perineal injury and episiotomy
TRANSCRIPT
PERINEAL INJURY AND EPISIOTOMY
OUTLINE OF PRESENTATION
• ANATOMY OF PERINEUM
• FIRST AND SECOND DEGREE TEAR – REPAIR
• THIRD AND FOURTH DEGREE TEAR - REPAIR
PERINEUM
• Diamond shaped area between the thigh
• Perineal body: – mass of interlocking muscular, fascial, and fibrous
components lying between the vagina and anorectum– attachment point for components of the urinary and fecal
continence mechanisms, which are commonly damaged during vaginal childbirth
• Anterior and posterior triangle
Anterior triangle: superficial compartment
• bounded deeply by the perineal membrane and superficially by Colles fascia
• closed compartment infection or bleeding within it remains contained
• Contains muscles that are cut during episiotomy:– Bulbospongiosus– Transverse perineal
Anterior triangle: deep compartment
Posterior triangle
• Contents:– Ischiorectal fossa– Anal canal– Sphincter complex
ANORECTUM
External anal sphincter
Internal anal sphincter
CLASSIFICATION OF PERINEAL INJURY
RCOG GREEN TOP GUIDELINE
• Risk factors (for 3rd degree tear):1. BW > 4.0 kg2. Persistent OP position3. Nulliparity4. IOL5. Epidural analgesia6. Prolonged second stage ( > 1 hour)7. Shoulder dystocia8. Midline episiotomy9. Forceps delivery
• Prognosis:– Good prognosis following EAS repair– 60 - 80% asymptomatic at 12 months– Those with symptoms: flatus incontinence or faecal urgency
– Endoanal ultrasound as part of follow-up persistent defects in 54–88% of women after primary repair of recognised third-degree tears
• Future deliveries (for those who sustained obstetrics anal sphincter injury):
– should be counselled about the risk of developing anal incontinence or worsening symptoms with subsequent vaginal delivery
– no evidence to support the role of prophylactic episiotomy in subsequent pregnancies
– Those who are symptomatic or have abnormal endoanal ultrasonography and/or manometry should have the option of elective caesarean birth