How To Repair Third Degree

Repair of Obstetric Perineal Lacerations

LAWRENCE LEEMAN, Grand.D., M.P.H., MARIDEE SPEARMAN, Grand.D., and REBECCA ROGERS, M.D., University of New United mexican states School of Medicine, Albuquerque, New Mexico

Am Fam Doctor. 2003 Oct fifteen;68(viii):1585-1590.

A more contempo commodity on prevention and repair of obstetric lacerations is available.

Abstract
Perineal Beefcake
Surgical Principles
Repair of 2nd-Degree Perineal Lacerations
Repair of Fourth-Caste Perineal Lacerations
Postpartum Care
Prevention
References

Article Sections

Abstract
Perineal Beefcake
Surgical Principles
Repair of 2nd-Degree Perineal Lacerations
Repair of Quaternary-Degree Perineal Lacerations
Postpartum Intendance
Prevention
References

Family physicians who deliver babies must frequently repair perineal lacerations afterward episiotomy or spontaneous obstetric tears. Constructive repair requires a knowledge of perineal anatomy and surgical technique. Perineal lacerations are classified according to their depth. Sequelae of obstetric lacerations include chronic perineal pain, dyspareunia, urinary incontinence, and fecal incontinence. With lacerations involving the anal sphincter circuitous, particular attention must be given to anatomy and surgical technique because of the loftier incidence of poor functional outcomes after repair. An overlapping technique to repair the external anal sphincter, rather than the traditional end-to-end technique, is existence investigated to decide if it might subtract the incidence of anal incontinence. Minimizing the employ of episiotomy and forceps deliveries can decrease the occurrence of severe perineal lacerations.

Perineal repair after episiotomy or spontaneous obstetric laceration is one of the most common surgical procedures. Potential sequelae of obstetric perineal lacerations include chronic perineal pain,1 dyspareunia,two and urinary and fecal incontinence.3–5 Few studies of laceration repair techniques exist to support the development of an evidence-based approach to perineal repair. This article discusses a repair method that emphasizes anatomic detail, with the expectation that an anatomically correct perineal repair may result in a amend long-term functional outcome.

Perineal Beefcake

Abstruse
Perineal Anatomy
Surgical Principles
Repair of 2nd-Degree Perineal Lacerations
Repair of Fourth-Caste Perineal Lacerations
Postpartum Care
Prevention
References

The perineal torso, located between the vagina and the rectum, is formed predominantly by the bulbocavernosus and transverse perineal muscles (Effigy one). The puborectalis musculus and the external anal sphincter contribute additional muscle fibers.

FIGURE 1.

Muscles of perineal body.

The anal sphincter complex lies junior to the perineal body (Figure 2). The external anal sphincter is composed of skeletal muscle. The internal anal sphincter, which overlaps and lies superior to the external anal sphincter, is composed of smooth muscle and is continuous with the smooth muscle of the colon. The anal sphincter complex extends for a distance of iii to 4 cm.6

Effigy two.

Anal sphincter complex (cadaver autopsy).

The internal anal sphincter provides well-nigh of the resting anal tone that is essential for maintaining continence. Laceration of this sphincter is associated with anal incontinence.4 Interestingly, repair of the internal anal sphincter is not described in standard obstetric textbooks.7,8

Surgical Principles

Abstruse
Perineal Beefcake
Surgical Principles
Repair of Second-Degree Perineal Lacerations
Repair of Quaternary-Caste Perineal Lacerations
Postpartum Care
Prevention
References

Obstetric perineal lacerations are classified as starting time to fourth degree, depending on their depth. A rectal examination is helpful in determining the extent of injury and ensuring that a third- or 4th-degree laceration is non overlooked.

Repair of the perineum requires expert lighting and visualization, proper surgical instruments and suture textile, and adequate analgesia (Tabular array one). Compared with surgical repair using catgut or chromic suture, repair using 3-0 polyglactin 910 (Vicryl) suture results in decreased wound dehiscence and less postpartum perineal pain.ix–12 [ Reference9—Show level A, randomized controlled trial (RCT); Reference10—Show level B, uncontrolled trial; Reference11—Evidence level A, meta-assay; Reference12—Evidence level B—systematic review of RCTs] Use of rapidly absorbed polyglactin 910 (Vicryl Rapide) suture decreases the need for postpartum suture removal after repair of second-degree lacerations.xiii

TABLE 1

Equipment for Repair of Obstetric Perineal Lacerations

Sterile drapes and gloves

Irrigation solution

Needle holder

Metzenbaum scissors

Suture scissors

Forceps with teeth

Allis clamps

Gelpi or Deaver retractor (for utilise in visualizing third- or fourth-degree perineal lacerations, or deep vaginal lacerations)

10-mL syringe with 22-estimate needle

one% lidocaine (Xylocaine)

3-0 polyglactin 910 (Vicryl) suture on CT-1 needle (for vaginal mucosa sutures)

iii-0 polyglactin 910 suture on CT-one needle (for perineal muscle sutures)

4-0 polyglactin 910 suture on SH needle (for pare sutures)

2-0 polydioxanone sulfate (PDS) suture on CT-i needle (for external anal sphincter sutures)

Local anesthesia can be used for repair of most perineal lacerations. Nonetheless, general or regional anesthesia may exist necessary to achieve adequate muscle relaxation and visualization for surgical repair of severe or circuitous lacerations.

Severe perineal lacerations involving the anal sphincter circuitous pose a surgical challenge. Recent studies3,14 have demonstrated a 20 to 50 per centum incidence of anal incontinence or rectal urgency afterward repair of third-caste obstetric perineal lacerations. These injuries practice not require immediate repair; hence, an inexperienced physician can delay the procedure for a few hours until advisable support staff are bachelor.

With severe perineal lacerations involving the anal sphincter circuitous, nosotros irrigate copiously to improve visualization and reduce the incidence of wound infection. Because these lacerations are contaminated by stool, a single dose of a 2nd- or third-generation cephalosporin may be given intravenously before the procedure is started.

Repair of Second-Degree Perineal Lacerations

Abstruse
Perineal Beefcake
Surgical Principles
Repair of 2nd-Degree Perineal Lacerations
Repair of Fourth-Degree Perineal Lacerations
Postpartum Care
Prevention
References

Repair of a second-degree laceration (Figure three) requires approximation of the vaginal tissues, muscles of the perineal body, and perineal skin. The steps in the procedure are as follows:

FIGURE three.

Second-degree perineal laceration.

The apex of the vaginal laceration is identified. For lacerations extending deep into the vagina, a Gelpi or Deaver retractor facilitates visualization.

An anchoring suture is placed 1 cm to a higher place the apex of the laceration, and the vaginal mucosa and underlying rectovaginal fascia are closed using a running unlocked three-0 polyglactin 910 suture. If the apex is likewise far into the vagina to be seen, the anchoring suture is placed at the most distally visible surface area of laceration, and traction is applied on the suture to bring the noon into view. The running suture can exist locked for hemostasis, if needed.

The sutures must include the rectovaginal fascia (Effigy iv), which provides back up to the posterior vagina. The running suture is carried to the hymenal ring and tied proximal to the band, completing closure of the vaginal mucosa and rectovaginal fascia.

Figure 4.

Vaginal mucosa and underlying rectovaginal fascia.

The muscles of the perineal body are identified on each side of the perineal laceration (Effigy 5). The ends of the transverse perineal muscles are reapproximated with one or two transverse interrupted iii-0 polyglactin 910 sutures (Effigy six)

Effigy v.

Second-degree perineal laceration with underlying muscles exposed.

Used with permission from Academy of New United mexican states School of Medicine, Department of Family and Customs Medicine, Albuquerque, N.Yard.

FIGURE 6.

Repair of transverse perineal muscles with single interrupted suture.

Used with permission from University of New Mexico School of Medicine, Department of Family and Customs Medicine, Albuquerque, N.G.

A single interrupted 3-0 polyglactin 910 suture is then placed through the bulbocavernosus muscle (Figure seven). The torn ends of the bulbocavernosus muscle are frequently retracted posteriorly and superiorly. Employ of a large needle facilitates proper suture placement.

Effigy 7.

Repair of bulbocavernosus muscle with single interrupted suture.

Used with permission from Academy of New Mexico Schoolhouse of Medicine, Department of Family and Community Medicine, Albuquerque, N.M.

If the laceration has separated the rectovaginal fascia from the perineal body, the fascia is reattached to the perineal torso with two vertical interrupted 3-0 polyglactin 910 sutures (Effigy 8)

FIGURE 8.

Reattachment of rectovaginal septum to muscles of perineal trunk.

Used with permission from University of New Mexico Schoolhouse of Medicine, Department of Family and Customs Medicine, Albuquerque, N.G.

When the perineal muscles are repaired anatomically as described to a higher place, the overlying skin is usually well approximated, and skin sutures generally are not required. Skin sutures have been shown to increase the incidence of perineal pain at three months subsequently delivery.15 [Evidence level B, uncontrolled trial] If the skin requires suturing, running subcuticular sutures have been shown to exist superior to interrupted transcutaneous sutures.16 The 4-0 polyglactin 910 sutures should start at the posterior apex of the skin laceration and should be placed approximately 3 mm from the border of the peel.

An alternative approach to repair of the perineal trunk muscles is a running suture that is continued from the vaginal mucosa repair and brought underneath the hymenal ring. All the same, we prefer the interrupted approach because it facilitates a more than anatomic repair, assuasive reapproximation of the bulbocavernosus muscle and reattachment of the vaginal septum with minimal use of sutures.

Repair of 4th-Caste Perineal Lacerations

Abstruse
Perineal Anatomy
Surgical Principles
Repair of Second-Degree Perineal Lacerations
Repair of Quaternary-Degree Perineal Lacerations
Postpartum Intendance
Prevention
References

Repair of a fourth-caste laceration requires approximation of the rectal mucosa, internal anal sphincter, and external anal sphincter (Figure nine)

Effigy 9.

Quaternary-degree perineal laceration.

A Gelpi retractor is used to split up the vaginal sidewalls to permit visualization of the rectal mucosa and anal sphincters. The noon of the rectal mucosa is identified, and the mucosa is approximated using closely spaced interrupted or running four-0 polyglactin 910 sutures (Figure 10). Traditional recommendations emphasize that sutures should non penetrate the complete thickness of the mucosa into the anal canal, to avoid promoting fistula formation. The sutures are continued to the anal verge (i.e., onto the perineal pare).

FIGURE 10.

Repair of rectal mucosa.

Used with permission from Rogers RG, Kammerer-Doak DN. Obstetric anal sphincter lacerations, part two. Female person Patient 2002;27(5):31–6.

The internal anal sphincter is identified equally a glistening, white, fibrous structure between the rectal mucosa and the external anal sphincter (Figure xi). The sphincter may be retracted laterally, and placement of Allis clamps on the muscle ends facilitates repair. The internal anal sphincter is closed with continuous 2-0 polyglactin 910 sutures.

Figure eleven.

Internal anal sphincter and external anal sphincter.

Used with permission from Rogers RG, Kammerer-Doak DN. Obstetric anal sphincter lacerations, part 2. Female Patient 2002;27(5):31–6.

The external anal sphincter appears as a band of skeletal muscle with a fibrous capsule. Traditionally, an end-to-terminate technique is used to bring the ends of the sphincter together at each quadrant (12, 3, 6, and 9 o'clock) using interrupted sutures placed through the capsule and muscle (Effigy 12). Allis clamps are placed on each stop of the external anal sphincter. We use 2-0 polydioxanone sulfate (PDS), a delayed absorbable monofilament suture, to allow the sphincter ends adequate time to scar together. Recent evidence suggests that end-to-cease repairs accept poorer anatomic and functional outcomes than was previously believed.3,4 [ Reference3 —Prove level B, descriptive study; Reference4 —Prove level B, prospective cohort study]

FIGURE 12.

End-to-terminate technique for repairing external anal sphincter.

An culling technique is overlapping repair of the external anal sphincter. Colorectal surgeons prefer to use this method when they repair the sphincter remote from delivery.14,17 The overlapping technique brings together the ends of the sphincter with mattress sutures (Figure 13) and results in a larger surface expanse of tissue contact betwixt the two torn ends. Dissection of the external anal sphincter from the surrounding tissue with Metzenbaum scissors may be required to achieve adequate length for the overlapping of the muscles. The suture is passed from superlative to bottom through the superior and junior flaps, then from bottom to top through the inferior and superior flaps. The proximal end of the superior flap overlies the distal portion of the inferior flap. Two more sutures are placed in the same manner. After all three sutures are placed, they are each tied snugly, just without strangulation. When tied, the knots are on the elevation of the overlapped sphincter ends. Care must be taken to incorporate the muscle sheathing in the closure.

Effigy 13.

Overlapping technique for repairing external anal sphincter.

Postpartum Intendance

Abstruse
Perineal Anatomy
Surgical Principles
Repair of Second-Degree Perineal Lacerations
Repair of Fourth-Degree Perineal Lacerations
Postpartum Care
Prevention
References

The literature contains little information on patient care afterwards the repair of perineal lacerations. We recommend the use of sitz baths and an analgesic such equally ibuprofen. If a woman has excessive pain in the days afterward a repair, she should be examined immediately because hurting is a frequent sign of infection in the perineal area. After repair of a third- or fourth-caste laceration, we include several weeks of therapy with a stool softener, such as docusate sodium (Colace), to minimize the potential for repair breakdown from straining during defecation.

The perineal muscles, vaginal mucosa, and skin are repaired using the same techniques described for the repair of 2nd-degree lacerations.

Prevention

Abstruse
Perineal Anatomy
Surgical Principles
Repair of Second-Caste Perineal Lacerations
Repair of Quaternary-Degree Perineal Lacerations
Postpartum Care
Prevention
References

The incidence of severe perineal trauma can be decreased by minimizing the use of episiotomy and operative vaginal delivery. A Cochrane review demonstrated that liberal employ of episiotomy does not reduce the incidence of anal sphincter lacerations and is associated with increased perineal trauma.18 [Evidence level A, systematic review of RCTs] A meta-analysis of viii randomized trials of vacuum extraction versus forceps delivery demonstrated that one sphincter tear would be prevented for every eighteen women delivered with vacuum rather than forceps.19 [Evidence level B, systematic review of lower quality RCTs]

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The Authors

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LAWRENCE LEEMAN, M.D., M.P.H., is assistant professor of family and community medicine, and obstetrics and gynecology, at the University of New Mexico Schoolhouse of Medicine, Albuquerque. He is also director of family practice maternity and infant care and comedical director of the mother-baby unit at the University of New Mexico Hospital, Albuquerque. After graduating from the University of California, San Francisco, School of Medicine, Dr. Leeman completed a family unit practise residency at the University of New United mexican states Schoolhouse of Medicine and a fellowship in obstetrics at the Academy of Rochester (N.Y.) School of Medicine and Dentistry. In addition, he earned a principal of public health caste at the Academy of California, Berkeley....

MARIDEE SPEARMAN, Thousand.D., is a resident in obstetrics and gynecology at the University of New Mexico School of Medicine. Dr. Spearman received her medical degree from the Medical Academy of South Carolina School of Medicine, Charleston.

REBECCA ROGERS, Thou.D., is assistant professor of obstetrics and gynecology at the Academy of New United mexican states School of Medicine and managing director of the Women's Health Urogynecology Center at the Academy of New Mexico Infirmary. Dr. Rogers graduated from Harvard Medical School, Boston, and completed a residency in obstetrics and gynecology and a fellowship in urogynecology at the University of New Mexico.

Address correspondence to Lawrence Leeman, One thousand.D., M.P.H., University of New Mexico Schoolhouse of Medicine, Department of Family and Customs Medicine, 2400 Tucker NE, 3rd Floor, Albuquerque, NM 87131 (email:lleeman@salud.unm.edu) Reprints are not available from the authors.

The authors indicate that they do non have any conflicts of involvement. Sources of funding: none reported.

Figure ii supplied by Janet Yagoda Shagam, Ph.D.

REFERENCES

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1. Albers L, Garcia J, Renfrew Yard, McCandlish R, Elbourne D. Distribution of genital tract trauma in childbirth and related postnatal pain. Birth. 1999;26:xi–7. ...

2. Signorello LB, Harlow BL, Chekos AK, Repke JT. Postpartum sexual functioning and its relationship to perineal trauma: a retrospective cohort report of primiparous women. Am J Obstet Gynecol. 2001;184:881–8.

3. Sultan AH, Kamm MA, Hudson CN, Bartram CI. Third caste obstetric anal sphincter tears: take chances factors and outcome of primary repair. BMJ. 1994;308:877–91.

4. Kammerer-Doak DN, Wesol AB, Rogers RG, Dominguez CE, Dorin MH. A prospective cohort study of women afterwards chief repair of obstetric anal sphincter laceration. Am J Obstet Gynecol. 1999;181:1317–22.

5. Viktrup L, Lose One thousand. The risk of stress incontinence 5 years later outset commitment. Am J Obstet Gynecol. 2001;185:82–7.

6. Delancey JO, Toglia MR, Perucchini D. Internal and external anal sphincter anatomy as it relates to midline obstetric lacerations. Obstet Gynecol. 1997;xc:924–seven.

7. Benedetti TJ. Obstetric hemorrhage. In: Gabbe SG, Niebyl JR, Simpson JL, et al., eds. Obstetrics: normal and trouble pregnancies. quaternary ed. New York: Churchill Livingstone, 2002:503–30.

eight. Cunningham FG, et al., eds. Williams Obstetrics. 21st ed. New York: McGraw-Hill, 2001:328.

9. Mahomed K, Grant A, Ashurst H, James D. The Southmead perineal suture written report. A randomized comparing of suture materials and suturing techniques for repair of perineal trauma. Br J Obstet Gynaecol. 1989;96:1272–80.

10. Mackrodt C, Gordon B, Fern Eastward, Ayers S, Truesdale A, Grant A. The Ipswich Childbirth Study: 2. A randomised comparison of polyglactin 910 with chromic catgut for postpartum perineal repair. Br J Obstet Gynaecol. 1998;105:441–5.

xi. Grant A. The choice of suture materials and techniques for repair of perineal trauma: an overview of the testify from controlled trials. Br J Obstet Gynaecol. 1989;96:1281–ix.

12. Kettle C, Johanson RB. Absorbable synthetic versus catgut suture material for perineal repair. Cochrane Database Syst Rev. 2003;(1):CD000006

13. Kettle C, Hills RK, Jones P, Darby L, Grey R, Johanson R. Continuous versus interrupted perineal repair with standard or rapidly captivated sutures after spontaneous vaginal birth: a randomised controlled trial. Lancet. 2002;359:2217–23.

xiv. Fitzpatrick 1000, Behan M, O'Connell PR, O'Herlihy C. A randomized clinical trial comparing master overlap with approximation repair of tertiary-caste obstetric tears. Am J Obstet Gynecol. 2000;183:1220–4.

xv. Gordon B, Mackrodt C, Fern E, Truesdale A, Ayers Southward, Grant A. The Ipswich Childbirth Study: i. A randomised evaluation of two stage postpartum perineal repair leaving the peel unsutured. Br J Obstet Gynaecol. 1998;105:435–xl.

sixteen. Kettle C, Johanson RB. Continuous versus interrupted sutures for perineal repair. Cochrane Database Syst Rev. 2003;(ane):CD000947

17. Sultan AH, Monga AK, Kumar D, Stanton SL. Principal repair of obstetric anal sphincter rupture using the overlap technique. Br J Obstet Gynaecol. 1999;106:318–23.

18. Carroli G, Belizan J. Episiotomy for vaginal nascence. Cochrane Database Syst Rev. 2003;(ane):CD000081

19. Eason E, Labrecque M, Wells M, Feldman P. Preventing perineal trauma during childbirth: a systematic review. Obstet Gynecol. 2000;95:464–71.

This article is one in a series of "Office Procedures" articles on obstetrics and gynecology coordinated past Brett Johnson, M.D.

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