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RUPTURE PERINEUMPrepared by :Christine Surbakti - 406147010Marcelly Raymando - 406147011Melani Sugiarti Wijaya Kangmartono - 4060147014

OBSTETRI AND GYNECOLOGY CLERKSHIP TARUMANAGARA UNIVERSITYRSUD CIAWI, BOGORPeriod 29 th December 2014 s/d 7th March 2015

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DefinitionLacerations of perineum are the result of overstreching or too rapid streching of the tissue especially if they are poorly extensile or rigid. Laceration of the perineum is a wound or irregular tear of the perineal tissues during childbirth.

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ANATOMYPerineum Perineum is a diamond-shaped space that lies below the pelvic floor.Is bounded by : Superiorly : Pelvic floor Laterally : the pelvic outlet consisting of subpubic angle, ischiopubic rami, ischial tuberosities, sacrotuberous ligaments and coccyx Inferiorly : skin and fascia

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This area is divided into two triangles by transverse muscles of perineum and base of urogenital diaphragm :Anterior trianglePosterior triangleMost of the support of perineum is provided by pelvic floor and urogenital diaphragm

ETIOLOGITear in perineum commonly occur at childbirth :Malpresentations such as breechThe head of the fetus is born too soonLabor is not headed properlyPreviously on peineum there is a lot of scar tissue

RISK FACTORRisk Factor for more complex laceration include :Midline EpisiotomyNulliparity ( Primigravida )Longer second-stage laborPrecipitous deliveryPersistent occiput posterior postitionOperative vaginal deliveryAsian RaceIncreasing Fetal birthweight

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EPIDEMIOLOGYOne in three women occurring spontaneous laceration in the first childbirth.Seven in ten women reported using episiotomy in their first childbirthIt estimates that 85% of women who have a vaginal delivery will have some degree of perineal trauma and that 60-70% will require suturing.

CLASSIFICATIONDegrees of Perineal Rupture :First-degree lacerations involve the fourchette, perineal skin, and vaginal mucous membrane but not the underlying fascia and muscle. These included periurethral lacerations, which may bleed profusely.

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Second-degree lacerations involve, in addition, the fascia and muscles of the perineal body but not the anal sphincter. These tears may be midline, but often extend upward on one or both sides of the vagina, forming an irregular triangle.

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Third-degree lacerations extend farther to involve the external anal sphincter.

Fourth-degree lacerations extend completely through the rectal mucosa to expose its lumen and thus involves disruption of both the external and internal anal sphincters.

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SIGN AND SYMPTOMSBleeding in a State where the placenta is born, uterine contractions and well, it is certain that the bleeding wounds of the street comes from the birth. Signs that threatens to tear the perineum, among others:the perineum Skin started flaring and tense.the perineum Skin colored pale and shinythere is bleeding out of the holes of the vulva, is an indication of a tear in the vaginal mucosa.when the skin of the perineum at the midline begins to tear, among the fourchette and the sphincter ani.

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EPISIOTOMYepisiotomy is incision of the pudendumthe external genital organs.The incision maybe made in the midline, creating a median or midline episiotomy. It may also begin off the midline and directed laterally and downward away from the rectum, termed a mediolateral episiotomy.

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Episiotomy should be considered for indications such as shoulder dystocia, breech delivery, macrosomic fetuses,operative vaginal deliveries, persistent occiput posterior positions, and other instances in which failure to perform an episiotomy will result in significant perineal rupture

EXAMINATION1. Routine ExaminationAlmost all clinicians examine perineum area after childbirth process to detect tears can be appear. Some clinicians also recommend having all labor, followed by routine rectal examination and inspection of the walls of the vagina and cervix. Routine examination of the rectal to detect the septal aims on mucosa recta, anal sphincter, and perineum by using one finger into the rectum.

2. Peri-ruleIs a standard tool for assessing the perineum tear stadium two objectively made of plastic scale.

MANAGEMENTLacerations should be repaired immadietly if possible, and certainly within hours of deliveryFirst step is to define the limits of the lacerations, which includes vagina as well as perineumAs accurate an approximation as possible of all tissues should be secured and no dead spaces are left

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There are many ways to repair a perineal lacerations, but the concept is still the same:The suture material commonly used is 20 chromic catgut.For shallow wound it can be repair with one stitch; for deep wound it can be repair with two or more.Each stitch should be reach to the base of the woundThird degree laceration need a special technique.

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Initially the walls of the rectum is sewn inverted with simple gut. The needle cannot be penetrate the rectum wall and into the rectum lumen then the layer is closed with fascia stitch on it. After that, the end of the sphincter ani is searched and connected with two or three stitch using chromic cat gut. Finally it is sewn like second degree laceration

Fourth-Degree Laceration Repair

Education in patients also need to be provided, can be :Clean the wound after defecation/urinationAvoid the use of toilet paper, perfume, or powder on the genital areaRest the pelvic area with no sexual intercourse, inserting tamponCheck if pain increases or settled more than 1 week.Check if excessive bleeding occursSpecifically for III and IV degree tears, avoid constipation, as well as consume a diet low in fiber, low residue, as well as a stool softener.In 6 weeks post partum, if the tear heal normally, physical examination on perineum indicated normal then the patient can continues her sexual activity.

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Post operative treatment Administering of antibiotics given to patients with ruptured perineum Control of pain in the days after birth, usually by administering NSAIDMaintain hygiene perineum

PREVENTIONThe incidence of severe perineal trauma can be decreased by minimizing the use of episiotomy and operative vaginal deliveryProper support of perineum at the time of crowning and expulsion of head

COMPLICATIONSInfectionCosmetic disadvantage3 and 4 degree tears if left untreated may lead to fecal incontinence

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PROGNOSISThe majority of patients with an episiotomy or tear will heal very well, with the disappearance of pain 6 weeks after delivery and minimal scarring, however the stool incontinence may occur in the short term and long term on 10% of patients with fourth degree laceration, although already done well handling. If there are no complications, no required care and monitoring for long a period of time