9 perineal repair

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Perineal Repair Perineal Repair


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Review of NormalReview of Normal

Female AnatomyFemale Anatomy


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Ex posing perineal tears


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B asic Instruments andB asic Instruments and

SuppliesSuppliesNeedle holder Tissue forcep

ScissorsHemostatGloves

Suture material withneedle

Lidocaine 1 or 2 %Syringe with needle

Gauze sponge

Antiseptics


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B asic Principles in

Repairing Lacerations

1. Adequate hemostasis2. Anatomical restoration3. Use minimum suture material

4. Adequate anesthesia


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C lassification of lacerations

1 st degree involving thefourchette,perineal skin andvaginal mucousmembrane


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2nd

degreelacerationfourchette, perinealskin and vaginalmucous membranePL USPL US the fascia and the fascia and muscles of themuscles of the

perineal body perineal body


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33 rdrd degreedegree

lacerationlacerationfourchette, perinealfourchette, perinealskin and vaginalskin and vaginal

mucous membrane,mucous membrane,the fascia andthe fascia andmuscles of themuscles of theperineal bodyperineal body PL USPL USthethe anal sphincter anal sphincter


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44 thth degree lacerationdegree laceration

extends throughextends through the rectalthe rectalmucosa exposingmucosa exposing the lumen of the lumen of the rectumthe rectum


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Steps in Perineal Repair

1. P roperly expose and explore the vaginaand perineum

2. Clean area with antiseptic solution3. Apply firm pressure on bleeding areas4. Clamp and ligate bleeders

5. Infiltrate site with local anesthetics6. Start suturing from the apex of the

laceration


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T echnique in infiltration of local

anesthetics Use 10 or 20cc syringewith gauge 22, 3 cmneedleFill with lidocaineInsert the whole lengthof the needle below theskinCheck for blood bypulling back theplunger Inject evenly as youwithdraw the syringe


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E pisiotomyE pisiotomy

incision of the pudenda or perineum P erineotomyTwo types :

1) Median or midline2) Mediolateral episiotomy


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E pisiotomyE pisiotomy 22ndnd degreedegree L acerationL aceration 22ndnd degreedegree


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T ype of episiotomyT ype of episiotomyAdvantages and disadvantagesAdvantages and disadvantages

C haracteristics Midline Mediolateral

1. Surgical repair

2. Faulty healing3. P ost-op pain4. Anatomical

results

5. Blood L oss6. Dyspareunia7. E xtensions

E asy

RareMinimal

E xcellent

LessRare

More Common

More difficult

More commonCommon

Occasionalfaulty

MoreOccasionalUncommon


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Continuous suturetechnique - used torepair the vaginal wall

Interrupted suturetechnique - used torepair the fascia and

muscle

D ifferent types of skin repair


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D ifferent types of skin repair

Simple interruptedsuture technique

Subcuticular suturetechnique


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1.1. ContinuousContinuous

suturesuturetechnique usedtechnique usedto repair theto repair thevaginalvaginalmucosamucosa andandsubmucosa.submucosa.

SuturingSuturing

T echniqueT echnique


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2. Re2. Re--approximateapproximatehymenal ring.hymenal ring.

InterruptedInterruptedsuturesuturetechnique usedtechnique usedto repair theto repair thefascia andfascia andmusclemuscle

SuturingSuturing



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3. Continuous suture technique used to3. Continuous suture technique used tounite the superficial fascia.unite the superficial fascia.

Suturing T echniqueSuturing T echnique


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4. Completion of 4. Completion of repair usingrepair usingInterruptedInterruptedsuture or suture or subcuticular subcuticular

technique totechnique toclose the skinclose the skin

SuturingSuturing



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Prevention of Perineal T earsPrevention of Perineal T ears

1. Avoid sudden expulsion of the fetalhead during the bearing-down effort.

2. Maintain flexion of the fetal head toallow smaller diameter to pass throughthe perineum.

3. Control extension of the head (RitgenManuever)

4. Await external rotation of the babybefore delivery of the shoulders.


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Postpartum care of the wound

1. P ain relief 1. P ain relief a) Give analgesicsb) Apply ice pack initiallyc) Warm compress to lessen the

edema

d) Hot sitz bathe) Medicinal / Herbal wash


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2. Wound care2. Wound careClean wound and perineum regularlyRemove sutures if with pusGive antibioticsRefer to clinicians for further evaluation if in doubt


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3. Hematomaa) Small hematoma of about 3 cm

maybe observed

b) Apply ice pack or cold compressc) Give analgesics.d) Use antibiotics.

e) Observe closely and follow uppatient.


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Good day!Good day!

9 perineal repair

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