Episiotomy, Perineal Repair (616)

• To control bleeding
• To prevent infection
• To assist the wound to heal by primary intention – healing is usually rapid and scarring is minimal providing there is no infection or excessive bleeding/haematoma

Prior to assessing perineal trauma midwives must:

• Provide a full explanation
• Gain informed verbal consent
• Ensure adequate analgesia
• Ensure adequate lighting
• Ensure a comfortable, sustainable position

Practitioners should only leave trauma unsutured when it is the woman’s explicit wishes and this must be documented in case notes.

Prior to carrying out a rectal examination the procedure and reason for the examination should be explained and verbal consent gained.

• On visual examination, the absence of ‘puckering’ around the anterior aspect of the anus may suggest OASIS trauma;
• Insert index finger into rectum and thumb into vagina and perform a “pill-rolling” motion to palpate the anal sphincter;
• When the sphincter is disrupted you feel a distinct “gap” anteriorly;
• If the technique is inconclusive ask the woman to contract her anal sphincter while your fingers are still in situ;
• The internal anal sphincter (IAS) is paler in appearance, similar to the flesh of raw fish, whilst the external anal sphincter (EAS) is a deep red, similar to raw red meat.
• Medical opinion (middle grade or above) should be sought if examination suggests a 3^rd or 4^th degree tear or if any uncertainty about the nature or extent of the trauma.

• Midwives or doctors undertaking perineal repair should be trained in the procedure.
• The extent of the perineal trauma should be evaluated by examining the vagina and perineum. A rectal examination should be performed as part of the assessment to exclude OASI injury;
• Suturing should commence ideally 30-60min following delivery of 3rd stage as the repair will be less painful and the risk of infection is reduced. NB Water birth – delay for 1 hour
• Handle tissues gently using non-toothed forceps;
• Ensure good anatomical restoration and alignment to facilitate healing;
• Ensure haemostasis between each layer and close all dead space to avoid haematomas developing
• Sutures should approximate not strangulate the tissues. Ensure knots are tied securely but not too bulky;
• PR after completion to ensure no suture material has accidentally been inserted into the rectal mucosa.

• Ensure adequate analgesia prior to repair
• If the woman has had an epidural ensure it provides adequate pain relief.
• The perineum is infiltrated using Lidocaine 1% .
• The maximum safe dose should be calculated - 3mg/kg of 1% lidocaine using a recent weight.

• 20 mls 1% lidocaine is the maximum dose administered by midwives.

The use of No 2/0 Vicryl Rapide with a 35mm tapercut needle should be used.  It is associated with a significant reduction in:

• perineal pain and subequent analgesic use;
• less dehiscence;
  

  RCOG (2004); QIS (2008) & NICE (2007).

• Modified Fleming technique should be used.
• This technique is associated with less short term pain compared with the traditional interrupted method NICE (2007) & QIS (2008).

1. Fully explain the procedure to the woman and gain verbal consent to carry out Perineal repair;
2. Ensure the woman is in a comfortable position with good exposure of the vaginal trauma.
3. Check equipment - swabs; sutures; sharps; instruments with an assistant;
4. Ensure adequate analgesia;
5. Thoroughly examine the vagina and perineum to establish the extent of the trauma and identify the apex. If there is any doubt regarding the extent of the trauma – ASK FOR HELP;
6. Insert a tampon, if necessary to provide a clear view and secure the tail with an artery forceps; ensure you have adequate light to carry out the repair.

• Confirm local anaesthetic is working prior to commencing suturing
• Consider inserting a tampon to provide a clear view of the apex of the tear.
• Identify the apex and insert the anchoring suture 0.5cm above the apex to allow for haemostasis of any small vessels, which may have retracted beyond this point
• Repair the vaginal wall using a loose, continuous, non-locked stitch with approx 0.5cm between each stitch
• Continue to suture from apex to introitus; ensuring sutures are not placed in the hymenal remnants
• Place the needle under the fourchette and emerge in the centre of the perineal muscle NICE (2007) & QIS (2008).

• Check the depth of the trauma
• Repair the perineal muscles in one or two layers with the same loose, continuous, non-locked stitch
• Ensure the muscle edges are apposed carefully leaving no dead space
• Visualise the needle between sides to prevent stitches being inserted into the rectal mucosa
• On completion of the muscle layer, the skin should align so that they can be brought together without tension NICE (2007) & QIS (2008).

• Reposition the needle and commence suturing the skin from the apex of the wound
• Stitches are placed below the surface of the skin, the point of the needle should be repositioned between each side (a side-to-side technique)
• Continue the sub cuticular stitch until the proximal end of the wound is reached
• Sweep the needle behind the fourchette back into the vagina. Pick up a small amount of vaginal tissue to tie off the stitch, knot, bury and tie off. Alternatively, the Aberdeen knot can be used NICE (2007) & QIS (2008).

• Inspect the repair to ensure haemostasis has been achieved. NB – “Less is more” – only carry out the required amount of suturing to achieve haemostasis – an excessive amount of sutures causes severe perineal morbidity
• Remove tampon 
• Perform PR to ensure no sutures have been accidentally inserted through the rectal mucosa
• Analgesia – Diclofenic 100mg PR if no contraindications
• Remove legs from lithotomy and ensure comfort
• All swabs, sharps and instruments should be accounted for and discarded safely
• Debrief and advise regarding perineal hygiene, pelvic floor exercises
• Document the repair and any difficulty during suturing i.e. friable tissue in case note.
• Sign prescription for local anaesthetic and analgesia (PGD) NICE (2007) & QIS (2008).