ie. Commit to it!
The episiotomy should be large enough to accomplish the purpose for cutting it.
The cut should be timed to avoid lacerations (too late) and unnecessary blood loss (too soon)
The perineum should be bulging, the vaginal orifice distended by approximately a 3-cm diameter of fetal presenting part between contractions; this is how you know timing is right.
Delivery of the presenting part should be expected to occur within the next two to four contractions

Question 18

technique for midline episiotomy

Answer 18

1) Place your index and middle fingers into the vagina, palmar side down and facing you. Separate them slightly and exert outward pressure – protects baby’s head
2) Keep pressure on the perineal body – doing this BETWEEN contractions.
3) The blades of the scissors are placed in a straight up-and-down position so that one blade is against the posterior vaginal wall and the other blade is against the skin of the perineal body, with the point where the blades cross at the midline of the posterior fourchette.
4) Palpate with your vaginal fingers and with your thumb of the same hand on the outside of the perineal body, palpate for and locate the external anal sphincter
5) Adjust the length of the blades of the scissors on the perineal body to the projected length of the incision (ie. not extending down to sphincter).
6) Cut.
7) Sponge, observe, and palpate again for the external sphincter.
8) Evaluate if another cut in this plane is needed.
9) Cut again, if needed.
10) Evaluate the extent of the incision into the vagina. Feel for a band of tight, restricting vaginal tissue just inside the introitus.
11) Extend the vaginal side of the incision, if needed, or if the band of tissue is there and needs to be incised.
12) Extension is accomplished by now pressing downward with your two vaginal fingers, holding them apart to splint the incision line and in far enough to extend beyond the projected lengthening of the incision line. Bring the scissors from above the back side of the hand to slide between the fingers and make the cut.
13) Apply pressure with 4 x 4 sponges to the incision

Question 19

technique for mediolateral episiotomy

Answer 19

same except start at midline perineum an dcut toward ischial tuberosity
avoid bartholin’s gland and anal sphincter

Question 20

repair of medial episiotomy

Answer 20

repair of perineal body–>approximation of muscular structures

Question 21

repair of mediolateral episiotomy

Answer 21

1)Start at apex
2)Approximate vaginal skin
3)Stitch slightly proximal of hymenal ring
4)Approximate fourchette
5)Bulbocavernosus Repair – locate one side of bulbocavernosus
Take deep, broad bite
Locate opposite side of muscle
Use crown stitch or simple interrupted
6)Approximate cut edges of sphincter vaginae
7)Suture securely but not too tight
8)Lacerated Arterioles - tie off bleeders separately
9)Interrupted sutures of deep muscle, including levator ani - continued deep repair, transversalis repair
10)Superficial repair – interrupted mattress stitch for perineal repair

Question 22

what causes cervical lacerations?

Answer 22

birth of baby through incompletely dilated cervix

Question 23

a deep cervical tear should always be suspected in cases of

Answer 23

profuse hemorrahge during the third stage of labor, especially if uterus is adequately contracted

Question 24

treatment for cervical lacerations

Answer 24

Repair using speculum, ring forceps and long needle holders. OK to transfer for repair bc difficult to visualize without proper lighting or positioning.

Question 25

pp care of perineum

Answer 25

ice packs immediately x24 hours
wash with peri bottle after every BM and void
homeopathic- calendula, arnica, hypericum, ledum (for injections)
sitz baths- fresh garlic, warm saline water, comfrey, uva ursi, calendula
kegel exercises